Annual plan doc v28 final public version rev contents page final 30july09


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Annual plan doc v28 final public version rev contents page final 30july09

  1. 1. ANNUAL PLAN 2009/10 Public Version Version 27 Date 28 May 2009
  3. 3. Past Year Performance 1 PAST YEAR PERFORMANCE 1.1 Chief Executive’s summary of the year The past year has seen us build on many of our existing strengths as we prepared for Foundation Trust status and continued to work towards delivering our key aims. Throughout 2008/09, the Trust has been firmly committed to ensuring the highest levels of patient safety and clinical quality. Delivering safe clinical services is the bedrock of the Trust and the platform from which we are able to pursue the development of specialist services and research. The organisation reinforced that the following are the key operational themes underpinning all that we do: - Clinical quality and safety - Patient experience - Productivity and efficiency Healthcare Acquired Infections are a matter of great importance to staff and patients. Good practice in relation to infection control procedures is becoming embedded across the Trust and infection rates have been decreasing year on year. We were one of a small number of Trusts to achieve our March 09 targets for both Clostridium Difficile (C Diff) and Methicillin Resistant Staphylococcus Aureus (MRSA). Based on our track record, we were selected as one of seven Showcase Hospitals across England to participate in the Healthcare Associated Infections Technology Innovation programme. The aim is to help further reduce levels of infection through the use of new products and technologies. The Trust has been at the forefront of implementing the NHS Institute for Innovation and Improvement’s Releasing Time to Care Productive Ward programme. The impact has been significant. We have seen an average increase of 14% in the amount of time that staff are involved in direct patient care and other improvements such as reduced food wastage and increased patient satisfaction in relation to pain management. The NHS Institute is using the Trust as a showcase site and we have demonstrated our successes to a global audience including delegations from Canada and New Zealand. A lot of preparatory work has been undertaken in developing indicators to measure quality and we have been one of the first wave of hospitals to take part in the NHS North West’s Advancing Quality initiative. We are now on the threshold of embarking on our own ground breaking Quality Campaign which aims to bring about sustainable change at all levels across the organisation. The New Hospitals Development (NHD) is another key element of our plans to enhance the quality of the care that we offer. The Trust is in the final year of a six year (Private Finance Initiative) construction agreement to deliver state of the art healthcare and research facilities on the Oxford Road site. The New Hospitals Development is a unique opportunity for the Trust to make a step change in the quality and effectiveness of patient care delivery for both secondary services for the local population and specialist services for the population of the North West. The appropriately configured new facilities, designed with substantial clinical input, will help the trust deliver our vision and national standards and targets. Central to the improvements for patients and to ensuring improved continuity of care is the 3
  4. 4. Past Year Performance amalgamation on one site of specialist children’s services with a range of redeveloped adult services, maternity and neonatal care. Strengthened assurance/management arrangements and detailed operational/commissioning plans for the hospital moves are in place and these plans have received external stress testing, scrutiny and validation. We remain on track to open the NHD during Spring/Summer 2009. A number of services have passed significant milestones during 2008/09 including undertaking the 1000th cochlear implant and the 4000th renal transplant. In addition we have seen some ‘firsts’ in pioneering surgery including the first hospital in the UK to perform a periscope endovascular aneurysm repair and one of only two hospitals in the region to have taken part in a highly successful pilot study in primary angioplasty. A number of our highly specialised services are developed and commissioned on a national basis through the National Commissioning Group (NCG). In line with our strategy that prioritises the development of tertiary and specialist services, the following have recently been designated for NCG commissioning: - Islet transplantation - from April 2008, the MRI has been one of the six national implantation centres for islet transplants. This procedure offers an alternative to insulin therapy for some diabetic patients who are at risk of hypoglycaemia, a life threatening condition. - Encapsulating Peritoneal Sclerosis (EPS) - during 2008/09 we were designated as one of two trusts able to treat EPS, a condition resulting from prolonged peritoneal dialysis which if left untreated, is fatal. - Neurofibromatosis (NF1 and NF2) - we are a national and international leader in clinical care and research into neurofibramatosis, a rare complex genetic condition. NF1 was designated a NCG commissioned service in 2008/09 and we are applying for NCG funding for NF2 in 2009/10. The development of research is one of our priorities. Undertaking research enables us to contribute to the development of medicine, but also deliver benefits to the population that we serve and to us as a business enabling us to - Provide new treatments - Improve patient outcomes - Attract and retain the best staff. These benefits will give us a competitive edge in the market, enabling us to increase our market share in the areas we plan to develop and enhancing our position as the leading specialist centre in the North West. In early 2008 the Trust, in partnership with the University of Manchester, achieved designation as a Biomedical Research Centre (BRC) and the year has seen ground breaking research undertaken across a range of specialties including ophthalmology (blindness in older people), orthopaedic surgery (repairing spinal discs) and obstetrics (identifying women at high risk of developing complications in pregnancy). The Trust is a key partner in the Manchester Academic Health Sciences Centre (MAHSC), one of just five centres approved nationally and the only one outside of the golden triangle of research hospitals in the South East. MAHSC comprises a range of organisations including a PCT and specialist mental health and cancer trusts and covers a diverse population with relatively poor health. We are working closely with 4
  5. 5. Past Year Performance our partners to deliver research, teaching and patient care which are among the best in the world. The aim is that this will deliver benefit to patients in terms of access to the latest treatments and newest technologies, leading to improved health locally and nationally and economic benefits for the region. We have met some very challenging targets during this year for healthcare associated infections, cancer waiting time and referral to treatment, however the A&E target remains a challenge for the Trust and the Manchester Health economy. In spring 2008 internal changes were made to the pathways for patients requiring emergency admission and capacity was increased by opening assessment beds off site. As a result performance against the 4 hour target improved significantly. However the Trust, like many other trusts in Greater Manchester, experienced an exceptional rise in pressure over the winter period and as a result our year end performance was 97.53% patients treated within four hours. In response to this growth in demand additional action plans were agreed with key partners and were progressively put in place. These included increasing resources, re-opening capacity outside hospital and strengthening processes for discharging patients. The changes to the internal pathways were also further reinforced. The impact of these measures is being monitored closely and reported to the Board. Performance since early March has returned to a consistent level above the 98% threshold. Our Council of Governors was elected and appointed in line with our Constitution. Following a comprehensive induction programme the Governors are beginning to work together as a council. They have agreed four areas on which they will focus their work initially; membership; patient experience; public health; and health promotion and corporate citizenship and are looking forward to developing a productive working relationship with the Board of Directors. Our strong commitment to corporate citizenship has seen our involvement with the City council continue to thrive. As key sponsor of the Manchester Health Academy developments are progressing well and the Trust is an integral player in The Corridor Manchester (formerly Oxford Road Corridor Partnership). The Trust’s lead on local employment initiatives has resulted in significant job placements for local people throughout the organisation during the past year. Building on centuries of tradition of excellence in health care in our hospitals, the move to Foundation Trust status and the imminent completion of the New Hospitals Development gives us an unprecedented opportunity to change our services to truly reflect what staff, patients and the public should expect from the NHS in the 21st Century 5
