Trust Board · TLC re -provision concluded saving 54k FYE (1.6WTE). Stock repatriation will create...

Trust Board Agenda Item 12. Date: 21.12.16

Title of Report Carter

Purpose of the report and the key issues for consideration/decision

Trust Board are asked to receive the report as the first of the Carter Programme Updates required to be presented each month, in line with the Carter sub-recommendation 8g “Trust boards being made accountable and mandated to review the dashboards for three clinical or medical specialties each month, to benchmark themselves against the established metrics and best practice, and routinely track progress by October 2016.”

Prepared by: Name & Title Alex Vincent – Senior Transformation Manager Richard Mundon – Director of Strategy and Planning

Presented by: Richard Mundon

Action Required (please X) Approve Adopt Receive for information

x

Strategic/Corporate Objective(s) supported by this paper

Safe, Effective and Caring Corporate Objectives

Is this on the Trust’s risk register? No

xYes

If Yes, Score

Which Standards apply to this report?

CQC X NHSLA X BAF Objectives X WWL Wheel X

Have all implications related to this report been considered?

Yes/No/NA Any

Action Required

Yes/ No/NA

Any Action Required

Finance Revenue & Capital Yes Equality &

Diversity Na. Na.

National Policy/Legislation Yes Patient

Experience Na. Na.

NHS Contract Na. Na. Governance

& Risk Management

Yes

Human Resources Na. Na. Terms of

Authorisation Na. Na.

Consultation/Communication Na. Na.

Human Rights

Na. Na.

Other: Na. Na. Carbon

Reduction Na. Na.

If action required please state:

Previous Meetings Please insert the date the paper was presented next to the relevant group

ECC Audit Committee

Quality & Safety

Committee

Finance & Investment Committee

Management Board

IM&T Strategy

Committee

HR Committee

NED Other

Na Na Na. Na. Na Na Na Na Na

2 Carter Programme 21/12/16

CARTER PROGRESS AND GOVERNANCE REPORT

No. Recommendation Update RAG Financial Opportunity

1. NHS Improvement should develop a national people strategy and implementation plan by October 2016 that sets a timetable for simplifying system structures, raising people management capacity, building greater engagement and creates an engaged and inclusive environment for all colleagues by significantly improving leadership capability from “ward to board”, so that transformational change can be planned more effectively, managed and sustained in all trusts.

Flu campaign

Implementation of CQUIN plan

Weight loss challenge awareness launch

Senior review of all LTS cases

Phased return framework agreed with OH

Sickness absence at Trust target of 4%

Every further 0.1% reduction saves the Trust

£127,845

2. NHS Improvement should develop and implement measures for analysing staff deployment during 2016, including metrics such as Care Hours Per Patient Day (CHPPD) and consultant job planning analysis, so that the right teams are in the right place at the right time collaborating to deliver high quality, efficient patient care.

Paper on e-rostering presented to workforce committee

Shadow rosters created in V9 of e-roster

Upgrade plan being agreed and formalised

Met with staff side re consultation paper on 24/11/16

Plan for payback of hours agreed with Heads of Nursing

Improved allocation of leave within rosters

resulting in reduction of temporary staffing;

potential savings £343k

3. Trusts should, through a Hospital Pharmacy Transformation Programme (HPTP), develop plans by April 2017 to ensure hospital pharmacies achieve their benchmarks such as increasing pharmacist prescribers, e-prescribing and administration, accurate cost coding of medicines and consolidating stockholding by April 2020, in agreement with NHS Improvement and NHS England so that their pharmacists and clinical pharmacy technicians spend more time on patient facing medicines optimisation activities.

TLC re-provision concluded - saving 54k FYE (1.6WTE). Stock repatriation will create space in our robot which will release 80K as a one off.

