FINAL DRAFT – 1st June 2006
South London and Maudsley NHS Trust Integrated Business Plan Chapter 1. Executive Summary (Final Draft – 1st June 2006)
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Executive Summary
The South London and Maudsley NHS Trust (SLaM) provides the most extensive portfolio of mental health services in the United Kingdom. The Trust was st created on 1 April 1999. Previously, mental health services across Croydon, Lambeth, Lewisham and Southwark had been provided by three different NHS Trusts. We now provide mental health and substance misuse services for people of all ages living in the London Boroughs of Croydon, Lambeth, Southwark and Lewisham and substance misuse services to the populations of Bexley, Bromley and Greenwich. We also provide specialist mental health services to adults and children from across the UK. We have close links in education and research with the Institute of Psychiatry and Guy‟s King‟s and St Thomas‟ Medical Schools, both of which are part of King‟s College London and we operate the largest mental health research and development provision in the country. Trust services are provided in partnership with non-NHS and NHS partners. Partnership arrangements have been formalised as Section 31 agreements, and operationalised through integrated management structures.
1.1.1
Mission, Vision and Strategy
The Core Value of our Trust is that, “everything we do is to improve the experience of people using our services and to promote mental health and well-being for all.” Improvement We will constantly look for ways of improving services in the interests of service users, carers and staff. We will try to see the service through the eyes of the service user and their carer We will acknowledge that the time of service users and carers is valuable We will extend service users‟ choice and sense of control We will train our workforce to deliver evidence based treatment and to act with courtesy and respect at all times. Learning We will foster innovation and positive outcomes through learning from experience, feedback, reflection, education and research to improve care We will promote sharing of best practice throughout the Trust and with our partner organisations We will collate information and experiences to encourage “expert patients.” We will listen to carers and learn from their knowledge and experience We will celebrate the achievements of our staff where they have improved practice through learning.
FINAL DRAFT – 1st June 2006
Team Work The team is everyone and everyone has an equal right to a voice and to be heard The team will flourish if everyone‟s contribution is valued We will work in partnership wherever possible Treatment is a joint activity between service users and professionals The team has much to learn from listening to carers The team will be robust enough to address and share difficult issues. Mutual Respect Mutual respect is the basis of our working relationships, and we expect to see this reflected in the behaviour of all our staff. We will value diversity and combat stigma and discrimination We will value, develop and support our staff We will not tolerance violence or abuse within our services. The Trust Vision is expressed as five Bold Ambitions. These are:
To offer the people we serve the best mental health services possible, tested against the best in the world. To go beyond the limits of health service to promote and improve mental well being in our local communities. To reduce illness and promote social inclusion – “to keep people in their lives” including supporting them when they choose to change their lives. To attain the highest standards in the management and professional leadership of mental health services. To implement, rapidly and systematically, improvements in care based on evidence of the best that is possible.
The Trust Strategy describes how we are going to achieve these Bold Ambitions. It sets out our plans to:
Effectively treat severe mental illness Work in partnership to promote mental well-being Support others by sharing our clinical knowledge and expertise. Rationale for FT status
1.1.2
The Trust believes that Foundation Trust status will enable it to achieve the Bold Ambitions. Specifically, it believes that Foundation Trust status will enable it to:
Make better decisions about the development of services to support the Bold Ambitions through the recruitment of staff, service users, carers and members of local communities as Members of the Trust.
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Use financial freedoms to achieve plans faster. Ensure that mental health has an “equal partner” position with others in the Local Health Economy. Ensure more coherent and interlinked business processes and more efficient use of our resources.
Part of the change of status to Foundation Trust status will be a move to embrace mutual values. As a mutual organisation, SLaM will need to shape its leadership, management and team development around the co-operative values of self-help, responsibility, democracy, equality, equity and solidarity. Cooperative members believe in the values of honesty, openness, social responsibility and caring for others. These values will help us create the necessary culture to sustain the essential creativity, innovation and entrepreneurial spirit to secure more choice, more personalised care, and real empowerment of people to improve their health. 1.1.3 Market Assessment
For local Borough Services two main population projections have been considered – that provided by the Office for National Statistics and that provided by the Greater London Assembly. There is a difference in projected population sizes over the long term (10 to 20 years), and a corresponding difference in demand projections. However, in the medium term (5 years) we believe that demand will remain steady, as reflected in our activity projections (Section 2.1.3). Our assessment of the market also includes an assessment of the overall statutory sector financial context. In general, this context is volatile and constrained. Across Child, Adult and Older Adult populations, our assessment takes into account joint working to implement agreed pathways of care – defining the Trust‟s role in partnership working. We believe that opportunities may exist for delivery of services to new markets within psychological therapies. For our Specialist services, our market assessment takes into account the potential impact of service reviews in Neuro-psychiatry, Mother and Baby and Eating Disorders services. It also takes into account services in which we continue to provide national and international services that are not replicated elsewhere. Our stated aim is to be the market leader for the services we provide. Competitors do exist to our services, but we believe that the clinical expertise we employ will be sufficient to maintain and develop our market position. However, we have identified the need to address estates and customer service issues to enable us to develop our current market share. We believe that we will gain business as a result of Patient Choice. Modelling work in one neighbouring NHS Trust confirms this assessment. Overall, we believe that we are well placed to continue to provide high quality services to our local population, and continue as the provider of choice for national specialist services.
FINAL DRAFT – 1st June 2006
1.1.4 Performance Review. – Historical Financial Performance. Financial Performance 2003/04 2004/05 2005/06
(£000) (£000) (£000)
Income Expenditure EBITDA Surplus/(Deficit) for the period Non-Financial Performance.
255,920 249,913 12,101 38
291,289 285,665 12,319 39
312,890 303,740 9,150 719
Having received a three star rating in 2003 and 2004, the Trust received a two-star rating in July 2005. The Trust achieved all five of the key national targets and also scored highly on the balanced scorecard areas of clinical focus and capacity and capability focus. However, the Trust received a marginally lower score on patient focus (based on the national Patient Survey results), which stopped it receiving three stars. As a result, the Trust has put in place an action plan to address the issues identified (appendix 12). This is monitored through Clinical Governance, Risk and Performance Management arrangements described in Section 9. The Trust‟s academic partner has consistently received the highest possible research rating. The Trust has currently declared “Insufficient Assurance” in one of the Core Standards of Standards for Better Health. This element is that: Healthcare service are provided in environments which promote effective care and optimise health outcomes by being well designed and well maintained with cleanliness levels in clinical and non-clinical areas that meet the national specification for clean NHS premises. The Trust has declared compliance with all other Core Standards. An action plan is in place that will enable the Trust to declare full compliance by 30 September 2006. Further details of this are included in Appendix 24
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1.1.5 SWOT analysis. Summary SWOT analysis. – full analysis included in Section 5 Key Strength Our staff and their expertise – world leaders in several fields. Involvement of Service Users and Carers in service development and delivery Consistently high level of performance High quality partnership working Service Innovation Service Quality High Quality management Our reputation Risk management infrastructure and arrangements. Research links with academic partner. Opportunity Track record of high quality innovation Involvement and Support Reputation Patient Choice Education and Training Key Weakness Complexity and Scale of the Trust. Integration of services with partners Business Processes Multiple Sites Maintenance Information infrastructure Outcome Monitoring Workforce Public perception of mental health services.
Threat Population Growth Statutory Sector financial context Recruitment and retention New Mental Health legislation
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1.1.6
Key risks and mitigation
Key risks to the Trust are identified in detail in Section 7.1.1 of this document. Areas of particular concern include: The financial context of the NHS. In the 2006/07 financial year, this has created a requirement for a 1% (£3.5 million) additional contribution to the NHS London financial position and significant disinvestment in services by Lambeth and Southwark PCTs (see sections 5 and 6). Information flows to support the new contracting regime – creating a risk that the Trust will not be able to ensure collection of income or timely reporting of problems. The condition of the Trust estate – potentially placing the Trust at a competitive disadvantage vis a vis competitors. Changes to Research and Development (R&D) funding – putting R&D funding received from the Department of Health at risk. All these risks have management plans attached to them, including an investment and improvement programme in IT (section 9.1.7), an estates programme (section 5.1.2.5), robust financial modelling (section 6), and an extensive bids programme against the revised NHS R&D programme (section 7.1.1).
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South London and Maudsley NHS Trust Integrated Business Plan Chapter 2. Profile of South London and Maudsley NHS Trust Final Draft (1st June 2006)
FINAL DRAFT – 1st June 2006
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Profile of South London and Maudsley NHS Trust Overview
The South London and Maudsley NHS Trust provides the most extensive portfolio of mental health services in the United Kingdom. We provide mental health and substance misuse services for people of all ages living in the London Boroughs of Croydon, Lambeth, Lewisham and Southwark and substance misuse services to the populations of Bexley, Bromley and Greenwich. We also provide specialist mental health services to adults and children from across the UK. We have close links in education and research with the Institute of Psychiatry and Guy‟s King‟s and St Thomas‟ Medical Schools, both of which are part of King‟s College London. Trust services are provided in partnership with non-NHS and NHS partners. In two boroughs (Lambeth and Lewisham), partnership arrangements have been formalised as Section 31 agreements. Elsewhere, they are operationalised through integrated management structures. Key facts include: Income 2006/07: some £327 million, including £26 million for Research and Development and £11.4 million as a provider of Education and Training. Staff. Approximately 4,500 (section 8) Sites: Over 140 (appendix D). This includes three dedicated psychiatric hospitals: Bethlem Royal, Lambeth and Maudsley. We also provide in-patient services at Guy‟s Hospital, University Hospital Lewisham and St Thomas‟ Hospital, as well as a medium secure unit at Cane Hill. Local Population: Approximately (ONS) 1,105,200 across four London Boroughs. Number of hospital beds: 1234 Number of people treated in hospital each year: Approximately 5000 Number of people registered on our Care Programme Approach register in 2005/06: 24,337
Commissioners Lambeth PCT Southwark PCT Lewisham PCT Croydon PCT Bexley, Bromley and Greenwich PCTs DH (R&D) SHA (Workforce) Local Authority
Contract type Block Block Block Block Block Block Block Block
2006/07 income (£m -rounded) 79.6 55.3 59.4 34.3 8.2 26.1 11.5 5.2
% of total (numbers rounded up) 24% 17% 18% 11% 3% 8% 4% 2%
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Charitable Other PCTs Other PCTs Other – NHS Other – Non NHS
Block 3 year average Volume Block Various
3.4 8.6 9.9 5.3 19.6
1% 3% 3% 2% 6%
FINAL DRAFT – 1st June 2006
2.1.2
Range of Services provided.
The Trust provides a full range of services, organised into the following streams: Croydon Adult Mental Health Services Lambeth Adult Mental Health Services Lewisham Adult Mental Health Services Southwark Adult Mental Health Services Child and Adolescent Mental Health Service in Croydon Lambeth Southwark and Lewisham National, Specialist Child and Adolescent Mental Health Services National Specialist Services Addictions Services Learning Disabilities Services Older Adults Services
All the services provided by the Trust fall into one of the following categories: Assessment Services: Walk-In Assessment Planned Assessment Acute Assessment Placement Review Mental Health Liaison Engagement Services: Early Intervention Assertive Outreach Treatment Services: Home Treatment Therapeutic Intervention Forensic Therapeutic Intervention Case Management Forensic Case Management Psychological Therapies Community Treatment Psychiatric Out-patient Treatment Psychological Therapies Out-patient Treatment Forensic Intensive Psychological Treatment Service
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Acute Treatment Psychiatric Intensive Care Medium Secure Community In-patient Treatment Day Hospital Clinical Support Crisis Helpline Carer Support Advocacy Speech and Language Therapy Physiotherapy Rehabilitation Services: Community Rehabilitation Community In-patient Rehabilitation Residential Rehabilitation – 24 hour staffed Supported Accommodation Low Secure Respite Care Day Support Challenging Behaviour Service A brief definition of these service types is set out in Appendix 16. The balance between different types of service and the precise configuration of teams used to provide services varies from borough to borough to provide a locally sensitive service. The services offered in each directorate, and the teams responsible for delivering them, are detailed in Appendix A, classified according the Care Group methodology.
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2.1.3
Predicted Activity levels
The table below summarises expected activity levels related to historic activity trends in key Trust services. These activity lines are split by PCT and borough in Appendix B. There are a number of predicted changes to activity levels. The impact of PCT disinvestment is not reflected in these tables (see section 5.2). Further detail of the activity plan the Trust is developing with PCT partners for contracting purposes, (showing the relationship between activity and capacity for the Trust as a whole) is given in Appendix C. These relate to the capacity assumptions detailed in Appendix 15.
a) Local Borough Services Service Area AMH Acute Wards Currency Admissions 2004/05 3,663 2005/06 3,390 2006/07 3,429 2007/08 3,464 2008/09 3,498 2009/10 3,533 2010/11 3,569 Notes Assumes admission rates remain steady and PCTs require a 1% non cash releasing CIP year on year Drop for 2006/07 is because leave days not being included. Assumes occupancy maintained at 95%. Assumes that activity targets maintained and that delayed discharges minimised. Assumes consistent achievement of this target. Assumes that activity assumptions achieved (cf Appendix 15). Assumes occupancy of 85% achieved. Assumes non cash releasing CIP will be required Assumes 85% occupancy achieved. Reduction in occupied bed days assumes that length of stay targets achieved (creates capacity for higher utilisation). Change from 2004/05 to 2005/06 due to service change in Lambeth directorate. Assumes LDP targets achieved. (LDP target is 631). Assumes that non cash
AMH Acute Wards
Occupied Bed Days
158,452
139,257
106,501
104,879
97,318
101,764
99,919
AMH Acute Wards AMH Acute Wards AMH Intensive Care wards
Trimmed AvLoS 28 Day readmission rate Admissions
27.5 7.2% 136
29.8 5% 169
31.35 5% 236
30.4 5% 239
28.3 5% 242
28.8 5% 244
28 5% 246
AMH Intensive Care wards
Occupied Bed Days
14,766
14,649
13,200
11,228
9,636
7,960
5,993
AMH Assertive Outreach
People treated (year end)
680
636
639
657
664
671
677
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AMH Early Intervention
People treated (year end)
418
444
616
622
628
634
641
AMH Crisis Resolution/ Home Treatment AMH CMHT
People treated at home
2,707
3,036
2,987
3,016
3,047
3,077
3,108
releasing CIP will be required. Assumes drop in numbers in 2006/07 due to Lambeth Service Review. Assumes LDP targets achieved with service development in 2006/07 year. Assumes 1% non cash releasing efficiency required. Assumes 1% non cash releasing CIP required. Assumes referral trends remain steady but that appropriateness is improved. Assumes that assessments offered are subject to non cash releasing 1% CIP year on year Assumes rates remain steady Drop in 06/07 due to service review implementation in Croydon. Downward trend due to improved referral back to primary care. Jump in first two years relates to increased number of beds. Reduction in year 3 related to transitional effect of new beds opening. Future years assuming 1% non cash releasing efficiency required. Assumes that no CAMHS grant allocated to CAMHS. Assumption of 1% non cash releasing CIP year on year. Assumes that no CAMHS grant allocated to CAMHS. Assumption of 1% non cash releasing CIP year on year. Assumes that no CAMHS grant allocated to CAMHS. Assumption of 1% non cash
Referrals received (assessments completed)
11,314
11,382
11,367
11,481
11,595
11,711
11,829
AMH CPA levels
Number on enhanced CPA Number on standard CPA
5,598 14,110
5,515 12,417
5,557 11,297
5,536 10,909
5,546 10,535
5,541 10,175
5,544 9,828
CAMHS Acute Inpatient
Number of admissions
125
161
155
156
158
160
161
CAMHS CMHT
Caseload
4,166
4,286
4,329
4,372
4,416
4,460
4,505
CAMHS outpatients CAMHS outpatients
New appointments
7,709
7,465
7,540
7,615
7,691
7,768
7,846
Follow-up appointments
49,201
54,910
55,459
56,014
56,574
57,140
57,711
FINAL DRAFT – 1st June 2006
releasing CIP year on year, MHOA Acute admission MHOA Acute admission Admissions Occupied Bed Days 555 42,617 571 46,363 572 43,181 577 40,749 583 68,056 589 36,133 595 33,751 Assumes 1% non cash releasing efficiency required. This is with occupancy at 95%. Assumes 1% non cash releasing efficiency required. Assumes that capacity targets (appendix 15) are achieved. Assumes referral rates remain steady Assumes referral rates and model of service remain steady. Assumes 1% non cash releasing CIP required. Assumes 3 year rolling average Reduction in placement numbers relates to growth in number of Trust beds (Section 5) Assumes 1% non cash releasing efficiency. Changes are impact of new forensic units opening (see section 5)
MHOA CMHT MHOA CMHT
Referrals Caseload
2,776 2,819
2,291 2,875
2,314 2,984
2,337 3,014
2,360 3,044
2,384 3,075
2,408 3,105
Weston Unit Medium Secure Care Medium Secure Care
Occupied Bed Days Private Sector placements
2,077 79
2,015 67
2,082 40
2,058 14
2,052 10
2,064 10
2,058 10
Admissions
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b) National Specialist Services (3 year rolling average contracts and cost per case) In-Patient Services:
Service Area Addictions Affective Disorders Anxiety Disorders Behavioural Disorders Unit Crisis Recovery
Currency Occupied Bed Days Occupied Bed Days Occupied Bed Days Occupied Bed Days Occupied Bed Days
2004/5 14,394 5,002 3,197 5,361 1,972
2005/6 14,921 5,404 3,089 6,150 2,025
2006/7 14,750 5,948 3,385 5,496 1,964
2007/8 14,688 5,451 3,224 5,669 1,964
2008/9 14,786 5,601 3,233 5,772 1,985
2009/10 14,742 5,667 3,281 5,646 1,971
2010/11 14,739 5,573 3,246 5,695 1,973
Notes Assumes 3 year rolling average Assumes 3 year rolling average Assumes 3 year rolling average Assumes 3 year rolling average Assumes 3 year rolling average
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Unit Eating Disorders Unit MIETS Mother and Baby Unit Neuro-Psychiatry (Lishmann Unit) National Psychosis Unit
Occupied Bed Days Occupied Bed Days Occupied Bed Days Occupied Bed Days Occupied Bed Days
6,359 5,214 3,340 4,689 8,062
7,790 5,069 3,056 5,285 8,530
7,272 4,927 3,282 5,486 9,414
7,140 5,070 3,226 5,153 8,667
7,401 5,022 3,188 5,308 8,871
7,271 5,006 3,232 5,316 8,984
7,271 5,033 3,215 5,259 8,841
Assumes 3 year rolling average Assumes 3 year rolling average Assumes 3 year rolling average Assumes 3 year rolling average Assumes 3 year rolling average
Out-patient Services: Service Cawley Centre Couple/ Sexual therapy Eating Disorders Mother and Baby Neuro-Psychiatry Psychosis Psychotherapy Affective Disorders Brain Injuries CADAT Currency OP appointments Referrals OP appointments Referrals OP appointments Referrals OP appointments Referrals OP appointments Referrals OP appointments Referrals OP appointments Referrals OP appointments Referrals OP appointments Referrals OP appointments Referrals 2004/05 263 23 808 198 4,227 436 311 304 1,555 718 938 263 3,350 682 937 346 593 69 2,688 428 2005/06 271 23 1,144 176 4,142 417 181 199 1,484 509 1,108 155 6,513 433 971 210 872 93 2,993 466 2006/07 258 26 976 187 4,268 419 246 251 1,557 610 984 221 4,931 557 926 280 767 144 2,940 435 2007/08 264 24 976 187 4,212 424 246 251 1,532 613 1,010 213 4,931 557 945 278 744 102 2,874 443 2008/09 264 25 1,032 183 4,207 420 224 234 1,524 577 1,034 196 5,459 516 947 256 794 113 2,935 448 2009/10 262 25 995 186 4,229 421 239 246 1,538 600 1,009 210 5,107 544 939 271 768 119 2,916 442 2010/11 263 25 1,001 185 4,216 422 236 244 1,531 596 1,018 207 5,166 539 943 268 769 111 2,908 445 Notes Assumes 3 year rolling average Assumes 3 year rolling average Assumes 3 year rolling average Assumes 3 year rolling average Assumes 3 year rolling average Assumes 3 year rolling average Assumes 3 year rolling average Assumes 3 year rolling average Assumes 3 year rolling average Assumes 3 year rolling average Assumes 3 year rolling average Assumes 3 year rolling average Assumes 3 year rolling average Assumes 3 year rolling average Assumes 3 year rolling average Assumes 3 year rolling average Assumes 3 year rolling average Assumes 3 year rolling average Assumes 3 year rolling average Assumes 3 year rolling average
FINAL DRAFT – 1st June 2006
Chronic Fatigue
OP appointments Referrals
2,006 491
2,100 256
1,982 392
2,029 380
2,037 343
2,016 372
2,027 365
Assumes 3 year rolling average Assumes 3 year rolling average
Daycare services Service Cawley Centre Eating Disorders Currency Attendances Referrals Attendances Referrals 2004/05 4,371 100 1,086 32 2005/06 3,606 40 969 24 2006/07 4,349 81 1,027 30 2007/08 4,108 74 1,027 29 2008/09 4,021 65 1,008 28 2009/10 4,159 73 1,021 29 2010/11 4,096 71 1,018 28 Notes Assumes 3 year rolling average Assumes 3 year rolling average Assumes 3 year rolling average Assumes 3 year rolling average
Addictions Community Services Service Community Teams Currency Contacts 2004/05 104,669 2005/06 102,010 2006/07 103,030 2007/08 104,060 2008/09 105,101 2009/10 106,152 2010/11 107,214 Notes Assumes 1% non cash releasing CRES. Borough detail set out in Appendix B. Assumes 1% non cash releasing CRES. Borough detail set out in Appendix B.