  6. 6. Past Year Performance 1.2 Summary of financial performance Financial performance for 2008/09 is summarised below in table 1.1 Table 1.1: Summary of Financial Performance in 2008/09 2008/09 plan 2008/09 actual Variance £'m £'m £'m Income Clinical income 502.4 510.5 8.1 Non-clinical income 99.6 101.6 2.0 PFI Specific Income 8.0 8.0 0.0 Total income 610.0 620.1 10.1 Expenses Pay costs (338.6) (337.6) 1.0 Non-pay costs (195.4) (204.8) (9.4) PFI Costs (43.8) (44.3) (0.5) EBITDA 32.2 33.4 1.2 Deprn/Interest/Dividend (26.4) (28.0) (1.6) Exceptional items Net surplus 5.8 5.4 (0.4) Clinical income is ahead of budget by 2% due to over performance across a range of clinical activity. Non-pay costs are higher than budget due to the additional costs incurred in delivering the additional activity. Overall actual out-turn was 93% of plan. 6
  7. 7. Past Year Performance 1.3 Other major issues On establishment as a Foundation Trust on 1 January 2009, the Trust implemented its revised governance arrangements in line with its Constitution. Board of Directors The Board of Directors comprises a Chairman, six Non-executive Directors and six Executive Directors. The following changes took place during 2008/09: Non-executive directors Blaize Nkwenti-Azeh term of office expired on 31 July 2008 Sheila Jones and Claire Nangle’s term of office expired on 9 November 2008 Three new non-executive directors appointed on 10 November 2008 - Stephen Mole BSc(Hons) FCMA PGCE - Brenda Smith FRSA D Litt MBA BSc(Hons) ACA - Lady Rhona Bradley MA BA(Hons) Sheila Jones and Clare Nangle were retained as Associate Non-executive Directors until 31 March 2009. Council of Governors The Council of Governors comprises 31 members, 17 public and 6 staff elected members and 8 representatives of partner organisations. The following changes to the Council of Governors took place during 2008/09: Charlie Davies resigned as the Children’s Forum representative on 2 January 2009 and was replaced by Sam King on 10 February 2009 Tom Ladds left the organisation and therefore resigned as a Staff Governor representing Nursing and Midwifery on 27 March 2009. He has been replaced through an election process by Mary Metcalf. 7
  8. 8. Future Business Plans 2 FUTURE BUSINESS PLANS 2.1 Overall vision The Trust’s Integrated Business Plan, developed as part of its application to become a Foundation Trust during 2007/08, set out the vision and strategic aims of the organisation. Our vision is: ‘to become the leading integrated health, teaching, research and innovation campus in the NHS and to position the Trust on an international basis alongside the major biomedical research centres, as part of the thriving city region of Manchester – with its strong emphasis on economic regeneration, science and enterprise.‘ The service related strategic aims below our vision are based on building upon our already strong position within the health economy and formally establishing the Trust as being: • The leading provider of tertiary and specialist services in the North West • A prestigious internationally renowned centre for research and innovation • An excellent district general hospital for the residents of central Manchester This vision will be underpinned by an operational focus on: • Clinical quality and safety • Patient experience • Productivity and efficiency and delivered by building on our existing strengths: - Firstly, our distinctive position as a provider of specialist and tertiary services to the population of Greater Manchester, the North West and beyond. - Secondly, the scale and significance of our research ambitions, which set us apart from other Trusts. Having attained Biomedical Research Centre status and being a key partner in the newly accredited Academic Health Sciences Centre is Manchester benefits the Trust both clinically and from a business perspective. It enables us to differentiate ourselves in service terms, recruit clinicians of the highest calibre and position ourselves as a leading centre for research and innovation which will give us a competitive edge within an increasingly competitive market. - Thirdly, our New Hospitals Development which is a unique opportunity for the Trust to make a step change in the quality and effectiveness of patient care delivery of both secondary services for our local population and specialist services for the population of the North West. This vision was developed initially by the Board of Directors. It was subsequently shared and refined through consultation with the senior clinical and management teams, the city council, host PCT, the University of Manchester and other key stakeholders. Finally the Foundation Trust consultation document set out the vision for the future and staff, patients and members of the public were given the opportunity to feedback their views. 8
  9. 9. Future Business Plans 2.2 Strategic overview 2.2.1 National and local challenges – impact on financial strategy National Economic downturn and its impact on public sector funding levels Following the 2009 budget statement delivered by the Chancellor on April 22nd, we have reviewed the current and medium-term forecasts for UK government finances and the probable impacts this can be expected to have upon the Health sector. It is clear that there will be serious downward pressure on public sector funding levels, sustained over a prolonged period from 2010 onwards and through into at least the middle of the next decade. We therefore expect a very challenging period ahead which will be quite different from the operating environment of the Health sector through the last two decades. - We have revised down our income inflation assumptions and revisited our cost inflation assumptions, ensuring both that we have taken a prudent view of the impacts on our overall trading gap year-by-year, and that we are being realistic about an increasing majority of solutions to these annual challenges, needing to come from productivity gains which release cost savings. - We have extended the scope and prioritised the implementation of a major programme of work to increase productivity and efficiency across all aspects of our work. These will ensure that we continue to deliver high standards of patient care and good clinical outcomes, as well as further improvements in positive patient experiences in our front-line service delivery(see section 2.2.3) Darzi report – High Quality Care for All The recommendations within Lord Darzi’s report have emphasised the need to continue to prioritise service quality, good outcomes and positive patient experience. The emphasis on these themes throughout our plans, has in turn been reflected in our service and financial plans for 2009/10. Commissioning landscape Commissioners are increasingly employing competitive tendering as a means of procuring services and designating organisations as accredited providers. We expect to see this approach and other developments in methods of procurement rolled out over future years, as part of a range of further responses/developments in the commissioning environment as the squeeze on real-terms growth in purchasing power takes progressively stronger effect. We are developing working arrangements with the newly formed procurement department of Manchester PCT. The Trust will use this as an opportunity to highlight areas which are in line with our strategic aims. Services that we expect to be tendered in 2009/10 include anti-coagulant service and designation of accredited providers for Endovascular Repair of Abdominal Aortic Aneurysm (EVAR). 9
  10. 10. Future Business Plans Introduction of new tariffs through HRG4 The intention of the new tariff was intended to underpin a proper level of recompense for more specialised services, with better differentiation of case-mix and higher cost areas of activity. Whilst the new tariffs represent a step towards this objective in many services, there has been an unintended adverse impact on specialist children’s services in particular. We have established effective working relationships with DH on further refinements of the new tariffs to address several of the adverse impacts identified. Further developments in national approaches to formulating future ‘Payment by Results’ tariffs are now being clearly signalled. These will include emerging ‘best practice’ tariffs. We will ensure that we engage effectively in the programmes of work which are developing these new tariff approaches and thus that we keep up-to-pace with assumptions being made about identifying best clinical practice and how this is connected to the prices which will be paid in future. The European Working Time Directive (EWTD) The achievement of compliance with EWTD and the associated requirements of Modernising Medical Careers, balanced with ongoing service delivery challenges, remains a continuing priority for the Trust. Further identified areas of medium-term service delivery and financial risk continue to be progressed, both through resource bids currently under review by commissioners and North West Strategic Health Authority (NW SHA) workforce team, and in ongoing re-design projects internally. Local Transfer of services into the New Hospitals Development The financial implications of the transfer of services into the New Hospitals Development and associated increases in the unitary payment have been incorporated in our financial plans and Long Term Financial Model (LTFM). - The Trust will incur costs related to maintaining patient activity and waiting times performance across the overall period of the Hospital moves, together with double running, staff training, orientation and backfill, and decommissioning of the hospitals being vacated. These exceptional costs have been assessed in depth and funding secured to enable them to be budgeted for in our plans for 2009/10 and 2010/11. - With the opening of the New Hospitals Development there is a significant step up in the unitary payment and associated costs. Reconfiguration of Children’s services across Greater Manchester – Making It Better The reconfiguration of children’s services across Greater Manchester is now moving into the full implementation phase. The financial consequences of all these challenges have been reflected in the financial plans of the Trust. See section 2.3 below. The Trust response to these challenges is clearly reflected in the key objectives for 2009/10 which are described in section 2.2.3 Key Actions. 10