HPTP accepted as green by NHS which is reflective of our previous good work in service transformation, our collaboration across GM and our future plans to modernise

NHSI stated that Pharmacy was the most advanced Carter programme of all of them & GM Devolution Pharmacy was the most developed of all the programmes

TBC Awaiting GM wide

savings opportunities

4. Trusts should ensure their pathology and imaging departments achieve their benchmarks as agreed with NHS Improvement by April 2017, so that there is a consistent approach to the quality and cost of diagnostic services across the NHS. If benchmarks for pathology are unlikely to be achieved, trusts should have agreed plans for consolidation with, or outsourcing to, other providers by January 2017.

Radiology - GM PACS potential of standardisation of Radiology departments across GM, same pathways, shared quality i.e. reporting images at other institutions e.g. cancer scans reported at Christie, neuro at Salford, etc. Work started on actual unit cost for WWL Radiology

Pathology - PQAD template combined with GM; following discussions with the NHS Improvement team, they have agreed to change the template as it would not provide the information they required.

Pathology - Total Costs less GP activity is £3.265m = 1.2% of total operating

costs (should be < 1.6% of operating expenditure.”)

5. All trusts should report their procurement information monthly to NHS Improvement to create an NHS Purchasing Price Index commencing April 2016, collaborate with other trusts and NHS Supply Chain with immediate effect, and commit to the Department of Health’s NHS Procurement Transformation Programme (PTP), so that there is an increase in transparency and a reduction of at least 10% in non-pay costs is delivered across the NHS by April 2018.

GM Head of Procurement / Cluster meeting took place on 23/11/16 – No major developments regarding the cluster.

Agreed to adhere to the 12 core set of NHS products defined by NHSI.

Carter metrics to start being reported monthly and will appear in Model Hospital portal– not confirmed yet.

Top 100 index being developed

Model Hospital information not available

6. Trusts should operate at or above the benchmarks agreed by NHS Improvement for the operational management of their estates and facilities functions by April 2017; with all trusts (where appropriate) having a plan to operate with a maximum of 35% of nonclinical floor space and 2.5% of unoccupied or under-used space by April 2017 and delivering this benchmark by April 2020, so that estates and facilities resources are used in a cost effective manner.

ERIC data work has been considerable, but now likely Model Hospital information will be aligned but will only be developed in mid-December.

Linen services savings to be rebased –Linen details and switchboard were combined in Carter.

Estate cost concern re: empty buildings – Capital issues mean potentially no funds to demolish therefore, increase Carter cost.

TBC


No. Recommendation Update RAG Financial Opportunity

7. All trusts corporate and administration functions should rationalise to ensure their costs do not exceed 7% of their income by April 2018 and 6% of their income by 2020 (or have plans in place for shared service consolidation with, or outsourcing to, other providers by January 2017), so that resources are used in a cost effective manner.

Consolidation of back office and pathology function being considered across the GM footprint with NHSI requests being managed by the GMHSCP team

Agreed to share FSD/ISD/PSD data

Currently 9.63% 7% = £7.6m reduction

6% = £10.4m reduction

8. NHS Improvement and NHS England should establish joint clinical governance by April 2016 to set standards of best practice for all specialties, which will analyse and produce assessments of clinical variation, so that unwarranted variation is reduced, quality outcomes improve, the performance of specialist medical teams is assessed according to how well they meet the needs of patients and efficiency and productivity increase along the entire care pathway.

All Q3 reviews completed o Medicine – Cardiology, Haematology and Palliative Care o Surgery – Critical Care, Paediatrics and Obstetrics &

Gynaecology o Specialist Services – Breast Screening, Plastic Surgery &

Trauma

TBC

9. All trusts should have the key digital information systems in place, fully integrated and utilised by October 2018, and NHS Improvement should ensure this happens through the use of ‘meaningful use’ standards and incentives.

