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Royal Berkshire NHS Foundation Trust

Operational Plan 2016/17

18 April 2016

Version for external publication

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1 Introduction & Context

Introducing the Trust

The Trust impacts directly on approximately half a million patients each year through the provision of

high quality acute medical and surgical services to the local communities. The Trust also provides

specialist services to a population of one million across Berkshire and its borders. The Trust provides

services from the following sites:

• Royal Berkshire Hospital.

• The Prince Charles Eye Unit, Windsor, provides eye services to the patients of East Berkshire.

• Dialysis services at a dedicated unit in Windsor.

• West Berkshire Community Hospital - day surgery unit and the acute outpatients department.

• Royal Berkshire Bracknell Healthspace – cancer, renal and outpatient services.

• Townland’s Hospital, Henley – outpatient services.

The geographical disbursement of these sites affords the opportunity of the patient to be treated closer

to home. In addition the Trust provides services from a number of other sites in the community and

directly provides some community services.

The Trust is a specialist centre for cancer, bariatric care, heart attack and stroke, with a designated

Hyper Acute Stroke Unit. In addition the Trust provides specialist care as part of a network in

neonatology, interventional radiology and trauma. The Trust also provides services which may not be

found in every hospital including spinal surgery.

The population served has a diverse range of needs. Whilst some areas are relatively affluent there are

pockets of deprivation with some areas in South Reading being ranked amongst the 20% most deprived

areas in the country. Population growth is expected, including in Wokingham and Bracknell, with

migration patterns suggesting that there are a number of older people moving into the Wokingham

area. Wokingham has a higher prevalence of cancer and asthma; South Reading has higher rates of

deaths from cardiovascular and respiratory disease, North and West Reading has a higher prevalence of

cancer and depression. People in Slough have higher levels of diabetes whilst those in Maidenhead,

Windsor and Ascot have a higher prevalence of cardiovascular disease and cancer.

2015/16 Achievements

The challenge that the Trust faced in 2015/16 was the need to deliver significant savings whilst ensuring

that it meets the standards for quality of care that our patients deserve. Responding to operational

performance improvement challenges and meeting rising demand put significant pressure on pay and

support costs. This has meant that, whilst the Trust continues to be proud of the quality of care it has

delivered, it has had to put robust focus on its short term financial recovery programme to ensure

maintenance of a strong cash position and delivery of cost improvement programme (CIPs) and

reduction in agency spend to target. The Operational Plan for 2016/17 will continue to build on some

notable developments in 2015/16:

• Strong cash controls maintained as evidenced by month end cash position exceeding plan.

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• The Trust forecasts that it will meet its Cost Improvement Programme (CiP) target of £16m.

• Medical productivity has improved, with job planning completed for over 99% of consultants

and tighter leave policies introduced. A new electronic system to support revalidation job

planning and rotas has been introduced.

• Two key projects in maternity and ophthalmology have been delivered as per plan, with the

unannounced inspection of maternity by the CQC evidencing success.

• The Trust has been working with colleagues in other organisations in progressing a Berkshire

and Surrey Pathology Service serving 5 hospitals.

• The Trust has been working closely with other health economy stakeholders to position the

system to be in a position to deliver in the new environment via a shadow Accountable Care

System (ACS).

• Improving links with GP practices and primary care to better understand issues, and to identify

key themes and trends.

• Good progress has been made on our quality priorities such as incident reporting, delivery of the

CQC action plan and ensuring safe staffing. The Trust is making additional efforts to improve

those areas that have not seen sufficient progress including medical records and improving our

administration systems.

• The Trust continues to demonstrate an on-going excellent patient experience through the

friends and family test.

The Royal Berkshire NHS Foundation Trust’s Operational Plan for 2016/17 explains how the Trust

intends to achieve balance between the provision of high quality services that comply with access

targets and also meet our financial control targets. This will bring us to a position of improved short

term financial sustainability by the end of 2016/17 and supports the development of system-wide long

term planning.

This plan provides assurance that the Trust has addressed the key aspects of activity, quality, finance

and workforce planning. The plan explains how the Trust is encouraging local representation through

our Governors and membership. The Trust has also set out its involvement in the development of the

system –wide Sustainability and Transformation Plan (STP), and the key actions that will be taken to

progress this in the coming months.

On-Going Challenges

The Trust continues to deliver but against a context of having an ageing estate, with little room for

significant expansion at the Royal Berkshire Hospital, with an ICU that is small for the population it

services. The Trust faces competition in its immediate locality from three independent sector providers

in a number of services which has seen work transfer but leaves the Trust with substantially the same

cost structure. The area the Trust serves is mostly affluent with associated higher costs of living than in

some areas of the country. This is believed to underpin some of the issues that the Trust experiences

with regards to being able to attract and retain staff.

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2 Sustainability and Transformation Plan (STP)

System-wide Planning

The Trust is working closely with system partners in developing new models of care both via the

Sustainability and Transformation Plan (STP) - Buckinghamshire, Oxfordshire and Berkshire West

footprint - and the locally established Accountable Care System (ACS) of Berkshire West. The STP

footprint describes a geographic area that has been mandated to work together to resolve issues across

the area to close the gaps in health and wellbeing, care and quality, finance and efficiency. The STP is a

plan that is based on place (this wider system) and not one based on organisation boundaries (such as

this plan). The footprint has only recently been confirmed and therefore work is at an early stage of

maturity. The Trust recognises the principle of subsidiarity, and the need to plan at different levels, and

continues to support the continued development the Berkshire West ACS. The operational plan that has

been developed is in line with the principles of the ACS and the principles underlying the STP. The Trust

has engaged with the wider footprint and continues to meet with partners in supporting the creation of

Berkshire West ACS.

The ACS is a more formal local arrangement established to facilitate the Trust, Berkshire Healthcare NHS

Foundation Trust and the local commissioners to working together. The ACS is a collective enterprise

that unites its members and binds them to the goals of the health system as a whole. This will help

system partners hold each other collectively to account for delivering the necessary transformation of

services and in getting the best value for money for patients and taxpayers. A Memorandum of

Understanding has been drafted to underpin this and further development by respective organisation

boards is expected The development of the ACS is underpinned by a clear and shared objective to

address the challenges articulated by the Five Year Forward View by ensuring that the Trust:

• increases the emphasis on primary prevention, health and well-being;

• improves quality of care through better outcomes and experience for patients and achieving

constitutional standards; and

• operates a financially sustainable system .

The development of the STP footprint and ACS will have a number of critical impacts in 2016/17 on the

Trust’s Operational Plan. The Trust will need to be more focussed on the development of clinical

decision-making and service developments which drive proactive management of care and provision of

care in the most effective settings. The Trust believes that this will underpin the development of a

Berkshire West system strategy, which in turn will support the STP development. In 2016/17, the

Berkshire West strategy will primarily focus on development of the frail elderly pathway and exploring

pathway changes and trialling new payment mechanisms beginning with dermatology and respiratory.