  11. 11. Future Business Plans 2.2.2 Quality Overview The Board of Directors view high quality and value for money as one and the same thing. Using the most effective treatments, reducing errors and getting things right first time contribute to the quality of care and to a more efficient and productive service. During 2008/09 the Trust has been focussing increasingly on quality as reflected in our three operational priorities of: • Clinical quality and safety • Patient experience • Productivity and efficiency The first stage has been to develop indicators that enable us to measure and monitor quality and to present this information to the Board of Directors. We have produced a Quality Report for 2008/09 setting out the Trust’s position on quality, priorities for the future and current performance against relevant indicators which has been included in our Annual Report. Going forwards the Chief Nurse/Deputy Chief Executive held a series of discussions, workshops and events with senior leaders across the organisation, facilitated by the Executive Director for Improvement from the NHS Institute to agree how we take the quality agenda on to the next stage. Through this work our aims and objectives were agreed. Our overall aim is: • To provide the best patient experience within the NHS This is to be underpinned by the following ambitious objectives: • To be in the top 20% of Trust’s in the National Patient Survey in the next 2 years • To improve staff satisfaction year on year by 10% on all indicators in the next 2 years Actions A two-pronged approach to quality for 2009/10 has been agreed: 1. Improvement programmes - a series of improvement programmes covering Patient Experience, Patient Safety and Workforce. The programmes are themed and include a number of work streams that will deliver continuous improvement as shown in table 2.1: 11
  12. 12. Future Business Plans Table 2.1: Quality Improvement Programmes Theme 1 Theme 2 Theme 3 Patient Experience Patient Safety Workforce Pain management Patient Track Leadership Food Falls prevention & Customer service reduction Privacy and dignity Reward and recognition Advancing Quality Communication Recruitment & retention Pressure ulcer prevention Customer feedback Reducing hospital acquired Environment infections End of life care Reducing high risk medication errors Each of these work streams is part of our core business and included in the corporate work programmes. They will be performance managed through the normal Trust accountability framework. 2. Quality campaign It was acknowledged that the work programmes alone will not achieve the change in culture in the Trust required to deliver the Best Patient Experience in the NHS. In order to deliver the step change in organisational culture there is to be a Quality Campaign The campaign will engage staff, patients and the public in the development of local initiatives that will improve quality. The aim is to move the locus of ownership for service quality closer to the patient. A dedicated team will be formed and resourced to lead the planning, launch and implementation of the campaign, however as the basis of the campaign is empowering staff and patients to make changes, their role will be to support and facilitate. Divisions will identify quality champions and education and training will be provided for key individuals to develop improvement capacity and capability within the divisions A communication strategy is planned using a variety of media The Campaign will be regularly reviewed and refreshed to reflect the engagement of staff and patients which will help set the direction for the team 12
  13. 13. Future Business Plans Indicators During 2008/09 a programme of work was undertaken to select indicators, set targets and establish data collection systems for measuring quality. This is an on-going process with regular review to ensure that the indicators continue to meet the needs of the Board of Directors. The Trust is currently reviewing the findings of the Healthcare Commission’s report on Mid Staffordshire NHS Foundation Trust and will reassess the range of indicators currently used in the light of this. The indicators are reported within the Intelligent Board report which is produced on a monthly basis. The report shows current and projected performance and a risk rating. For any indicators that are rated as red there is an action plan with timescales and a lead director identified. Table 2.2 shows the indicators used at the beginning of 2008/09 and the expanded set of indicators developed during 208/09 that will be used in 09/10. These will be scored during 09/10 to give a quantitatively description of the quality of care. 13
  14. 14. Future Business Plans Table 2.2: Quality Indicators Indicator Indicators used 08/09 09/10 Patient Hospital Standardised Mortality Rate √ √ Safety MRSA √ √ C diff √ √ Falls* √ √ Medication errors* √ √ Clinical Stroke** √ effectiveness – time spent on stroke ward Surgical non elective admissions** √ – operated on within 24 hours Primary coronary angioplasty** √ – time to revascularisation Fracture neck of femur** √ - time to operation Compliance with pathway √ - Acute myocardial infarction Compliance with pathway √ - Coronary Artery Bypass Graft Compliance with pathway √ - Hip and knee replacement Compliance with pathway √ - Heart failure Compliance with pathway √ - Community acquired pneumonia Patient Clean √ experience Clean wards √ Infection control √ Hotel services √ Communication √ Nutrition √ Pain √ Privacy and dignity √ Complaints √ √ – replied within 25 days * Targets have not yet been set. A programme of work is underway to establish what the targets should be. ** Data under validation 14
  15. 15. Future Business Plans The Trust also uses a number of externally validated and benchmarked databases as a guide to outcomes for some services. These include: - PICAnet (Paediatric Intensive Care Audit) – compares actual with expected mortality for children admitted to Paediatric ICU. - ICNARC (Intensive Care National Audit and Resource Network) - benchmarks patient outcomes based on risk adjustment for severity of illness, not just the illness itself (developed by the Intensive Care Network for the UK). - CCAD (Central Cardiac Audit Database) - analyses the outcome for every patient undergoing cardiac surgery, using a cumulative sum (CUSUM) curve to reflect expected and actual outcome. - UKTSA (UK Transplant Support Service Authority) - outcomes (patient death and graft loss) for renal transplant patients. In addition to this at divisional level each division has selected its own set of specific clinical indicators that are used to monitor clinical quality. We will take on board feedback and learning in drafting future quality reporting through the annual report. 2.2.3 Key actions to deliver Trust vision The key actions required to deliver our vision are captured each year in our principal objectives. The Trust principal objectives for 2009/10 are set out below. The first three objectives reflect the three themes that have been identified as being essential to underpin the achievement of our vision: • Clinical quality and safety • Patient experience • Productivity and efficiency 1. The fusion of patient experience, clinical quality and customer service into an integrated campaign of improvement, underpinned by performance metrics. The Trust aims to provide the best patient experience within the NHS. As set out under section 2.2.2 Quality, a series of improvement programmes themed around Patient Experience, Patient Safety and Workforce have been developed. In addition to this, to deliver the step change in culture necessary to achieve the Best Patient Experience in the NHS, the Trust is developing a high profile Quality Campaign. The indicators used to measure quality have been developed alongside and are integral to our trading gap plans. 15
  16. 16. Future Business Plans 2. The commissioning and operational management of the New Hospitals Development coming on stream during 2009/10. 2009/10 sees the completion of a six year (PFI) construction agreement to deliver state of the art healthcare and research facilities on the Oxford Road site. This is a unique opportunity for the Trust to make a step change in the quality and effectiveness of care for our patients. The management of the transfer of services and the establishment of the new service models planned for the future will be a significant element of our work for 2009/10. The transfer of services is a major undertaking. The service transfers to take place in 2009/10 are: June 2009 Children’s Hospital – transfer of the two specialist childrens hospitals, which are currently located off site, into the New Hospitals Development July 2009 St Mary’s Hospital – transfer of St Mary’s which is currently on the hospital campus into the NHD August 2009 MREH and MRI – transfer of the eye hospital and some acute services which are all currently on the hospital campus into the NHD The moves have been risk assessed within and between divisions to ensure the most appropriate sequencing. This is the biggest risk facing the Trust in 2009/10 and so arrangements are in place to provide assurance to the Board of Directors that action has been taken to address all the risks and to ensure, as far as possible, a smooth transfer of services. These include: - Internal peer review of plans within and across divisions. - Review of risks and mitigating actions through the New Hospitals Development Implementation group. - Monitoring of progress through a range of key performance indicators covering: construction, IT, communications, costs, whole Hospital Policy, HR and the New Hospital Development Move Plan. - External peer review of plans and action planning to capture the lessons learnt - Liaison with other organisations who have recently undertaken major service changes eg the airport authorities in relation to terminal 5 at Heathrow and Manchester Business Continuity Forum on their experience managing operational disruption to services as a result of utilities and IT failures. The move will be co-ordinated across the range of emergency services i.e. the Fire Service, Ambulance Service and Greater Manchester Police. Operational meetings are taking place with the individual emergency services to agree move protocols and timescales. 16