Community Team
Referrals
4181
3785
3823
3861
3900
3939
3978
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2.1.4
Protected Assets
The majority of services provided by the Trust are based in community premises. A key element of providing such services is that they should be flexibly arranged and are not, by necessity, tied to any particular building. The Trust wishes to retain maximum flexibility in how and where to provide such services, and does not consider that any of its community properties should be designated as Protected Assets. In respect of hospital sites, the Trust considers that the following assets should be Protected Assets as a Foundation Trust:
The Bethlem Royal Hospital site The Maudsley Hospital site The Lambeth Hospital site
The St Thomas‟Hospital, Guy‟s Hospital and Lewisham Hospital sites are not owned by the Trust. The Cane Hill site (used only by the Trust) would not be protected under this proposal. This is because the Trust is moving in-patient services off the site, following the re-provision of medium secure beds at Lambeth Hospital (section 5.1.2). The Trust intends to dispose of this site over the course of this IBP. Details of the sites and properties utilised by the Trust are set out in Appendix D. 2.1.5 Financial Summary
2006/07 Financial Year (plan) Income Expenditure EBITDA EBITDA margin Surplus/Deficit for the period Reference Cost Index (RCI) after Market Forces Factor Asset base
£327.7m £327.4m £15.7m 4.8% £0.3m 113 (based on 2004/05 costs – the latest submission) £322m
The Trust believes that it will achieve the plan for the 2006/07 financial year, and is committed to supporting the London Health Economy through achievement of a 1% surplus and delivery of service reductions in line with PCT decisions around disinvestment. The Trust has successfully achieved financial targets, and is projected to continue to do so. Some significant risks remain (detailed in Section 7), and the RCI of 113 will require action to reduce it. We have taken account of this requirement in financial modelling (section 6).
FINAL DRAFT – 1st June 2006
2.1.6
Performance. Historical performance against key healthcare targets.
The table below gives an overview of Trust performance against national Healthcare Commission Performance Ratings targets:
Key Targets
2002/03 Achieved 7 out of 7 targets.
Clinical Focus
Achieved 5 out of 5 targets
2003/04 Achieved 6 out of 7 targets. Underachieved (score of 2.8 against threshold of 3) on hospital cleanliness. Achieved 7 out of 7 targets
2004/05 Achieved 5 out of 5 targets
Patient Focus
Achieved 5 out of 6 targets. Underachieved against patient complaints (42% resolved within 20 working days against national average of 59%).
Achieved 11 out of 12 targets. Underachieved against service user survey (57 against national figure of 63).
Capacity and Capability focus
Overall Star Rating
Achieved 10 of 12 targets. Underachieved against data quality (0.79 against national median of 0.9) and fire health and safety (36 against a median of 5) Three Star
Achieved 10 out of 12 targets (data not available for CAMHS expansion, and in Band 1 (poor) for physical environment. Three Star
Achieved 6 out of 7 targets. Underachieved on 12 week retention rate in substance misuse services (55% against national median of 61%). Trust remained in top band of performance in this focus area. Trust was banded in band 3 (range 1 (poor) –5 (good)) in 7 of 8 categories and in band 4 in the remaining category. The trust was placed in the lowest band of performance in this focus area. This rating related particularly to the Trust‟s Patient Survey results. The trust achieved 7 out of 8 targets with data not available for the other target.
Two Star
These Performance Ratings have been replaced with a revised Performance Management framework. The Trust‟s analysis of its performance against these standards is detailed in Section 4.1.7. Messages from the 2004/05 Performance Ratings have been taken on board, and an action plan developed to address areas of relatively weak performance. Details of this action plan are included as Appendix Twelve.
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2.1.7
Summary of contractual relationships.
The Trust has a strong working relationship with purchasers (both NHS and Local Authority). The Trust‟s strategic direction has been agreed with purchasers, and service development in each of the PCT areas is progressed through joint working in Partnership Boards (Sec 4.1.4). The major contracts (many of which are currently NHS SLAs) between the Trust and purchasers of Trust services are as detailed above (section 2.1.1). Contracts are negotiated on an individual PCT basis. Throughout the 2006/07 negotiation process, the Trust has been working with PCTs on the development of the model contract for local use. Part of this process has been a commitment to working with these PCTs to establish an activity base to these agreements. The Trust has agreed with PCT partners that activity based contracts will begin in October 2006. This work in ongoing – details of the timetable are attached as Appendix 17 The assumptions being developed are as detailed in Appendix 15 Details of the Trust‟s assessment of its use of capacity to meet the projected demand are set out in Appendix C. As part of this process, the Trust has also set out a number of principles with Lambeth and Southwark PCTs, in the context of their disinvestment decisions. The Trust believes that these will form the basis of a mature partnership arrangement with purchasers for managing such situations in the future, and will be seeking to include these principles in contract documentation. These principles are detailed in Appendix 18. Heads of Agreement for the 2006/07 financial year have been signed with Croydon, Lambeth, Lewisham and Southwark PCTs. These SLAs are rolling st agreements, with at least six month notice terms. PCTs have agreed with the Trust to use model contract documentation from 1 October 2006. Of other st NHS SLAs, 88% are agreed in principle or signed (as at 1 June - see appendix H). 2.1.8 Procurement Arrangements.
Procurement arrangement are organised through the South East London Shared Services Partnership. As part of the Trust‟s application for Foundation Trust status, procurement arrangements are being reviewed to ensure that they are fit for purpose. This process has identified scope for procurement efficiencies in respect of drugs and e-procurement. These are reflected in the CRES analysis (appendix 5). The process has also confirmed the scope for further efficiencies with respect to provision for medium secure placements. These are reflected in the service developments detailed in Section 5.1.2.1 and 5.1.2.2. Further work has been identified on the overall Trust Procurement Strategy. This work is in relation particularly to how procurement arrangements facilitate an entrepreneurial and flexible approach to service delivery. The need to take forward further work is reflected in the Board Statements of Intent (section 3.1.2).
FINAL DRAFT – 1st June 2006
2.1.9
Joint Venture Information.
The Trust has two Section 31 agreements in place with Local Authority partners in Lambeth and Lewisham. At present, the Lambeth Section 31 agreement establishes the Trust as the lead provider of mental health care for adults of working age. Local Authority and PCT resources are pooled by this agreement, although in practice individual commissioning funds have remained with the respective organisations. The annual audit letter (September 2005) identified that real pooling of budgets and partnership working had not yet been implemented. At present, the Lewisham Section 31 agreement establishes a pooled budget arrangement with local authority resources transferred into a commissioning pool, and Joint Commissioning arrangements. This year there have been pressures on this pooled budget that have helped to bring into focus weaknesses in the governance arrangements for managing such situations. As part of the 2006/07 SLA negotiations, the Trust has raised the need to review these arrangements. PCTs have accepted the need to do so. The Trust has proposed that any Section 31 agreements should be between Local Authority and PCT partners. The Trust has also proposed that these partners should jointly contract with the Trust via Joint Commissioning arrangements. PCTs have accepted this in principle, and have progressed work on Activity Based Contracts on this basis. As part of the negotiations, it has been agreed that Section 31 arrangements will be reviewed by October 2006.
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South London and Maudsley NHS Trust Integrated Business Plan Chapter 3. Strategy (Final Draft – 1st June 2006)
FINAL DRAFT – 1st June 2006
3. 3.1.1
Strategy Trust Vision and Mission Statement
The Core Value of our Trust states that, “everything we do is to improve the experience of people using our services and to promote mental health and well-being for all.” Improvement We will constantly look for ways of improving services in the interests of service users, carers and staff. We will try to see the service through the eyes of the service user and their carer We will acknowledge that the time of service users and carers is valuable We will extend service users‟ choice and sense of control We will train our workforce to deliver evidence based treatment and to act with courtesy and respect at all times. Learning We will foster innovation and positive outcomes through learning from experience, feedback, reflection, education and research to improve care We will promote sharing of best practice throughout the Trust and with our partner organisations We will collate information and experiences to encourage “expert patients.” We will listen to carers and learn from their knowledge and experience We will celebrate the achievements of our staff where they have improved practice through learning. Team Work The team is everyone and everyone has an equal right to a voice and to be heard The team will flourish if everyone‟s contribution is valued We will work in partnership wherever possible Treatment is a joint activity between service users and professionals The team has much to learn from listening to carers The team will be robust enough to address and share difficult issues. Mutual Respect Mutual respect is the basis of our working relationships, and we expect to see this reflected in the behaviour of all our staff. We will value diversity and combat stigma and discrimination We will value, develop and support our staff We will not tolerance violence or abuse within our services.
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The Trust Vision is expressed as five Bold Ambitions. These are:
To offer the people we serve the best mental health services possible, tested against the best in the world. To go beyond the limits of health service to promote and improve mental well being in our local communities. To reduce illness and promote social inclusion – “to keep people in their lives” including supporting them when they choose to change their lives. To attain the highest standards in the management and professional leadership of mental health services. To implement, rapidly and systematically, improvements in care based on evidence of the best that is possible.
3.1.2
Strategy
The Trust has a clear strategy to enable it to achieve its five Bold Ambitions. This Strategy has been agreed following public consultation between September and December 2005. The Strategy has been agreed by our key stakeholders (including voluntary sector and service users stakeholders through local Partnership Boards) and is in line with the overall strategy of the Local Health Economy (see Section 4.1.4). Further detail of the consultation process and the support received is attached in Appendix 14. This Strategy sets out the Trust‟s plan to ensure that we are:
Effectively treating serious mental illness Working in partnership to promote mental well-being Supporting others by sharing our clinical knowledge and expertise.
Effectively treating serious mental illness means ensuring that all service users have access to the right treatment to achieve the best possible clinical outcome for them. It means: Reliably providing treatment that helps people get well and stay well: clarity about what treatment options are provided where; targeting expertise to the treatment of those with the most complex needs; supporting and supervising the delivery of programmes of care within multi-disciplinary teams. Getting the fundamentals right. This includes ensuring that hospital and community services work as efficiently as possible to prevent people reaching “crisis point” wherever possible, and to promote recovery. At the same time, we need to make sure that people have rapid access to effective crisis services when and where they need it. We also need to ensure that the environments in which we provide care are clear and in good repair and that we recruit and train people with the personal qualities to deliver an empathic, sensitive, mental health service. A focus on recovery, which helps everyone who uses our services to maximise their potential. This includes: helping people access employment and education opportunities; not providing services that encourage institutionalisation within the community; regularly reviewing packages of care to ensure that they are not creating dependence. We need to work with service users and their carers and social networks to support people “in their lives.”
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Building on our track record of delivering nationally and internationally innovative specialist treatments. Using our knowledge and expertise, we need to develop new and innovative services that challenge the traditional ways of providing care. We also need to encourage innovation in other areas of service delivery, such as social care and housing provision. Continuing to train, recruit and retain expert mental health practitioners in all professions and disciplines. This includes developing new roles that diversify and strengthen the workforce. We also need to bolster expertise in areas where the Trust does not have such a strong track record. Creating a working environment where staff are able to do their job to the best of their ability without having to face any form of discrimination or harassment. Equally, it is about providing a healthcare service that recognises, respects and responds to the diversity of the local communities we serve. Broadening the multi-disciplinary team, to include a wider range of colleagues from other agencies and sectors. We need to develop expertise or ask for help from experts elsewhere in areas where we currently struggle (such as access to housing). Fitting our services to people, not people to services, ensuring that people moving between services are not hindered by arguments about inter-agency responsibilities that have no real bearing on their care. Involvement in research that helps us identify what works best and why.
Working in partnership to promote mental well-being for all means promoting good mental health in the local population as a whole. It means developing our role in areas such as: Supporting universal services (such as primary care, the voluntary sector, education and housing), not least through the provision of our knowledge and expertise. Providing supervision, support and advice to other agencies to help intervene to prevent situations worsening. Providing training and information to support other agencies in working with people with mental health problems. Providing expertise and services that help other agencies achieve their objectives, working with organisations such as the Benefits Agency, Local Authorities and the Police. Support the development of ever more effective user and carer networks. Promoting better public awareness and understanding of mental health issues. Challenging stigma and discrimination faced by people with mental health problems. Promoting good physical health for people with mental health problems. Working with employers to provide opportunities for service users. Providing infrastructure support to social enterprises that release the entrepreneurial spirit of service users. Taking a proactive role in community development; marketing our infrastructure expertise to support local business and community organisations,
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including providing advice and support to regeneration and community development initiatives. We also need to maximise the use of the training infrastructure provided by the Trust. Working with business to improve the mental well-being of employees in the workplace.
Sharing our knowledge and expertise means: Expanding our consultancy work based on our areas of clinical and organisational expertise. Sharing knowledge through making best use of technology. Providing supervision and advice through better use of tele-psychiatry. Maximising our role as an education provider. Continuing to provide a wide range of education and training, and diversifying into new areas of work; developing new partnerships with further education providers that make best use of our training infrastructure.
The implementation of this strategy is being supported by a focus on five themed areas of work. This five-point framework is as follows: 1. The future of in-patient care. This includes consideration of the impact of all new mental health legislation and guidance on the operation and physical environment of wards, the interaction between staff and service users, and the full potential for alternatives to admission. 2. The future of long-term arrangements for health and social care. We want to think about how we can maximise independence and not create dependency, particularly in the use of residential placements. 3. The reliable, systematic delivery of packages of treatment and care. This includes providing a clear statement to service users about what they can expect, in the context of greater choice, and defining the most effective way of delivering this care. 4. The relationship with primary care. We need to consider the impact of GPs taking on primary care based commissioning, and the possibility that they will want to develop shared arrangements for providing their own mental health services (or possibly opting not to provide them.) 5. Promoting mental well-being in communities. In particular, we need to consider how we can avoid the real danger of “mental well-being” becoming a slogan that isn‟t supported by material action. There is real potential for partnerships with new agencies and working for new customers outside the conventional world of health, as well as extending existing arrangements in this area. How would what we do look different if we were really to develop the potential for this? What new services would we provide; who would pay for them and what would we no longer do? Responses to the consultation about our long-term strategy highlighted the need to outline clear objectives. As a result, we have developed the following Statements of Intent. These are the key areas where we believe we can make real progress through the greater freedom and flexibility that would be available to us as an NHS Foundation Trust.
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As an NHS Foundation Trust, working with our partners and with the resources available to us, we will: Consistently provide services users and carers with access to the most effective services. We will also provide clear explanations of what treatment involves and what choices are available to them. This will involve developing an improved and shared understanding with service users and carers about what constitutes effective treatment and care. Explore way to ensure that the diversity of the communities we serve is increasingly reflected within the workforce at all levels across the Trust. We will also ensure that our services are fitted to the needs of individuals from all backgrounds. Generate additional income through mental health promotion work such as training. This income will be reinvested to help us establish a more active community presence, in areas such as schools, to promote mental well-being. Extend the provision of psychological therapies and invest in the development of psychological therapy centres for the wider population. Seek peoples‟ views, through our membership and wider consultation, and listen to what they tell us. We will value the full range of opinions from everyone who has an interest in the services we provide. Where we can adjust services in response to feedback, we will. Where we cannot, or where we do not believe it is appropriate to do so, we will explain why. Continue to find ways of providing people with care as close to home as possible. Foster a collaborative working culture that enables staff to maximise their creativity and expertise. Turn the results of local, national and international research into improved services. Improve the quality of environment within all the facilities from which we provide clinical services. This many mean providing services from fewer sites in order to make most effective use of the resources available to us. Become a „greener‟ organisation across the full range of issues that affect the environment, such as energy, transport, waste management, and the sourcing and provision of goods and services. One example where we are beginning to put this into practice is by commissioning a local Black and Minority Ethnic social enterprise firm to provide African Caribbean meals for some of our inpatient services. This enables us to source local products and improve the choice and quality of food, and to reinvest money in the local community.
These Statements of Intent have been included in the formal consultation process on our Foundation Trust application.
3.1.2
Rationale for FT status
The Trust is applying for Foundation Trust status because it believes that this will enable it to:
Make better decisions about the development of services to support the Bold Ambitions through the recruitment of staff, service users, carers and members of local communities as Members of the Trust.
The Trust believes that involving the public, service users and staff as members will give greater ownership to strategic development. For example, issues such as the development of new services for forensic clients, reviewing crisis services and the development of new services within limited financial resources
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will be enhanced by engagement and involvement with membership. Further detail on how the Trust will effectively engage and involve membership is given in Section 9.
Use financial freedoms to achieve plans faster.
This Integrated Business Plan includes the details of the Trust Strategy and Service Development Plans. These will be progressed using Trust financial resources that will be available to the Trust under the Foundation Trust regime.
Ensure that mental health has an “equal partner” position with others in the Local Health Economy.
The Trust believes that the move to Foundation Trust status will give mental health equal status with physical healthcare in the Local Health Economy. This is particularly the case in the context of an overall financial environment in which there are particular financial pressures within the physical healthcare sector (section 4.1.1) that are impacting on the mental health economy.
Ensure more coherent and interlinked business processes and more efficient use of our resources.
The requirements of the reporting and business management processes set out in the model contract will require the Trust to improve its business processes and efficiency (as set out in the Trust SWOT analysis – Section 5.1). The Trust sees the Membership and Corporate Governance Structures as well as the financial freedoms of Foundation Trust status as being central to how we implement our Strategy. Turning the goals in the Strategy into reality will require engagement with a range of stakeholders and local communities. Similarly, the detail of developing areas such as mental well-being will need input from all our constituencies of members.
3.1.3
Summary of outcome of consultation process.
th th
The Trust consulted on its application for Foundation Trust status between 20 February and 15 May 2006. The Trust Consultation Paper was discussed at nearly 200 meetings with staff and partner agencies during this period. In total, 41 written responses were received, with additional feedback from the th Partnership Tim Event held on 14 March (attended by over 100 service users, carer, staff and members of the public). Broad themes emerging from the consultation responses were: Support: A general endorsement of the Trust‟s application and direction of travel Clarity: More detail needed on the rationale for Foundation Trust status, and direct benefits to clinical services. Governance: How will the new arrangements work in practice? How will they complement existing, borough based, partnerships.
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Membership: Service users and carers need an equal voice (but not necessarily in the same constituency). Statements of Intent: More clarity and explanation required. They need to be measurable.
The Trust has considered these issues (as detailed in more specific points) and its response is as set out in the following table: Issue 1. Why isn‟t Mayday represented on the Members‟ Council? Trust’s response 1. In order to keep the Members‟ Council at a manageable number two acute hospitals have been nominated as appointed representatives on the Members‟ Council. GSTT was selected because SLaM has wards and other services based on their estate, KCH was selected because of the links with SLaM on the Denmark Hill campus and the Institute of Psychiatry. It is intended that these Trusts will represent the views of all the acute hospitals that the Trust works with. The Trust intends to maintain its partnership with Mayday and would like to engage in a dialogue to ensure that the interests of Mayday are represented. 2. The Trust is working on clarifying this arrangement see (section 9). Part of the difficulty, as observed with current FTs, is that these arrangements need to reflect local need and it is difficult to finalise what these arrangements will look like until the Members‟ Council has settled into its new role.
2.The Trust needs to clarify the relationship between Members‟ Council and Board
3.Ensure greater local representation of elected Council Members
3. There will be a PCT and a Local Authority representative for each borough. The Trust plans to facilitate communications between all Council Members and their constituencies. The Trust also intends to ensure that the Public constituencies and the Service Users and Carers constituency are representative of the communities that they are drawn from. This together with the single transferable voting system should ensure that elected Council Members are representative of the communities that the Trust serves. The Members‟ Council is not intended to replace local partnerships and forums, which will continue to work and to evolve.
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4.How to ensure professional groups are represented on Council?
4. As for the service user and carer constituency the Trust aims to ensure that the staff constituency reflects the different professional groupings in the Trust as well as the different geographical locations and specialisms of staff in the Trust. Elections by single transferable vote should ensure that each of these areas should be represented on the Members‟ Council. Furthermore staff representatives will be asked to represent the staff membership as a whole and the Trust will facilitate the means for doing this. It is important to note that the Members Council will not replace discussions with staff-side groups at all levels and professional heads will continue to have a role on the Trust Executive. 5. The Trust has had to balance having comprehensive representation from the voluntary sector with maintaining a manageable size of the Members‟ Council. The Trust intends to continue with local partnerships and use these to feed in to the Members‟ Council where appropriate through both appointed and elected representatives.
5.Charity representation on Council: include more than one rep and more local representation?
6.Establish a federal structure „underneath‟ main Council?
6. To a large extent the Trust already has this structure in place. This reflects the organisational structure of the Trust with separate management for Croydon, Lambeth, Lewisham and Southwark. The Trust intends to facilitate communications between the Members‟ Council and these structures, including local partnership boards and forums, to ensure that local communities‟ views are represented. 7. The Trust sees the governance arrangements as building on local borough based partnerships. See point 6 above. 8. Whilst the Trust appreciates that this could ensure continuity for the Members‟ Council it is uncertain whether the legislation allows this. The Trust will seek further advice on this point. However, it is worth noting that all formal meetings of the Members‟ Council are held in public and substitutes of appointed members may attend as observers. 9. The Trust sees value in keeping the PPI Forum independent as reflected
7.The Trust needs to ensure that FT governance arrangements do not undermine existing local, borough based partnerships. 8.Allow substitutes for appointed Council Members?
9.Appoint a Public and Patient Involvement forum member to the Council?
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in the PPI regulations. However we also acknowledge that it is important that the PPI forum have an opportunity to work with the Members‟ Council in areas of mutual concern. The Trust aims to facilitate this joint working as well as continuing to develop its relationship with the PPI Forum at all levels. 10.Create membership constituencies for Bexley, Greenwich and Bromley? 10. The Trust has had to balance ensuring representation of local communities with not having an overly complex membership structure. It was particularly with these boroughs in mind that the Trust has proposed having a Rest of England and Wales public constituency. It is envisaged that this constituency will predominantly include members from Bexley, Bromley and Greenwich. Furthermore service users and carers from these boroughs will be eligible to join the service users and carers constituency. The Trust has also needed to take into account that Oxleas NHS Foundation Trust that provides mental health services in these boroughs is also seeking membership from the public in these areas. 11. The Trust is keen to ensure that its membership and the Members‟ Council are representative of the communities and constituencies that we serve. The Trust intends to do this by working closely with partner organisations that have links to underrepresented groups to recruit members and encourage engagement. Furthermore the Trust will monitor membership recruitment by ethnicity, gender, age and postal address to highlight areas of the membership requiring action. The Trust also intends to work with the membership constituencies to identify a representative sample of nominees for the Members‟ Council. 12. As for the other constituencies the Trust is working to ensure that service users and carers are proportionally represented in the service users and carers constituency. For example the Trust has recently provided funding on a temporary basis for a number of service users and carers to recruit others to this constituency. In addition – and as a direct result of consultation feedback – we have revised our governance arrangements to create a separate carers membership constituency. Three dedicated places for carer representatives will now be allocated to the Members‟ Council, alongside nine allocated service user places.
11.How to ensure Black and Minority Ethnic representation within membership and on Council?
12. Risk of including carers within the service user membership constituency: they do not necessarily share the same views, may lead to unequal representation on the Council.