Our lead commissioner has demonstrated a clear commitment to move towards a payment system that

moves resources to the optimal part of the system that rewards providers appropriately; aligns

incentives and risks; and helps all organisations achieve long term financial balance by unlocking

efficiencies. This will help ensure that negative incentives to pursue the most profitable market share

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are removed. However, whilst a number of different mechanisms need to be considered, it is at a very

early stage and no revised payment mechanisms have been agreed. The Trust will be working with the

commissioners and other providers to ensure that there is robust financial analysis to support this.

As a system, we are also prioritising the establishment of a governance structure reflective of a unified

leadership team, with delegated powers from the constituent organisations. This is the critical enabling

milestone as this will allow us to release back office efficiencies through closer joint working. This will

allow the development of a dedicated work stream exploring how IT, HR, finance, payroll,

communications and facilities management functions can be streamlined across the constituent

organisations. This work has yet to be established but will look to find the best solution for the local

area.

The timeline for 2016/17 identifies the following key actions:

• Stabilise the financial position with no further deterioration from agreed control totals across

the system

• Secure operational performance

• Develop the five year Sustainability and Transformation Plan

• Develop the five year financial plan for Berkshire West

• Introduce some Gain and Loss sharing within the system across all organisations

• Begin the proposed pathway changes, trialling new payment mechanisms

• Review economies of scale and commence rationalisation of back office functions Develop a

shared approach to system enablers

Impact on our Operational Plan

The vision of the local health system is for healthcare organisations of Berkshire West to plan and act

cooperatively on behalf of our population to deliver the best possible experience and outcomes within

our available resources. The Trust will enable this through organising around the needs of the

population rather than planning at an organisational level. The Trust’s own vision has been formed

directly in alignment with that of partners, namely to ensure that patients are treated seamlessly across

organisation boundaries and that the hospital will always deliver both excellent care along with

improved health outcomes for the population. The Trust’s strategic aims are being developed to focus

delivery of this vision through:

Quality care, centred on meeting the patients’ expectations and ensuring that they live longer and

healthier.

• We will improve how we listen to and learn from patient experiences and involve patient

leaders in our services.

• We will prioritise continuous quality improvement, focussing on ensuring that we reduce harm

with a strong safety culture

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• We will focus quality improvement initiatives on the patient outcomes and our strategic

initiatives on ensuring the achievement of better health outcomes for the population, with our

partners.

• Our behaviours will be aligned with Trust Values, aligned to the NHS Constitution to drive quality

• We will be a learning organisation with comprehensive structures of disseminating

improvement across all staff.

Achieving the right balance of delivering quality within all available resources, to ensure we invest for

the future.

• There will be an equal consideration of quality, efficiency and cost in our business planning and

prioritising processes, demonstrating good stewardship of taxpayers’ money.

• The consideration of clinical risks and financial viability will be integrated.

• Our commitment to the pursuit of optimal productivity and efficiency will be supported by

transparent decision-making processes and prioritisation.

Productive partnerships with patients, staff, partners and commissioners that deliver improved

outcomes for the public.

• We will work as a system leader to support change and transformation to meet NHS regional

and local goals.

• All staff will model and demonstrate leadership behaviours that support integration and system

working.

• Identify system KPIs that show real long term benefits for the population and integrate these

into our Trust objectives.

A positive culture that supports and develops our staff to always strive for excellence.

• All staff will have an effective and structured appraisals and performance development plan.

• Succession planning and talent mapping will be put in place, supported by a programme of

training and development that is centred on our values and our objectives.

• Outcome-focussed health and wellbeing and equality and diversity programmes will be

refreshed to target areas of need.

2016/17 Trust Objectives

The Trust continues to build upon the strategic goals developed as part of last year’s Strategic Roadmap.

As part of the on-going development the Roadmap, the Board has reviewed the Corporate Objectives

for 2016/17. The Objectives have been based on the Board’s analysis of performance against the

previous year; consideration of the key financial, quality and operational performance challenges; and

the reflection of the 2016/17 NHS England 9 ‘must dos’ as articulated in the Five Year Forward View:

1. Develop a high quality and agreed STP, and determine the most locally critical milestones

for accelerating progress in 2016/17 towards achieving the triple aim as set out in the

Forward View.

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2. Return the system to aggregate financial balance. This includes secondary care providers

delivering efficiency savings through actively engaging with the Lord Carter provider

productivity work programme and complying with the maximum total agency spend and

hourly rates set out by NHS Improvement.

3. Develop and implement a local plan to address the sustainability and quality of general

practice, including workforce and workload issues.

4. Get back on track with access standards for A&E and ambulance waits, ensuring more than

95 per cent of patients wait no more than four hours in A&E, and that all ambulance trusts

respond to 75 per cent of Category A calls within eight minutes.

5. Improvement against the standard that more than 92 per cent of patients on non-

emergency pathways wait no more than 18 weeks from referral to treatment.

6. Deliver the cancer waiting standards, including by securing adequate diagnostic capacity;

and make progress in improving one-year survival rates; and reducing the proportion of

cancers diagnosed following an emergency admission.

7. Achieve and maintain the two new mental health access standards.

8. Deliver actions set out in local plans to transform care for people with learning disabilities.

9. Develop and implement an affordable plan to make improvements in quality particularly for

organisations in special measures.

The 2016/17 Corporate Objectives are set out below mapped to the Trust’s Strategic Goals. They will

form the basis of the Executive and Senior Management appraisal process and objective setting for next

year and subsequently will be reflected in individual appraisal documentation.

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3 Quality

Quality Improvement

The Trust-wide Quality Improvement Strategy is jointly led by the Director of Nursing and the Medical

Director and focuses on clinical effectiveness, patient experience, patient safety and culture. This

strategy is reviewed annually and 2016/17 will be the third year of our current strategy which continues

to demonstrate achievement. The improvement approach of the Trust is based on a combination of

project management and quality improvement methodologies. There is a clear governance structure in

place through the Trust Improvement Programme Board chaired by the Chief Operating Officer and

jointly managed with the Director of Finance to ensure that the right balance is achieved between

quality and finance. This Programme Board reports into Senior Management Team and Board.

The Trust has developed a Clinical Audit and Quality Improvement annual programme based on an

analysis of patient safety and experience data from 2015-16 and aligned to the Trust’s key quality

priorities for 2016-17. The completion of this programme will be monitored through the Trust’s Clinical

Outcomes and Effectiveness Committee chaired by the Medical Director. Throughout the year

additional quality improvement projects may be identified in response to specific quality issues and

service needs; these will be evaluated and approved by the clinical leads and managed by the clinical

audit and improvement facilitators within the Quality Governance Team.