  17. 17. Future Business Plans The corporate management arrangements under the leadership of the Director of Patient Services/Chief Nurse have been reviewed to ensure they are fit for purpose. A tiered approach to the overarching arrangements to support the move has been developed. The tiers reflect the traditional approach adopted by the emergency services to ensure strategic and operational control over complex situations, i.e. Gold, Silver and Bronze command. All divisions have plans in place to ensure business continuity so that they can deliver the move as well as maintaining safe clinical services. They also have plans in place to phase activity so that the Trust can continue to meet its targets, despite the down time associated with the moves. 3. The implementation of service development and trading gap plans for 2009/10 and in advance of 2010/11, together with preparation for the implementation of future plans. A framework of productivity programmes for 2009-14 has been developed. Implementation will start in 2009/10. The key elements of the framework are: Table 2.3: Framework of Productivity Programmes Theme Outputs Strategic portfolio reviews including profit - Strategic decisions on priorities and and loss position from Service Line on areas for investment/disinvestment Reporting Identify and maximise opportunities - Timely final agreements with relevant around potential service configuration other parties changes - Clear margins identified and implemented in future trading gap plans Maximise further opportunities for - Update previous plans for ‘economies of scale’ and removing opportunities post-move. duplication, arising through the New - Clear savings identified and Hospitals Development implemented in future plans Strengthen the alignment/ contribution of - Progressive elimination of ongoing consultant productivity towards overall APS usage productivity strategies - 10% step up in in-house capacity/utilisation by March 2010 Clinical productivity programmes (linked - Improvement rate sustained to above) - Benchmarks achieved - Margins converted as savings unless new funded demand growth arises Implement cost reduction programmes - Clear savings identified and implemented in future plans, exceeding ‘October 2008’ plans 17
  18. 18. Future Business Plans A Clinical Service Portfolio Review is also being undertaken during 2009/10. This is part of the process of continually evaluating our clinical and business strategies in the light of the changing environment within which we operate. The purpose of the review is to: - update our strategy for the development of individual clinical services, and - identify areas for investment and disinvestment - address the worsening economic environment the NHS is going to face over the coming years. The review will include analysis of the current position, the market and financial position using financial and non-financial analysis tools. The exercise will be undertaken within the clinical divisions led by the Divisional Director supported by the Divisional team with corporate support if required. The programme will start in surgery and be rolled out to other clinical divisions in phases, with a target completion date of June 09 for the pilot and October 09 for the whole of the Trust. To support this process, the Trust is in the process of refining its service-line reporting systems. Service Line reporting is seen as an integral part of this process and a significant amount of work has been done to refine the allocation of overhead costs. A project is being undertaken to review pathology to improve the allocation of these overheads to specialties. A further project is being undertaken, driven by the move into the New Hospitals Development to review estates and cost of capital costs. The cost base relating to these costs changes significantly with the move and the introduction of International Finance Reporting Standards (IFRS), so a recosting exercise is being undertaken. The new refined information is expected to be available by September 2009, once the move to the NHD is completed. Alongside the three key objectives are our other principal objectives necessary to underpin the achievement of our strategic aims: 4. To continue the implementation of the Research and Innovation Strategy Through the Biomedical Research Centre (BRC) our researchers and clinicians are tackling some of the major diseases affecting the local population, focussing on the five priority areas of: - Developmental medicine - Genetics - Cardiovascular medicine - Diabetes/endocrinology - Musculoskeletal medicine. Funding for the BRC will be used to support the strategic recruitment of new professorial appointments and fellowships, the development of research facilities and infrastructure and public engagement and involvement. Research will be strengthened by the implementation of technology and methodology platforms in areas such as genomics, proteomics and metabolomics. 18
  19. 19. Future Business Plans We plan to develop and enhance existing links with specialist BRCs and faculties of the University of Manchester. We are also increasing our collaborative efforts with industry by linking with TrusTECH, the National Technology Adoption Centre and Manchester Integrating Medicine and Innovative Technology. We are a key partner in the Manchester Academic Health Science Centre (MAHSC). MAHSC comprises a range of organisations including a PCT and specialist mental health and cancer trusts and covers a diverse population with relatively poor health. We are working closely with our partners to deliver research, teaching and patient care which are among the best in the world. The AHSC award will help us to deliver the benefits which flow from BRC research activity to patients more quickly and more effectively. The Trust is seeking to maximise funding opportunities in order to grow research income through 2009/10. We will actively bid for National Institute for Health Research (NIHR) grants for programmes of research in our priority areas. Key objectives are: - To implement the recommendations of the External Review of Research in the Trust during 2009/10, focusing on the areas for investment and disinvestment - To prepare, during 2009/10 the resubmission for the Biomedical Research Centre - In conjunction with partner organisations develop during 2009/10 the Manchester Academic Health Sciences Centre - Successfully appoint up to 12 clinical academic chairs to commence in post during 2009/10 5. To maintain financial stability - To achieve and maintain a Monitor Financial Risk Rating of at least “3” overall for 2009/10 - To achieve a net income and expenditure break-even in 2009/10 - To achieve a closing cash balance of £9 million at March 31st 2010 - To deliver the 2009/10 capital programme within Board approvals - To achieve the full-year harmonisation savings of £10 million from July 2009 onwards - To develop financial plans, budget setting and activity for 2010/11 for Board approval by March 2010 6. To ensure that excellent HR practice underpins the key strategic service changes - To implement the workforce strategy for the Children’s move during 2009/10 - To implement the workforce strategy for any agreed harmonisation and repatriation initiatives during 2009/10 - To achieve 100% compliance with the EWTD for medical staff in 2009/10 19
  20. 20. Future Business Plans 7. To continue to strengthen the IT and information supporting infrastructure - To implement a new data warehouse to support the Intelligent Board reporting in 2009/10 - To continue to develop and implement the next stages of Connecting for Health during 2009/10 by implementing Lorenzo Release 1 in two pilot areas during October 2009 and subsequently planning for implementation across the Trust during 2010/11 8. To implement the marketing strategy - To implement in 2009/10 the Marketing Strategy developed in 2008 and approved by the Trust Board, focusing on building strong relationships with key stakeholders and using the media more effectively - To implement media training for key individuals in 2009, particularly to coincide with the opening of the New Hospitals Development - To implement the publicity campaign and community engagement plan for the hospital moves from January 2009 through to completion of the moves - To further develop the new website as a business, marketing and commercial function in 2009/2010 - To embed branding identities across the organisation in 2009/2010 9. To develop governor and stakeholder engagement - To grow the public membership to 10,000 members during 2009/10 - To implement the four Governors’ working groups during 2009 - To develop Governor involvement with forward planning and strategy with the Board of Directors during 2009 - To continue to play a key role during 2009/10 in the development of:- - The Health Academy - The Corridor, Manchester - The Carbon Trust Initiative - Corporate Citizenship including employment opportunities The financial consequences and benefits of all these objectives have been reflected in the financial plans of the Trust. See section 2.3 below. 20