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The Trust will also work to communicate the perceived benefits of Foundation Trust status (3.1.2), and to develop the Statements of Intent in order to address the responses received. Further detail relating to the consultation process is set out in Appendix 26.
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South London and Maudsley NHS Trust Integrated Business Plan Chapter 4. Market Assessment (Final Draft – 1st June 2006)
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4.
Market Assessment
In this section, we assess the environment within which the Trust operates, our relative strength in the marketplace, and anticipate the impact of a number of potential changes. This includes consideration of: Local Health Economy goals Major Changes in the External environment (PEST) Competition from other providers Assessment of new markets for the Trust Our performance relative to other providers Description of the Local Health Economy and the Trust‟s role in it.
4.1.1
The Trust is a vital part of the NHS in South London, providing mental health services for over 20,000 people at any one time across the four local health economies of Croydon, Lambeth, Lewisham and Southwark. These four PCT commissioners are the four main Trust Commissioners. In all four boroughs, there is no alternative NHS provision of secondary mental health services. The Trust is also responsible for the delivery of social care. For these local health economies, the Trust provides tertiary, secondary, community and some primary care services. The Trust also acts as a commissioner of non-statutory sector services and a sub-contractor for some specialist mental health services for the local population. At present, the Trust manages the population risk in each of these boroughs. As detailed in the principles set out in Appendix 18, the Trust will be moving away from this responsibility as an activity based contract is developed with PCTs. As a result of the Trust‟s role, it is involved in the local health and social care economy in the four local boroughs. As a consequence of this involvement, it works very closely with Croydon, Lambeth, Lewisham and Southwark PCTs and the four London Boroughs to plan services in both the short and medium term. This is achieved through a variety of joint planning mechanisms involving these organisations, as well as the voluntary sector, users and carers. In common with other mental health communities, close, collaborative working relationship exist between providers in the statutory and non-statutory sectors. The Trust provides mental tertiary, specialist, mental health services in the local health economies of Bexley, Bromley, and Greenwich. Similarly, the Trust is a provider of specialist mental health services to England, Gibraltar, Guernsey and Jersey. The Trust provides professional undergraduate and post-graduate teaching and training. The Trust works particularly closely with Guy‟s King‟s and St Thomas‟ Medical School, as well as with South Bank and Greenwich Universities to provide a range of medical, nursing and therapy staff training. Education and Training provision accounts for around £11million of Trust income (including MaDEL and SIFT income). The Trust also has a vital role in Research and Development in mental health. Working in partnership with the Institute of Psychiatry, the Trust currently receives some £26million Support for Science money, and is involved in world-leading research.
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The financial position in the local health economies is volatile and difficult. During the first month of the 2006/07 financial year, this position has worsened. London wide pressures have led to the requirement to contribute a 1% surplus to the London position. This money is, at present, scheduled to be returned to the Trust in the 2007/08 financial year. However, given changes in the management arrangements at Strategic Health Authority, the Trust is cautious regarding whether or not this will be the case. The overall position, and particularly pressures on local health economies resulting from changes to the NHS financial regime (not least the impact of short notice changes to the arrangements for the Purchaser Parity Adjustment (PPA)) have impacted materially on the position of the local health economies in Lambeth and Southwark. In turn, PCTs in these areas have signalled the need to make disinvestments in services. In Southwark, the full year effect of disinvesment is 7.2%. In Lambeth, it is up to 5%. This is despite the Purchaser Parity Adjustment being entirely unrelated to mental health services. The plans that the Trust is making to adjust activity and capacity to reflect this are detailed in Section 5. The Trust has also set out a number of principles to guide the way in which these changes are to be made (see section 2.1.7). 4.1.2 Illustrative map of Local Health Economy showing the four main boroughs served by the Trust.
A map showing the areas served by the Trust is attached as Appendix 30.
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4.1.3
Key factors driving demand (eg demographics, population trends).
The Local population. The population structure varies significantly between Croydon, Lambeth, Lewisham and Southwark. In Lambeth, Lewisham and Southwark, the age profiles are very different from the national average. There is a very large proportion of young adults aged 20-39 and comparatively fewer people aged over 44. There are proportionately more infants, but fewer 10-19 year olds. The graphs below indicate the population structure in the four boroughs (source: ONS – 2005) Lambeth Southwark Lewisham Croydon
Within Lambeth, Southwark and Lewisham, the population is also characterised by high levels of unemployment (around 6%), high levels of single parent families (10% in Lambeth), low levels of housing ownership (only 32% of the population in Lambeth and Southwark are owner occupiers), poverty and rates of crime. All these are significant risk factors in increasing the prevalence rate of mental health problems. The make-up of the population in Croydon is broadly in line with the national average, although the borough has the highest working residential population in London (160,000). Within all four boroughs, there are high numbers of refugees, asylum seekers and homeless people. In Southwark, for example, there are estimated to be approximately 10,000 asylum seekers and refugees. For this group of people, mental health issues are often a major health problem, not least because they have often experienced trauma in their own country or through their move to the UK. The transience of local populations also presents a challenge to services.
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As set out in the table below, between 30% and 38% of the population belong to an ethnic minority group, and there are particularly large Black African and Black Caribbean communities. Over 130 different languages are spoken in the four local boroughs. Borough Lambeth Southwark Lewisham Croydon White % 62 63 66 70 Black Caribbean % 12 16 12 8 Black African % 11 8 9 4 Asian 13 11 11 14 Other % 2 2 2 4
Applying Incidence and Prevalence rates to weighted population figures is one source for projecting potential demand for services. These suggest the following maximum figures for the Trust as a whole (based on ONS population projections): Incidence Rates Schizophrenia Schizo-Affective Disorder Prevalence Rates Schizophrenia Bi-Polar Disorder Major Depression Panic Disorder OCD Agoraphobia Alcohol Abuse Anorexia Nervosa Bulimia Nervosa Substance Misuse Paranoid Personality Disorder Schizoid Personality Disorder Anti-Social Personality Disorder Borderline Personality Disorder Narcissistic Personality Disorder Dementia 2006 329 1426 2006 6705 19722 74258 33389 26733 40812 71364 3034 6068 54249 11881 13366 13366 68316 5940 3876 2007 330 1428 2007 6707 19725 74286 33388 26743 40812 71432 3006 6012 54292 11886 13371 13371 68343 5943 3921 2008 330 1431 2008 6711 19738 74343 33393 26763 40821 71542 2981 5962 54363 11895 13382 13381 68395 5947 3973 2009 330 1434 2009 6720 19765 74444 33425 26800 40861 71680 2964 5928 54459 11911 13399 13399 68489 5955 4048 2010 331 1436 2010 6732 19801 74574 33467 26847 40914 71852 2949 5898 54579 11932 13423 13423 68608 5966 4044
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Further detail of these projections (split by borough) is attached as Appendix G. Many of these people will receive treatment in primary rather than secondary care. However, these numbers do emphasise the extent of mental health problems in the population, and the importance of working across social, primary and secondary care to ensure that the right treatment is delivered at the right time to the population as a whole. The figures also emphasise, however, that over the five year period covered by the Integrated Business Plan, the level of mental health problems within the population is not predicted to change significantly. However, using Greater London Authority (rather than Office for National Statistics) population projections (Scenario 8.1) that make use of dwelling stock figures suggests a higher level of need and a higher level of growth in the population. For the populations of Lambeth, Southwark and Lewisham, this projection (which is not reflected in Health Service funding) suggests a population grown of 89,400 in these three borough by 2011. GLA projections also suggest a growth of 22% in these boroughs by 2021, whilst ONS projections suggest a growth of 1% (a completely different order of magnitude, arising from very different assumptions).
Lambeth, Southwark and Lewisham Population Projections
1000000 900000 800000 700000 600000 ONS GLA
e
20 06
20 11
20 16
Projections of the numbers of people affected by mental health problems vary accordingly. The gap between these projections is an area that will need to be monitored closely. If the GLA based assumptions are proved correct, then the Trust will work with PCTs to focus resources as effectively as possible. This might, for example, include raising thresholds for admission to services to ensure that capacity limits are not breached.
Ba se lin
20 21
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However, whilst the Trust will work with PCTs to address demand pressures, financial risk (under an activity based contract) will remain with PCTs. This is because the basis for the activity levels contained in Appendix C will be shared capacity assumptions (Appendix 16). These assumptions are based on clinical and commissioner views and set, in effect, maximum activity levels that can be delivered within the capacity purchased.
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4.1.4
Objectives of the Local Health Economy (LHE)
The overall Strategic Framework within which the Trust provides local borough services is, at present, the South-East London Strategic Health Authority Strategic Framework (2005-2008). This articulates the strategic aims of the NHS in South-East London, which are: Improving local people‟s health. The aim is to promote work that aids people‟s abilities to manage and improve their own health, and to keep a form focus on health promotion and illness. To encourage NHS organisations to work more closely with local authorities and the voluntary sector. To maximise the NHS‟s role as a major employer in South-East London. Developing patient-driven services. To set up a process for dialogue with the public. To explore ways to respond positively and imaginatively to patient choice. To promote involvement of the independent sector and to encourage providers to create strategic alliances. Engaging with and contributing to the wider community. To ensure that black and minority ethnic staff and communities are able to contribute equally to shaping local health services and get access to opportunities brought about by system reform. To encourage the NHS to be responsible and creative in its role as a major educator and employer. To facilitate collaboration between health services and universities. To support work to improve the environment and to achieve sustainable development. Achieving affordability without reducing quality. To expect systematic cycles of measurement, review and improvement to be applied to health organisations across south east London. To facilitate work between local commissioners and providers to explore ways of managing the financial risks associated with system reform and how they could rise to this challenge through greater partnership working. Ensuring commissioning is fit for purpose. To facilitate a development programme to support PCTs and GPs in improving their commissioning functions in the light of system reform. To support commissioners and providers in setting up a joint process for handling decisions about strategic or service change across borough boundaries. To monitor each PCTs „menu‟ of choices for patients, to ensure that genuine choice is offered and that the menu is generated in conjunction with the patient form. We will recommend that all PCTs initially offer a „menu‟ including all NHS providers in south east London, plus any other current providers and at least one independent provider. Increasing our capability and capacity for system development.
Each of the four borough PCTs has also developed Local Development Plans, in partnership with the Trust. These are reflected in the Service Level Agreements reached for the next financial year. Given the overall financial context of the NHS, these focus on financial balance above all. The Trust is also an integral part of the delivery of Integrated Service Improvement Plans (ISIP) in each of the four local borough PCTs. Local Health Economy ISIP objectives of which the Trust is part are:
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- To support the management and treatment of patients with long term conditions, leading to more planned and proactive care, and reducing reliance on unplanned care (Lambeth) - Implementing the multi-agency mental health promotion strategy, including early detection and support for dementia (Lambeth) - To reduce expenditure on institutional care by 10% (Lambeth - To develop alternatives to residential care, improve transition planning and inter-agency working for clients with Learning Disabilities (Lambeth) - To support the development of a sector diagnostics plan and to develop a Lambeth diagnostic plan (Lambeth) - To reduce the demand for unscheduled and scheduled secondary care (Lambeth) - To engender a culture and process across the local health economy to use information to support achievement of priority objectives (Lewisham) - Implement agreed unscheduled care service model to provide 24/7 primary care service on UHL site from April 2006 (Lewisham) - Deliver care more effectively and with improved services to patients within expected standards (Lewisham) - Implement Every Child Matters and the Childrens‟ Act (Lewisham) - To develop the market, and improve the quality of care and patient experience (Southwark) - To focus on long-term conditions and high cost placements (Croydon) All four local PCTs have confirmed (see Appendix 14) in their responses to the Trust Strategy consultation that Trust plans are in line with the Strategic Objectives in their PCT area. Both South East London and South West London have also confirmed that the Trust‟s Strategic direction is in line with the strategic direction in those areas. The Trust is therefore, in a position to state that its strategic direction is aligned with the strategic direction of NHS commissioning across South London. Statutory sector financial position Within the NHS market in London there are significant financial pressures. For the 2006/07 financial year, this has led (over and above the national requirement for a 2.5% cash releasing efficiency saving) to the requirement for the Trust to contribute a 1% surplus to the new London Strategic Health Authority. It has also led to disinvestment in services in Lambeth and Southwark. We have, however, based this Integrated Business Plan on a continued requirement for CRES saving in line with the Gershon review. This is because the actions this year are in the context of material system change and the need for the NHS as a whole to achieve financial stability. The Trust does not believe that they represent a sustainable approach beyond the current financial year. Given the financial position, we have factored in no growth assumptions, other than that already committed to two Medium Secure Unit schemes (Lambeth Hospital and Bethlem Hospital). We have assumed that client group specific grants (eg CAMHs and Addictions) will not be received. On top of this CRES target, the Trust‟s contribution to achieving financial balance, as reflected in the Integrated Business Plan, is to: - Participate fully in LHE plans to achieve sector financial balance, whilst maintaining the financial integrity of the Trust. - To progress service developments and quality improvements through modernisation - To put effective mitigation strategies into place where this is not possible based around the principles outlined in Appendix 18. Organisational changes st On 1 July 2006, the South-East London Strategic Health Authority will become part of a new London-wide Strategic Health Authority. A number of the
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current assumptions and ways of working within the South-East London Strategic Health Authority may no longer be valid. At present, we are not in a position to analyse these in more detail, but we will build them into our risk analysis (see Section 9) as they become available. The Trust is well connected to the processes and discussions which are contributing to the development of the new London SHA. 4.1.5 Major changes in external environment/competition. These include:
Change in Research and Development funding streams. A revised Research and Development Strategy for the NHS was launched in February 2006. This removes the current R&D levy received by the Trust over a three year period starting in 2006/07. The levy is replaced (over a three year period) with a bidding process. Transitional arrangements have been put in place for current funding, with the Trust receiving decreasing transitional support over the three year period. This change offers both opportunities and threats and the Trust‟s approach to it is detailed in Section 9. Overall, we believe that the Trust is likely to lose some £5 million income as a result of these changes (appendix 21 gives details of Trust bids). Move to Practice Based Commissioning. It is not yet clear what the effect of this will be in mental health in the local areas. However, the contracting framework for the Trust is complex. As well as agreements with a range of non-Statutory partners, the Trust has 60 contracts with PCTs across the country (19 in London and 41 outside London) and two Section 31 agreements in place. Despite this range, a significant majority of the Trust income is currently purchased under block contracts. Whilst this gives stability and security to income, in many cases, the block contract arrangements do not specify activity requirements. In effect, this makes the Trust responsible for holding the risk for meeting the total secondary care mental health needs of the population, including Special Needs Placements. In the case of forensic placements within Lambeth, Southwark and Lewisham, the Trust took on responsibility for managing financial risk in 2002/03. The difference in terms and particularly the lack of clarity over the linkages between activity and income streams and the management of risks between the parties and costs represents a risk to the Trust. As a result, the Trust is working with the four borough PCTs to move contracts onto an activity basis in a planned manner (appendix 17). The Trust will also be entering into a three year contract with PCTs in the 06/07 financial year (with a one year notice period) in order to enable the Trust to manage the transition to Practice Based Commissioning more effectively. One assumption behind activity projections is also that current referral patterns (which differ between and within boroughs) represent the relationships and differing patterns of provisions between primary and secondary care. It has, therefore, been assumed that current referral patterns are, in the initial 3 year period, likely to remain steady. The Trust will work with PCTs and Primary Care during this period to prepare for any changes. (section 3.1.2). Implementation of Payment by Results (PbR). It is not yet definite what form the tariff will take in Mental Health services. At present, the Trust is involved in leading the development of this at a national level. The aim of this work is to create an arrangement which puts in place incentives for providers to keep people as well as possible, to avoid excessive consumption of secondary care interventions and to maximise independence. This would involve a tariff based on an individual‟s needs where the risk rests with providers to manage care along a pathway. Demand risk would, however, rest with commissioners. Whilst such a tariff is not scheduled to be introduced until 2008, the Trust is working with local PCTs to undertake the relevant preparatory work with them (beginning
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through the 2006/07 SLA negotiations). In preparation for such a system, this work is developing currencies that relate to the number of people treated (see Appendices 15 and C). These leave risk related to the management of capacity with service providers, whilst demand risk rests with PCTs. The Trust recognises that the introduction of PbR will require strong information and finance systems, particularly on activity and costs. As a result, investment has been targeted towards these areas in a systematic and planned way. This includes the full introduction by April 2006 of the Electronic Patient Journey (an electronic patient notes system), the subsequent roll-out of the Integrated Reporting System (a data analysis tool to be made available both internally and to major customers), and the development of the Electronic Information System (a Performance Management System) which will be rolled out by Summer of 2006. Together, these developments place the Trust in a much stronger position in relation to the information requirements of the new marketplace (see section 9.1.7). At the same time, we have also reviewed our own internal systems to establish their fitness for purpose for this new world. As a result, we have reengineered the way in which the Trust is approaching contracting (with more effectively defined core teams) and will be putting structures in place to ensure that the appropriate corporate support is available on an ongoing basis. Patient Choice and Contestability in healthcare provision: Within services for those people who are care co-ordinated on enhanced CPA, the focus of the implementation of Patient Choice within mental health is on giving people choice at the relevant point along the care pathway. In order to meet the challenges of providing Choice in a systematic way, the Trust is developing a Choice Strategy, piloted in the Lambeth borough services. Based on an approach that marries academic research with service user, carer and staff research, this work is suggesting that the essence of providing choice will be to provide people with access to - Life Choices - A choice of how to contact mental health services - Choices when having an assessment carried out - A choice of care options This Choice Strategy will require the Trust to build on the approach that it has taken in the past to developing service delivery in working in partnership with clients and stakeholders to provide a range of options. It may also require the focus of services to shift from risk management to risk taking in a more explicit way. This strategy is also identifying specific suggestions for service developments. These focus on how to provide person-centred journeys in SLaM services. Key areas for change have been identified as: - Changing the focus of services - Seeing the 360 degree view of users‟ lives - Holistic assessment and care planning - Access, Information and advocacy - Choice of treatment and services - Addressing social inequalities
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- Making choice real. Action plans in these areas will be developed, and the current draft of the recommendations of the strategy work is attached as Appendix 27. We do not believe that the implementation of the Patient Choice policy will affect the take up of services by people on the CPA. Indeed, the Trust believes that if services meet these criteria, the net effect of the implementation of Patient Choice will be an improvement in levels of engagement with services rather than a move away from services. Furthermore, Section 31 agreements mean that services users on enhanced CPA could not receive an integrated package of care from another Trust, which we believe will be an additional incentive for service users to remain with the Trust. For the Specialist and primary care services that the Trust provides, the implementation of Patient Choice and the introduction of contestability into services will impact in a different way. It is likely that circumscribed interventions, such as psychological therapies, will be funded under the PbR with an intervention specific tariff. There is a risk that service users will go to either of the neighbouring mental health trusts (South West London and St George‟s NHS Trust or Oxleas NHS Foundation Trust) or to the private sector. This is particularly the case in areas where there are significant waits for psychological therapies within Trust Services. As a result, since January 2005, the Trust has had a plan in place to address capacity levels and the efficient use of capacity in these areas. All Trust services achieve the national target relating to waits from GP referral to consultant appointment. The Trust also has an internal target of a 13 week wait from referral to assessment for all patients referred into services. In many cases (CMHT services, for example) the average waiting time is substantially less than this (4 weeks). For the limited number of services that have not yet achieved this target, trajectories to achieve this have been planned and are subject to the monthly performance management framework. The Trust has also put in place a process of modernisation of booking procedures (to ensure easier access to services). Since December 2005, all services have been offering services that offer a choice of appointment time and date to service users and the Trust is piloting services on the Choose and Book system. If the Trust achieves Foundation status, it will seek to take full advantage of the potential offered by extended choice element of the Choose and Book system. The Trust also believes that there may be opportunities for the development of psychological therapies to a wider population than is currently the case. We have a number of clinical leaders in this field working within the Trust. As a result, it is our intention to explore the opportunities offered in this market. Based on this, we have stated the intention to develop Psychological Therapies Centres (Section 3.2). For the Specialist Services that the Trust provides, we have carried out a market assessment and service review. Based on clinical need, commissioner intentions, service user demand, and financial viability, we believe that the services we offer will remain competitive within the market place. However, the review has identified areas in which the Trust needs to address costs, margins and casemix. Overall, the implementation of this review will lead to: - A broader spread of PCT purchasers - Focus on adult developmental disorders as a potential area of growth - More effective strategic integration of services. Further details of this review are set out in Appendix 19.
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Part of our analysis of the market is based on contacts with private and voluntary sector providers across South London. These have included one formal th stakeholder event, facilitated by the South-West London Strategic Health Authority [6 February 2006]. The analysis of the market and what it needs to achieve was common across all sectors and focused on: - The tight financial situation within the statutory sector - The need to define quality as well as price - The importance of strategic integration - The importance of ensuring access for hard to reach groups. In terms of the Trust‟s competitive relationship with private providers, it is our strategy to seek to be the market leader for specialist services. We believe that we already have a significant national and international reputation in these fields. We are fortunate to have amongst our staff the national and international clinical leaders in some of these areas. We also have competitive prices. However, our attention to the basics of customer services has not always been sufficient to give us confidence that we could effectively compete with private sector providers. This has particularly been the case in relation to the estate from which these services are provided. The quality of estate is, therefore, identified as a major risk to the Trust. This is described accordingly in Section 7. The market for CAMHS services has potential for significant growth until 2008, with a national 10% increase in the size of the CAMHS grant to PCTs year on year. However, given financial pressures, current indications are that this will not be available to the Trust. We have made assumptions accordingly within our financial modelling (Section 6). The Trust is also an important element of the forensic services market, as are both the neighbouring NHS Trusts. As detailed in our Service Changes (Section 5), we have established developments (Lambeth Hospital and Bethlem Royal Hospital) that secure our position as the provider of choice for Lambeth, Southwark, Lewisham and Croydon PCTs. We believe that through these developments we will be able to secure a well integrated provision of all levels of forensic care (except High Secure care) and that we will be able to ensure that in the medium term, the capacity that is available is used to ensure that no out of borough beds are needed to provide these services to the population of these four PCTs. We also believe that there may be opportunities to expand into providing prison outreach services. Finally, the Trust is also an important player in the provision of Addictions Services. These are not provided under tariff, and therefore not affected by Payment by Results. At present, similar to CAMHS services, there is a 10% uplift in year on year funding for these services in each of the seven borough based Drug Action Teams. However, as with CAMHS funding, indications are that this will not be available to the Trust. We have made assumptions accordingly, within our financial modelling (Section 6). Within Addictions services, there is a risk to the Trust that Oxleas NHS Trust may wish to provide these services within the boroughs of Bexley, Greenwich and Bromley, as set out in that Trust‟s Service Development Strategy. If this is raised with the Trust by the relevant PCT, we will, of course, take a full part in any discussion about how these services should be provided.