In addition, root cause analysis (RCA) investigations are completed for all identified ‘Serious Incidents

Requiring Investigation’ (SIRIs) and incidents for which significant learning has been identified. From

these investigations robust action plans for improvement are developed and learning shared across the

organisation to mitigate the patient safety risks highlighted. Regular thematic reporting from SIRIs goes

to the Trust Quality Assurance and Learning Committee for oversight and wider dissemination of

learning and improvements made. The Quality Assurance & Learning Committee is primary committee

for providing assurance to the Board (via the Clinical Governance Committee) of clinical quality across

the organisation.

Quality Priorities and Risks for 2016/17

The Trust has identified its quality priorities for 2016/17 based on patient and staff feedback, on-going

work streams from 2015-16, and key national targets. Each priority has an identified lead and action

plan for improvement which will be monitored throughout the year by the Quality Assurance and

Learning Committee.

• Staffing: substantive nursing, midwifery and medical vacancies Ensuring our hospital is staffed

with the appropriate number and skill mix of clinical professionals is vital to the delivery of

quality care and keeping patients safe from avoidable harm. Vacancy rates have been a

challenge across all staff groups, in particular midwifery and nursing. The Trust has an active

strategy for recruitment and retention which has included: re-launch of the ‘refer a friend’

scheme; use of social media for recruitment; overseas nursing recruitment campaigns to

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Portugal and Italy; recruitment open days held for nursing and midwifery; and recent leavers

written to and encouraged to return. In addition we have incentivised our student nurses to

stay with the Trust on qualification by offering bespoke rotation programmes and support with

interview techniques and practice. In 2016-17 we will continue our recruitment and retention

campaign through recruitment open days; offering ‘Golden Hello’ payments to new staff in

orthopaedics and elderly care; undertaking further overseas recruitment campaigns; promoting

our relocation package to attract those based further afield; and offering a skills development

programme for nurses.

• The timely identification and treatment of sepsis. Sepsis has been high on the Trust’s agenda

for nearly 10 years now, and an on-going collaborative, trust wide, multi-professional approach

has continued to transform our improvement capability, capacity and resilience in trying to

make a significant difference to those patients with a diagnosis of sepsis. Our learning and

collaboration extended across the local health economy, where we are now working together

across primary, secondary and community care using a common sepsis language and

methodologies such as NEWS and sepsis screening tools. This has been collaborative team

working across a wide range of work streams all resulting in the aggregation of marginal

improvement gains across the range of different drivers. However, we recognise there is still

more work to be done. We have benchmarked ourselves against recently published national

guidance and will be implementing actions to ensure all the recommendations are solidly

embedded into our daily practice. Our work will include the “front door” admissions, but also

focus on patients developing sepsis on the wards.

• Reducing waiting times to ensure treatment is received at the right time for patients with

cancer. Further discussion of this may be seen in the activity section. The Trust has been

working with the IST to improve cancer services and has redesigned pathways and escalation

triggers. Additional staffing has been agreed to support the cancer pathway and one stop

services in a range of services have been developed. Capacity and demand work is on-going and

improved performance is targeted in 2016/17.

• Improving the availability and quality of medical records. This was a quality priority for 2015-16

which the Trust was not fully able to realise. The Trust has already automated requests of

inpatient admission, improved retrieval processes and introduced monthly audits. In 2016/17

the Trust will deliver training to all clinical and administrative staff, reduce temporary records

through tighter controls, redesigning the Health Records department – including RFID tagging,

and heightened audits.

• Improving antimicrobial stewardship. Antimicrobial resistance has risen significantly over the

last 40 years which poses a serious risk to public health. Inappropriate and overuse of

antimicrobials is a key driver. Improving antimicrobial stewardship is therefore an important

national priority for clinical effectiveness and safety. The Trust has a programme of education

and training on antibiotic prescribing and stewardship. This is supported by a new ‘app’ for

mobile devices to access antibiotic clinical guidelines for prescribers on the wards. Our

improvement programme for 2016-17 includes developing a local antibiotic consumption vs.

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resistance monitoring system; greater antibiotic auditing and real-time feedback to prescribers;

and improving turnover times for microbiology testing to support the acute care pathway.

• Improving the Trust’s administration systems. In 2015 the Trust restructured the administrative

teams into 14 Clinical Administrative Teams. The programme for 2016-17 encompasses

improvement work streams focussing on telephony, estates, staffing and recruitment,

technology, information and training.

• Improving the care of patients with dementia and support for carers. The Trust has undertaken

much work on its elderly care wards in order to improve the care of patients with dementia

including the introduction of colour-themed wards; improvements to flooring; a cinema room;

and distraction therapy. In addition, a Trust-wide dementia training programme for staff is in

place and the Trust is ensuring all relevant staff have this training. Links have been established

and will continue to be developed with the Alzheimer’s Society who regularly visit ward areas in

order to provide expert support for carers of dementia patients. Additional planned

improvements for carers include open visiting hours, improved communication and

collaborative working, and greater involvement in the discharge process. A Dementia Strategy is

in development which will provide a framework for the continuing improvement work.

The above priorities have been developed by reviewing progress against last year’s objectives, reviewing

themes that have arisen from internal quality indicators such as incidents, complaints, clinical audit and

consultation with key stakeholders. In order to capture the patient’s perspective a conference was held

to develop suggestions and the Trust also consulted with its Governors in finalising these choices. All

staff were given the opportunity to give suggestions and vote for the quality priorities. The long-list of

quality objectives were also shared with Commissioners, Healthwatch and Health and Wellbeing Boards.

Therefore, given the way that the priorities have been developed they are designed to address some of

the key risks that the Trust faces.

Seven Day working

In addition the Trust has a specific project implementing ‘seven day services’ as part of the Trust

Improvement Programme. The scope of this programme is to identify and implement measures to

ensure compliance against the four priority standards next year (time to first consultant review,

diagnostics, intervention/key services, ongoing review). The initial phase focuses on establishing the

Trust’s position and outlining the plan for achieving the standard. The programme will include actions to

ensure improvements against the remaining six standards as per an agreed trajectory with our CCG at

the end of quarter 1 in 2016/17. The seven day services project is in place with a project plan, project

team and milestones to enable the achievement of the service development and improvement plan. The

seven day services programme includes representation from the Head of Contracting, Head of Access

and Performance, Operational and Clinical staff. The programme has an executive lead, the Chief

Operating Officer and the Trust is in the process of appointing a new clinical lead to drive forward the

actions in 2016/17. This project is supported by the PMO with monitoring of actions through the Trust

Improvement Programme Board each month.

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Royal Berkshire participated in the national audit in August 2015 which identified that the Trust was

compliant with standards 5 and 6 and was compliant in 4 out of 10 areas against standard 2 and

compliant in 6 out of 12 areas against standard 8. In 2016/17, the Trust’s 7 day services programme

looks at the measures required to improve compliance in these priority areas and the implementation of

improvements agreed in the Service Development and Improvement Plan in the standard contract with

the CCG. This plan includes actions to progress the following four priority standards next year:

1. Standard 2: Time to Consultant Review. This was a CQUIN in 2014/15 for the Trust and the key

areas for development at the moment are Cardiology and Surgery. In both areas an action plan

to address non-compliance will be taken forward in 2016/17. A trajectory for improvement will

be agreed with the CCG by the end of quarter one with delivery against the trajectory being

monitored through the Trust Improvement Board and contract meetings.