  21. 21. Future Business Plans 2.2.4 Service Development Plans Clinical Service Developments Key areas in which growth is expected The table below shows key areas where volume growth is expected. These can all be seen to clearly link to our vision and strategic aims. There is specific commissioner support for all the growth related to specialised services and to changes following strategic reviews. Growth expected based on historic activity is the subject of contract negotiations. Table 2.4: Areas of Expected Growth Strategic aims Specialty/Service Description The leading provider Renal dialysis Increase in capacity of tertiary and Bone Marrow Transplants Increase in activity specialist services in & Matched Unrelated the North West Donor transplants Adult Congenital Heart Development as hub for the Disease region and spoke for Manchester Renal Pancreas Increase in activity Transplantation Encapsulated Peritoneal Development as a nationally Sclerosis Service (EPS) commissioned service Islet Transplantation Development as a nationally commissioned service Renal transplantation Increase in activity Genetics including Increase in activity and development of NF1/NF2 development of nationally commissioned complex genetics service Paediatric critical care Increase in capacity Electrophysiology Increase in activity Laser eye treatment Increase in activity Dental implants Increase in activity Dental sedation Increase in activity for adolescents Oral medicine Increase in activity IVF (NHS) Increase in activity An excellent district Programmed Investigation Increase in activity general hospital for Unit the residents of central Endoscopy Increase in activity Manchester Obstetrics Expansion in response to MiB and development of a MLU General growth Increase in eg A&E, surgery, ophthalmology and childrens outpatient activity 21
  22. 22. Future Business Plans Capabilities and resources required to put strategy into action The Trust is deliberately building on areas of existing strength. Specialised services have been prioritised where the Trust is often the designated or accredited service or where we have the critical mass (expertise/infrastructure) required to deliver the service. The identification of services for development follows a market assessment which has indicated that there is demand or is in response to the commissioning intentions of commissioners such as the North West Specialised Commissioning Team. Compliance with PPI cap The plans include a forecast of private patient income of £2.0m (0.4% of patient related income). The Private Patient Income (PPI) cap for the Trust, calculated by reference to the 2002/03 activity levels is set at 1.1% of income (circa £6.5m). Therefore current levels of income are well below the cap. This provides the Trust with opportunities for the future. 22
  23. 23. Future Business Plans 2.3 Summary of financial forecasts 2.3.1 How the plan was built The plan has been developed based on the LTFM produced for the Trust’s application to become an NHS FT and has been updated to reflect 2008-09 out-turn position and the latest assessment of the financial out-look for the next 5 years in the tightening economic climate. 2.3.2 Impact of IFRS The Trust enters the final stage of the PFI scheme with the New Hospitals Development handed over for commissioning on 30 April 2009. By 30 September 2009 all services will have moved into the NHD. The capital value of the development is over £410m. Therefore the move to International Financial Reporting Standards (IFRS) which has the effect of bringing the New Hospitals Development onto our balance sheet, has a significant impact on the financial forecasts of the Trust. 2.3.3 Key financial assumptions The key assumptions relating to activity and capacity that underpin the financial plans are as follows: • Underlying growth in elective and new out-patient activity is projected at prudent, low annual rates following delivery of the 18-week referral-to- treatment target in 2008 and Commissioners intentions. • Full account is taken of implementation of the Greater Manchester PCTs’ decisions following the ‘Making it Better’ consultation, in relation to children’s services where local secondary care provision will transfer to Salford Royal and North Manchester General Hospitals respectively, alongside the timing of transferring tertiary and specialist children’s services into our New Children’s Hospital in 2009. • Similar account is taken of the commitment, also following ‘Making it Better’ decisions, for growth in Obstetrics provision to an annual number of births reaching 6,600 following the move into the new St Mary’s Hospital in 2009, which achieves the required capacity. • Based on the demand trends of 2008/09 growth in non-elective medicine activity has been built into the 2009/10 plans. After this year schemes being developed by the commissioning PCTs are expected to be fully operational, so no further growth has been assumed. • Other than in these three areas, non-elective activity projections are ‘flat- lined’ at 2008/09 actual levels across all other services, which reflects the most recent trend experience, in its overall impact. • Planned step-by-step further expansion of the specialist children’s Critical Care facilities and in 2013 a major expansion of the adult Critical Care services, to ensure capacity to deliver more intensive and high dependency care in support of a continuing growth in the most complex and intensive aspects of our patient case-mix. 23
  24. 24. Future Business Plans • Identified pipelines of specific specialist service developments from each Division are included. Much of the growth is in high cost/low volume activity areas, such as renal transplant and specialist children’s services. The impact of these activity assumptions has been tested against existing bed capacity plans in our New Hospitals Development, and this work confirms that the Trust can deliver all aspects of these plans from an operational perspective. Our projections have also been tested through ongoing substantive discussions with our two leading commissioners, the North West Specialised Commissioning Team and Manchester PCT. The forecast impact of the overall position across government finances, on future allocation of resources to the health sector, particularly from 2011 onwards, has been taken fully into account. The key assumptions in relation to the Income and Expenditure are as follows: • Income inflation is as follows: Table 2.5: Income Inflation Assumptions Inflation - Base Case 2009/10 2010/11 2011/12 2012/13 2013/14 Tariff inflation 1.7% 0.0% -1.0% -1.0% -1.0% Non-Tariff inflation 1.7% 0.0% 0.0% 0.0% 0.0% Non NHS Clinical income inflation 1.7% 2.0% 2.0% 2.0% 2.0% Education & Training 1.7% 1.0% 0.0% 0.0% 0.0% Research & Development 0.0% 0.0% 0.0% 0.0% 0.0% Other income 3.0% 2.0% 2.0% 2.0% 2.0% • We will continue to strengthen our input and contribution to key Department of Health Payment by Results (PbR) development work programmes as national PbR policy and rules continue to evolve each year. We have also strengthened substantially over the last year, our arrangements to ensure accurate clinical coding is achieved (and within tightening contract timescales for completion) appropriate to the full clinical circumstances of our patient workload in each specialty. • All further service developments will be assessed and managed within the ongoing Business Case framework operated within the Trust, based on a case by case assessment of each scheme. • Specific service developments have been assessed on a case by case basis to determine the forecast level of activity, related income and cost. • We have estimated the financial impact of specific continuing cost pressures such as Agenda for Change, the European Working Time Directive, Modernising Medical Careers, Consultant Contract, NICE drugs. These estimates fall within the framework of an overall assumption regarding ‘tariff deflation’ on our NHS clinical income streams. For 24
  25. 25. Future Business Plans 2010/11 onwards the assumption we make about the level of nationally- determined efficiency built into tariffs, has been increased to around 4% in line with our assessment of annual cost inflation pressures. • Other inflation rates are: Table 2.6: Other Inflation Assumptions Inflation - Base Case 2009/10 2010/11 2011/12 2012/13 2013/14 Pay Costs 2.4% 2.0% 2.0% 2.0% 2.0% Continuing incremental progression 1.0% 1.0% 1.0% 1.0% 1.0% Drug Costs 1.7% 1.7% 4.0% 4.0% 4.0% Clinical Supplies & Services 1.6% 1.8% 4.0% 4.0% 4.0% Other Costs 3.0% 2.4% 4.0% 4.0% 4.0% Unitary Charge 0.4% 2.0% 2.3% 2.5% 2.5% • A full review and re-fresh of the financial dimensions of our PFI New Hospitals Development has been undertaken. This reflects a comprehensive updated assessment of the ongoing costs resulting, as the summer 2009 commissioning of our New Hospitals Development draws ever nearer. Experience now accumulated over the four years since Full Business Case sign-off, together with the several significant commissioning and operational transfer milestones already completed, has been fully reflected in this update. We are also maintaining our contacts with other major hospital PFI sites, to ensure our understanding of future and ongoing risks is informed by experiences elsewhere. • Contributions towards the overall revenue affordability of our New Hospitals Development, from the many areas of harmonisation and consolidation within our clinical and supporting services, are now built into our operating budgets as we move into the New Hospitals Development in 2009. • Alongside these projections in relation to our NHS clinical service delivery, we have updated our detailed forecasts covering research activities in particular, in light of the withdrawal in 2009 of remaining historic NHS ‘levy’ funding for our Research & Innovation infrastructure. This infrastructure is now fully recovered through income from our ongoing research activities. Further development of our strengths in research over coming years, will continue to build on our designation as a NIHR Biomedical Research Centre from April 2008, together with the more recent successful accreditation (by DH) of Manchester as one of five Academic Health Science Centres in the UK. • Similarly, specific developments relating to our Teaching and Education income and activities, are reflected where these indicate any significant variations in this aspect of our work within the forward planning horizon. 25
