Appendix X - PEST and SWOT

8/8/2019 Appendix X - PEST and SWOT

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Appendix X: PEST and SWOT Analysis




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A. PEST ANALYSIS

A.1 POLICY AND POLITICSA.1.1 Forces and drivers for change

Guidance from the Royal College of Surgeons of England, the Royal College ofPhysicians of London, the British Association for Emergency Medicine, the Faculty ofAccident & Emergency Medicine of the Royal College of Surgeons in England andthe Academy of Medical Royal Colleges that:

• Emergency surgical services should be organised for a population of 450-500,000

• The provision of comprehensive elective surgical care on a stand alone basisby a DGH is not sustainable and should be replaced by a network of hospitalsserving populations of 500-600,000

• The ideal unit for fully comprehensive medicine and surgery is a hospital or

group of hospitals serving a population of 450-500,000• The lowest catchment population for ‘district hospitals’ providing 24 hourchildren’s services, 24 hour surgical services and maternity services as wellas acute medicine and surgery is 250,000

• ‘local hospitals’ serving a population less than 250,000 are unlikely to be ableto sustain 24 hour/emergency surgery or inpatient paediatrics or consultantled obstetrics and may have to operate a ‘selected medical take’

• There should be no single handed consultants in any major subspeciality• Smaller A&E units seeing less than 40,000 new patients per annum should be

supported where they are able to demonstrate their effectiveness, safety andquality and where they serve geographically isolated populations

• The above changes will be triggered by a lack of medical manpower followingon from the introduction of the EWTD.

West Midlands SHA has identified that paediatrics, maternity, A&E and emergencysurgical services within the region are ‘challenged’ ( Investing for Health Chapter 6)

DoH policy emphasising the shift towards greater levels of care being provided byprimary and community care providers or in a community setting

Growing recognition at national level that set against the advice of a range ofprofessional bodies and DoH policy that traditional models for the organisation andmanagement of local health economies are increasingly outdated and that centralgovernment has a role in brokering the necessary structural change

DoH policy emphasising more aggressive management of chronic disease/long termconditions

Roll out of Patient Choice

Roll out of Practice Based Commissioning




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Creation of competitive market for NHS funded healthcare (evidenced by four sets ofoverlapping changes: creation of a new regulatory framework; transfer ofresponsibility for service provision from government to Foundation Trusts and thegranting of private sector providers equal status with FTs; reduction in the constraints

on capacity (and hence competition) represented by a limited supply of medicalstaffing; empowerment of patients through Choose & Book and the introduction of atariff based reimbursement system for providers)

Entrance of private sector into market for NHS funded healthcare

Establishment of Foundation Trusts and acquisition by FTs of NHS Trusts unable todemonstrate viability

Increasing regulatory burden

Policy differences between NHS England and NHS Wales

Investment by the DoH in the development of “world class” commissioning

Potential establishment of a Public Services Trust by Herefordshire PCT andHerefordshire Council

Impact:

HHT needs to adopt a strategy based on a clear recognition and understanding ofthe ‘dogbone effect’. This is the phenomenon whereby smaller secondary careproviders lose services or referrals to larger secondary/tertiary providers with thenecessary critical mass/able to meet increasingly stringent quality standards on theone hand and to primary and community care providers on the other.

A number of services provided by HHT – specifically A&E, obstetrics, paediatrics andemergency surgery – are vulnerable.

The management of the challenges posed by the ‘dogbone effect’ and thevulnerability of core DGH services needs to be put in the context of the introductionof a market for NHS funded healthcare characterised by patient choice andcompetition between providers, of a recognition that changes to the traditionalstructures of healthcare economies are in some instances both necessary anddesirable and of a new commissioning regime.

HHT cannot expect to be shielded from the challenges facing it. Survival as anindependent organisation is not guaranteed. The organisation needs to ‘reinvent’




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itself and develop and implement a strategy which allows it to ‘punch above itsweight’.