2. Standard 5: Diagnostics – the Trust was found to be compliant in August 2015. In 2016 as per

agreement with the CCG the Trust will carry out an audit for plain x-ray and echocardiograms

3. Standard 6: Intervention and key services – the Trust is compliant with this standard and no

further action is anticipated.

4. Standard 8: On-going review – Royal Berkshire will complete a self-assessed baseline based on

the results of the NHS England audit. Following this audit, a trajectory will be agreed for key

specialities and actions implemented to meet the trajectory by quarter four.

The Service Development and Improvement Plan agreed with the CCGs, also covers the other 6 clinical

standards and progress against each of these standards will be assessed each quarter. As agreed with

the CCGs, the Trust will seek to achieve compliance, or make progress towards it, within the current

resources and financial envelope. The seven day services programme will seek to baseline compliance in

the first quarter; develop the action plan for improvement in quarter 2; and implement the actions in

line with the contract agreed with the CCG.

Monitoring and Quality Impact Assessment processes

The Board receive an integrated performance report covering safety, experience, access, clinical

measures, workforce and finance, supported by a suite of exception reports as required. Performance

issues are identified and appropriate actions to be taken which are then logged. These action points are

developed and Board sub-committees are used to further explore key issues and to help achieve

resolution. Items sent by the Board to the sub-committee will be followed up in subsequent Board

meetings until resolved. A comprehensive governance process, including an assurance and escalation

framework exists to support the Board underpinned by a hierarchy of committees.

All QIPP projects (cost and quality improvement) are identified through a series of workshops with the

Care Groups and corporate functions, which include representation from clinical and non-clinical staff.

The impact on safety, outcomes, patients and staff experience is assessed during the initial identification

of projects and the subsequent QIPP programme is signed off by the Trust Improvement Programme

Board, Finance and Resources Committee, Senior Management Team and then the Board.

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Quality Impact assessments (QIA) are completed for all QIPP projects, by the project lead or quality

improvement lead, supported by the PMO lead. This process allows the simultaneous consideration of

clinical risk and financial viability. The areas of quality that are addressed and scored for impact and

likelihood are: Duty of Quality; Patient Experience; Patient Safety; Staff Safety; Education; Clinical

Effectiveness; Prevention; Productivity and Innovation. The Medical Director and Director of Nursing are

informed weekly of all QIAs that have been submitted. Escalated QIAs are reviewed by the Trust

Improvement Programme Board to agree which of 4 actions to take and the Project Lead is informed of

how to proceed, with the risk rating being adjusted accordingly. Post-project QIAs are completed for any

projects with escalated QIAs and approved by the Trust Improvement Programme Board, six months

after implementation of the project.

Well-Led Framework

Significant progress has been made in relation to implementing action plans to embed improvement in

relation to the Well-Led elements. The most notable areas of progress include:

• Strategic Planning: Systematic and system-wide service and strategic planning processes are in

place and, with a dedicated focus on strategy by the Board, the Trust has developed a clear

vision and objectives for 2016/17 aligned to that of partners. This has been supported by robust

progress against 2015/16 objectives.

• Risk Management: The Trust has addressed identified areas of weakness across risk

management processes and roles. This has included establishment of improved Board and

Corporate process including embedding of changes to Executive risk portfolios; the refresh of

the Board Assurance & Escalation Framework; a significantly revised Corporate Risk Register;

and improvement to more granular processes such as utilisation of the Datix risk management

modules.

• Culture & Workforce: With the appointment of a new Chair, a Chief Operating Officer and

delivery of an enhanced Board development programme, the Board of the Trust has the

experience, capacity and capability to ensure that a system strategy can be delivered. Reviews

and changes to senior roles, portfolios and governance structures are complete with a strong

leadership structure in place.

• Information management: Progress has been made in the development of Board performance

and exception reports. The effectiveness and integration of reporting and decision-making is

much improved as has Board challenge of performance and holding management to account.

The Trust has received its external assessment against the Well Led Framework on 31 March 2016. In

response to that, during 2016/17 the Trust will be focused on developing the following to further

improve our capability regarding the Well Led Framework:

• Establishment of a clinically-led service strategy that is fully aligned with commissioner and

system intentions in relation to development of the STP and the development of new models of

care.

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• There is further progress needed to ensure that risk management processes have been cascaded

effectively down to ward level via Care Group risk registers and that the clinical audit strategy is

fully reflective of risks to the Trust’s core objectives.

• There is additional work to be done in developing a more systematic approach to delivering a

corporate quality culture that is recognised equally across the organisation. A key work stream

will be pursued in 2016/17 around our organisational development, which has previously been

constrained by capacity, including our values and behaviours, the effective impact of staff

engagement impact and the effectiveness of our leadership and management.

• The Trust will deliver enhanced Care Group performance reports (and ward reporting) aligned to

Board reporting and to Trust objectives. This will be supported by an improved Performance

Management Framework. Performance reviews along pathways (via Service Line Management)

and the delivery of a significant element of the data assurance programme will deliver enhanced

information systems to support Trust and LHE system requirements.

Membership and elections

The Trust has public governors representing five local geographic areas, as well as volunteer, staff and

partner governors. The Trust has a number of vacancies for governors and will be looking to hold

elections this year for eight seats. In order to facilitate this process the Trust and its governors have

been raising their profile with the membership through a number of methods including having a session

for people to meet their Governors in all membership meetings. Proposed dates for events between the

membership and the Governors have been circulated to the Governors. The Trust is currently exploring

having an open day to generate greater membership attendance.

In 2015/16 the membership meetings and focus groups have been oversubscribed and these meetings

have been used as an opportunity to encourage people to develop their relationship with the Trust by

encouraging them to become members. In addition the Trust seeks to encourage people to stand for

Governor through the Trust's Pulse magazine. Where there has been an under-representation of the

population we have served the Trust has sought to work with Governors to help address this issue and

has identified possible alternative ways of recruitment, for instance the Trust is currently assessing the

opportunity to engage with university students.

To help the Governors fulfil their role the Trust has strengthened its induction programme and sought to

develop them through the committees with which they engage. In addition the Governors are sent the

NHS providers newsletter.

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4 Activity Planning

Activity Planning Process

In setting the draft 2016/17 activity plan, the Trust and the CCGs are following an agreed process to

ensure affordability. A projection for full year outturn was used to form a baseline of activity and

analysed in conjunction with seasonal variation, anticipated population growth, full year impact of

agreed business cases for service development and repatriation of activity. This analysis forms the basis

of the Trust’s growth assumptions. The Trust is in the process of concluding its negotiations with

commissioners and whilst optimistic that this will reach an agreed conclusion, cannot rule out the need

for arbitration.