  26. 26. Future Business Plans The resulting I&E position is as follows: Table 2.7: Forecast I&E Position 2009/10 2010/11 2011/12 2012/13 2013/14 £m £m £m £m £m Income and Expenditure indicators Income NHS Clinical 529.6 548.5 561.4 574.6 586.8 Non-NHS clinical 10.2 10.5 10.6 10.8 11.1 Other income 116.5 102.0 101.0 101.6 103.1 TOTAL INCOME 656.3 661.0 673.0 687.1 700.9 Expenditure Operational costs (592.3) (594.6) (603.9) (615.4) (625.7) EBITDA (Earnings before Interest, tax, 64.0 66.4 69.1 71.7 75.2 EBITDA % 9.7% 10.1% 10.3% 10.4% 10.7% Depreciation and impairments (32.6) (30.5) (31.9) (33.9) (37.6) Interest payable/receiveable (23.6) (29.3) (30.4) (30.6) (30.2) PDC dividend (7.3) (6.1) (6.1) (6.2) (6.4) (63.5) (65.8) (68.4) (70.7) (74.2) Surplus for the year 0.5 0.6 0.8 1.0 1.0 Surplus % 0.1% 0.1% 0.1% 0.1% 0.1% 2.3.4 Phasing Income Activity and the related income have been phased based on the number of days in a month for non-elective activity and on working days in a month for elective and out- patient activity. Income relating to the funding of transitional costs has been phased to match the trend of the costs (see below) All other income is phased equally across the year. Costs Costs are generally phased equally across the year, however adjustments have been made to reflect the following issues: − Clinical supplies are phased in line with the activity and income profile − Change in cost base when services are repatriated to Salford and North Manchester following the closure of the Children’s Hospitals in June 2009 − Reduction in costs due to harmonisation of services when all services have moved onto the one new site. − One-off costs related to the move into the New Hospitals Development (transitional costs). As the move takes place between May and August 2009 the majority of the costs have been phased in this period. 26
  27. 27. Future Business Plans Working capital The major items to affect the phasing of working capital and in particular the cash balance are: − receipt of Research & Innovation income; − timing of cash settlements from Primary Care Trusts for contract over- performance; − half-yearly payments of PDC Dividend; − receipt and spending of transitional funding around our hospital moves; and timing of capital programme 2.3.5 Investment and disposal plans Capital Investment The major element of the capital plan for 2009/10 is the equipping of the New Hospitals Development. This expenditure will have to be incurred by the end of August and has been phased in the first two quarters of the year. The remainder of the capital programme is spread across the year. The major capital scheme for future years is the proposed adult Critical Care development. An estimated capital scheme of has been included spread across 2010/11 to 2012/13, as a marker at this stage for the indicative level of capital investment, in line with the outline Business Case currently being drafted. This investment now appears in the capital plan due to the adoption of IFRS - which removes the off-balance sheet financing method assumed in previous versions of the long term financial model. The Board will be considering this outline Business Case in July 2009. 2.3.6 Loans and working capital Compliance with the Prudential Borrowing Code The impact of the above borrowings on the Trust’s Prudential Borrowing Limit (PBL) has been reviewed. This shows that the Trust’s loans will remain within the upper cap of potential borrowing, defined in relation to a ‘Tier 2’ borrowing limit within Monitor’s updated Prudential Borrowing Code (PBC): Table 2.8: Impact of Borrowing on PBL PBC Ratios Limits 2009/10 2010/11 2011/12 2012/13 2013/14 Minimum Dividend Cover >1 5.5 6.1 6.3 6.6 7.0 Minimum Interest Cover >2 2.7 2.3 2.3 2.3 2.4 Minimum Debt Service Cover >1.5 2.0 1.8 1.7 1.7 1.8 Maximum Debt Service to Revenue <10% 4.8% 5.7% 6.0% 6.0% 6.0% However under the new PBC regime the following steps are expected: − Monitor will provide the Trust with a ‘Tier 2’ limit to accommodate our existing borrowing commitments, now including the finance lease creditor consistent with the IFRS ‘on-balance-sheet’ accounting treatment for our New Hospitals Development. − The Board of Directors will consider making an application for an additional Tier 2 limit for 2010/11 to allow the adult Critical Care project to be financed. In line with the Trust’s previous timetable, the Outline Business Case is due to be presented to the Board of Directors in July 2009. 27
  28. 28. Risk Analysis 3 RISK ANALYSIS 3.1 GOVERNANCE RISK 3.1.1 Governance commentary Legality of constitution The constitution of the Trust was approved by Monitor at authorisation as a Foundation Trust on 1st January 2009. Approval for any changes will be sought from the members at the Annual Members’ meeting in September 2009. Growing a representative membership The Trust serves a diverse population and is mindful of ensuring that our membership is representative of the population. We have actively managed a number of recruitment initiatives and have specifically targeted under represented areas. We plan to continue those initiatives that proved successful and introduce some new ways of recruiting members (as set out in section 5.2). In particular we plan to focus some of our recruitment on young people and socio economic groups C2, D and E which are currently under represented across our membership. Appropriate board roles and structures The Board of Directors has overall responsibility for the operational and performance management of the Trust. A good working relationship is being developed between the Board and the Council of Governors. As part of our preparation for Foundation Trust status the Trust reviewed the Board roles and committee structure. A revised committee structure is now embedded across the organisation. The committees of the Board monitor performance across finance and activity, patient experience, risk and clinical effectiveness and are now performing effectively in providing assurance to the Board of Directors. A register of interests is kept and no director of the Trust has registered a material conflict of interest. One of the Non-executive Director’s term of office ends during 2009/10. A replacement will be appointed in line with our constitution. Service performance Achievement of key targets is closely monitored, particularly through the Intelligent Board report (see section 2.2.2 Quality). We have recently supplemented this process with the introduction of a Standards Monitoring Framework that covers a much wider range of standards and targets including for example the period assessments undertaken for the Annual Health Check, Commissioning for Quality and Innovation (QUIN), Advancing Quality and on-going national programmes of clinical standards audit. 28
  29. 29. Risk Analysis The framework ensures that: - All external assessments over the coming three year period are mapped into a three year rolling plan - Early assessments are scheduled in to the plan in a timeframe that allows results to be reviewed and corrective action taken if necessary - Supporting data/information flows are set up and responsibility assigned - Reporting and performance management mechanisms are set up The framework is overseen by a Clinical Measures Group which is also responsible for formally reviewing the Trust position against plan. Using this framework the Trust is able to monitor and manage performance against all targets, in particular those that are measured periodically or on an ad-hoc basis through one off assessments, and assure the Board that the Trust is compliant across the constantly increasing range of indicators. The main service performance risks for 2009/10 are: 18 weeks A&E target Clinical quality Over the last year the Trust has placed considerable emphasis on the development of clinical quality measurement and using clinical effectiveness indicators and related interventions to improve the patient experience. The Board of Directors receive clinical quality reports as part of the Intelligent Board Framework and are able to drill down to ascertain any existing risks and mitigation. Moving into 2009/10 the Trust has signed up to the Patient Safety 1st initiative and one of our key objectives is to deliver an integrated campaign across the Trust to improve patient experience, clinical quality and customer service as described in section 2.2.2. Effective risk and performance management The Trust’s Risk Management strategy describes the arrangements in place for the identification, evaluation, control and reassessment of all types of risk. The Risk Management Committee is chaired by the Chief Executive and monitors all clinical and non clinical risk across the organisation. A report of significant risks is presented at each Audit Committee and at each Board of Directors meeting. All serious incidents are subject to Root Cause analysis; the outcomes of these reports inform the risk registers, training needs and action plans. The Audit Committee receives reports from Internal and External Audit and other external assessment bodies. The tracking of recommendations is closely monitored. The Trust achieved Level 2 accreditation Clinical Negligence Scheme for Trusts (CNST) for General Services in 2008/09 and has Level 3 for Maternity Services. We assessed ourselves as fully compliant with all the core standards within the Health Care Commission’s Standards for Better Health. 29