A.1.2 ECONOMICS

Forces and drivers for change:

Reduced levels of NHS growth 2008/9 onwards

Roll out of Payment By Results and reduced real terms income per HRG

High costs of capital

High costs of labour

Reducing costs of some new technologies

Increasing costs of drugs and therapeutics

Increasing costs of litigation

Impact:

HHT needs to put in place systems, structures and processes to support costcontainment and improved productivity

Investments made in services or infrastructure need to provide the maximum returnon investment. HHT needs to become ‘smarter’ in the way it invests in newtechnologies

The costs of poor quality (and the centrality of quality in the operation of the market)will force a more aggressive approach to the management of quality

1. SOCIETY


Demography: an increase in the proportion of older people within the population, inthe absolute numbers of older people and in the numbers living alone




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Epidemiology: increased prevalence and incidence of obesity and diabetes

Increased mobility

Demand for local access to services in a rural area with a scattered population

Increasing public expectations

Immigration into Herefordshire by EU migrant workers

Continuing problems in recruiting key staff

Impact:

HHT needs to develop an overarching model of care which recognises the uniquecombination of challenges posed by local demography and geography, a moredemanding ‘customer’ who is able to access other providers

HHT needs to understand and respond to the needs and wants of migrant workers

HHT needs to ensure that it is seen in the labour market as an attractive employer.Failure to attract ‘mission critical’ staff (or failure of the education system to ensurean adequate supply of trainees) will potentially accelerate the ‘dogbone effect’

A.1.3 TECHNOLOGY


Increasing complexity of hospital care

Increased levels of subspecialisation within the traditional taxonomy of secondarycare services

Changes in clinical practice: shorter lengths of stay; increased levels of day surgery

Increased volumes of care traditionally provided by secondary care providers nowprovided by primary and community care providers

Increased volumes of secondary care traditionally provided in an institutional setting




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now provided in a community setting

Increased volumes of ‘hi tech’ secondary care now being referred to tertiary careproviders

Increased use of standard care protocols

Introduction of new technologies (eg genetic technologies) resulting in therapeuticrather than surgical interventions, delivery if ‘hi tech’ care in a ‘lo tech’ setting

Increased mobility/miniaturisation of diagnostic equipment

Continuing advances in IT

Impact:

Alongside HR, technological change will potentially accelerate the ‘dogbone effect’.‘Technological change’ in this context includes both ‘soft’ technologies(subspecialisation and changes in clinical practice) and ‘hard’ technologies (newequipment).

HHT needs to support the delivery of (demonstrable) high quality care throughincreased use of formal protocols and pathways

New technologies offer the potential to support decentralisation and the extension ofthe HHT service portfolio

The potential benefits of current investment in IM&T needs to be maximised




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B. SWOT ANALYSIS

B.1 STRENGTHS

Themes and supporting evidence:

THEME EVIDENCE

Key ‘internal’ strengthsare:

New, skilled andexperienced Executive

Management Team

HHT is a small, single siteprovider

Increasing expertise inserviceredesign/productivityimprovement/LEAN

Clinician enthusiasm forService LineReporting/decentralisationof decision making

An increasing recognitionacross the organisationthat ‘good housekeeping’needs to be replaced byorganisationaltransformation

Key ‘external’ strengthsare:

Consistent delivery ofaccess targets/compliancewith core Standards for

Better Health

Self diagnosis

2007/08 income totalled £Xm; HHT operates from theCounty Hospital site in Hereford City. Althoughambulatory care is provided in community settingsacross Herefordshire and Powys, these communityfacilities are neither owned nor operated by HHT

LEAN has been applied to the following services ALAN DAWSON TO NAME . The lead Clinical SystemsEngineer for the Trust has a PhD in this subject

Outputs from clinical strategy workshops

Outputs from Executive Management Team, StrategicForum and Great Escape meetings/events

PETER GORIN TO INSERT




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Relative efficiency

Provision of a broad range

of secondary care/DGHservices

Modern hospitalenvironment

High levels of ‘ownership’of and identification withthe County Hospitalamongst local residents

Supportive local media

HOWARD ODDY TO INSERT (06/07 RCI of 95)

Self diagnosis

The ‘new’ County Hospital was opened in YEAR???