The Trust continues to build on capacity and demand analysis undertaken during 15/16, utilising the

expertise and tools made available through support from the Intensive Support Team (IST) and FourEyes

consultancy. A specific piece of modelling identified through the Trust Cancer Action Plan has been

commissioned, with external insight and support being provided by the IST to model both sustainable

management of demand and improvement in the cancer access and treatment standards. The outputs

from these models and projected levels of activity are being discussed with commissioners in parallel to

the 16/17 contractual and activity negotiations to ensure agreed levels of work are realistic, achievable

and support recovery to compliance where applicable. Final activity levels are subject to negotiation

with our commissioners.

Growth varies by different services and methods of presentation but includes a base level growth based

on changes in population size and profile. Emergency Department attendance has been agreed with

commissioners and is reflective of an on-going trend of increase demand, uplifted as a result of Q4

attendance being significantly higher than previous years. And the high level outcome of the activity

planning can be seen in the figures shown below.

Growth

Type 2015/16 2016/17 Vol %

Emergency Department Attendance (A&E) 116,882 121,612 4,730 4.0%

Outpatient Attendances (incl OPPROCs) 565,355 586,900 21,545 3.8%

Non-Elective Activity (incl Obs NELNE) 54,629 56,023 1,394 2.6%

Elective Activity 47,912 50,956 3,044 6.4%

Final activity levels are subject to on-going negotiation with our commissioners. In particular the Trust is

awaiting details of the Commissioner QIPPs and their potential impact on Trust activity levels. It is noted

that under the National Contract the impact of Commissioner QIPPs remains at their risk as the Trust will

get paid for the activity undertaken. Every effort is being made to arrive at signed contracts as soon as

possible.

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Changing Market Conditions

2015/16 has seen continued growth in attendance at the Emergency Department, with attendances in

January and February being very high in comparison to the same period in the previous year. At the

same time the Trust has seen a substantial increase in non-elective admissions in comparison to the

previous year.

In elective services the picture is more mixed but as can be seen from the above diagram the Trust’s

market share of elective procedures overall has been declining since 2011. Whilst the picture varies, this

downward market share can be seen in the diagram below for Orthopaedic procedures.

In outpatients some services such as ENT have seen increasing new attendances in recent years.

Gynaecology has seen increased numbers of new attendances since December 2012 but a decline in the

market share from our most local CCGs. Cardiology has seen growth in new attendances and cardiac

procedures undertaken. Orthopaedics in addition to its declining elective market has seen a decline in

its share for new outpatients. This decline in Orthopaedics has been mirrored by an increase in activity

and market share for an independent sector provider.

17

Capacity

Negotiations between the Trust and Commissioners are underway with a view to efficiently using local

resources to deliver activity levels together with utilising local independent sector resources where

current activity level demands. The Trust is currently supported by the independent sector in the

delivery of a number of diagnostic modalities including endoscopy, diagnostic breast services and

elements of radiology. These agreements have been in place through 15/16 and the Trust expects to

continue in this format.

As part of the Trust-wide development plans we continue to pursue ways of increasing internal

efficiency and maximise the use of Trust capacity. Where gaps are identified through capacity analysis

options appraisals are being developed to define sensible and efficient solutions to meet demand within

Trust services and in collaboration with the independent sector. It should be noted, however, that

identifying sufficient capacity for endoscopy is a continuing unresolved risk for two reasons: firstly there

are significant recruitment difficulties; and secondly there are limited options for suitably accredited

additional capacity in the independent sector or from other local hospitals. Demand and capacity work

will also be being progressed, with commissioners, regarding capacity for other diagnostics (e.g.

Radiology) given the increased need for improved access to smooth through patient pathways.

Operational standards

Whilst activity plans are under negotiation with our commissioners the Trust has factored in on-going

recovery plans where key performance standards are not being met. 2015/16 has seen significant

internal and external interrogation of the Trust’s cancer performance, resulting in thorough analysis of

specialty and sub-specialty pathways and management processes. A detailed recovery action plan has

been developed detailing needs to provide efficient and maintainable cancer services to our patients

and service users. In order to assure delivery of these improvements a number of action groups have

been created to ensure system wide accountability, clinical engagement and realisation of plans. To

support delivery of these plans, improvement trajectories have been developed and discussed at length

with commissioners, and are in the final stages of interrogation.

There have been significant improvements in the Trust’s ability to recover what is recognised to be a

national issue within Dermatology. Sustainability plans are in progress with the Trust expecting a 16/17

Q1 recovery of the Two Week Wait standard. The 62 day standard remains a significant challenge to the

Trust and requires changes to local processes, the ability to apply pathways in a timely fashion, and

resourcing clinical service to a level that enables highly efficient pathways. As a result of in depth

analysis in to sustainability improvements and availability/feasibility of additional capacity the Trust

projects a 16/17 Q3 recovery of the 62 day standard and this is currently being discussed with

commissioners.

Sustainable performance in the Referral to Treatment (RTT) incomplete standard, one of the key access

targets for the Trust, remains a high priority and is being factored in to the planning

negotiations. 2015/16 provided a challenge to accommodate and respond to national rule changes

enabling the Trust to concentrate on its pathways as a whole. This work has prompted a programme of

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work to streamline its reporting and data capture processes, to increase the level of efficiency and

visibility of patient pathways across the Trust and to optimise the tools at our disposal. All areas of

activity supporting the delivery of efficient elective services are in scope of these discussions and specific

plans are being developed through early 16/17 with an expectation to realise change throughout the

year

The Trust has included seasonal variance in Emergency Department demand to identify required

escalation resource similar to 2015/16 winter pressures support. Due to predicted increases in ED

demand in the region of 4% (circa 5,000 attendances over the year) in a department that is already over

stretched the Trust will be expected to maintain similar performance to 15/16 and strive for a year end

compliant position with improvement on 2015/16 unlikely. Sustained performance in ED will need to be

realised through efficiency gains in patient pathways and greater collaboration with primary and social

care providers to support the wider health economy in accessing care within the community setting.

Where standards are being achieved activity planning will factor in expected growth and any

adjustments/planned changes to services over 2015/16 outturn.

Commissioner QiPPs

Notwithstanding the actions undertaken between the Trust and Commissioners we have continued to

see on-going growth in activity, particularly non-elective. Consequently, whilst the Trust is working with

the system looking at both Commissioner and Provider QiPPs, this one year activity and operating plan

assumes negligible delivery of Commissioner QiPPs given historical trends.

The Trust recognises that, as submitted, this one year Operational Plan does not address the financial

sustainability of the sector. This will need to be done through the Five Year Sustainability and

Transformation Plans as part of the Accountable Care System and the wider Berkshire/ Oxfordshire/

Buckinghamshire footprint.