  30. 30. Risk Analysis The Finance Scrutiny Committee reviews the adequacy of mitigating actions agreed to remedy financial variations from plan. Performance management by the Board is through the dash board approach of the Intelligent Board report. The three areas of performance management are:- • Clinical quality and safety • Patient experience • Productivity and efficiency. The report integrates activity, workforce and financial performance and has a subset of performance indicators for each of the three areas. Co-operation with NHS Bodies and local authorities The Executive Directors meet regularly with their counter parts in Manchester PCT and the Board of Directors has met the Board of the PCT. There is a strong working relationship with our commissioners and specialist commissioning body. We have established excellent links with Manchester City Council as part of our corporate citizenship focus and are working jointly on initiatives such as the Health Academy, local employment plans and Manchester’s economic development plan. Our New Hospitals Development and our clinical academic campus are major contributors to the development of Manchester. Our research and innovation capacity combined with the Biomedical Research Centre and the Manchester Academic Health Sciences Centre cements our already strong relationship with the University of Manchester. 3.1.2 Significant Risks The significant governance risks are: Critical care - insufficient critical care capacity for future demand arising from further concentrations and growth in specialist surgery New Hospitals Development – scale and complexity of moves gives rise to clinical and operational risks A&E target – increases in pressure on the urgent care system compromise our ability to deliver the 98% target Surgery – a range of internal constraints and external drivers causing medium term vulnerability Laboratory services – technological and policy drivers exist for the rationalisation of laboratories 18 weeks – remaining risks to achievement of 18 week target, particularly during the hospital moves period 30
  31. 31. Risk Analysis 3.1.3 HCAI targets The table below sets out the targets and actuals for 2008/09 and the 2009/10 targets for MRSA and C Difficile. Table 3.1: Targets for HCAI Target Q1 Q2 Q3 Q4 MRSA 08/09 target 6 6 6 6 08/09 actual 6 5 3 3 09/10 target 6 4 5 4 C diff 08/09 target 77 75 75 75 08/09 actual 66 58 64 54 09/10 target 60 60 62 84 31
  32. 32. Risk Analysis 3.2 Mandatory Services Risk 3.2.1 Significant risks There are no material risks to the Trust’s ability to comply with its authorisation relating to the provision of mandatory services 3.3 Financial risk 3.3.1 Commentary on financial risk rating Based on the financial projections in section 2, the Trust has a financial risk rating of 3, throughout the period. 3.3.2 Significant financial risks See Future Business Plans 3.4 Risk of any Other Non-Compliance with the Terms of Authorisation The New Hospitals Development is the biggest risk facing the Trust in 2009/10. The Board of Directors has been provided with assurances that the risks associated with the transfer of services have been addressed through peer reviews of plans, external reviews of plans, reporting of KPIs and learning from organisations who have recently delivered major service reconfigurations. These are described in more detail in section 2.2.3 32
  33. 33. Declaration and Self-Certification 4 DECLARATION AND SELF-CERTIFICATION Central Manchester University Hospitals NHS Foundation Trust Board Statements 2009/10 Clinical quality The board of directors is required to confirm the following: the board is satisfied that, to the best of its knowledge and using its own processes (supported by Care Quality Commission information and including any further metrics it chooses to adopt), its NHS foundation trust has, and will keep in place, effective arrangements for the purpose of monitoring and continually improving the quality of healthcare provided to its patients; and the board will self certify annually that, to the best of its knowledge and using its own processes , it is satisfied that plans in place are sufficient to ensure ongoing compliance with the Care Quality Commission’s registration requirements Service performance The board of directors is required to confirm the following: the board is satisfied that plans in place are sufficient to ensure ongoing compliance with all existing targets (after the application of thresholds) and national core standards and a commitment to comply with all known targets going forwards; Risk management The board of directors is required to confirm the following: issues and concerns raised by external audit and external assessment groups (including reports for NHS Litigation Authority assessments) have been addressed and resolved. Where any issues or concerns are outstanding, the board is confident that there are appropriate action plans in place to address the issues in a timely manner; all recommendations to the board from the audit committee are implemented in a timely and robust manner and to the satisfaction of the body concerned; the necessary planning, performance management and risk management processes are in place to deliver the annual plan; a Statement of Internal Control (“SIC”) is in place, and the NHS foundation trust is compliant with the risk management and assurance framework requirements that support the SIC pursuant to the most up to date guidance from HM Treasury (see; 33
  34. 34. Declaration and Self-Certification The trust has achieved a minimum of Level 2 performance against the requirements of their Information Governance Statement of Compliance (IGSoC) in the Department of Health’s Information Governance Toolkit; and all key risks to compliance with their Authorisation have been identified and addressed. Compliance with the Terms of Authorisation The board of directors is required to confirm the following: the board will ensure that the NHS foundation trust remains at all times compliant with their Authorisation and relevant legislation; the board has considered all likely future risks to compliance with their Authorisation, the level of severity and likelihood of a breach occurring and the plans for mitigation of these risks; and the board has considered appropriate evidence to review these risks and has put in place action plans to address them where required to ensure continued compliance with their Authorisation. Board roles, structures and capacity The board of directors is required to confirm the following: the board maintains its register of interests, and can specifically confirm that there are no material conflicts of interest in the board; the board is satisfied that all directors are appropriately qualified to discharge their functions effectively, including setting strategy, monitoring and managing performance, and ensuring management capacity and capability; the selection process and training programmes in place ensure that the non- executive directors have appropriate experience and skills; the management team have the capability and experience necessary to deliver the annual plan; and the management structure in place is adequate to deliver the annual plan objectives for the next three years. Signature……………………………… Signature……………………………… Printed name…………………………. Printed name…………………………. Date………………………………..….. Date……………………………..…….. In capacity as Chief Executive & In capacity as Chairman Accounting Officer Signed on behalf of the board of directors, and having regard to the views of the governors 34
  35. 35. Membership 5 MEMBERSHIP 5.1 Membership report Membership Size and Movements Public Constituency Last Year Next Year 2008/09 2009/10 At Year Start (April 1) 4,636 8,329 New Members 4,324 2,480 Members Leaving 631 809 At Year End (March 31) 8,329 10,000 Staff Constituency Last Year Next Year 2008/09 2009/10 At Year Start (April 1) 8,965 8,664 New Members 1,147 1,136 Members Leaving 1,448 1,200 At Year End (March 31) 8,664 8,600 Note – Staff opt out of membership. Staff numbers fluctuate during the year. Service reconfigurations and hospital moves as part of our New Hospital Development have been taken into account. 5.2 Membership Commentary Constituencies and changes in membership numbers The Trust serves its local population for secondary services and provides specialist services to the residents of Manchester, Greater Manchester and England and Wales. There are two membership constituencies, a public constituency and a staff constituency. Within the public constituency are 3 areas:- • Manchester • Greater Manchester • Rest of England and Wales. Within the staff constituency are 4 categories:- • Medical and Dental • Nursing and Midwifery • Non clinical and support • Other clinical staff. Staff are members on an ‘opt out’ basis. 35
  36. 36. Membership Elected governors are drawn from each of these constituencies, totalling 23 governors (17 public and 6 staff). Eight governors are nominated by our partner organisations. Our partner organisations are:- • The University of Manchester • Manchester PCT • NHS North West Specialist commissioning • Manchester City Council • The Youth Forum. Membership has grown steadily over the past year due to a number of initiatives. These have included the following:- • Working with patients and the public through our patient partnership department to encourage membership • Production of a newsletter for existing members including a membership form for family and friends • Friends and family initiative for staff • Children’s youth forums, wards and schools visited to encourage membership • Lead nurses and ward managers have been fully briefed and supplied with membership forms to encourage patients to become members when discharged • A series of presentations on local radio • Targeted telephone recruitment • Distribution of membership forms to:- - University of Manchester staff – direct mailing to home addresses - Multi-Faith groups - Previously discharged patients on a monthly basis - Retired staff - Patient groups - Community groups - Trust’s charity donors - Outpatient departments • Updating our Foundation Trust website and made it an integral part of the new Trust website. The recruitment of discharged patients has been particularly successful as has the targeted recruitment of the Chinese community which had been shown to be significantly under represented through out regular analysis of our membership. Our public membership for our first year as a Foundation Trust has exceeded our target of 8,000 and stands at 8,329. Plans to develop a representative membership Our plans for 2009/10 centre on growing the overall membership base and using specific initiatives to target under-represented groups, We have developed a Membership working group for our Governors with the first meeting held in January 2009. A workshop took place in March 2009 with the focus 36