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New Markets for the Trust Given its size and reputation, the Trust believes that there are opportunities for developing into new markets over the next five years. These do not include the provision of core NHS mental health services to the catchment areas of any surrounding NHS Trust. The Trust does believe that, as stated above, it is in a strong position to offer integrated tertiary and secondary care in areas that have traditionally been considered as tertiary. Eating Disorders, Neuro-Psychiatry and Mother and Baby services are good examples of these. We will, therefore, seek to use the opportunity of Specialist Commissioning reviews to develop better value for money care pathways in these areas. The Trust also believes that some degree of shared service provision of specialist services with South West London and St George‟s Mental Health Trust may be possible. We believe that with the advent of a London wide SHA, there will be more opportunity to demonstrate the value of this integrated approach, and the possibilities it gives in relation to the most cost effective delivery of care overall. The Trust will also be seeking to expand into non tariff based markets. As detailed in the Strategy (Section 3) these include the provision of health promotion and mental well-being services, and consultancy and advice to other organisations. The Trust has identified the need to develop a formal Marketing Strategy. This will be progressed during the summer of 2006. 4.1.6 Summary PEST analysis The following table summarises the Political, Economic, Social and Technological factors that the Trust has identified Factor New Mental Health Bill Impact on Trust The Queen‟s Speech (2005) signalled the government‟s intention to introduce this legislation. However, the Bill is currently being reviewed. It is therefore difficult when, and in what form, any Act will come into force. Action Plan The Trust will continue to monitor the proposals for all new legislation and guidance and to quantify the impact on staffing capacity associated with it. (See Section 9). It does seem clear that any proposed changes will alter the relationship between service users and professionals, require increased administrative support to the use of legal powers, and increase levels of advocacy and representation for service users. The Trust will continue to exploit the focus on local strategic planning to ensure that mental health services for children receive sufficient funding and profile. To date, this legislation has not adversely impacted on Trust business. This is reflected in our assumptions in financial modelling (Section 6)
Political
Political
The Children Act (2004)
The provisions of this Act significant change the organisation and provision of services for children, with potential impacts on the range of services provided by the Trust.
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Political
The Human Rights Act
Political
Duties under Health and Safety legislation.
The application of this Act will continue to place a requirement on the Trust to review its systems and processes. It will continue to conflict (in some cases) with key government targets such as the “four hour target” in A&E departments for clients who are being detained under the Mental Health Act. Continued implementation of these duties will remain a priority.
Continue to review systems and processes in line with legal requirements.
Political
Race Relations Amendment Act
The Trust will continue to review its services and governance procedures against the requirements of this Act.
Political
National Policy Framework – multiple change Adult Social Care Green Paper “Our Health, Our Care, Our Say.”
Political
There is a period of uncertainty in London, with the establishment of a new Strategic Health Authority and discussion of sector wide commissioning arrangements. The approach is based on client choice, and a focus on prevention. Sets a direction about moving services from inpatient to community, and gives a commitment that by 2008 each LDP must have plans to ensure a shift of resources from secondary and into primary and community setting. Impact on Trust The Trust analysis of the impact on the Trust is referenced in Section 4.1.5 The revision of national CRES targets to reflect
Priorities in this area include the duty to provide a safe environment for patients and staff, implementing the strategies (in line with NICE guidance) developed by the Trust Nurse Consultant on violence and aggression. The implementation of H&S duties will also lead to a ban on smoking within Trust properties – a major change to the current provision of services. The Trust will achieve the targets set out in its Race Equality Scheme, in areas such as medication, improving access to talking therapies and control and restraint. Funding to achieve these is included the baselines within the financial model detailed in Section 6. This is detailed in Section 4.1.5 above and included in our risk modelling in Section 9.
Political
The Trust will concentrate on implementing its Strategy and its response to the Patient Choice agenda, which link closely with the drivers behind this Green Paper. Continue to work to implement the Trust Strategy, as this is fully in line with the strategy direction of the White Paper.
Economic Economic
Factor Introduction of Payment by Results NHS Financial
Action Plan See Section 7 – risks We have assumed in our financial modelling that continued
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economic realities will impact on the level of CRES that the Trust is required to make. It may also lead to further disinvestment by PCTs.
CRES in line with Gershon is required throughout the timespan covered by this IBP. We have also set out clear principles for managing any process of PCT disinvestment. The implication of the national financial position is also included as a major risk to the Trust in Section 7. Trust is reviewing its internal processes to ensure that they are fit for purpose as detailed in Section 4.1.5 above.
Economic
Workforce
Economic
Drug Costs
Moves towards activity based contracts will prove to be a challenge to local health economy established practice and systems. This applies to the Trust as much as to commissioners. There are particular recruitment and retention pressures with respect to certain professional groups. The Trust will have to adopt a flexible approach to workforce as national recruitment issues lead to changes in skill mix and a shift in traditional professional demarcations. Drug costs may continue to rise as a proportion of Trust expenditure. It is recognised that a greater proportion of prescribing is held by the Trust than is the case for equivalent secondary care providers.
Identified as an issue for the Trust in the HR and Education strategy (Section 8)
Economic
Private Sector Placements
The Trust holds financial responsibility for a number of high cost private sector placements.
Trust action plan in place to reduce the level of prescribing carried out in secondary care. This aims to reduce levels of community prescribing to 75% of March 2005 levels by March 2009. In parallel, the Trust has a plan to improve drugs procurement and to reduce levels of wastage by a minimum of 5% per year. Plans are in place to improve local services and to reduce over reliance on the private sector. This risk is dealt with in more detail in Section 5.1.1 and 5.1.2. Action Plan As detailed in Section 4.1.5 The Trust will continue to work in partnership with the relevant organisations and individuals, in line with the Trust Strategy (Section 3) To continue to offer services that meet local population needs, and to ensure that the Trust workforce reflects local population. This is a key element of the Trust Strategy and
Social Social
Factor Patient Choice Social Inclusion
Social
Diversity
Impact on Trust The Trusts analysis of the impact of Patient Choice is detailed in Section 4.1.5 The presence or otherwise of effective means of social inclusion has a major affect on the effectiveness of the Trust‟s work with clients. As detailed in Section 4.1.3 the population served by the Trust is very diverse. This impacts on the Trust‟s need to ensure that services are accessible and
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Social
Dual Diagnosis
Social
Stigma
Social
Litigation
appropriate for all parts of the population. In the local boroughs served by the Trust there is a significant level of substance misuse that increases the rate and complexity of referrals as well as the complexity of effective treatment. Attitude surveys indicate less positive attitudes towards people with mental health problems. This may lead to increased levels of stigma and discrimination, and impact on the Trust‟s Strategic goal to help people “live their lives.” Trends within English society suggest that the risk of litigation directed at the Trust will continue to grow.
the Trust Board‟s Statements of Intent (Section 3.3) The continued development of specialist research in this area and the local implementation of dual diagnosis strategies will be critical to the effective development of services. To continue to work to challenge stigma and put effective health promotion initiatives in place.
The Trust has put in place robust governance mechanisms to improve its CNST and RPST ratings, and to provide integrated governance that minimise the risk of legal action against the organisation (see Section 9.1.3 for details of the Trust CNST rating).
Technological
Factor ICT developments
Impact on Trust The development of new ICT systems has the potential to introduce new ways of working to the Trust and to enhance service delivery.
Technological
Clinical Equipment
Equipment that is not fit for purpose does pose a clinical risk No new drug treatments are predicted in the next five years. However, there is increased prominence of CBT and Family Therapy as a result of NICE guidance.
Technological
New Medical Technologies
Action Plan The Trust has invested in the implementation of new clinical and management IT systems. It is also investing in the delivery of Tele-Psychiatry projects, particularly within the Specialist Directorate, in support of the Strategic Aim to support others in delivering high quality care (Ref: Section 3 and Section 9.1.7) The Trust has recently carried out an audit of medical devices and is investing in up-to-date medical equipment where the need for this has been identified. The Trust has a goal to expand psychological therapies provision (ref Section 3).
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4.1.7
Summary of how the Trust performs against comparators.
The Trust is a national and international leader in mental health service provision and research. Uniquely, SlaM: - Offers an internationally leading research base to service provision - Provides the widest range of mental health services in the country - Has a track record of achieving all targets - Provides a very high quality of clinical care, being the only mental health Trust in London to have achieved CNST level 2 (with a score of 100%) - Trains the next generation of mental health nurses, psychologists, OTs and psychiatrists. The Trust has consistently performed to a high standard against National Targets. It is one of the few Trusts to have been awarded the highest possible score for research by the Healthcare Commission. The Trust has achieved LDP, NSF and NHS Plan targets. Areas where the Trust is (relatively) weaker than competitors are the quality of estate (ref section 5.1.2.6), and Patient Focus, as represented in the results of the Patient Survey. (ref Section 2.1.6) The Trust also believes that the Choice Strategy work will enable it to address these areas more effectively in future. Benchmarking Information. One source of information for the Trust in understanding its performance relative to other mental health providers is the London Mental Health Trust Benchmarking Exercise. In-patient data (in the table and graph below) for the 2004/05 financial year shows the Trust services operating at high levels of occupancy but low readmission rates relative to other London Trusts. Admission rate of 100k population Rank (out of 32) 1 31 28 22 % occupancy (incl leave) Rank (of 32) 5 26 24 29 Mean Average Length of Stay (in days) Rank (of 32) 24 22 9 20 Median Average Length of Stay (in days) Rank (of 32) 24 23 3 22 % Admissions with LoS less than 3 days Rank (of 32) 9 24 32 14
Borough Croydon Lambeth Lewisham Southwark
Table showing 90 day readmission rates in London mental health trusts (by borough).
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35 30 25 20 15 10 5 0
Haringey
Hounslow
Kensington and Chelsea
Croydon
Hackney and City
The Durham Service Mapping dataset is used by the Trust to provide comparative information on staffing levels across services. These suggest that SL&M services are relatively well resources when compared to other London Trusts. Benchmarking information also confirms that the Trust has high reference costs across all in-patient care categories when compared to other London mental health trusts.
Tower Hamlets
Wandsworth
Southwark
Havering
Barking
Redbridge
Bromley
Enfield
Bexley
Lambeth
Merton
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Perceptions of the Trust The Trusts uses information from a number of different sources that enable it to judge its performance relative to other providers. These sources confirm that the Trust performs well relative to other providers, and is particularly strong in terms of the clinical quality of the services that it offers. The National Staff survey also gives valuable information that indicates how the Trust is perceived by its staff, relative to other mental health trusts in London. Overall, SlaM staff scored the Trust similarly to other staff groups scorings across London, and with very similar scores to other mental health trusts in South London. The Patient Survey results also give indications of how the Trust has performed relative to comparator trusts. The most recent survey (carried out in 2005) indicated that, overall, Patients valued the contact they had with professionals, and had, relatively, more contact than in comparator trusts. However, they also reported, relatively, worse access to psychological therapies, not having enough say in decisions about treatment care and were only averagely satisfied with the care they received (ref Section 2.1.6). Other feedback used by the Trust in comparing its performance with comparator trusts is analysis of the results of the Performance Ratings, and Standards for Better Health declarations. In particular, the Trust analyses the achievements of its nearest geographical competitor trusts – South West London and St George‟s NHS Trust and Oxleas NHS Trust. In the draft self-declaration against Standards for Better Health, South London and Maudsley NHS Trust had a similar rating to Oxleas NHS Trust (four ratings of insufficiency assurance for Oxleas Trust against Three for SLaM), whilst South West London and St George‟s Trust made three declarations of insufficient assurance and two declarations of “not met.” This suggests that, against core standards at least, the Trust is not at a disadvantage when standards of care are compared. With respect to the most recent set of Performance Rating (2004/05), the Trust had very similar scores to Oxleas NHS Trust. Nevertheless, Oxleas Trust was awarded three stars, whilst South London and Maudsley NHS Trust was awarded only two. The area in which Oxleas out-performed South London and Maudsley NHS Trust was that of Patient Focus. This highlights further the importance to the Trust‟s competitive position of continuing to focus on this area of its operations. Similarly, South West London and St George‟s NHS Trust was placed in a higher banding than South London and Maudsley NHS Trust in this area of focus. It was, however, placed in a lower banding that South London and Maudsley NHS Trust in all other focus areas. However, the Trust believes that it has a particularly strong selling point in that it provides very high quality services. This is confirmed by, for example, the CNST process. This process, aimed at assessing quality (clinical and safety) confirms that the Trust is a particularly strong performer, having recently achieved 100% in all categories at CNST level 2.
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South London and Maudsley NHS Trust Integrated Business Plan Chapter 5. Service Changes (Final Draft – 1st June 2006)
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5. 5.1.1
Service Changes Internal Capability assessment/SWOT analysis/ Commentary on SWOT analysis
An assessment of potential Strengths, Weaknesses, Opportunities, and Threats has been generated in every part of the Trust services through the 2005/6 Business Planning process. These have now been assessed and refined by Executive Directors, and by further testing with staff. The result is a high-level view of the Trust‟s strengths, weaknesses, threats and a set of potential opportunities for further study and development. Details of all issues gathered and considered as part of this are set out below in tabular form. STRENGTHS Our staff and their expertise EVIDENCE National and international leaders in their fields. Nationally recognised specialist services. Staff constantly seeking to improve. HOW WE BUILD ON THIS Ensure that 100% of staff have an up-to-date appraisal and Personal Development Plan, linked to the Knowledge and Skills Framework. Education and Training plans in place for staff across the organisation. DOCUMENTED IN HR Strategy (section 8.1.4)
Education and Training Committee Minutes. Annual Training Plan. ABCD Board Minutes. Clinical Governance and Audit Committee Minutes. Trust Strategy
Effective Implementation of Modernisation Programmes and NICE guidelines.
Continued Implementation of Trust Modernisation Programmes and NICE guidelines.
Involvement of Service Users and Carers in service development and delivery
Regular Partnership Time Events. Development of a Service User Bank User Involvement a core element of service reviews and provision within the boroughs.
Developing strengths in consultancy and advice to other organisations based on our clinical expertise. (section 3.2) Foundation Trust Membership Strategy will help develop more formal integration of Service User role within the Trust. (section 9.1.1) Launch Patient Participation Group to look at issues such as self-management. Improving the provision of information to service users and
Foundation Trust Membership Strategy (section 9.1.1) Trust PPI Policy
Business Plan 2005/06.
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carers. Consistently high level of performance. (section 4.1.7) The Trust Values. Development of more consistency in delivery of high levels of performance across the organisation.
Trust Race Equality Scheme. Trust Strategy (section 3.3). Trust Controls Assurance Framework (section 9.1.3) Trust Controls Assurance Framework. Risk Management Committees Minutes. Trust Controls Assurance Framework. Trust Risk Register. CHI Clinical Governance Review and implemented Action Plan. Trust Assurance Framework (9.1.3) Trust Business Plan 2006/07
The Bold Ambitions
Delivery of Core and Developmental Standards of “Standards for Better Health.”
Trust Performance Management Framework and Key Performance Indicators Positive CHI review. Financial track record. Financial Management systems. Services provided on an integrated basis with Local Authority Social Services Departments. Effective Partnership working with the Institute of Psychiatry. Strong partnerships with education providers. Innovative Services such as Lambeth Early Onset (LEO), the Cares of Life Project, Carers Website and new treatments for treatment resistant service users.
Management of key clinical and corporate risk areas.
Need to develop contracting infrastructure. Need to review areas of risk and current risk share arrangements. Development of CAMHS services in line with requirements of Children Act and Expansion, Improvement and Reform.
High quality partnership working.
Develop a wider range of partnerships to promote mental well-being, and to use others expertise to improve service quality.
Trust Strategy
Service Innovation
Organisational development strategies aimed at developing best practice and innovation across the organisation. Developing an entrepreneurial culture. To address areas where services continue to be provided
Trust Strategy
Trust Strategy. Borough
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on historic models (especially in-patient care). Implementing the Next phase of the National Service Framework. Develop greater consistency in the delivery of high quality across all our services and infrastructure departments. Develop alternative Crisis Services.
Service Reviews. Trust Business Plan 2006/07 Trust Strategy
Service Quality
Award Winning services.
Evidence of current waits experienced by people who present in crisis (eg waits in A&E or Emergency Clinic). Robust Clinical and Corporate Governance processes.
Minutes of Crisis Services Review.
Full implementation of NICE guidelines and Modernisation Programmes.
Continue to address clinical and corporate risks through the Trust Assurance Framework and corporate and local risk registers.
ABCD Board Minutes. Trust Clinical Governance and Audit Committee minutes. Trust Assurance Framework and Trust Risk Register.
Improving environments of care delivery.
PEAT action plans. Trust Risk Register and Assurance Framework. Business Cases for new builds of MSU and Adolescent Units. Audit Committee minutes. Trust Risk Register. ABCD Board. Trust Assurance Framework.
Processes in place for learning from adverse incidents.
Improve processes for implementing learning from adverse incidents. Develop a detailed action plan in response to the Modernisation Agency “10 High Impact Changes.”
Strategies to develop new services where current services lack capacity or are underdeveloped (eg forensic services).
Forensic Project Board minutes. Business Cases
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for new builds of MSU units at Lambeth Hospital and Denis Hill Unit. (section 5.1.2) Develop our capacity to provide remote supervision and support to external services. Management Development Programme being developed Trust Strategy Leadership and Management development strategy (Appendix 23) Trust Bed Management meeting. HR Strategy
High Quality Management
CHI Clinical Governance Review.
Review the management of our in-patient bed use.
2004/05 Staff Survey results. “Freedom within a Framework” gives clear expectations from the Trust on the framework within which organisational business is conducted. Supported by Trust Mission and Values. Award Winning services and reputation for clinical expertise and research. High standards of teaching. Most comprehensive portfolio of mental health services in the UK Corporate and local risk registers in place. Performance management framework.
Development of organisational Code of Conduct for staff and Staff Charter. Improve Information systems to provide real time information to inform better management decisions.
IRS Project Board. (section 9.1.7)
Our reputation
Develop our capacity to provide supervision and support for external services. Addressing areas where we are perceived as being in “an ivory tower.”
Trust Strategy
Specialist Services Review (Appendix 19) Trust Strategy (Section 3) Trust Assurance Framework (9.1.3)
Risk Management arrangements.
Develop integrated controls assurance framework to ensure that Core and Developmental standard in Standards for Health are achieved.
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Research links with academic partner
CHI review rating International reputation of Institute of Psychiatry and Trust.
Maximise potential of new research and development strategy.
Research and development strategy bids (appendix 21)
WEAKNESSES Complexity and Scale of Trust
EVIDENCE Trust operates from over 140 sites, and in 7 London Boroughs providing a wide range of services based on different historical patterns of service provision.
HOW WE MANAGE THE RISK Effective internal communication systems Embedding the culture in which managers involve staff at all times in decision-making and where staff feel able to contribute, and feel confident that their contribution counts and is valued. Development of IT infrastructure across all sites (Section 9.1.7)
DOCUMENTED IN Good levels of attendance at networks such as Partnership Time Events, Ward Managers Forum and Administrators Network Feedback from staff survey and Improving Working Lives assessment. ICT Project Boards Trust Risk Register and Controls Assurance Framework (9.1.3) Borough Strategies.
Integration of Services with partners
Number of clients in secondary care, relative to neighbouring Trusts.
Work to improve the interface between Primary and Secondary care, with a view to reducing dependence on secondary mental health services. (Section 3.2) Work to move people to the most independent accommodation that meets their needs. (Section 3.2) Work with partners to address inequalities in uptake of services. Continue to implement the Trust Race Equality Scheme. (Section 3.2) Trust Capital Volunteering project to develop social
Number of clients in supported and residential accommodation. Differences in types of service accessed by different groups within the population.
Borough Strategies
Trust Race Equality Scheme
Community Opportunities Service
Trust Capital Volunteering
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working with clients to support people using services to access available community resources.
inclusion opportunities for people with severe and enduring mental health problems. (Section 3.2) Implementation of Patient Journey System, integrating clinical information. (Section 9.1.7) Development of three year Business Planning cycle.
Scheme
Business Processes
One Year business planning process.
Patient Journey Project Board. Trust Business Plan. Trust Controls Assurance Framework. Trust Performance Management Framework. Trust Controls Assurance Framework. Trust Business Plan and Contracts Working Group.
Performance Management framework identified as input rather than output based.
Develop Performance Management framework as output based. (see Section 9)
Basecase assessment identified contracting framework as area of concern. ICT security issues to be addressed
Development of Contracts map and robust contracting arrangements. (section 4.1.5)
ICT Security Committee to be re-instated and to oversee governance programme in this area. (See Section 9.1.7) Rationalisation of estates, focusing in particular on isolated, and high costs elements of the estate. Target to eliminate backlog maintenance (Section 3.1.2)
Multiple Sites Maintenance
Trust operates from over 140 sites. Backlog maintenance estimates (related to PEAT scores) of £23million.
Trust Risk Register. ICT Security Committee minutes. Estates Strategy. (section 5.1.2) Trust Estates Plan (chapter 5) and Capital Programme (appendix E) Trust Controls Assurance Framework
Lack of Trust-wide approach to the maintenance and servicing of medical devices. Cleaning Regimes have been insufficient to guarantee high standards of cleanliness.
Develop a medical devices maintenance and servicing contract.
Review of cleaning contracts.
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Information Infrastructure
Currently, multiple patient records
Implement Patient Journey system to ensure that up-todate information is available when required. (Section 9.1.7) Implement the Integrated Reporting Solution Project (Section 9.1.7) Develop Outcome based service monitoring. (Appendix 9)
Trust Controls Assurance Framework. ICT Project Boards.
Outcome Monitoring
Lack of real time management information. Current information is predominantly process and activity based. Vacancy rates
Recruitment and Retention in certain areas
Develop current initiatives around childcare and housing to attract staff (chapter 8) Retain IWL Practice Plus.
Trust Strategy. Trust Clinical Outcomes Group minutes. HR Strategy, Trust Controls Assurance Framework.
Impact of vacancy rates on waiting lists and referral criteria Particular issues relating to transition of staff between Band 5 and Band 6.