E-Catalogue delivery at planning stage

E-prescribing in place

EPR in place

TBC

10. DH, NHS England and NHS Improvement, working with local government representatives, to provide a strategy for trusts to ensure that patient care is focussed equally upon their recovery and how they can leave acute hospitals beds, or transfer to a suitable step down facility as soon as their clinical needs allow so they are cared for in the appropriate setting for themselves, their families and their carers.

Share to Care programme continuing to deliver as planned: o 9/23 areas connected o 9/23 areas in configuration o 5/23 rationale received

SRG meet weekly to work together to best manage discharge and transfer of care

TBC

11. Trust boards to work with NHS Improvement and NHS England to identify where there are quality and efficiency opportunities for better collaboration and coordination of their clinical services across their local health economies, so that they can better meet the clinical needs of the local community.

Locality plan in place and programmes underway to deliver health and social care across the Borough.

Health Economy Saving £87m

12. NHS Improvement should develop the Model Hospital and the underlying metrics, to identify what good looks like, so that there is one source of data, benchmarks and good practice.

Reporting and processes being developed in line with Model Hospital information. Further development will occur as Model Hospital portal comes online.

No direct saving

13. NHS Improvement should, in partnership with NHS England by July 2016, develop an integrated performance framework to ensure there is one set of metrics and approach to reporting, so that the focus of the NHS is on improvement and the reporting burden is reduced to allow trusts to focus on quality and efficiency.

Reporting and data validation delivered in line with GM Framework Updated and revised frameworks will be implemented as further information is released.

No direct saving

14. All acute trusts should make preparations to implement the recommendations of this report by the dates indicated, so that productivity and efficiency improvement plans for each year until 2020/21 can be expeditiously achieved.

Locality leadership programme developed – nominations received from all partners

Coaching pool established, with regular CPD

Internal leadership programmes reviewed and running with established scheduled

TBC

15. National bodies should engage with trusts to develop their timetable of efficiency and productivity improvements up until 2020/21, and overlay a benefits realisation system to track the delivery of savings, so that there is a shared understanding of what needs to be achieved.

Planning and delivery commenced based on current information. Updated and revised plans will be created as timetable details are released.

Cost Improvement Plans 17/18 £14.5m

18/19 £


Clinical Service Reviews

The three specialties, one from each clinical division, highlighted for December are:

1. Surgery – General Surgery 2. Specialist Services – Dermatology 3. Medicine – Respiratory


General Surgery

ATC £1.06

NB: Benchmark information and ATC based on 2014/15 data


your hospitals, your health, our priority 2

Speciality Overview

2

Speciality Overview Key service changes Key changes planned over

next two Years?

Team:

4 consultants + 0.50 shared with Acute

Medicine (leaving and out to advert)

2 Registrars

5 Sleep Nurses (4.49 WTE)

3 Asthma / ILD Nurses (2 WTE)

5 COPD Nurses (4.80 WTE)

2 Oxygen Nurses

2 Bronchoscopy Nurses

2 Cancer Specialist Nurses

Services provided:

- Day Case / Elective (c700 p.a.):

- EBUS & Bronchoscopy

- Outpatients (> 15,600 p.a.):

- Sleep

- Asthma / ILD

- COPD

- Oxygen

- TB

- Cancer

- Inpatients (Ince & Winstanley Ward):

- Ward rounds (5 day senior

cover)

- Acute Medicine on call rota

Internally driven:

- New consultant post

- Initiation of Wrightington O/P clinic

- New : follow-up ratio (2.83 in 14/15 >

2.24 in 15/16)

- GM lead for EBUS

- Chronic Recurrent Admissions MDT

(reviews patients with 3+ admissions

in 12 months)

Externally driven:

- Breathlessness Service (community)

changes from Health First to BOC

- NICE Cancer Guidance

Internally driven:

- New Cancer pathway being trialled

- 5th Consultant post

- IPC service

- Ideally in-reach but would need 6th

consultant

Partnerships:

- NW Severe Asthma ODN

- NW ILD Network (Specialist

Commissioned)