  37. 37. Membership on reviewing the membership strategy and the communication and engagement plan with the governors. Our governors will play a pivotal role in identifying initiatives for raising the profile of the membership, keeping our members informed and updated about the work of the Trust and agreeing on the future action for membership recruitment. Communication with our membership involves a dedicated section of our website and regular newsletters and our governors receive an e-bulletin from the Chairman each month. A week long community event at the Trust in March 2009 enabled Governors to recruit additional members from the local community and in particular, successfully engaged with young people from a number of local schools. We are able to learn from the level of success of recruitment of members through previous initiatives and rationalise efforts where the return of membership recruitment was low and build on some of the previous initiatives which were successful. Contacting our discharged patients with the invitation to become a member has proved very fruitful and we plan to continue this and expand this in to areas not previously covered e.g. maternity and young people. Future actions for 2009/10 include:- • The publishing of posters for internal locations and external key areas in the community – supermarkets, dentist/doctor surgeries, libraries for example • Further mail shots to recently discharged patients • Mailing to staff leavers inviting them to become public members • Continuing work with community groups in order to build a representative profile of members from the community • Continuing with our work with patient groups • Further road shows within the Trust to continue to promote interest and improve understanding of governance arrangements • Tele-recruiting to target under represented areas/groups • Membership news item in Manchester City Council’s newspaper (circulation 200,000) • Targeted recruitment of young people at the Universities and Colleges across Manchester e.g. open days, freshers’ week and websites. We regularly review the make-up of our membership. Based on a recent analysis we have found that young people and people from socio economic groups C2, D & E are under- represented at present. We plan to have a focused campaign on recruiting to these groups. Another challenge we face is ensuring member representation from our England and Wales constituency and we will be working with our governors from this constituency to address this. 37
  38. 38. Membership Mechanisms by which the Board review membership plans, growth and engagement during the year The Board receives regular reports on membership recruitment including initiatives taking place, analysis of the membership profile and notification of community and membership events. The minutes of the Membership working group for Governors are reported to the Council of Governors and noted by the Board of Directors. We are planning to incorporate performance against our membership numbers and profile into the Intelligent Board reports. Through our governors, we are also planning to involve our directors in further engagement with our members. Explanation for the membership plan for the future and measures to increase engagement We detailed earlier a number of initiatives we have planned for 2009/10. Working closely with our patient partnership department we plan to actively work with our patient members during the year to ensure their views are sought. Local events and meetings with the local community will be targeted to recruit new members. We aim to ensure that our annual members meeting is well publicised so that attendance is high and our governors can meet and talk to the members. Through our Governor Membership working group in addition to monitoring the membership profile and reviewing the membership strategy, we plan to develop ways that governors can build a meaningful relationship with members and carry out their role as the conduit between the membership and the Board of Directors. The working group reports to the Council of Governors. Our governors’ own networks will be explored as a means of building our membership base and profile. Our newsletter ‘Foundation Focus’, which is sent to all members and is on our website, will be used to promote membership. The newsletter will also enable us to seek the views of the membership on various topics through questionnaire inserts. Development of our governors will continue throughout the year with the provision of dedicated sessions and workshops, a number of which will include our Board of Directors. These will enhance the performance of our Governors in supporting the membership through their representation on a number of committees and working groups of the Council of Governors:- • Appointments Committee • Remuneration Committee • Membership Working Group • Patient Experience Working Group • Public Health Working Group • Corporate Citizenship Working Group The following appendices are attached: Appendix A - public membership numbers by area. Appendix B - membership profile as a percentage of total membership by area Appendix C- membership profile showing deviation from base population by area 38
  39. 39. Membership Election turnout and trends The Board of Directors can confirm that the elections for public and staff governors were held in accordance with the election rules as stated in the constitution approved by Monitor. Elections were held during June 2008 to establish a shadow Council of Governors prior to authorisation on 1st January 2009. All public governors were elected in the June 2008 elections. All staff governors other than in the Medical and Dental category were elected in June 2008. No nominations had been received in time for the Medical and Dental category. A by-election was held in September 2008 and one governor was elected. One staff governor (nursing and midwifery) resigned in March 2009. A by-election is planned for April 2009. The following is a breakdown of the turnout at the elections in June and September 2008. Through the governors we will work to improve the turnout at forthcoming elections in 2009. The percentage turnout is a good indicator of Member engagement and ways of promoting the elections will be explored. Elections: Public & Staff – June and September 2008 Date of Constituencies Number of Number Number of Election Election Involved Members in of Seats Contestants Turnout Constituencies Contested June 2008 Public - 2,695 9 32 30.7% Manchester June 2008 Public - 1,738 2 15 39.6% Greater Manchester June 2008 Public - Rest 451 2 4 43.7% of England and Wales The 4 contestants with the next highest number of votes are also elected June 2008 Staff - Medical 1 0 No election and Dental held June 2008 Staff – Nursing 3,679 1 6 15.1% and Midwifery June 2008 Staff – Non- 1 1 Uncontested Clinical and Support Staff June 2008 Staff – Other 1,471 1 5 19.6% Clinical Staff The 2 contestants with the next highest number of votes are also elected September Staff – Medical 792 1 5 24.7% 2008 and Dental 39
  40. 40. Appendices 40
  41. 41. Appendix A – Public Membership Numbers by Area Rest of City of National Statistics Greater National Statistics England and National Statistics Manchester City of Manchester Manchester Greater Manchester Wales Rest of England Totals Number of Members 4,766 336,927 2,849 1,790,773 714 42,811,357 8,329 Rest of City of National Statistics Greater National Statistics England and National Statistics Gender Manchester City of Manchester Manchester Greater Manchester Wales Rest of England Totals Female 2,427 172,617 1,436 919,525 339 21,977,559 4,202 Male 2,245 164,315 1,371 871,277 350 20,833,763 3,966 Unknown 94 0 42 0 25 0 161 Rest of Monitor City of National Statistics Greater National Statistics England and National Statistics Ethnicities Manchester City of Manchester Manchester Greater Manchester Wales Rest of England Totals White 3,059 272,769 2,346 1,664,804 586 39,097,497 5,991 Asian 795 30,773 250 89,253 38 1,843,182 1,083 Black 555 15,215 98 10,291 14 958,710 667 Mixed 102 10,870 30 17,336 8 542,603 140 Other 76 7,305 35 9,117 6 369,330 117 Unknown 179 0 90 0 62 0 331 Rest of City of National Statistics Greater National Statistics England and National Statistics Age Range Manchester City of Manchester Manchester Greater Manchester Wales Rest of England Totals 0-16 104 31,962 152 174,421 32 3,848,018 288 17-21 131 40,585 86 121,042 43 3,027,359 260 22+ 3,852 264,380 2,344 1,495,310 603 35,935,980 6,799 Unknown 679 0 267 0 36 0 982 Rest of City of National Statistics Greater National Statistics England and National Statistics NRS (Age 16+) Manchester City of Manchester Manchester Greater Manchester Wales Rest of England Totals ABC1 2,885 126,756 1,961 780,231 486 20,092,828 5,332 C2 240 35,690 431 258,585 92 5,855,653 763 D 18 66,574 89 314,825 14 6,595,231 121 E 1,610 65,788 363 269,139 47 6,205,246 2,020 Unclassified 13 0 5 0 75 0 93 41