Monitor impact of Agenda for Change implementation on recruitment and retention. Continue developing staff career pathways. Continue to develop new roles within the Workforce. (section 8.1.4) Development and monitoring of policy and best practice in line with National guidance and statutory requirements in the areas of smoking control and stress. Develop roles and support systems for staff in line with changing standards and processes of professional regulation. (Section 8.1.4) Prepare for the Electronic Staff record. Review Occupational Health Services. Continue to build links with local communities through PPI initiatives and membership. To develop more systematic health promotion/disease
HR Strategy.
Smoking Policy
HR Strategy
Public Perceptions of Mental Health Services.
Public opposition campaigns to Trust service developments. We do not fulfil our potential to influence
HR Strategy. Trust Controls Assurance Framework. Trust PPI policy.
Trust Strategy
FINAL DRAFT – 1st June 2006
mental well-being beyond the Trust
prevention programmes. (Section 3.2)
OPPORTUNITIES Track record of high quality innovation
INDICATORS Range of innovative services. Involvement in cutting edge research projects.
HOW WE BUILD ON THIS Continued involvement in cutting edge research projects. Implementation of innovative services. Working across unhelpful organisational boundaries. (chapter 3) To develop more effective tele-psychiatry approaches. Support for the connection of services to communities to encourage the values of co-production and reciprocity (eg the development and support of Time Banks). Seize opportunities to influence widely Develop further health promotion training, and embed this within the work of the Trust. Continue to implement and develop media and communication strategies. To promote SL&M as an employer of choice within local communities. To develop a range of consultancy services to support external organisations. Develop the Trust Performance Management system to better meet the requirement of Standards for Better Health (chapter 9) Putting in place effective contracting, information and financial management systems for operation as a Foundation Trust.
Involvement and Support
Involvement in Foundation Trust governance arrangements will ensure that sound decisions are taken. Current review of governance arrangements within the Trust.
Reputation Business Processes
The Trust has a reputation for clinical excellence and achievement of targets Developing coherent and inter-linked business systems and refined performance review processes
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Patient Choice
Initiatives to provide high quality information, access and choice and access to a range of therapies.
Roll out best practice in all these area across the Trust. Implement Choice Strategy (section 4.1.5) To ensure that all service users have a copy of their CPA care plan. Carers of patients on enhanced CPA to be offered a Carers‟ Assessment Develop further links as a provider of further education, not least by developing further partnerships with other education providers. Adapt to changes in professional training to ensure that the Trust remains a leading edge education provider. Ensure that the Trust‟s Education and Training infrastructure is fully utilised.
Education and Training
Trust is a major provider of education and training to a wide range of professions.
THREATS Population Change
INDICATORS ONS population projections suggest little change in the local population. However, GLA projections suggest significant growth. NHS funding is predicated on ONS population levels, and the GLA scenario would challenge the Trust and the local Health Economy. Lack of clarity about the implementation of PbR in Mental Health.
RISK MANAGEMENT PLAN Ensure that the Trust monitors the local population and demand against both ONS and GLA scenarios. (section 4.1.3)
NHS Financial position
Develop more robust financial modelling and contracting framework as part of FT application process. (section 2.1.7) Address costs to ensure that the Trust operates within Reference Costs (chapter 6)
Financial pressures in the local health economy cause increased financial pressure for the Trust.
Work with local health economy partners as set out in Chapter 4 above.
FINAL DRAFT – 1st June 2006
Recruitment and retention. New Mental Health legislation
Addressing vacancy and turnover rates. Administrative costs of new legislation.
Implement HR Strategy, including Workforce Modernisation Strategy (section 8.1.4) Put in place plans to ensure sufficient provision of advocacy services for service users. Work with service users and carers when designing the implementation of the new legislation.
Potential to undermine relationships between service users and the service.
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5.1.2
Summary of future initiatives
Planned Service Changes include: Plans with Commissioner Support: 5.1.2.1 89 bed Adult Forensic Medium Secure Unit (Edward Oxford House at the Bethlem Royal Hospital) that will open in the 2007/8 financial year. The capital business case for this development (£32,052,000 at MIPS 447FP) has been agreed by the South East London Strategic Health Authority, and is supported by Croydon, Lambeth, Lewisham and Southwark PCTs. The net effect of this development will be to reduce the level of private sector medium secure placements in these boroughs (see section 2.1.3) and move provision for Croydon residents from South West London and St George‟s NHS Trust to SL&M. Risks associated with this scheme are detailed in Section 9. The net growth to the Trust of the scheme will be £6.5million, and this is included in the financial modelling (section 6). The scheme is being procured through P21 arrangements. 5.1.2.2 24 bed Adult Forensic Medium Secure Unit (Lambeth Hospital) that will open in the summer of 2006. The capital business case for this development (£10,470,000 at MIPS 447FP) has been agreed by the South-East London Strategic Health Authority, and is supported by Lambeth and Southwark PCTs. The net effect of these developments will be to reduce the level of private sector placements (see section 2.1.3) and to free up space within the Denis Hill Unit for use by Southwark clients. Risk associated with this scheme are detailed in Section 9. Plans being considered by PCTs to achieve disinvestment totals: There are a number of service changes being considered by commissioners in response to the decision on disinvestment by Lambeth and Southwark PCTs. These are detailed in Appendix 25. The total effect of these is not finalised as they have not been approved or consulted on by PCTs. Indicative impacts are detailed in Appendix 25. These schemes represent Tranche 1 of the savings required. Tranche 2 will be identified by September 2006, and will take effect from April 2007. Implementation of both tranches will be managed in line with the principles agreed with PCTs (appendix 18). Service Changes – Internal Efficiency 5.1.2.4 Mental Health of Older Adults Services are in the process of implementing a three year recovery plan (ending in April 2008). A specific service efficiency arising from this is merging in-patient services commissioned by both Lambeth and Southwark PCTs. There is projected to be no impact on the Trust‟s ability to manage commissioned activity levels (see appendix 25) 5.1.2.4 A further efficiency arising from this recovery plan in Mental Health of Older Adults services is the merger of Continuing Care services. There is projected to be no impact on the Trust‟s ability to manage commissioned activity levels (see appendix 25)
FINAL DRAFT – 1st June 2006
Corporate Development Plans 5.1.2.5 Estate Developments. The Trust has developed principles for the management of the estate. These are attached as Appendix 31. These give a framework for addressing estates issues, including physical condition (56% of the structures within the portfolio is currently ranked below B status) and functional suitability (ie not in acceptable physical condition). Under this framework, the Trust plan is focused on: Taking steps to clear backlog maintenance. The Trust Capital Programme sets out the way in which capital will be allocated to begin achieving this aim. The Capital Programme (May 2006) is attached as Appendix E. A programme of in-patient site rationalisation. Ultimately, the Trust intends to move its in-patient sites off the St Thomas‟, Guys and Cane Hill hospital sites. A further element of this rationalisation is that the trust intends to vacate the Cane Hill site in Coulsdon following the opening of the new forensic unit beds at the Bethlem Royal Hospital (5.1.2.1). This work is being progressed through an In-Patient Services Project Board. The Third is a programme of community estate rationalisation. The two elements of this are addressing the cost per square metre of Trust accommodation. Currently, around 20% of Trust estate accounts for around 60% of costs. Addressing this will release a saving of some £2,000,000. An additional target is (through more flexible working practices – see section 7) to reduced the square meterage of the community estate by 2% per year, with an associated programme of disposals (see appendices E and F for details of disposals).
5.1.2.6 Development of Consultancy Services. This Service Development Plan seeks to establish a coherent framework within which the Trust offers consultancy support to organisations in the UK and Europe. This will build on the specific pieces of work that The Trust Consultancy Service, CAMHS, the National Division and the Estia Centre already provide in these areas. This provision will establish the trust‟s capacity to respond to tender opportunities, develop relationships in markets that we have already begun to penetrate (in particular, mental health service development in Ireland) and to develop an integrated approach that offers clinical expertise, team development, and individual coaching in the mental health field. This will include putting internal frameworks in place to train additional trust staff in consultancy skills, and recruit additional Chartered Management Consultants. The aim of this strategy is to develop the current Trust Consultancy Services so that they generate significant return on investment for the Trust as well as internal consultancy and change management support within the organisation (see section 7)
5.1.3
Resource Implication of activity plans
The following table summaries the resource and activity implications of the Proposed Service changes
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Service Development Plan
Date
5.1.2.1. Bethlem Royal Hospital 89 bed Medium Secure Unit (opens in 2008/09).
January 2008
Capital/Nonrecurrent investment £32,052,000 at MIPS 447FP
Activity Implications
Staffing Implications
Revenue Impact
+5 MSU admissions per year over 2006/07 baseline. -21 MSU private sector procured placements.
+ 132.40 wte.
5.1.2.2. Lambeth Hospital 24 bed Medium Secure Unit (opens in summer 2006) 5.1.2.5 Estate Rationalisation
August 2006
£10,470,000 at MIPS 447FP
No impact on admission capacity per year. -21 MSU private sector procured placements Reduction of cost per metre of high cost 20% of Trust estate to mean average levels and reduction of community square metreage by 2% per year. In-patient rationalisation
+ 74.80wte.
By March 2011.
Nil
Nil
£6.5 million net growth to Trust. No CRES impact from repatriation of private placements. CRES saving of £1,100,000 in 2007/08 financial year. --£2million (appendix 5
5.1.2.6 Development of Consultancy services. 5.1.2.7 Service Disinvestments (Tranche 1)
By April 2009 By April 2009 By April 2007
Nil
£60,000 in years one and two TBC as plans are finalised.
Increase in billed consultancy days
Significant variations in activity and capacity (See Appendix 25)
TBC as plans are finalised
-£300,000 (appendix 5) 6% return on investment by April 2009. TBC as plans are finalised
FINAL DRAFT – 1st June 2006
South London and Maudsley NHS Trust Integrated Business Plan Chapter 6. Financial Plans (Final Draft – 1st June 2006)
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6.
Financial Plans
The Trust‟s financial planning for the five year period from 2006/07 to 2010/11 is based on our sound financial position over the past years. Key risks to achieving plans relate to financial instability in the London and local health economy (see Chapter 4) and changes to Research and Development funding (see Chapter 7).
6.1.1
Historical Performance Analysis and Financial Projections.
South London and Maudsley NHS Trust reported a small deficit of £480k in its first year after formation (1999/2000), but has achieved financial balance in each year since then. At the same time, the Trust has implemented year on year cash releasing efficiencies (detailed in Appendix Two). In 2005/06, the Trust had a surplus of £719k. The Trust has operated within the external financial limit (EFL) and capital resource limit (CRL). It has provided brokerage to the Strategic Health Authority and achieved a 97% compliance rate against the Better Payment Practice Code by volume of invoices and 94% by value. Particular areas of achievement over the past five years have included:
Acute overspill placements outside the Trust have been significantly reduced. From a peak of 65 placements per day in 2000/01, the Trust used just over one placement per day in the 2005/06 financial year. The original reductions were made possible by significant investment in community services, particularly in establishing Home Treatment Teams. Recent PCT investment in crisis resolution and assertive outreach teams have also helped to maintain this situation. Drug overspends have fallen by over £1 million across the Trust following PCT investment through the generic uplifts to contracts and a recent reduction in the price of clozapine.. However, drugs expenditure is still a continuing financial issue for the Trust, particularly in Croydon and Older Adults. The overspend on forensic placements has fallen through a combination of additional income and success in moving people through the system and into low secure/rehabilitation accommodation.
Current cost drivers Six key cost drivers are identified and routinely reported on to the Trust Board. Performance in these areas is as follows: 1) Acute overspill. Acute overspill has been maintained at a low level. In 2005/06, the Trust used 1.2 overspill beds, all in the Lambeth adult directorate. 2) Agenda for Change (AfC). The majority of staff have been assimilated with 3,900 staff now paid on their new pay scale. This equates to 93% of the workforce. As this takes place, the Trust‟s costing model is updated to replace forecast data with actual. To date, the funding set aside is just within the forecasted cost. However, this remains an area of risk to the Trust given unknowns such as the number of successful appeals and impact on external contracts and the nurse bank. 3) Ward Nursing Costs. Ward nursing costs were cumulatively overspent by £1.9 million in the last financial year, compared to £180k over in the previous year. Addressing this issue will be focused on addressing workforce KPIs in the 10 wards that account for 80% of this overspend. 4) Adult Drugs costs. For the 2005/06 financial year, the Trust is reported an underspend of £298,000 across its drug budgets. This compares to an overspend
FINAL DRAFT – 1st June 2006
of £24,000 at this stage last year. The improvement in the annual position reflects the impact of a 50% reduction in the price of clozapine. This will remain an area of focus for the Trust, and is a key element of the forward Cost Improvement planning. This is focused around reductions in price of further drugs and reductions in volume of prescribing (plans in place in each directorate). 5) Forensic Placements. In 2005/06, this budget was £1.5million overspent. The year was the most difficult year since risk transferred from the PCTs to the Trust. The Total overspend for the Trust resulting from the risk share to date is £2.75 million. This presents a significant risk to the Trust. As identified elsewhere in this IBP (sec 4.1.6), the Trust is reviewing current risk arrangements with PCTs as part of the SLA negotiations for the 2006/07 financial year. 6) Cost per case income. This income is considered to be a risk to the Trust given its variable nature and the general move away from three year rolling average arrangements. For 2005/06, a deficit of £52k is being reported against this income stream. This issue is being addressed in the Specialist Services Review (Sec 5.1.1) Particular pressures relating to these cost drivers exist in the Older Adults, Lambeth Adults and Specialist Services directorates. As a result, these directorates have been designated as being “in recovery” mode. A Board has been set up, chaired by the Director of Finance and Corporate Governance to work with each directorate to achieve financial balance. 6.1.2 Contract Arrangements
Contract arrangements reflect the historical position for the Trust. Predominantly, Trust income is covered by Block Contract arrangements. As set out in Chapter 2, the Trust is working with partners to move to activity based contracts. The majority of specialist services are provided on a 3 year rolling average arrangement. This mitigates the effect of peaks and troughs in activity for both purchasers and the provider. See section 2 for details of the amount of activity purchased under rolling average arrangements. 6.1.3 Predicted financial position – financial modelling. The Basecase.
Income and Expenditure The Trust is taking account of the requirement to contribute 1% of turnover to the new London Strategic Health Authority in 2006/07. In the most recent plan, the st ability to generate a surplus has been compromised by the local PCT requirements for £7million reductions in income in 2006/07, rising to £8 million by 1 April 2007. For the years 2007/08 to 2010/11, the Trust is projecting to spend any surplus in implementing the Trust Strategy. As a result, financial projections show the Trust breaking even in these years. The assumptions made in the basecase model (appendix F) are: significant impact from changes to Research and Development funding (c£5million) by 2008/09 transitional support of £1.8 million to Southwark PCT, £1 million to Lambeth PCT, and £900k to Lewisham PCT in the 2006/07 financial year. reduction in the Trust Reference Cost to 98 by the end of the 2010/11 financial year. As a result, a 2% CRES is included in the basecase for the three
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years from 2008/09 to 2010/11. The Trust will seek to achieve an increase in activity over the same period in order to address remaining RCI pressures no further PCT disinvestment in the years 2007/08 to 2010/11 That the Trust funds transitional costs of £1.3million relating (in the 2007/08 financial year) to the Bethlem Royal Hospital forensic development (section 5.1.2.1)
Inflation Assumptions We have received the national 4% inflation uplift in 2006/07. For the rest of the period, we have assumed a lower rate of inflation as follows, as detailed in appendix 3. Inflation assumptions in relation to expenditure are detailed in Appendix 4. Cash Releasing Efficiency programme The Cash Releasing Efficiency programme for 2005/06 was £4.0 million (1.28% of total trust income) – see Appendix 2. The CRES requirement for the 2006/07 year is £8.1 million. The basecase projection for the period 2007/08 to 2010/11 is for a CRES requirement of £43.5 million. The main areas of focus within the CRE programmes over the five year period are: Estates Rationalisation (sec 5.1.2.6) Reduction in drugs expenditure (Section 4.1.6) Rationalisation of in-patient services (see section 5.1.2.4 and 5.1.2.5 as part of this process). The capacity utilisation ratios that enable these changes are detailed in Appendix 15 Skill mix changes. The capacity utilisation ratios that enable these changes are detailed in Appendix 15
The “granular” level of detail of the 2006/07 financial year CRES programme is shown in Appendix 5. This sets out how the Trust will generate efficiency savings in the current year. Savings are identified for the five year period of the basecase. Cash Projections The basecase model shows the Trust building up a £42 million cash position by March 31 2011. The cash position at the end of 2006/07 is £13 million. This takes account of cash brokerage into the sector health economy at the end of the 2005/06 financial year, improvements in debtor management, and a £6.8 million cash outflow relating to the payment of Agenda for Change arrears. Cash management arrangements have been reviewed as part of this application process, and the current proposals from this process are attached as Appendix 28.
st
FINAL DRAFT – 1st June 2006
Ratios I&E: The EBITDA margin increases to 7% by the end of the 5 year period (see appendix 29 – Normalised Earnings Schedule) Liquidity Ratio: This improves over the five year period as cash increases. The historical ratios are artificially low due to the NHS financial regime year-end cash holdings target of 0.3% of turnover. The basecase model projects no usage of the Working Capital Facility. PBC: The Trust has no borrowings planned in the basecase.
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South London and Maudsley NHS Trust Integrated Business Plan Chapter 7. Risks (Final Draft – 1st June 2006)
FINAL DRAFT – 1st June 2006
7. 7.1.1
Risks Summary of key business risks
The analysis contained in the previous sections of this Integrated Business Plan has led the Trust to develop the following analysis of key risks. These are detailed in the following table, along with proposed mitigation plans. Nature of Risk Financial Context [Impact of £8 million(FYE) in 2006/7 financial year] [CRES requirement of 1.7% assumed in following financial years – appendix 3] [Impact of missing one month data return would be £995,000 across all PCTs] Impact on Trust Financial pressure on the Trust and mental health sector as a whole. The demand induced pressures on the financial system as whole make it likely that funding allocations will continue to be top sliced on a London wide basis. We have assumed that this will equate to a CRES requirement on the trust in line with Gershon. In a tight financial context, commissioners are more likely to seek to challenge payment of bills for which adequate information has not been provided. Service Reductions to achieve CRES targets, and the increased clarity that PbR arrangements bring to current risk holding arrangements undertaken by the Trust increase financial pressure further on the system. These, in turn make demand management in primary care more difficult. Training and Education funding Possible withdrawal of MPET funding, along with salary costs of junior doctors Rating High Mitigation Strategy The Trust will continue to propose service reductions (in some cases linked to other Service Development Plans) for any financial reductions over and above the requirements of the national framework. We have built in the 1.7% CRES requirements of the Gershon Review in the modelling for 2007/08 and beyond. The Trust will apply the Key Principles (appendix 18) and contract terms to mitigate the impact of any disinvestment in services.
Medium
As set out in section 4.1.5, an emphasis on data quality becomes essential for the Trust.
Low
The Trust contribution to preventative work and promoting mental well-being becomes increasingly important.
Low
Close involvement in negotiations about any possible changes.
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Medium Secure service developments Risk Share arrangements [Impact is a £1.52 million pressure in 2005/6.] Capacity of new MSU builds exceeds demand
There is no risk share in place to cope with demand pressures in Lambeth, Southwark or Lewisham. Over the three years since the current arrangements have been in place, the Trust has borne a commissioning pressure of £2 million. The risk is that the Trust has high cost capacity that is not used, and which exposes the Trust to significant risk Medium
The Trust is putting in place activity based contracts with commissioners. These clarify the activity levels in medium secure care that are purchased by PCTs. Some risk also mitigated by forensic service developments (sections 5.1.1 and 5.1.2)
The Trust would bring back clients from current cub-contractors, or would provide beds for a different client group (eg Learning Disability clients) or sell beds across London.
Failure to control costs on new Medium Secure Units [pressure of £190,000 in 2005/06 financial year] A failure to provide fit for purpose estate. Changes to NHS R&D funding arrangements.
The impact on the Trust would be the cost of overspending on staffing. Ward staffing currently represents a significant area of overspending. (section 6.1.1) Has an impact on the Trust‟s ability to compete with private sector providers. (section 4.1.5) The changes announced in February 2006 replace the current R&D levy with bid funding. The Trust will receive decreased transitional funding against its current levy over the three year period beginning in 2006/07. R&D funding for the 2006/7 financial year has been confirmed as £26,185,441 (2.99% net increase) including the full 4% inflationary uplift with a reduction for the first year transitional effect. Our assessment is that the most likely impact, after mitigation, is the lost of some £5million of current R&D income. However, the worst case (loss of £26 million) is major impact on trust income streams, the need to identify (differentially across directorates given
Medium
The mitigation plan for both units is based around the impact that a new, more appropriate design, of unit will have on models of care, staffing levels and (in the case of the Cane Hill unit) more appropriate geographical location. Rationalisation of estate (see section 5.1.2.) to provide cost effective, high quality estate. The Trust has put in place a joint plan with the Institute of Psychiatry to maximise the potential of bidding against new research allocations. As by far the largest and most effective mental health research institution in the UK, the Trust (with the IoP) is in a strong position in making these bids. At present, the Trust is bidding for or planning to bid for (see Appendix 21): - A Technology Platform for neuroimaging (with King‟s College Hospital). £8 million is available nationally. - Bio-Medical Research Centre for Mental Health (£10 million per year for five years). - Identifying posts for faculty funding. - Programme grants for applied research (£2 million each over 3-5 years).
High
High
FINAL DRAFT – 1st June 2006
differences in how the R&D levy feeds into directorate overheads) the equivalent amount of CRES saving, and a major impact on recruitment and retention. Recruitment and retention issues would be likely to have a particularly big impact on our Specialist Services. Operating in a marketplace Demand Pressures This is the risk that demand pressures related to PCT disinvestment in services create financial pressures for the Local Health Economy as a whole. High The immediate financial risk to the Trust is mitigated by the move to an activity based contract. However, we will need to work with PCTs and Local Authorities as required to assist in the quantification of demand risk and the management of demand.
Contract Underperformance
This is the risk that we will not be sufficiently swift to react to contract underperformance and will incur costs without income with which to match them The risk to the Trust is that Section 31 agreements are not reviewed in time for operation as an FT, and therefore expose the Trust to demand risk. The risk to the Trust is instability in activity levels introduced by multiple purchasers. A further risk to the Trust is the continuation of pressure on some cost per case services (section 6.1.1) Local political environment reduces flexibility for service change.