19

5 Workforce Planning

Trust workforce planning processes

The Trust is committed to a robust workforce planning process and workforce issues receive Board

attention which includes reporting on key measures to the Board as part of the Integrated Performance

Report. Regular progress reviews will also be undertaken by Senior Management Team and key risks

relating to the workforce are currently highlighted on the Board Assurance Framework and reviewed

monthly to ensure mitigating actions are in place. Where appropriate some developments such as 7 Day

working will receive support from the Trust’s PMO team to facilitate successful delivery. This will ensure

that these important developments receive appropriate support and scrutiny. The Trust workforce plan

will be submitted to Health Education Thames Valley for onward submission to Health Education

England. The Trust complies with the HEE requirements for plans to provide details by occupational

codes which specify the specialty and skill level of the future workforce.

The Trust regularly reviews all relevant metrics to identify workforce risk areas and produces a ward KPI

report that combines safety metrics with workforce indicators such as turnover and sickness absence,

which is reviewed by the senior nursing team. The workforce plan will be reviewed on a quarterly basis

to update the current workforce against the plan and to identify any actions required. Workforce risk

areas will be identified along with mitigation plans. Progress against mitigation plans will be monitored

by the Trust Workforce and Education Board.

System-wide development

The Trust is currently developing a workforce plan for 2016/17 which will be linked to the Clinical

Services Strategy. The plans are based on a template that incorporates the planned activity for each

service, the budgeted establishment, and a plan for temporary staffing expenditure through the year.

PESTLE and SWOT analyses identify the main influences on the service and the workforce strengths and

risks. Our clinical services teams have been developing and updating their strategies as part of an on-

going planning process. Workforce analysis was carried out across all services in June 2015. During the

latter part of 2015/16, services have been asked to consider the potential opportunities of a system-

wide Accountable Care System to deliver better value healthcare for our local population. Current

workforce KPIs are discussed together with reviews of new ways of working in order to achieve the

service QIPPs. The workforce planning documents are being used to identify workforce initiatives for

2016/17, but also to look ahead to further service redesign.

However, this work has particularly identified the need to review end to end pathways in detail with our

partners across the health and care system to ensure that the Trust is using scarce resources in the most

effective way. These discussions have sought to identify how the Trust can better use people to provide

services and what opportunity there would be to do things differently. This detailed planning will then

be used to develop transformational workforce plans for the Trust and other providers in the pathway

which ensure the achievement of a sustainable balance between high quality safe services and

affordability.

20

The work that will underpin the Trust workforce plans will be conducted in parallel with the Berkshire

West 10 Workforce Integration & Workforce Planning Project, with which the Trust participates. This

Project plans to include the redesign of the workforce across the system linking to the Better Care Fund

national conditions including 7 day working across health and social care, care co-ordination, joint

assessments and care planning. The BCF schemes that include workforce redesign include: Hospital at

Home; Enhanced Care Home Support; Re-ablement Services Integration; Frail Elderly Pathway; Primary

Care Development.

Productivity and improvement

There is a continued focus on workforce productivity schemes including the reliance on (and cost of) a

temporary workforce and external agency workers. E-rostering software is used to ensure that staff are

allocated to shifts in the most efficient manner. The system prompts ward/service managers to reassign

staff where the shift is beyond the levels identified by the Director of Nursing as the appropriate staffing

level. There is a daily staffing huddle supported by robust, real-time roster reports, to review staffing

levels across the organisation and reallocate based on risk assessment. The Trust regularly reviews all

relevant metrics e.g. safe staffing levels and skill mix to identify any workforce risk areas and enable

rapid development of mitigating action plans. Nursing leads receive monthly rostering KPI reports that

highlight outcome against target including the use of agency staff against budget.

The Trust has a Workforce Productivity Delivery Programme which forms part of the CIP Service

Improvement and Transformation Programme for 2016/17. The savings target for this programme is

currently being developed, and for nursing CIPs will be reviewed in conjunction with the Safe Staffing

Review completed by the Director of Nursing. The Trust workforce plan will also reflect other significant

local transformation programmes e.g. the pathology services are being reconfigured to become part of

Berkshire Surrey Pathology Services; and the implications on local midwifery services of the National

Maternity Review and its recommendations for multi-agency involvement in the provision of pre and

post-natal care. The Trust will be implementing two workforce productivity schemes: one relating to

medical workforce productivity; and the other relating to the remaining workforce. The implementation

of an electronic job planning module will allow each service to better align the senior medical workforce

activity to the commissioned activity.

As a result of our planning work the Trust believes that there will be other system-wide transformational

workforce programmes that could deliver more sustainable service delivery. In maternity services there

is a significant shortage of qualified midwives. The Trust is investigating the potential to map key

interactions along the patient pathway through pregnancy, birth and early parenthood which may

identify tasks currently undertaken by midwives that could be done by others or could be provided in

more innovative ways.

Staffing levels

The requirement to use agency staff should be a balancing item to better match resources and demand

in a flexible manner. Therefore, a key focus remains on recruiting staff, reducing staff turnover and

21

reducing absence. The Trust performs well on sickness management in comparison with other NHS

Trust’s and has a 2.8% target rate which it remains in line with. Leave on wards is actively managed to

reduce peaks in annual leave that could lead to an increase in demand for agency staff. The new on-line

leave booking system for senior medical staff will improve the visibility of days booked and allow for

improved forward planning. Limits have been set on the number of senior medical staff within a

specialty who may be absent at any one time. This limit is set by sub-specialty within some surgical

teams with the aim of achieving improved theatre utilisation. Recruitment and retention meetings have

been set up with high agency use areas to identify reasons for vacancies and to discuss ideas as to help

to retain staff and develop initiatives for recruitment.

The Trust is currently reporting on a weekly basis any breaches against the agency rules (both the use of

non-framework agency and against the price caps). The Trust has an e-Rostering policy that details a

Standard Operating Procedure (SOP) for ensuring the most cost effective method of ward cover at safe

staffing levels as set by the Director of Nursing. This SOP is reviewed regularly by Care Group Directors

of Nursing to ensure that it is updated with current costing information and follows best practice. The

Trust is looking to review the roster production processes, so that details of the shifts which need to be

filled by temporary staff are made available more quickly. The Trust restricts non framework agency

usage and this is only considered to ensure patient safety. Every agency has been contacted to discuss

compliance with Monitor rates. Agencies that do not comply are removed from our tier 1 workflow and

placed on tier 2, whereby they receive the shifts 72 hours in advance, when a tier 1 agency are unable to

supply. Routine contracting is with agencies that are on the approved framework, although in

exceptional circumstances the Trust may have to go outside of the framework. New agencies are being

engaged that meet the agency rules. Senior Trust staff meet with NHS Professionals on a weekly basis

and scrutinise all breaches, both in regards to the price cap and the use of non-framework agencies.

The Trust is reviewing its bank rate against rates paid by surrounding trusts. The Trust has approved a

proposed rate increase for NHS Professionals Bank Staff in ICU in order to reduce the reliance on agency

staff. This will assist with our ability to achieve safe staffing levels whilst reducing cost and the number

beaches against the agency rules. The Trust is exploring the option of the proposed rate increase for

NHS Professionals Bank Staff in Paediatrics. The Director of Nursing or Chief Operating Officer is

required to authorise the use of Thornbury staff. In order to reduce agency spend the Trust is working

on a number of other initiatives including promoting the ‘refer a friend’ scheme, holding a number of

recruitment open days and proactively promoting joining our bank through the “Love the NHS”

campaign.