Feedback from GPs, Members, OSC, MPs and otherstakeholders

Cuttings archives/support for FT application process

Implications:

HHT has the necessary ‘ingredients’ for success

Internally, it has an effective management team, it is free of the complexities resultingfrom large size or split site working, it has buy in from the clinical teams, it recognisesthe need to change clinically and has the technical skills set to do this.

Externally, the Trust is able to evidence compliance with core HealthcareCommission standards, relative efficiency, a range of services consistent with its roleas a ‘local’ District General Hospital, modern facilities, a supportive/loyal customerbase and a positive media image

B.2 WEAKNESSESThemes and supporting evidence

THEME EVIDENCE

Key ‘internal’weaknesses are:

Under-appreciation of thethreat to the organisation

represented by PESTanalysis





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Structure that is not ‘fit forpurpose’

Systems and processesthat are not ‘fit for purpose’

– planning, financial andperformance management

Lack of changemanagementcapacity/capability

Poor quality operational,clinical and planninginformation; inadequateIM&T systems

PFI financed facilities:highfixed costs; inflexibility inuse of facilities

Historic dependency onnon-recurrent measures todeliver financial targets

Poor track record in thedelivery of CIPs/ failure todeliver target CIP andsurplus in 2007/08

Limited knowledge ofprofitability of individualservice lines

‘Mixed’ track record in therecruitment and retentionof high quality staff

Lack of a market drivenbusiness culture at themiddle management andacross the clinical teams


Self diagnosis

Self diagnosis

Self diagnosis

Treasury (October 2007) put HHT PFI charge 2008/9£12.6m or 13.4% of 2006/7 turnover; this percentagecited a third highest of all PFI schemes in NHS England

HOWARD ODDY TO INSERT…

HOWARD ODDY TO INSERT…

JOHN HOWDEN TO INSERT…

Self diagnosis

Feedback from Birmingham and Black Country SHA onHHT wave 3a FT application




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Historical lack of ambitionand willingness to self-promote

Key ‘external’weaknesses are:

Continued used of threeWWII ‘temporary’ wards

High occupancy levelsresulting from high levelsof emergency admissionsand hence a negativeimpact on electivecapacity

High levels of cancelledoperations

Continuing problems in thedelivery of 18 week RTTtimes

High levels of HCAIs

Sub-optimal stroke care

Over-centralisation ofambulatory care services

on the County Hospitalsite

Inconsistency in servicequality/lack of clear qualityUSP (eg faster accesstimes)/provision of a lowerquality service thanGloucestershire HospitalsNHS Foundation Trust(HHT’s main competitor)

67 ‘general and acute’ beds (30% of general and acutebed stock) accommodated in hutted wards

Average bed occupancy level is c.98%. INSERT LATEST PERFORMANCE DATA ON LEVELS OF EMERGENCY ADMISSIONS AND ACTUAL V CONTRACT ON ELECTIVE ACTIVITY

INSERT LATEST PERFORMANCE DATA

ALAN DAWSON TO INSERT…

Insert latest performance data

ALAN DAWSON TO INSERT…


Comparative data from Healthcare Commission website,Dr Foster Good Hospital Guide and NHS Choiceswebsite

Feedback from GPs




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Poor standard of customercare to GPs

Implications:

HHT’s potential success could be compromised by a mixture of ‘internal’ and‘external’ weaknesses.