Low
The mitigation plan involves setting clear occupancy level targets based on turnover and Length of Stay for community and in-patient services, against which the Trust is able to performance manage effectively (detailed in appendix 15) The mitigation plan is to review Section 31 arrangements as set out in Section 2.1.9.
Section 31 Partnership arrangements
Low
Contestability in service provision. [Practice-Based Commissioning and Patient Choice]
Medium
The Trust has plans to address areas around accessibility, costs and choice that will position Trust services to be services of choice. [section 4] The Trust is carrying out a review of Specialist Services, aimed at more effective positioning of services within the marketplace. (section 4.1.5). Clearly defined service specifications and activity targets that give some flexibility to the provider in how it utilises capacity.
Medium
Political Environment
Medium
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7.1.2
Sensitivity Analysis
The Trust has developed the following scenarios to test its plans (basecase). They model a combination of risks, plans and growth to give realistic scenarios to test the financial projections.
No
NHS wide context (Section 4 and 7) Continued London top slice of 3% leads to £8 million income reduction every year to 2010/11. Requirement to contribute 1% to London position every year to 2010/11.
Impact of R&D policy (Section 7) Failure to achieve centre and technology platform. Only half current IoP recharge funded through R&D faculty 5 programmes successful. Therefore, total funding of £6million from 2008/09
CRES targets (Section 6) Failure to achieve strategic changes (estates, skill mix)
1
Service Change (Section 5) Failure to achieve MSU savings by 2010/11. Failure to achieve disinvestment targets by 2010/11.
Growth/Loss of business (Section 4) Loss of 3% of business to neighbouring trusts by 2008/09
New contracting system (sections 4 and 9) Information systems not adequate and Trust is fined £995,000 in 2006/07 ands 2007/08. Failure to recover 10% of income in 2006/07 and 2007/08.
Impact
Mitigation Plans
Clear disinvestment plans. Good IT investment (see section 9) Trust investment in quality and reputation mitigate loss of business. FT status mitigates impact of NHS context. Clear project management on service changes Clear disinvestment plans. Good IT
2
Continued London top slice of 3% leads to £8 million income reduction every year to
Failure to achieve centre and technology platform. 75% of IoP recharge
Failure to achieve strategic changes (skill mix)
Failure to achieve MSU savings until 2009/10.
Loss of 2% of business to neighbouring trusts by 2008/09
Information systems not adequate and Trust is fined £995,000 in
FINAL DRAFT – 1st June 2006
2009/10. Requirement to contribute 1% to London position every year to 2009/10
funded through R&D faculty 5 programmes successful. Therefore, total funding of £8million from 2008/09
Failure to achieve disinvestment targets until 2009/10.
2006/07. Failure to recover 10% of income in 2006/07 and 2007/08.
investment (see section 9) Trust investment in quality and reputation mitigate loss of business. FT status mitigates impact of NHS context Clear project management on service changes Clear disinvestment plans. Good IT investment (see section 9) Trust investment in quality and reputation mitigate loss of business. FT status mitigates impact of NHS context Clear project management on
3.
Continued London top slice of 3% leads to £8 million income reduction in 2007/08. Requirement to contribute 1% to London position in 2007/08
Achieve centre. Fail to achieve technology platform 75% of current IoP recharge funded through R&D faculty 5 programmes successful. Therefore, total funding of £18 million from 2008/09
Partial achievement of strategic targets (75%)
MSU and disinvestment targets are 50% achieved on time, and 50% achieved in 2008/09.
Loss of 1% of business to neighbouring trusts by 2008/
Information systems not adequate and Trust is fined £995,000 in 2006/07. Failure to recover 10% of income in 2006/07
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4.
No requirement for any additional contributions beyond Gershon
Achieve centre and technology platform. Only half current IoP recharged funded through R&D faculty 8 programmes successful. Therefore, total funding of £17.2million from 2008/09 Achieve centre and technology platform. 75% of current IoP recharge funded through R&D faculty 10 programmes successful. Therefore, total funding of £20.5 million from 2008/09 Achieve centre and technology platform. 100% of current IoP recharge funded through R&D faculty 20 programmes
Achieved
Disinvestment targets are achieved on time. Bethlem MSU does not open until April 2009 (ie 6 month delay).
No change.
Systems adequate
service changes Clear disinvestment plans. Clear project management on service changes.
5.
No requirement for any additional contributions beyond Gershon
achieved
MSU and disinvestment targets achieved.
Growth of 2% per year in non NHS income on back of Statements of Intent. Growth in NHS business of 1% by 2008/09 from neighbouring trusts.
Systems adequate
Clear disinvestment plans. Clear project management on service changes.
6
No requirement for any additional contributions beyond Gershon
Achieved
MSU and disinvestment targets achieved.
Growth of 2% per year in non NHS income on back of Statements of Intent Growth in NHS business of 2% by 2008/09 from neighbouring trusts.
Systems adequate.
Clear disinvestment plans. Clear project management on service changes.
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successful. Therefore, total funding of £22.1 million from 2008/09
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South London and Maudsley NHS Trust Integrated Business Plan Chapter 8. Leadership and Workforce (Final Draft – 1st June 2006)
FINAL DRAFT – 1st June 2006
8
Leadership and Workforce
Providing Mental Health Services is labour intensive, requiring a skilled and flexible workforce. The way in which the Trust recruits and develops its staff is, therefore, central to determining the cost and quality of care. This section sets out the ways in which the Trust a) b) c) d) Recruits the right staff at the most appropriate cost Develops those staff to ensure that they provide safe and effective services Retains flexibility in the workforce to ensure that it can react to changing service needs Provides the leadership framework and organisational structure to maximise the contribution of all members of staff.
8.1.1
Management Arrangements
The Trust Board The Board of Directors consists of the Chair, seven Non-Executive Directors, the Chief Executive, the Director of Finance, the Medical Director, the Director of Nursing and the Director Developing Organisation and Community. The constitution will allow between four and six Executive directors in addition to the Chief Executive. The constitution will allow seven or eight Non-Executive Directors and the Chair, all appointed by the Members‟ Council. The composition and skill mix of the Board of Directors will in the first years of the Trust reflect the aspirations of the Integrated Business Plan. The Board is also the Corporate Trustee of the South London and Maudsley Charitable Funds. Summary CVs of all Board Members are in Appendix Six. In 2005, in preparation for Foundation Trust status two new Non-Executive Directors were appointed. As a result, the Board now has the range of competencies needed for it and the Executive to deliver the Integrated Business Plan. This has consolidated a strong Board, but the skills of the team will be further refined following the retirement of a Non-Executive Director in November. There will also be a new Dean of the Institute of Psychiatry - the university appointment on the Board - in December. The delivery of the work programmes detailed in this document require a high level of skill in organisational change. They also require the Board and Executive to continue to operate effective systems of financial management and organisational governance. The table below identifies the skills and experiences of the Board team, matched against the broad strategic requirements to run the Trust successfully.
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Strategic Requirements Strategic Direction
Skills and Knowledge required Partnership working with a multiplicity of stakeholders Political context (local and national) Awareness of Academic and Service provision developments. Public and media interest.
Board member skills and experience The Chair has a depth of political experience and skill which enables full diversity of opinions and perspectives to be voiced whilst at the same time bringing the group to decisions. This is manifest both in public Board meetings and in the Trust‟s work with partner organisations. All Board members are experts in their own fields who are able to draw upon experience at board level in other contexts to contribute to the strategic development of the Trust. Several members of the Board have contributed to the development of policy at a national level ranging from NHS R&D, Payment by Results, mental health nursing strategy to community development and health. The Dean of the Institute of Psychiatry leads the pre-eminent mental health research institution in the world outside the USA. One NED has long experience as the Director of a voluntary organisation responsible for providing local mental health services and working with service users. One NED has a background in media relations and a majority of Board members are very experienced at handling high profile media issues. All Board members have strong interpersonal and influencing skills with a confidence to express and defend their opinions, not be afraid to challenge the thinking of others and to welcome the opportunity to apply their personal and professional experiences and knowledge to debates. This is fundamental to effective risk management, and the Board collectively devotes a significant amount of time, both in formal meetings and in seminars to the examination of risk issues. The Chair is a practising barrister and a non-executive director has a legal background; others have academic experience of risk management issues. One NED has involvement in financial regulation. The Chief Executive and Finance Director both have experience of performance managing complex and devolved operations at a regional and national level. The Medical Director is a national leader in his profession in the development of clinical governance, and the Director of Nursing and Education has a number of national leadership roles in the development of nursing practice and education. The Chair has considerable local government experience including dealing with significant financial management issues at Cabinet level. Two NED‟s have specific relevant experience –
Risk Management
Financial management
Management of strategic risk and processes of assurance in a large and complex organisation carrying out inherently risky tasks. Understanding governance in a devolved organisation. The statutory and broad legal framework within which the Trust operates. Understanding key risks for the Trust. Ensuring prompt action is taken to rectify any identified risks. Understanding of financial management issues, to
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maintain the Trust‟s financial position.
one as a commercial Finance Director, one as an economist, while a third is a member of the Consumer Panel of the Financial Services Authority, and a fourth the Chief Executive of a charity with involvement in investments. The Board has devoted significant time to developing it own skills in analysis of financial matters and to improving its financial reporting systems resulting in a one page finance balanced scorecard. The Finance Director is a chartered accountant with experience of financial monitoring at regional/DH level as well as at Trust level. All Board members are well equipped to support the Chair and the Chief Executive in realising the vision, strategy and operation of the Trust, working with other Board members to ensure that all its operations are conducted to the highest standards, and the Board itself has a considerable track record of managing complex change, starting with the successful merger of three Trusts which brought South London and Maudsley into being. Since then there has been a continuous process of service redesign and change across the Trust which has had leadership from the Board. The Chief Executive has in depth experience of change management and was responsible for leading the change management consultancy team of a former Regional Health Authority working with all type of NHS organisations across a wide range of change issues. One Executive Director has specific responsibilities for supporting change across the Trust, and for managing change with partners, in addition to other non-Board Executive Director roles, directly accountable to the Chief Executive, with lead responsibility for HR management and Estates, Facilities and Capital Planning. One of the newly recruited NEDs has significant experience of capital development and finance. All Board members are actively involved in the decisions of the Board and there are monthly opportunities for all NEDs to meet with the Chair and the Chief Executive in private for in depth discussion of particular areas of interest, including the development of the Board itself and of the Trust as a whole. All members are encouraged by the Chair to provide impartial, objective and pragmatic advice, whilst listening to and considering the views of others. Because of the Trust‟s close academic partnership the Board is able to ensure it is kept up to date with new ideas mental health care so as to identify future opportunities for development. It draws regularly on the advice of the R&D Director – again a non- Board Executive Director role – who is able to provide an international context and perspective. The Chief Executive, alongside other senior figures in the Trust, is personally involved in a range of London-wide and national
Leading complex organisational change
Understanding of project management and complex change. Overseeing a continual programme of service change to address risks, and deliver financial balance. Includes understanding HR implications and the management of change with partners. Estates management skills
Developing the Trust
Focus on opportunities and market assessment. Process of open challenge to ensure focus on excellence is maintained over time.
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initiatives relating to innovation in mental health services, most recently with Lord Layard in the encouragement of psychological therapies to support people returning to employment.
As part of this application process, the Board has undertaken a development programme. This has centred around a series of Board Seminars. These have focused on: the Integrated Business Plan, Risk Management and the Assurance Framework, Improving Financial understanding and reporting, the management of Complaints and Incidents and the changes that the Board will make to its operation in order to be effective in a Foundation Trust environment. The ongoing development plan for the Board includes: - Strong focus on the development of activity based contracts - Focus on key risk areas and formal 6 monthly review to ensure that these remain the risks that the Board should be monitoring - Annual session with executive leads to update on issues in each area of the Trust - Further seminars focusing on both financial and clinical management issues. - Continued utilisation of key ratios to inform decision making. - Engagement with the Members‟ Council in strategy work. All members of the Board are subject to a process or appraisal of their performance. The Chair reviews the performance of Non-Executive Directors; the Chair and a committee of Non-Executive Directors review the Chief Executive‟s appraisal of Executive Directors; the Chair and Non-Executive Director‟s review the Chief Executive‟s performance, and the Chair and Chief Executive have had their performance reviewed by the SE London SHA. These reviews have been used to develop the skills of individual Board members and for the Board collectively to improve effectiveness in implementing the IBP. In addition the Board has held awaydays at least annually to reflect on its performance and to prepare itself in depth for the issues which face it in the year to come.
The Trust Executive The Trust has a strong executive team. The Chief Executive has led the Trust since its formation in April 1999, and the executive team as a whole contains a wealth of senior level experience across the range of mental health service provision, performance management, public engagement, commercial experience, national policy making, in academia, and service development. The table below summarises the Trust‟s view of the skills needed at executive level to run an NHS Foundation Trust and the range of skills and experiences developed by the executive team. The development of the Executive Team is progressed through regular (biannual) awaydays which focus on either developmental or operational issues (often both) and a monthly Developmental Executive meeting (see Appendix 7).
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Requirements Leadership and Collective working
Self-Management
Leading complex service change and organisational development in a context of increasing public scrutiny. Partnership working
Risk management and involvement in organisational governance.
Executive skills and experience The Executive team is experienced and stable, and has been working effectively together over a sustained period of achievement. There have been new appointments to the team to refresh skills, most recently in HR, in Estates and Facilities management and in Strategy, and they are active participants. The Executive meets four times a month, but has at least two awaydays a year to take stock of its own functioning and areas for development. As a result of this it is now able to function with two of the four meetings being for part of the membership concentrating respectively on governance and operational matters, and two with all members present - one focussing on developmental activities (including training for the whole team), the other on formal decision making requiring the involvement of the whole team. This has enhanced the ability to lead through others, remain strategic and collaborate as an Executive, while improving chairing and self-management skills that enable opinions to be voiced whilst bringing the group to decisions that are adhered to. As a matter of routine several members of the Executive have experience of chairing it to improve resilience and ensure that decisions can be made promptly. The whole executive undertook the NHS Leadership Qualities Framework 360 degree feedback process, and the Chief Executive encourages all members of the team to have personal mentors/coaches. This enables a large team to function effectively, but also enables very senior service directors to have a direct report to the Chief Executive, and to participate directly in discussions about the development of the Trust. This ensures that the Trust has high calibre senior managers with high levels of delegated authority working directly with local commissioners and local authority partners, but who are also directly connected to corporate decision making by the Trust. It also enables the Chief Executive and other corporate Directors to keep in close and contemporaneous touch with operational services without becoming unnecessarily involved in operational decision making. Team members have practical experience of leading change across systems and boundaries whilst working in an open and inclusive way. The Executive has delivered a significant amount of complex service change – new developments, reconfigurations and service closure – over the last seven years, often with a high degree of public interest and involvement. Some of this is handled at Service directorate level, some as a Trust wide project depending on the circumstances, priority and profile of the individual change programme. This has developed leadership and communication skills across the Executive team and left it with flexibility and resilience to deal with issues emerging in future. Service Directors play a leading role in a variety of local Partnership Boards involving a wide range of stakeholders. In addition the Trust has a long standing programme of events, processes and opportunities to engage with a wide range of people at a corporate level. These are coordinated by the Director, Developing Organisation and Community, but can involve all members of the Executive as appropriate.. There is a monthly process of performance management chaired by the Chief Executive, but involving all members of the Executive team. This lasts two days and enables each directorate to be held to account for its performance, but also the cross fertilisation of ideas about performance improvement (see section 9.1.4). The process explicitly addresses risk management and relates directorate risk registers to performance, cross checking for consistency and progress on actions. It also allows governance issues to be raised with individual directorates, for example in relation to Standards for Better Health. Professional Heads and Corporate Directors are involved in reviewing overall governance arrangements as members of the Governance Executive, and receive reports on the performance management process to consider in relation to those policies and systems,
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Clinical Service management
Financial management
People management Understanding of determinants of mental illness and social inclusion
There is deep experience and knowledge of clinical services management in the Executive team. Service Directors are from a mixture of general management and clinical backgrounds, but have many years experience of service management and leadership roles. The Professional Heads – who are, without exception, national figures in their fields do not have line management responsibilities for service provision with some small exceptions, but work closely with service directors to ensure that professional leadership and regulatory structures are aligned with the needs of service delivery. The team has successfully managed financial resources over seven years. Key to success in that has been the effective devolution of budgetary responsibility and budget management skills to team level. There is strong financial and HR support to each Directorate to ensure that there is a clear understanding of the Directorates current and underlying position. The systems and process for financial and HR management have been continuously developed to equip others to be involved more effectively.. Following the implementation of the Trust‟s electronic patient journey clinical information system the activity reporting systems are being upgraded to support fully integrated information reporting systems at team level. The Trust‟s IWL status reflects the skills of the executive team, and that the balance is right between clear and delineated rules and boundaries for staff and providing sufficient space for staff to feel valued and creative. This is critical to the delivery of the Trust Strategy. Service and Executive directors are leading work of national significance in building the context within which service users are more likely to be able to move forward to rehabilitation and recovery.
Organisational Structure The diagram in Appendix Seven shows the Trust‟s Organisational Structure. Also set out in this appendix are the Terms of Reference of the different Trust Executive meetings. These give a clear description of powers delegated to the Trust Executive. Further detail on governance structures are provided in Section 9. “Freedom within a Framework” – The Trust management approach The Trust is proud of the effective working relationships between all staff groups. Multi-disciplinary working is at the heart of effective mental health services and this approach underpins all aspects of our work. The quality of clinical care is led from the executive by the professional heads, who lead professional development across the Trust. There is material clinical involvement in management, and an expectation of partnership and team working to deliver services at all levels in the organisation. This is essential to both the delivery of high quality care, and the effective management of risk (often two sides of the same coin). Responsibility for performance is, similarly, shared. Every clinician is in a matrix structure of professional and line management accountability. . At a leadership level, this
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matrix structure is reflected in a quarterly Senior Leaders Group meeting. All this has informed, and strengthened the Trust‟s approach to change management. We involve service users, carers and staff, whenever possible, to ensure that we take account of directly reported experience of using and delivering services to inform change in service delivery. Similarly, the directorate based planning and delivery structures bring together all partners to decide the local delivery of services for each care group. These structures are highly effective, and mean that the Trust Executive can take a more strategic overview of management within the Trust. As part of the process of developing this Integrated Business Plan, the Trust has considered the extent to which these structures are fit for purpose. A particular area which has been addressed is the extent to which they allow the Board to be assured that standards and processes are consistently achieved across the Trust. Following this consideration, the Trust has confirmed its view that the current management structure strikes the most operationally and strategically appropriate balance between the promotion of management autonomy and sufficient corporate oversight and control. Areas in which cross directorate working is advantageous are co-ordinated through a Project Board or Committee approach. These groups operate with delegated authority from the Trust Executive and are chaired either by members of relevant directorates or by the Chief Executive or Director of Strategy. This approach has been successful in enabling the Trust to respond in a coherent manner to key strategic and operational demands, whilst maintaining an appropriately devolved structure. Examples include: - The Forensic Services Project Board – responsible for the development of new forensic services (section 5.2.1.1 and 5.2.1.2) - The In-Patient Services Project Board – responsible for reviewing, changing and developing in-patient estate across all services in Lambeth and Southwark (see Section 5.1.2.25) - The Service Planning and Performance Development Group – co-ordinates the Business Planning Process across the Trust - The Trust Bed Management group – responsible for co-ordinating approaches to bed management across all Trust directorates.
8.1.2
Workforce KPIs
The Trust currently directly employs 4844 people. The table below shows some of our major workforce indicators.
Staff Consultant Non Career Grade Junior Dr Qualified Nursing Unqualified Nursing AHPs
H/count 198 58 244 1733 641 319
Wte 161 52.02 238.8 1650.14 602.83 266.55
F/Time 120 45 231 1510 554 204
P/Time 78 13 13 223 87 115
Male % 58.59% 46.55% 50.00% 36.58% 37.29% 24.14%
Female % 41.41% 53.45% 50.00% 63.42% 62.71% 75.86%
BEM % 52.06% 68.95% 68.85% 64.97% 70.97% 37.31%
Sick % 0.30% 0.29% 0.45% 5.88% 7.94% 3.61%
T/Over % 11.11% 22.41% 35.66% 10.79% 11.08% 14.73%
Stability 88.38% 98.28% 98.77% 99.48% 97.35% 93.10%
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A&C Senior Ancillary Maintenance Clinical Psychology TOTAL
912 161 97 33 41 407 4844
814.16 154.02 88.92 32.013 35.14 326.54 4422.133
658 142 76 29 28 243 3840
254 19 21 4 13 164 1004
19.19% 42.86% 62.89% 84.85% 48.78% 21.87% 34.21%
80.81% 57.14% 37.11% 15.15% 51.22% 78.13% 65.79%
44.85% 39.12% 45.35% 24.24% 63.43% 41.29% 65.23%
4.62% 2.47% 7.82% 10.40% 6.57% 1.45% 4.86%
13.49% 9.32% 10.31% 15.15% 26.83% 18.18% 13.73%
99.67% 80.12% 105.15% 109.09% 97.56% 93.86% 97.36%
In addition, the Trust has seconded staff from Croydon, Lambeth, and Southwark Social Services departments. These staff work as part of our integrated Community Mental Health Services. Our close links with the Institute of Psychiatry results in an additional 80 consultants who hold honorary contracts with the Trust. 8.1.3 Agency and Recruitment Arrangements
The Trust operates an internal Bank system (Trust Temps). This is the conduit for all bookings of temporary staff. The Trust has put in place preferred provider arrangements to contain unit costs. These are covered by PASA agreements for nursing and medical staff. The Trust has, however, identified the need to develop similar in house provision for medical and administrative temporary staffing. In order to ensure that the right people are recruited to the right jobs, the Trust has centralised recruitment to campaigns teams. Recruitment is linked to the competencies required to carry out a certain post. In turn, this will link to KSF outlines as these are developed for all posts within the Trust. All mangers who carry out recruitment have been trained in this approach. The Trust is also able to make use of its role as a provider of clinical education and training to attract recruits into roles within Trust services. 8.1.4 Recruitment hotspots and actions to address
There are certain recruitment hotspots at points in time. However, these tend to be within specific services or areas, rather than relate to difficulties in attracting specific groups of staff. Whilst there are variations in vacancy levels across staff groups, these are, broadly, in line with comparator trusts. Where there is work to be done, however, is in addressing levels of sickness and turnover, and the representation of BME staff within the workforce. As a result, we have consulted on and are subsequently implementing a Trust Human Resources Strategy (Our People, Our Vision). This sets the following goals:
To become the market lead employer in the Sector. To fully develop our Staff, not least by implementing the education and training strategy. To improve staff morale
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To increase people management skills. To support service delivery, innovation and modernisation
The detail of the objectives of the Strategy is set out in Appendix Eight. The 2005 NHS Staff Survey (which reflects the first year of implementation of the Trust HR Strategy shows that in 15 of the 28 areas covered by the survey, the Trust results have shown a statistically significant improvement. One of the most positive findings in this survey was that 98% of staff in the Trust had received training in the last 12 month. The table below sets out the areas that we will be focusing on in implementing this strategy, how it impacts on areas such as Pay Modernisation, and how we believe it will impact on the Trust KPIs set out above. The table details work that will need to be done to put the strategy into place. Strategy Workforce KPIs Impact Agency and Recruitment arrangement Implement the Electronic Staff Record (ESR) and erecruitment. Review targets for reducing recruitment episodes. Recruitment Hotspots Agenda for Change (AfC) European Working Time Directive (EWTD) Maintain position of 100% compliance with EWTD. Undertake a more detailed analysis of medical out-ofhours roles, evaluating the move to shift working. Consultant Contract Relationship with Unions
Becoming the Market Lead employer
Revised KPIs as follows: Vacancy Target of 12.7% in 2006/7, reducing by 1% per year every year until 2010/11 Sickness rate of 5.1% in 2006/7, reducing by 0.3% per year every year until 2010/11. Turnover rate of 13.5% in 2006/7 reducing to 11.5% by 2010/11. Stability to remain at over 85% (90% in 2004 and 89% in 2005). Agency/Bank/Overtime reducing from 17.6% of paybill in 2006/7 to 12.6% in 2010/11.