The agency spend ceiling for 2016/17 is set at £10.32m which is considerably below the expenditure in

2015/16. When the price caps were introduced the Trust met with the agencies to discuss how they

were going to continue their level of supply given the reduction in rates. All providers adhered to the

November price cap but when the February price caps were introduced some agencies were not

complying and as a result the tiering structure was implemented. The Trust operates a padlock system

so shifts are only released to approved agencies once the Trust bank has been exhausted. The Trust is

implementing tighter control measures to prevent unnecessary use of agencies. The Trust predicts that

whilst it will be a challenge to achieve, it will be able to manage within its agency ceiling for 2016/17,

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but will continue to complete the self-assessment tool to identify opportunities to further strengthen

controls.

Safe staffing is assured by 6 monthly nursing skill mix reviews combined with robust daily planning and

risk management processes. The safe staffing reports are reported to the Board quarterly and actions

are identified to ensure that safety is maintained.

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6 Financial Planning

Overview

The Board has approved this plan which assumes £9.9m incremental funding for 2016/17 from the

Sustainability and Transformation Fund, and accordingly delivers a planned financial surplus of £4.8m,

versus a £9.1m deficit in 2015/16. The Trust had £11.5m cash at the end of March 2016, and expects

£9.05m cash at the end of March 2017. The Trust expects to conclude 2015/16 with a FSRR of 2 and

expects this to remain at 2 through 2016/17.

The table below summarises the key financial KPIs by quarter.

£m Qtr1 Qtr2 Qtr3 Qtr4 Full Yr

FSRR 2 2 2 2 2

Trust Surplus/(Deficit) (£'m) (1.47) 1.25 2.70 2.33 4.80

Income (£'m) 98.27 99.92 100.19 98.69 397.07

Pay Costs (£'m) (55.19) (55.49) (55.62) (55.31) (221.62)

Headcount at quarter end 5054 5098 5132 5139 5100

Trust QiPPs (£'m) 3.72 3.89 4.10 4.99 16.70

Contingency (£'m) 0.00 (0.30) (0.60) (0.60) (1.50)

Restructuring (£'m) (0.75) (0.75) (0.75) (0.75) (3.00)

Capital Spend (£'m) (2.32) (5.92) (6.42) (5.34) (20.00)

Sale of Craven Road 0.00 1.30 0.00 0.00 1.30

Cash at quarter end (£'m) 10.50 10.11 15.67 9.05 9.05

Key Assumptions inherent in the 2016/17 operating plan are detailed below:

£m

Margin

Impact £'m)

Base Activity growth of circa 2% 6.13

Impact of CCG QiPPs 0.00

Tariff Inflator 1.9% 5.83

Sustainability fund 9.90

Pay cost inflation & Employer Pension Contributions (9.31)

Drugs Income growth at 4.5%, cost growth at 4.5% (0.23)

Non Pay cost inflation at 1.2% (1.21)

Increase in NHSLA costs (2.11)

Trusts QiPPs 16.70

Contingency (1.50)

Restructuring (3.00)

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Income

Income is based on the roll-over of the ETO contract option as currently expected. This is consistent with

early contract conversations with Commissioners. However, those conversations are continuing and the

current Operating Plan as submitted is contingent on those negotiations concluding as currently

anticipated.

Whilst the Trust has included what might be seen as a conservative position with regards to growth we

are assuming that the 2016/17 contract will include a roll-over of winter funding monies received this

year (£1.2m) and that Commissioners will re-invest the MRET and readmission monies in-line with

current year (circa £3.5m). At this stage we have not included any activity reductions relating to

Commissioner QIPPs as history tells us that, notwithstanding the success of such schemes, the net

growth in activity has always been at least 2% for the Trust. This level of assumed growth in base level of

activity has traditionally been agreed with Commissioners as part of the planning assumptions and the

Trust expects that to be the same this year. The assumed activity growth provides income growth of

£6.2m, with a margin of £1.4m. The tariff inflator (1.9%) increases income by £5.8 whilst the allocation

from the Sustainability Fund increases income by £9.9m.

Pay

Pay includes a 4.3% inflation increase to cover an assumed annual pay award along with changes to

employer pension and NI contributions. Collectively these add £9.3m to the pay cost of the Trust. In

addition we have included an increase of £4.0m in pay to support the delivery of the incremental activity

growth. Reducing the pay costs is an assumed saving in QIPPs of circa £10.9m, with an assumed cost of

restructuring of £1.5m. Further detail on in year cost QIPPs is provided below.

We note that Monitor’s latest planning guidance suggests pay inflation of 3.3% which, if proved correct,

presents an opportunity versus the current budgeted pay costs of circa £2m.

Drugs Cost

Drugs cost has been assumed to increase at a rate of 4.5%, increasing costs by £0.255m.This is lower

than historical experience so has been included in our risk analysis. A further increase in drugs cost of

£2.92m in Planned Care is associated with correlated increase in drugs income.

Non Pay

Non pay inflation has been assumed at 1.2%, equating to £1.2m increased costs. NHSLA costs are

planned to increase by £2.1m as per our latest quoted contribution for 2016/17. Whilst we have

included these costs in our Operating Plan we have asked for further detail as it is not immediately clear

to us what is driving this increase in premiums and hence whether or not it is legitimate. Included in

non-pay in 2016/17 is an assumed restructuring cost of £1.5m. We note that Monitor’s latest planning

guidance suggests non-pay inflation of 1.7% which, if proved correct, presents a risk versus the current

budgeted non-pay costs of circa £0.5m.

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Contingency

The Trust has taken a top level view of key risks and opportunities as a result of which we have included

a contingency of £1.5m, in line with the previous year. The table below summarises the main risks and

opportunities.

Residual Risks and Opportunities

Gross Assessed Surplus

Per Operating Plan 4.8

Risks:

Commissioner QiPPs deliver or reduced

NEL marginal rate reinvestment (6.00) (2.00) (2.00)

Trust QiPPs deliver at 75% (4.18) (1.00) (1.00)

Non Pay inflation at 1.7% (0.50) (0.50) (0.50)

Planned Care contribution risk (2.00) (1.00) (1.00)

Network Care contribution risk (1.00) (0.50) (0.50)

Opportunities:

Activity/tariff growth higher 2.00 1.00 1.00

Urgent Care contribution growth opp 1.00 0.50 0.50

Pay inflation at 3.3% 2.00 1.00 1.00

Restructuring costs restricted to £2m 1.00 1.00 1.00

Cost Contingency 1.50 1.50 1.50

Plan net of risks and opportunities (6.18) 0.00 4.80

Cash Management

The Operating Plan for 2015/16 resulted in the Trust being in a low cash position by December 2015.