The organisation needs to develop and execute an Organisational Developmentprogramme which delivers an organisation that is ‘fit for purpose’ and addressessystems, structure, strategy, skills, staff. shared values and style (ie all elements ofthe McKinsey 7S model)

The Trust also needs to ensure that it engages with its customers, develops andimplements a more attractive model of care and delivers tangible improvements inquality thus enabling it to differentiate itself from its competitors. Specifically, HHTneeds to reprovide the hutted wards, ‘protect’ the flow of elective patients, adopt azero-tolerance approach to infection prevention and control and ‘fill’ any gaps inservice provision

B.3 OPPORTUNITIES


THEME EVIDENCE

Expansion into the easternpart of central Walesthrough ‘codification’ ofrelationship with PowysLHB, development ofambulatory care servicesat Llandrindod Wells

community hospital andpost ‘downgrading’ ofNevill Hall Hospital

Capture of an increasedpercentage of market onthe ‘borders’ betweenHerefordshire,Gloucestershire,Worcestershire andShropshire

Market analysis

Market analysis




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Diversification egacquisition of PCTprovider arm services,social care, primary caresupport (diagnostics,accommodation etc),niche services (terminalcare, lifestyle services,chronic diseasemanagement etc)

Market analysis

Implications:

HHT has opportunities to expand into eastern Wales and increase its share of the

local NHS England along the ‘borders’ with Gloucestershire, Worcestershire andShropshire. It also has a number of opportunities to diversify.

B.4 THREATS


THEME EVIDENCE

Relatively small size ofHHT catchment populationand vulnerability of someservices

Failure of commissionersto articulate clear strategyfor local healtheconomy/economies

Cost pressures resultingfrom lack of critical massand operation in a tariffbased market

Higher co-morbidity of an

Herefordshire’s resident population totals X; thecatchment population of Powys covered by HHT totals Y

The report of the Academy of Royal Colleges ‘Acutehealth care services – report of a working party’(September 2007) and WMSHA’s strategic framework‘Investing for Health’ (September 2007) identifiedpaediatrics, obstetrics, A&E and emergency surgery aspotentially vulnerable

Lack of up-to-date commissioning strategies whichinform LDP negotiations

The replacement of a ‘cost = price’ system with a fixedtariff based system has resulted in HHT being exposedto a range of cost pressures in services which the costsof delivering a safe/high quality service exceed tariffbased income




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older catchmentpopulation resulting inhigher costs potentiallyexceeding tariff income

Ineffective joint workingacross the Herefordshirehealth and social caresystem resulting in HHTeffectively cross-subsidising provideragencies

Lack of political supportwithin NHS Wales for use

of English provider

Patient Choice,commissioner preferencesand competition from localprivate sector andGloucestershire NHScompetitors resulting inreduced market sharealong the ‘borderlands’and within HHT’s ‘core’

catchment area

Establishment of anaggressive communityservice provider able to‘cherrypick’ lo techoutreach and/or diagnosticwork

Development by PracticeBased CommissioningGroups of primary carebased alternatives to HHTservices

Age profile of HHT’s catchment population and patientworkload

Distance from optimum ALOS and day surgery rates

Historical financial performance of HHT

Insert latest data on delayed discharges and n:f/up ratios (versus PCT target of 1:1)and inappropriate referrals

+MARTIN WOODFORD TO INSERT…

Market analysis

Market analysis

Market analysis

Implications:

HHT’s potential expansion could be compromised by the loss of vulnerable servicesand a combination of issues relating to critical mass, the increased costs associated




with delivering services to a small catchment population in a rural setting and theoverall effectiveness of the local health and social care system

The Trust’s main commissioners have yet to confirm their strategic intentions. Thenew administration in Wales has signalled that it wishes to minimise/terminate theuse of English providers.

The organisation is vulnerable to competition from Gloucestershire Hospitals NHSFoundation Trust, new market entrants able to ‘cherrypick’ lo tech cases and thetransfer of care from a hospital into a primary care setting.

Appendix X - PEST and SWOT

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