Review and benchmark underlying trends to ensure that we fully aware of our comparative position. Review vacancy targets across directorates. (see KPI column) Take particular account of retirement issues over next five years. Raise the proportion of
Increase the proportion of staff with Performance Appraisal and PDPs to 100% Identify the proportion of BME staff working at Band 6 or above. Identify the proportion of new and redesigned posts that take account of AfC flexibilities. Increase this year on year.
Maintain at 100% the proportion of consultants with job plans that clear specify their role and responsibilities.
Maintain the Partnership Agreement with Trade Unions. Review the role of the Joint Staff Committee to ensure that it fits with new governance arrangements. Achievement of IWL Practice Plus a joint achievement with Unions. Implementation of AfC being carried
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To fully develop our Staff.
Implementation of the Trust forecasting model, enabling us to predict requirements more effectively (see section 8.1.4) Enhance equality and diversity monitoring, and the implementation of the Positively Diverse programme.
Assumption of reduced reliance on agency staff as a result of reduced vacancy rates. (see KPI column)
staff using flexible working options from 70% to 80% by 2010/11. Increased availability of flexible learning and development. Ensure that 100% of staff have an up-todate Personal Development Plan. Achieving sickness, vacancy and turnover KPIs.
out in partnership with unions.
100% of staff with completed appraisal and PDP against KSF outlines..
Continued compliance with EWTD.
Increased % of consultant staff under new contract arrangements. 100% of all job plans renewed annually.
Increased staff involvement in this group. 5 learning representatives identified by April 2007.
Improving Staff Morale
Implement the Trust HR strategy to raise staff satisfaction (as reported by the annual staff survey) from 3.5 to 3.8 (highest in London) by 2010/11.
To increase People Manageme nt skills
Implement the Trust Leadership and Management Development Strategy to raise staff satisfaction (as reported by the annual staff survey) from 3.5 to 3.8 (highest in London) by 2010/11. An increase in staff perception of high quality leadership in the staff survey.
Improved morale impacts on sickness rates, and, in turn, on use of temporary staff (achieving KPIs set out in column 1). Impact on achievement of KPIs.
100% of managers training in use of the Knowledge and Skill framework.
Continued compliance with EWTD
100% of consultants receive a reviewed job plan.
Aim to develop staff so that between 10% and 12% of all vacancies filled are the result of promotion within the Trust.
100% of managers‟ covered by the Management and Leadership Development framework.
Continued compliance with EWTD
100% of consultants receive a reviewed job plan
Partnership agreement with Joint Staff Committee. Joint approach to service disinvestment issues. Schedule of joint training on policies and procedures. Ensure that formal industrial relations cases are not disproportionately
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To support service delivery, innovation and modernisa tion
Implement Trust Capacity model planning tool to provide clarity about service expectation, and efficiency targets. (section 8.1.4) Review HR KPIs as part of the Trust Balanced Scorecard (see Section 9.1.4) to assess strategic achievement.
Reduction in agency usage through better use of role redesign, contributing to achievement of KPI.
100% of KSF outlines linked to service delivery.
Continue to maintain 100% EWTD compliance when developing services.
Increase to 75% by 2010/11 the percentage of consultant time focused on direct clinical contact.
from certain sections of the workforce. Awareness of Business Plans and predicted impacts shared with Staffside.
Development of the workforce. The Trust has in place a number of processes to ensure the effective development of the workforce. These lie behind the Trust KPI relating to the percentage of the vacancies filled by promotion, and include: Appraisal and Personal Development Plan processes. These ensure that all members of staff have an annual appraisal and Personal Development Plan that address areas of weakness and develop areas of strength. These are being revised in light of the implementation of the KSF, and training has been provided to appraisers and appraisees to ensure that this system remains an effective means of staff development. The Trust Education and Training Strategy provides the training and education framework that ensure that staff remain skilled to provide the services required. Levels of training include mandatory training (focused primarily on safety and statutory requirements), and professional and skills development. Training and Education provision also considers how to address issues at a team, as well as an individual, level. Particular workforce development (particularly team development) issues are addressed through the internal consultancy provision provided by the Trust Consultancy Service. This service works with teams to address issues of effectiveness, and is a successful intervention at that level. In the 2005/06 financial year, the Consultancy Service provided 467 days of input to Trust teams (covering 24% of Trust staff). Team development work is also ongoing in a number of Trust teams, using the Michael West model of Team Effectiveness. Profession specific development programmes such as the Band 6 development programme for nurses and the OT development programme. The implementation of the Trust Leadership and Development Strategy (appendix 20)
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Specific structures in place (and a specific development programme) for administrative staff
Development of the Organisation Notwithstanding the Trust‟s view that the organisational arrangements that are in place are suited to the requirements of operating as a Foundation Trust, there remains a significant organisational development agenda that the Trust will need to address over the course of this IBP if the targets within it are to be achieved. Areas to be addressed will be: Contract and Customer focus, “Reaction time,” consistency in service delivery, and an Outcome focus. The detailed implementation plan in these areas will be developed following the Trust Conference in July 2006. This Conference will bring together (for the first time), Senior Managers, Consultant Psychiatrists, Consultant Psychologists and Team Leaders to plan the organisational development of the Trust. In doing so, it will develop a shared Trust approach to future challenges in line with the areas set out above. The following table sets out the Trust response to anticipated changes to the Trust workforce, relating to proposed activity levels and service changes. Change Service Changes – disinvestment (Section 5) Service Growth (Section 5) Impact of retirement Productivity (capacity utilisation) – Appendix C Impact and Plan Trust is working in partnership with staff side to address the impact of changes. +200wte forensic staff. Skill mix reviewed in line with role redesign principles. Team effectiveness programme in place. -230wte (5%) over the five year period of this IBP, assuming that all staff retire at the statutory retirement age. The impact of this is spread across all directorates, and falls mainly on the A&C and unqualified nursing groups (both 7%). The Trust will address this through the recruitment, role development and retention strategies set out above. Over the five year period, the Trust will put in place training and development programmes that provide professional pathways that support the predicted and strategic move away from in-patient services and into more community provision. The Trust will also put in place the relevant training and support programmes to enable efficiencies to be achieved from more flexible working options.
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South London and Maudsley NHS Trust Integrated Business Plan Chapter 9. Governance Arrangements (Final Draft – 1st June 2006)
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9. 9.1.1
Governance Arrangements How stakeholder interests will be represented
Public - Elected LSLC Service Users National Service Users Carers LSLC Public National Public
6
3
3
5
3
NEDs = 7 or 8
7 to 8 4
Stakeholders Croydon PCT Lambeth PCT Lewisham PCT Southwark PCT
Board of Directors Executive Directors Chief Executive Finance Director Medical Director Nursing Director DOC Director Provision for 2 additional Executive Directors
Chair
Board of Governors = 39 Croydon LA Lambeth LA Lewisham LA Southwark LA
4
5 to 7
6 1
King‟s College London (IoP) Guy‟s & St Thomas King‟s College Hosp National Charity
Staff - Elected
3
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1. 1.1
Membership: Public Constituency: The Trust plans to have two Public Constituencies as follows: One constituency based on the local authority electoral areas that make up the London Boroughs of Croydon, Lambeth, Lewisham and Southwark. One constituency of an area covering the rest of England and Wales It is envisaged that a significant number of service users and carers of the Trust that do not want to be identified as such, will register as members in the public constituency. Whilst the majority of the Trust‟s services are based within the London Boroughs of Croydon, Lambeth, Southwark and Lewisham, there are a significant number of substance misuse services in Bexley, Bromley and Greenwich. Furthermore there are a few services outside South East London and there is certainly the potential that in the future the Trust will work closely with services across South East England and beyond. It will be important for residents neighbouring all the Trust‟s services as well as potential service users to have a voice in the strategic direction of the Trust especially as a significant proportion of the Trust‟s work is based in local communities. However, as most of the Trust‟s services are based in the London Boroughs of Croydon, Lambeth, Lewisham and Southwark and local Trust services are configured on a Borough basis it is seen as important that this area is recognised in the Membership and on the Members‟ Council (Board of Governors). It is envisaged that each borough will recruit Public Members in their own way and engage with them through the development of existing forums. . The Trust‟s Specialist Directorate works with service users from across the UK, details of numbers are provided in Table 1. As mental health treatment, and in particular the Recovery Model, involves working with psychosocial factors, it would be beneficial to enable the relatives, friends and neighbours who are not direct carers of service users to have a stake in the organisation that provides their care and support. Table 1 Service users seen in 2004/05 by Specialist Services Region North of England Midlands and East of England South of England Wales
Inpatients 10 137 176 13
Outpatients 19 418 977 26
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London (not including LSL&C) Ireland Scotland Channel Isles Other Oversees Total
449 1 5 5 0 796
1470 1 4 11 2 2928
The Trust has a reputation well beyond South East London for leading the way in certain aspects of mental health treatment and care, and together with the Institute of Psychiatry, for pioneering research into mental health issues. The Trust recognises that mental health issues can affect a large number of people irrespective of where they live, and there will be a wide range of people who would like to lend support to the Trust. Indeed a number of people from around the UK and abroad have expressed an interest in becoming members. The Trust‟s networks include national charities and research bodies and it is through these the Trust hopes to recruit and develop its Rest of England and Wales Public Constituency. Membership of the Public Constituency will be open to any person of 16 years of age or above so as to enable relatives and friends of patients to demonstrate their support for the Trust. We will however consider ways in which under 16's might participate in the activities of the Trust without becoming full members (so that they might be interested in becoming members when old enough). Benefits for younger members include developing an awareness of Mental Health issues and in particular how to maintain mental well being. The specific issues it is envisaged that children and young adults under eighteen years of age will be able to contribute to include: development of child and adolescent services, development of facilities in hospitals for young people who are relatives and friends of patients, advice on improving longer term support for young people who are relatives and friends of patients, improving information available to young people on mental well being and mental illness.
1.2
Service Users and Carers Constituency: The Trust plans to have a Patient Constituency that would include carers, this will be called the Service Users and Carers constituency. This constituency would be divided into three classes, namely: Service Users living in the London Boroughs of Croydon, Lambeth, Lewisham and Southwark; Service Users living in the rest of England and Wales Carers The reason for having a separate constituency for patients is to ensure that service users and carers have an identified voice on the Members‟ Council (Board of Governors) and to ensure there is a strong presence of service users amongst members that is explicitly recognised. The constituency will be for Trust service users and their carers who have attended Trust sites over the previous 5 years.
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It is envisaged that the Service Users and Carers membership will include service users resident outside England and Wales. The Specialist Services Directorate does work with service users from Scotland and the Channel Islands, see table 1 for details. The Trust intends to adopt an opt-in system for Service Users and Carers membership with the aim of working to develop a quality membership of service users and carers who are aware of the benefits of membership and the responsibilities it entails. It will be the responsibility of each member to notify the Trust when they become ineligible to be a member of their respective constituency.
1.3
Staff Constituency The Trust proposes to have a single staff constituency, to reflect multidisciplinary working. This constituency will also include Institute of Psychiatry and Social Services staff who exercise functions for the purpose of the Trust for 12 months or longer. The constituency will also include Bank staff and staff of partner agencies (for example: Grosvenor Nursing Agency, Belle Recruitment, ISS Mediclean; Dalkia; Family Health ISIS; Hexagon Housing Association, Penrose Housing Association) who also exercise functions for the purpose of the Trust for 12 months or longer. The staff constituency will also include volunteers who carry out functions for the purpose of the Trust. It is proposed that people on the Patient and Public Involvement Register will be ineligible to become members of the staff constituency. The rationale for including staff of partner organisations is to be as inclusive as possible and support partnership working in keeping with the Network Approach. As for the above constituencies it will be the responsibility of each member to notify the Trust when they become ineligible to be a member of their respective constituency. The Trust intends to adopt an opt-in system for staff membership with the aim of working to develop a quality membership of staff who are aware of the benefits of membership and the responsibilities it entails. An opt-out approach will be used for new joiners and for current staff applying for new posts, this is because the Trust will promote itself as a Membership organisation and new staff will be encouraged to start their new roles as signed up members. The Trust intends to use the “network approach” and existing communications mechanisms as noted in the internal communications strategy to recruit and develop existing staff as members.
1.4
Eligibility for Membership The Trust is intending to include the following further restrictions to eligibility for Membership beyond that defined in the Health and Social Care (Community Health and Standards) Act 2003:
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Any person found to be in breach of the Trust‟s procedures for the protection of patients and staff from violence and abuse. Any former employee dismissed for gross misconduct. Any person removed as a member by the Members‟ Council or Board of Directors, unless their application has the approval of the board which removed them. Anyone who has been considered a vexatious complainant by the Trust. Anyone who: prejudices the ability of the Trust to fulfil its purposes or otherwise to discharge its duties and functions harms the Trust‟s work with other persons or bodies with whom it is engaged or may be engaged in the provision of goods and services adversely affects public confidence in the goods or services provided by the Trust otherwise brings the Trust into disrepute All members will be expected to confirm their commitment to the Trust‟s code of conduct for members. Members’ Council (Board of Governors) The body referred to in the Health and Social Care (Community Health and Standards) Act 2003 as the Board of Governors will be called the Members‟ Council. The reason for this is to avoid confusion with the Board of Directors and avoid members misconstruing the council as having a governing role. It is envisaged that the Members‟ Council will be one element of the Membership „voice‟ and emphasis will be placed on developing structures and processes to allow members more broadly to engage with the organisation. With this in mind it is intended that the Members‟ Council‟s role will be in addition to the statutory requirements to take an overview of other service user, carer, staff and public forums to inform their work with the Board of Directors. The statutory duties include appointing (and removing) the Chair and Non-Executive Directors, approval of the appointment of the Chief Executive, appointment or removal of the auditor, to receive the annual reports and accounts and to receive the report of the auditor. The Board of Directors will have regard to the views of the Members‟ Council on forward planning.
2. 2.1
2.2
Structure: It is proposed that 6 Council Members will be elected from the Croydon, Lambeth, Lewisham and Southwark Service Users class, 3 Council Members will be elected from the Rest of England and Wales Service Users class, 5 Council Members will be elected from the Croydon, Lambeth, Lewisham and Southwark Public constituency and 3 Council Members will be elected from the Rest of England and Wales Public constituency.
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Six of the representatives on the Members‟ Council will be elected from the staff constituency. This is to recognise the importance of staff members‟ roles in the public benefit corporation and to ensure that a range of staff groups are represented with adequate influence on the Members‟ Council. Professional heads and their equivalents for non-professional groups will be expected to put in place arrangements to ensure that individuals from their respective groups of staff are developed and encouraged to put themselves forward for nomination for election to the Members‟ Council. Similarly directorate leads will be expected to put in place similar arrangements to encourage a range of staff from different directorates to be nominated for election. The four PCTs of Croydon, Lambeth, Lewisham and Southwark will be invited to appoint representatives to the Members‟ Council, as will the local authorities in these four boroughs. These representatives will sign up to a code of conduct that will emphasise an undertaking to represent the views of Bexley, Bromley and Greenwich PCTs and local authorities as well as any other PCTs and local authorities that commission services from the Trust or provide services for the Trust. One representative on the Members‟ Council will be from King‟s College London, the medical school associated with the Trust. The partner organisations on the Members‟ Council will be representatives from: Guy‟s and St Thomas‟ NHS Foundation Trust, King‟s College Hospital NHS Trust and London Strategic Health Authority. The organisations would be expected to represent the views of all health organisations that the Trust works with. A fourth partner organisation representative would be from a national charity and would be asked to represent the views of all voluntary agencies that the Trust works with. The Trust is currently drafting a code of conduct for the Members Council. This will clearly state the requirement of Council Members to represent the views of other parties where appropriate. For example it is expected that the Council Members from the PCTs will represent the views of all the PCTs the Trust works with. Nonetheless it is recognised that the Members‟ Council is an inadequate vehicle for involving partner organisations and forums are being mapped to be identified for ensuring this engagement. It is not intended that the Members‟ Council will diminish the importance of the existing partnership working mechanisms. The person fulfilling the Trust Secretary role will draft standing orders for the Members‟ Council. These are to be ratified by the Members‟ Council as soon as practicable after it is formed. The standing orders will outline the decision making process for the Members‟ Council including what constitutes a quorum, voting rights, role of the chair, forming working parties, holding meetings in private as well as a dispute resolution process.
2.3
Elections The method of electing the Service Users and Carers, Public and Staff representatives on the Members‟ Council will be the Single Transferable Vote system based on the recommendations of the Report of the Independent Commission on the Voting System (the Jenkins Report).
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2.4
Terms of Office Representatives on the Members‟ Council may hold office for no more than 3 years. The Trust is considering how to stagger terms so that the whole council does not come up for re-election at the same time. It is likely that the Election Rules will stipulate that Council Members that were elected last in the first elections will stand down after 2 years to enable the Trust to stagger elections in the future. There will be no limit on the number of terms for which Council Members may be elected. The Trust is intending to include the following further restrictions to eligibility for the Members‟ Council beyond that defined in the Health and Social Care (Community Health and Standards) Act 2003:
Directors of the Foundation Trust If Monitor has exercised its powers to remove that person as a Member of the Members‟ Council of the Trust If they have within the preceding two years been dismissed, otherwise than by reason of redundancy, from any paid employment with a health service body If they are a person whose tenure of office as the Chair or as a Member or Director of a Health Service Body has been terminated on the grounds that his appointment was not in the interests of the health service, for non attendance at meetings, or for non-disclosure of a pecuniary interest Representatives on the Members‟ Council may be removed if they do not abide by the Members‟ Council code of conduct. The Members‟ Council will decide by a resolution to remove a Members‟ Council representative. 3. Board of Directors The Board of Directors will consist of the Chief Executive, the Director of Finance, the Medical Director, the Director of Nursing and the Director Developing Organisation and Community. The constitution will allow between four and six Executive directors in addition to the Chief Executive. The constitution will allow seven or eight Non-Executive Directors and the Chair, all appointed by the Members‟ Council. The Members‟ Council will in consultation with the chair form a committee, to appoint the Non-Executive Directors and to agree terms and remuneration for the Non-Executive Directors. Each of these committees will be composed of at least one representative from Public, Patient, Staff and Partner representatives on the Members‟ Council. The composition and skill mix of the Board of Directors will in the first years of the Trust reflect the aspirations of the Service Development Strategy.
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4.
Constitution Consultation on the draft constitution has taken place with a range of stakeholders.
4.1
Amendments to the constitution In future years the constitution may be amended only by recommendation of the Constitution Working Party, formed of representatives from the Board of Directors and Members‟ Council. Any amendments to the constitution must be approved by a majority vote on each amendment made at an Annual General Meeting or Extraordinary General Meeting of the Members Council and with the approval of Monitor. The Proposed Constitution, with changes to the Monitor model tracked, and the rationale for them, is attached as appendix 35.
Membership Development 1. Introduction South London & Maudsley NHS Trust will build on the values and principles of co-operative and mutual organisations in developing membership. This document outlines how the trust will build focus on: Voluntary and Open Membership, by adopting an opt-in approach to membership, Democratic Membership, by using a network approach to ensure that the membership, that will elect the majority of the Members Council, reflecting the demographics of the communities we serve. Member Participation, by adopting an approach that focuses on engaging the membership actively in the Trust beyond the work of the Members Council Autonomy and Independence, to give service users and carers, staff and local communities a say in how mental health services are provided and to give local services the freedom to develop to meet the needs of service users, carers and communities whilst maintaining high standards Education, Training and Information, by engaging in a mutual learning process with the service users, carers and members of local communities in how to develop and provide appropriate services, that will improve mental well being for all. Co-operation, by working with new and existing partners to develop the health economy in South East London
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Community, by taking a community development approach to go beyond the limits of the health service in order to promote and improve mental well being in our local communities.