Consequently the Trust signed a £10m working capital facility with the ITFF in August 2015. The Trust

does not expect to draw down any of this facility in 2016/17. Whilst the Sustainability Fund allocation

provides significant cash during the year it is noted that this is provided quarterly in arrears. The Trust

will continue to monitor the cash position weekly and will advise the Board on future risks that may

result in the need to draw down on the working capital facility.

Efficiency savings for 2016/17

Cost QIPPs

The Trust sought to introduce a more transformational approach to cost QIPP planning and delivery in

2015/16. Whilst this has had some success, progress has not been as much as hoped, so this approach

will be reinforced in our 2016/17 plan. From 2016/17 the objective is to align the QIPP Programme to

the Trust Road Map, ensuring that each year the QIPP programmes support the strategic objectives and

transformational change. Therefore in 2016/17, the Transformation portfolio focuses on ‘strengthening

26

our foundation’, through programmes aimed at increasing the efficiency of our resources to provide the

current services, building a solid foundation for future change

The Trust has identified some 18 programmes which are a combination of cost improvement, service

improvement and transformation schemes. Each programme has a senior management lead, a

programme lead and a named PMO support lead. All programmes have scoping briefs and Project

Initiation Documents. The scoping briefs detail the phasing of the savings, the key milestones and

baselines to monitor delivery and are signed off at the Trust Improvement Board.

These programmes can be categorised as cost improvement, service improvement and enabling projects

and include on-going programmes such as medical productivity, workforce productivity, theatre

efficiency, medicines management, patient flow, and business as usual, but have been supported by

new programmes which act as key enablers and identifiers of opportunities for transformation. Key

amongst these are technology transformation, and service line management

The delivery of the cost QIPPs are overseen by the Chief Operating Officer, working with the Director of

Finance. All programmes are monitored for delivery through the monthly Trust Improvement Board and

achievement is tracked through the PMO database. The executive team is briefed weekly on the cost

QIPP programme and the Finance and Resources Committee and Board receive monthly reports on

progress, and exception reporting where appropriate. There is a clear risk rating for each of the

programmes.

The Trust is targeting cost QIPPs of £16.7m in the Operational Plan. As at 13 April, the Trust had

identified actions with potential savings of £18.3m in 2016/17 (full year effect £21.3m), with a current

PMO risk assessment of £13.0m. Work continues to both improve the pipeline of opportunities and to

increase the PMO risk assessment. This is an area which has been modelled for sensitivities as part of

our risk and opportunities analysis. The Trust has allowed for restructuring costs of £3.0m within the

Operating Plan to deliver the cost QIPP Programme. The project which will incur the largest

restructuring costs is the consolidation of Pathology services with Surrey acute providers. Total

restructuring costs of up to £6m are expected, with £1.5m, being the share funded by the Royal

Berkshire. The Business Case shows savings in excess of £1.6m per year for the Trust with a payback of

circa 2.5 years when £2.6m capital costs of implementation are included. The cost of restructuring will

be monitored monthly to ensure that the Trust remains within budget or any further restructuring costs

are more than covered by incremental in-year savings.

The Trust has engaged positively with the Lord Carter team, particularly with regards to the model

hospital work done in autumn 2015, however, as yet we have not seen this translate into savings. The

Trust will accelerate our engagement with Lord Carter’s team and included his recommendations into

the relevant QIPP programmes. The commitment to the Lord Carter programme is underpinned by the

Board as part of our acceptance of the conditions of the incremental monies from the Sustainability

Fund.

The Trust is involved in the CCG QIPP programme although our financial baseline is not predicated on

the success of their programme. The Trust will continue to engage with the CCG to ensure that the QIPP

27

Schemes identify are realistic and implementable. The Trust will continue to work with the CCG to

identify opportunities for working together, if appropriate, as part of their QIPP agenda. Once agreed we

will also need to ensure the Trust’s QIPP programme is linked to ACS priorities and the Sustainability and

Transformation Plans.

Agency Rules

The Trust reviews its agency spend on a monthly basis at its Board Finance and Resources Committee

Meeting. Whilst there has been some reduction in agency spend, particularly within administration and

management there are a number of areas where the availability of staff remains challenging, vacancy

rates remain high, and hence our ability to reduce agency spend has proved difficult. These are nursing,

operations management and IM&T. The Trust has a number of on-going actions to continue to seek to

drive a reduction in agency spend as outlined below.

Procurement

Procurement has helped the Trust to deliver significant cost savings over a number of years achieving

£2.9m in 2014/15 and forecasting savings of £2.8m in 2015/16. In order to tighten procurement controls

on capital works an Internal Audit report was commissioned which made a number of recommendations

in light of which the Trust has introduced an electronic tendering system. The Trust shares its data on

prices paid for non-pay items. Clinicians are engaged appropriately in trialling some items ahead of

making purchasing decisions.

A key development in the management of non-pay in 16/17 will be the implementation of an electronic

inventory management system which will see significant benefits through improved ordering and

stockholding. The Trust will also continue to engage positively with Lord Carter’s team to drive the

maximum benefits of broader sector wide benchmarking of usage and bulk pricing.

Capital

The Trust is in the middle of its capital planning for 2016/17 with the potential calls on the capital

programme far exceeding what is likely to be affordable. Whilst calls on the capital programme

currently total circa £40m, only £30m can be afforded with £17.5m being funded directly by the Trust,

£10.0m being funded by lease or new financial arrangements such as loan or managed services, and

£2.5m being funded by charity. The table below shows an indicative split of the capital programme at

this stage.

28

£m

Buildings- Statutory 3.92

Buildings- Maintenance 2.75

Buildings- Major Works 15.23

Medical Equipment-below £100k 4.30

Medical Equipment- over £100k 8.00

IM&T 6.18

Prioiritisation need to limit capex (10.38)

Total Trust Spend 30.00

Lease / other funding (10.00)

Charity / third party grants (2.50)

Total Trust Cash Funding 17.50

The above programme is based predominantly on those areas of spend that the Trust regards as

essential, such as buildings works, which is required to maintain the state of assets such as medical

equipment replacement and IM&R sustainability work, or which directly contributes to in year savings as

part of the Trust’s cost QIPP targets. Work continues on reviewing and prioritising capital spend, along

with sources of funding.

The Trust has an active programme of disposals with proceeds from disposals totalling £2.0m in 2015/16

and proceeds in future years expected to exceed £1.1m. The Trust is working with the local Health

Sector, Local Authorities and Lord Carter’s team on a strategic approach to estates management within

our area as a means of identifying further efficiencies where possible.

Financial Sustainability

The Trust recognises that, as submitted, this one year Operational Plan does not, of itself, address the

financial sustainability of the sector. This will need to be done through the Five Year Sustainability and

Transformation Plans as part of the Accountable Care System and/or the wider

Berkshire/Oxfordshire/Buckinghamshire footprint