2. Developing the Membership: The Trust is planning to take a “network approach” to recruiting and developing membership. This is illustrated in Appendix 32 entitled “Network Approach to Recruiting and Developing Membership” It is envisaged that using this approach will help to establish a representative membership. The approach suggests using a number of existing networks and developing new networks to establish an enduring mechanism for recruiting, developing and communicating with membership. This will entail working closely with the organisations that we commission services from, to encourage their service users/members and employees to express an interest in becoming public members of the proposed SLaM NHSFT. We also intend to work with other partner organisations in the same way – essentially developing a network of organisations in local communities that will make up our public membership. Partner and community organisations include: local authority departments, non-profit agencies, social enterprises, schools and Children‟s Trusts, the police and probation, community and voluntary groups including faith groups, and residents‟ groups. Working with the latter organisations will ensure that the public that may not already have a connection to the Trust will have an opportunity to engage and become members. In practice the “Network Approach” will work through local directorates in the Trust who will initially liaise with the groups mentioned above and will be supported centrally by the Membership Group and Developing Organisation and Community Unit. In developing links with groups we will build on the existing good practice of outreach such as mental health promotion work and community development approaches within the Trust. This approach will not exclude individuals from becoming members and in tandem with the above we are recruiting membership through means such as an Internet web site, advertising, leaflets, open days and membership recruitment events. As the Trust is adopting an opt-in system for patient and staff membership it is envisaged that the recruitment of membership will be an extended process. The aim being to develop a large membership that is fully signed up to the Trust values and the principles of a public benefit corporation. It is envisaged that initial uptake of membership will be moderate but as momentum is gained and enduring processes for developing membership are established the membership will increase significantly. The Trust sees value in the membership over and above the Members‟ Council. With this in mind the membership will, through individual 1 “conversations” , be asked what „skills‟ they can offer the Trust in order to establish roles for members in the structures and processes of engagement with the organisation. Once individuals have shown an interest in becoming members, the Trust intends to survey skills and interests that might be of
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The Trust plans to create ‘self portraits’ of members to gain a better understanding of what the Trust can offer members and of what members can offer the Trust.
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benefit to the Trust. In return the Trust anticipates that by offering the opportunity for active engagement to members it will be helping them maintain and improve their mental well being. The Trust will consider ways in which under 16's and interested parties resident outside England and Wales might participate in the activities of the Trust without becoming full members (so that they might be interested in becoming members when old enough). The Trust Membership Strategy and Members‟ Recruitment plan are detailed in appendices 33 and 34 respectively. 3. Benefits of Membership: It is envisaged that the benefits of membership for service users, staff and the public will be: To elect representatives to the Members‟ Council (H&SC Act 2003) May become a Members‟ Councillor (H&SC Act 2003) May become a Non-Executive Director (H&SC Act 2003) Help us put mental health on the map and become part of a network of people who take an active interest in their own health and the health of the communities they live and work in. Add your weight to the voice of SLaM membership and Help us make the most of membership to create a strong organisation for public benefit, accountable to service users and carers, staff and local communities. An opportunity to influence the Trust's strategic direction. An opportunity to engage in a Conversation with the Trust about the services we provide and to influence service provision. Get information on mental health and well being. Make us truly representative. Reduce stigma and discrimination. A password protected web site - opportunity to go to a virtual Partnership Time Event, discussion forums, information on Mental Health & Well Being.
4. Targets for membership:
Constituency
Croydon ,Lambeth, Lewisham, Southwark Service Users Rest of England & Wales Service Users Carers Staff Croydon, Lambeth, Lewisham, Southwark Public
Dec 05 actual 25 213 64
Mar 06 actual 67 360 88
June 06 actual ~80 ~20 45 495 134
Sept 06 400 300 300 1000 800
Dec 06 600 400 400 1200 1000
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Rest of England & Wales Public Total
302
44 515
96 872
300 3100
400 4000
These figures were arrived at by weighing up the demands of having a large membership that will support democratic elections and be representative of local communities and a manageable membership for communications and engagement whilst ensuring cost effectiveness.
5. Ensuring Representative Membership It is through the network approach that the Trust hopes to develop a representative membership. This will be done by regularly monitoring the demographics of the membership and comparing that with the demographics of the populations from which the membership is drawn. Where there are under represented groups the Trust will identify organisations in its networks that have contact with these groups and will work with these organisations to recruit members. In areas where engagement in the membership are facing particular challenges such as children and adolescents services, older adults services and learning difficulties services the Membership, Governance and Communications Group will work with the service user involvement officers and the Public and Patient Involvement leads for these areas to develop appropriate ways of engaging with these groups. In order to ensure representation of minority ethnic groups in the membership we will build on the existing links with minority ethnic partner organisations in the borough based directorates. A similar approach will be used to ensure the membership is representational by gender, geographical location and socio-economic status. The Trust has procured services from a private sector membership management organisation to manage and monitor the membership database. In the longer term the Trust intends to undertake a formal procurement process to find an organisation that can meet its needs for membership database or perhaps manage the membership internally. The Trust has a Membership, Governance and Communications Group that will regularly monitor the membership and put in place arrangements for the long term. The Trust does not underestimate the complexities of ensuring membership is representative given the high diversity of the areas where the Trust provides its core services. The Trust‟s Developing Organisation and Community directorate focuses on community development, and there are leads in each directorate for Equality and Public and Patient Involvement. There are a number of forums set up in the Trust to progress the work and monitor Diversity and Equality issues and it is envisaged that these will all play a role in ensuring that the Membership is representative. To illustrate the diverse nature of the Trust‟s populations Appendix B provides details of the demographics for the populations eligible to join the Public and Staff constituencies. The details relating to the Patient constituency are included in the Integrated Business Plan.
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6. Structures supporting the Members’ Council The Trust‟s strategy has 5 bold ambitions namely: 1. To offer the people we serve the best mental health services possible, tested against the best in the world. 2. To go beyond the limits of health services to promote and improve mental well being in our local communities. 3. To reduce illness and promote social inclusion – “to keep people in their lives” including supporting them when they choose to change their lives. 4. To attain the highest standards in the management and professional leadership of mental health services. 5. To implement rapidly and systematically, improvements in care based on evidence of the best that is possible. It is proposed that once the Members‟ Council is in place, non-executive directors, executive directors and Council Members will develop these themes providing tangible workstreams to involve the wider membership. In parallel with developing the membership arrangements for the proposed Foundation Trust, the organisation continues to build on its long standing commitment to involving service users and carers in all its governance arrangements. Currently, we are working on a number of ideas developed by a recent joint staff/service user “PPI Creative Group”. These focus on three areas: a) Further enhancing our proactive service user and carer involvement through working with existing local user groups to develop a new, Trust wide service user grouping able to provide a strategic input to service development and evaluation across all our service streams (currently being discussed with the Trust‟s PPI Forum); consolidating and improving arrangements to ensure that clients who wish to engage with us have the training and support required to do so effectively; developing a structure of formal role descriptions for service user or carer consultants to ensure that opportunity and inclusivity are maximised and that people are able to identify and access the roles best suited to them; considering the development of an annual conference / event, organised jointly with service users and carers, to share best practice in Patient and Public Involvement (including external developments and ideas) and to reward achievements in this area and ensuring that all of the above take full account of the needs of ethnic and other minority communities locally
b) Working with staff at all levels to ensure that public and patient involvement is incorporated in all aspects of their work through developing a PPI workbook with clear guidance on consultation and engagement strategies applicable at individual, team and service levels engaging staff in the putative PPI conference as above and rewarding success through the Trust‟s existing Clinical Governance Awards scheme and the proposed PPI awards as above
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c) Developing innovative ways of evaluating involvement activity and in particular adapting the locally developed Mental Well Being Impact Assessment tool to ensure that Work done on PPI has – and can demonstrate – a positive impact on client experience of services PPI work is effectively implemented across the organisation and that systems are in place to share innovations and learning Our experience, successes and failures can be shared with others working in health and social care and in particular our partners in the local health economy It is envisaged that members and in particular the Members‟ Council will take a lead role in developing some of these structures, in particular the PPI conference. These structures will, through their membership, link to the Members‟ Council for feedback on the strategic direction of the Trust. It is also intended to have Special Interest Groups of the Member's Council to ensure that Children‟s and Older Adults‟ interests are considered. The Developing Organisation and Community Unit together with the Chief Executive‟s Office are developing a Membership Office function to support the Members‟ Council and wider membership and provide links to the areas above. This function is developing a workplan that will include putting in place support structures for the Members‟ Council such as induction, training, seminars and mechanisms for linking with the Board and the Membership. 7. Evaluating the Membership Development Strategy In evaluating the impact of the membership the Trust will build on a number of established mechanisms. Among these are: the Annual Patient Survey and the Annual Health Check consisting of a self assessment by the Trust evaluated by the Healthcare Commission consultation with our partners, stakeholders and local community. This will be based on the seven dimensions of Standards for Better Health. It is proposed that the Members‟ Council will take responsibility for evaluating the Membership Development Strategy and further development of the strategy. This will be supported by the membership office function mentioned above. 8. Reporting to the Independent Regulator As part of Monitor‟s Compliance Framework the Trust is obliged to provide regular reports on election results, membership numbers and turnover, membership targets for the following year. The Trust will also need to submit an annually updated membership strategy that identifies how a representative membership will be achieved.
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9. The Relationship between the Board of Directors and the Members’ Council The Board of Directors is the body responsible for the operation of the Trust in accordance with the 2003 act. The Members‟ Council will be responsible for appointments as outlined above (section 2). Whilst the Board of Directors will pay due regard to the views of the Members‟ Council, it will remain the body responsible for governing the Trust. The Trust is, however, proposing to put a number of processes in place to facilitate joint working between the Board of Directors (the Board) and the Members‟ Council. The aim of these processes is to ensure that both bodies are clear about their respective roles and supported to carry them out. These include: The Members‟ Council will meet 3 times per year. All Board members will attend Members‟ Council meetings. Members of the Members‟ Council will be offered the opportunity to contribute to the development of Trust Strategy through the five strategy workstreams (section 3.1.2). Each of the working groups will include a non-executive and executive Board member. There will be an additional workstream focusing on areas as proposed by the Members‟ Council and agreed by the Board of Directors. The ability to establish ad hoc working parties will be possible as agreed by the Members‟ Council and the Board of Directors. The Board is to have a standing agenda item (every three months) for the Members‟ Council to report on progress, raise issues requiring a formal reponse and receive questions from the Board, Council Members will receive minutes and papers of Board meetings and have an open invitation to attend all public Board meetings. The Board is to present a forward planning issue to each formal Members‟ Council meeting in order to familiarise the Members‟ Council with the forward plan and seek further comment from the Members‟ Council. To have an annual awayday for the Board and Members‟ Council to consider the annual plan before final approval. The Members‟ Council is to report to the Board on the membership strategy as developed by the Members‟ Council
Communications with constituencies: The Trust will support the Members‟ Council to maintain a dialogue with members and other stakeholders via facilitated meetings and forums, surgeries, Trust e-mail addresses and on-line discussions. The Trust will also facilitate dialogue with the PPI Forum, OSCs, service user groups, carer groups and staff groups as appropriate. Dispute Resolution: Disputes should be resolved through discussion between relevant members and the Members‟ Council and the Board. However, in the event that any dispute remains unresolved, the Board and Members‟ Council will take decisions in line with their respective roles. That is, the Board of Directors will remain the decision making body, with the Members‟ Council retaining sanctions as set out in the constitution.
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Proposed Membership Structures as of 31 May 2006 Constituencies
Service Users living in the London Boroughs of Croydon, Lambeth, Lewisham and Southwark; Service Users living in the rest of England and Wales Carers Staff including staff exercising functions for the purposes of the Trust and employed by the Institute of Psychiatry or Croydon, Lambeth, Lewisham, Southwark, Bexley, Bromley or Greenwich social services and Staff exercising functions for the purposes of the Trust for more than 12 months and employed by other organisations e.g. Dalkia, ISS Mediclean Residents of The London Boroughs of Croydon, Lambeth, Lewisham and Southwark Residents of The Rest of England and Wales
Members‟ Council 6 x Service Users from Croydon, Lambeth, Lewisham and Southwark 6 x staff members Croydon PCT Lambeth PCT Lewisham PCT Southwark PCT Croydon Local Authority Lambeth Local Authority Lewisham Local Authority Southwark Local Authority King‟s College London
3 x Service Users from the rest of England and Wales
3 x Carers
5 x Public from Croydon, Lambeth, Lewisham and Southwark Guy‟s & St Thomas‟ NHSFT King‟s College Hospital NHS Trust London SHA A national mental health charity Total: 39 members
3 x Public from the rest of England and Wales
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9.1.2
Corporate governance and management
The current Corporate Governance Structure is set out in diagrammatic form in Appendix 22. The structure could be considered as being divided between committees that deal with risk and compliance issues (the “Framework” of “Freedom in a Framework”) and those that deal with operational issues. Governance and Risk reporting structures are currently undergoing a review and consideration has been made of the impact of Foundation Trust status as part of this review. The recommended structures from this review are those represented in Appendix 22. The Trust will be reviewing its Standing Orders, Standing Financial Instructions (last reviewed in May 2005), Decisions Reserved for the Trust Board (first drafted in April 1999) and the Scheme of Delegation to address any gaps by September 2006. The Scheme of Delegation outlines the responsibilities delegated by the Board to committees and individual officers. The proposed Constitution outlines the responsibilities of the Members‟ Council in relation to other bodies. Please see completed Governance Checklist for details of proposed arrangements. (appendix 1). Operational decisions are made at team level, service level, directorate level and/or Executive level (see Section 8.1.1) depending on the impact that the decision will have on other parts of the Trust and external bodies. Generally, where decisions will have an impact on another team, service or directorate any decisions are made at the next level up. Decisions made in response to external directives will be fed down from Executive level although generally left to local structures to decide on implementation. This process is monitored through the Chief Executive‟s Performance Management meetings (section 9.1.4) which in turn feeds back to the Executive, and directly to Directorate Executive teams. Decisions reserved for the Board will often be scoped through this route with the Executive and other bodies considering issues, making recommendations and refining responses before forwarding onto the Board. 9.1.3 Risk management
The Trust framework for risk management is set out in the Risk Management Strategy. The aim of the risk management arrangements is to identify, evaluate, control and re-assess risks that fall into one of the following categories. Clinical Financial Strategic Health and Safety Operational Staffing Organisational [as defined by controls assurance standards] The current Risk Management Committee structure was introduced in 2005. This Structure has recently been reviewed as set out in diagrammatic form in Appendix 22. Under this system, assurance that risks are being managed is provided to the Trust Board through the Clinical Governance and Risk Management Board Sub Committee. This Committee is chaired by a non-executive member of the Trust Board, and all executive Board Members are included in the Committee Membership. This Committee receives reports from both the Clinical Effectiveness Committee, the Clinical Risk Committee and the Risk Management Committee. These, in turn, received reports from defined sub-committees. The Trust is currently consulting internally on the
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consolidated Risk Management Assurance Framework policy to present the new strategy to the Board in September 2006. Development of the Trust Assurance Framework The integrated Trust Assurance Framework has been the subject of considerable development during the 2005/6 financial year. This ensures that systems are in place to provide Board Assurance that strategic and operational risks are being effectively managed. The Trust expects to receive a significant or full assurance opinion from the Head of Internal Audit for 2005/06. This Assurance Framework outlines 6 key areas for Assurance (the Principal Objectives). These link to the Trust Bold Ambitions. The Board has also identified Key Strategic Risks to the organisation (appendix 13) that cross reference to the Principal Objectives in the Assurance Framework. The development and monitoring of the Principal Objectives is been informed by the Trust Risk Register. This, in turn, is informed by Directorate Risk Registers, that are developed at a Directorate Level. In each Directorate there is a Directorate Risk Management Committee charged with developing, maintaining and using these registers at a local level. A risk rating tool developed in accordance with national guidance ensures a consistent approach is taken to prioritising risks and incidents. The risk register is a standing item on the Chief Executive Performance Review agenda and facilitates the identification of newly identified risks and ensures progress in reducing risk The DATIX risk management database is used to record and monitor risk management activity across the Trust. The Trust is currently at Level Two CNST and RPST. The Trust was assessed at Level Two CNST in March 2006. A summary of the scores is given below: Learning from experience: 100% Response to major clinical incidents: 100% Advice and Consent: 100% Health Records: 100% Induction, Training and Competence: 100% Clinical Care: 100% The Management of Care in Trust‟s Providing Mental Health Services: 100% The Trust has been invited to apply for level 3 in 2006.
Serious Untoward Incident (SUI) management The Trust reviewed its Incident Reporting and Management Policy in January 2006. The guidelines for investigation and reporting were revised. The Trust has fully trained investigators in the use of Root Cause Analysis techniques, to ensure that lessons are learnt effectively. All SUIs are reviewed through the investigation process, and then at a Directorate Committee level. The lessons from these reviews are collated at a Trust-Wide Committee level, and
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recommendations are taken forward at both Trust and Local levels as appropriate. Particularly serious incidents may also be subject to Board Level Scrutiny to ensure that lessons are learnt and appropriate recommendations are put in place.
9.1.4
Performance management reporting framework
The Trust Board considers regular, quarterly, Key Performance Indicator (KPI) Report. This covers key measures including the Trust Performance Indicator Set, indicators on Patient Experience, Workforce measures and Outcome Measurement. The Trust has a systematic, monthly, Performance Review Framework in place. This is led by the Chief Executive and is attended by all Service Directorates, Estates, ICT and HR on a monthly basis. Other Infrastructure Directorates attend on a quarterly basis. The meeting focuses on performance across all areas of service delivery, and is not simply financially orientated. Indeed, compliance with “Assessment for Improvement – The Annual Health Check”, has become a key element of the Trust framework. The Chief Executive is supported in this process by the Trust Head of Performance Management, who has a key role in co-ordinating this process and progressing actions from it. This role also acts as the conduit between the Performance Management meetings and the Trust Executive. The Chief Executive also provides a monthly report to the Board highlighting key issues arising from Performance Management reviews as well as from Executive meetings, the local health economy and the wider NHS. The Framework also includes Themed Reviews that consider specific areas of Trust Business. The reviews identify and share good practice across the organisation, as well as focusing support where progress is not being made. In the 2005/6 financial year, these included: - 04/05 Star ratings - Improving Working Lives (IWL) - Race Equality Scheme - Consultant Job Plans - Standards for Better Health (StfBH) - NSF Autumn Assessment Themed reviews planned for the 2006/7 year include: - StfBH - Patient and Public Involvement - IWL – update - Equality and Diversity - Healthcare commission – Improvement reviews Where relevant, the Framework also includes reports on services that have been placed on Special Measures (signifying that the service is under extra
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scrutiny and monitoring). The next stage in developing this process is the implementation of a Balanced Scorecard approach on the Executive Information System (see section 9.1.7). This format includes:
Indicator Workforce Patient Experience Standards and Targets Finance Activity
Sources of evidence Staff Survey, HR KPIs, Appraisal/PDP Service User Survey, Access Times, Complaints Standards for Better Health, existing and new Standards, LDP targets Recovery Plans, Variance, Business Plan Data Quality, PJS usage, Contract monitoring.
Over the next year, Part of this implementation will be to focus these meetings more effectively on the achievement of outcomes. This includes the implementation of a programme of work to identify effective non-financial metrics that will enable the Trust to monitor outcomes (see Appendix 9). Information Technology support for this process will also be introduced, with the planned roll out of the Executive Information System (EIS) during 2006 (sec 9.1.7). This electronic performance management tool will provide up to date information across all domains of the Balanced Scorecard to support the formal Performance Management process, but also to assist managers in day to day management of service delivery. 9.1.5 Financial controls and reporting
The Trust complies with relevant NHS and Legal requirements in relation to Standing Orders and Standing Financial Instructions. Details of the Standing Financial Instructions Are set out in Appendix Eleven. Compliance with these is monitored through the Audit Committee, and breaches are communicated and Performance Managed through directorate management structures. The Trust has a robust financial reporting mechanism in place, with the Board considering a regular monthly report and analysis. In preparation for applying to be a Foundation Trust, we have revised the format and content of Board Financial reporting to ensure that all Board members are aware of the key financial information on a regular basis. An example of our revised format is attached as Appendix Twelve. The format and content of Board reporting is subject to regular review to ensure it is fit for purpose and meets the needs of Board members. Monthly reports and analysis are provided to the Executive and Directorates through a dedicated management accounts team. These are published on the Trust intranet to minimise delay in information reaching managers. The Annual Audit Letter (September 2005) confirmed that the auditors had concluded that they could place reliance on Trust processes for budgetary control,
FINAL DRAFT – 1st June 2006.
the main accounting system, and year-end closedown procedures. The Auditors issued an unqualified audit opinion on the accounts by the NHS deadline of July 2005. There were no issues that needed to be reported by Auditors to the Audit Committee. The Internal Audit function for the Trust is provided by South Coast Audit (SCA). This audit work is overseen by the Audit Committee (a Board SubCommittee). In 2005, the Trust allocated additional resources to the management of the Audit Committee to establish the role of Audit Committee Secretary. As part of this, a critical review of how the committee functioned against standards of best practice was carried out. Overall, the results were good, and the Trust has implemented changes to further strengthen this committee. One particular area in which development work is being carried out is in ensuring that the audit reports are seen by committee members in a timely manner. This was identified in the Trust‟s last Annual Audit letter as an area for action, and has been addressed. Counter-Fraud. The auditors, in their annual audit letter, found that the Local Counter Fraud Specialist (LCFS) had a “proactive role which is demonstrated in the work plan agreed by the Audit Committee.” The letter suggested that guidance on counter-fraud arrangements should be included in induction packs, and this has been actioned. The Trust has commissioned 225 days of counter fraud work (both reactive and proactive) for 2006/07.
9.1.6
Compliance Framework
The Trust will ensure compliance with the Regulator‟s framework. Indeed, for the 2006/07 Business Plan, the Trust has used the draft IBP as the planning framework. The Financial model is also being used to assess and development recovery plans (section 6). Key monitor ratios are regularly reported to the Board (appendix 12) and the Trust has identified the need to amend its organisational structure to include the role of Company Secretary. The integrated reporting systems that the Trust has put in place (section 9.1.7) give the Trust confidence that all areas of reporting will be robust. 9.1.7 IT systems.
As detailed in the SWOT and PEST analyses in this document (Sections 4 and 5 ) the Trust is currently implementing improvements to the Information Technology infrastructure and systems. The ICT renewal programme includes an overhaul of historic systems relating to: Infrastructure: A modern data centre, resilient inter-site network, VoIP, Active Directory, Improve Security, SAN Storage, Improved Disaster Recovery/Continuity and Quality of Service. The Implementation of the Patient Journey System (the Trust electronic patient record) The implementation of the Trust Integrated Reporting System, including Benchmarking intelligence, analytical functions, performance management data and commissioning information.
This programme will provide a reliable information system to ensure that the Trust is able to record and analyse activity in a robust and timely manner. The systems to deliver this will be in place by the point of submission of this application (see Appendix 27 for further detail).
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Links with Connecting for Health. The Trust is closely involved with and committed to the Connecting for Health programme. As the table in appendix 23 indicates, infrastructure improvements have been funded through this programme. In common with other mental health trusts, SLaM remains committed to implementing the strategic solution to the mental health patient record as this is developed. The Patient Journey system is this Trust‟s interim solution whilst this development takes place.