- International Medical Fellow (Sept >)

- NW Research Network & 2 multi-

national trials

Notable successes:

- Finance & CIP performance

- New to Follow-up ratios

- 4 Consultant service

- 3 x Royal College & Undergraduate

assessors

- Finalists for Patient Safety Award &

represented Trust nationally

- Effective contributor for IHI meeting

Externally driven:

Pathway redesign with WBCCG

‘Be Clear on Cancer’ campaign

imminent

Notable successes continued:

- Regional level services (EBUS,

Sleep, ILD, Home NIV)

- Combined Rheumatology clinic


Service Change

Business Cases

etc.

Summary of Purpose Latest position / benefits

realisation

Service Change review (last 3 years)

3

Trial of 5th consultant (half

Respiratory / half Acute Medicine)

Implementation of Wrightington clinic

Increase activity and income levels

Demand management & resilience in

Respiratory and Acute Medicine

Wrightington clinic activity 62% out of

area.

Activity levels (O/P first and EBUS)

increased.

Research involvement

Involvement in Research Network

Multi-National trials

Commercial & non-commercial studies

£24,000 in last 2 years

2 commercial drug trials running &

several non-commercial studies

Regular flow of expressions of interest

for potential new respiratory studies

Combined Rheumatology ILD clinic

at Wrightington

66 patients in 2015/16

£4,611 profit in SLR


your hospitals, your health, our priority

Financial information – SLR DataRespiratory Medicine - SLR Data to Q4 (April – March 2016)

• This is the SLR Data for Respiratory Medicine

for April 2015 – March 2016 – Overall

Contribution is positive £1.2m.

• ATC values of less than £1.00 mean the costs

of delivering the service are less than the

national average – Outpatients are performing

well compared to ATC.

• Based on the Department of Health trust saving

drill down there is potentially £640k savings

opportunity in respiratory medicine including

overheads, (£767k), which are largely

uncontrollable by the clinical team.

• Day case ATC is higher than the national

average by £0.27, meaning there is 27% more

cost incurred than the national average – offset

by lower costs in outpatients.

• Respiratory as a whole is performing well

posting an ATC very close to the national

average.

• DZ06Z : Minor Thoracic Procedures , is

currently loss making in SLR (£21k)

• SA13A : Single Plasma Exchange,

Leucophoresis or Red Cell Exchange, 19 years

and over, is currently loss making in SLR (£21k)4

Point of Delivery Number of Activities Income Direct Costs Indirect Costs Direct & Indirect Costs Contribution Contribution % ATC

Day Case 706 £1,317,618 £466,249 £86,305 £552,553 £765,065 58% £1.27

Outpatient - Follow Up 8,883 £1,620,925 £896,448 £385,582 £1,282,031 £338,895 21% £0.70

Elective 82 £173,307 £82,147 £31,664 £113,811 £59,496 34% £0.69

Outpatient - First 3,973 £1,152,443 £836,349 £270,733 £1,107,081 £45,362 4% £0.70

Outpatient - None Face to Face 2,531 £229,366 £198,174 £28,788 £226,962 £2,404 1% £0.70

Outpatient - Procedure 187 £34,088 £31,331 £9,147 £40,479 -£6,390 -19% £0.92

Total 16,362 £4,527,749 £2,510,699 £812,218 £3,322,917 £1,204,831 27% £1.03


Improvement Opportunities

Improvement opportunities

Additional

Annual

Activity

Notional

saving £

1 If the specialty increased the number of patients seen in OPD by 5%628 14,346£

2 if the specialty reduce DNA rates to Trust target 851 16,754£

3 If the new to follow up penalty is reduced by 20% 0 -

4 If the specialty reduced drugs expenditure by 5%5% 13,016£

5 If expenditure on diagnostic tests is reduced by 5%5% 31,462£

6 If length of stay is reduced by 2% - requires step changes 2% 19,975£

7 If nursing sickness is reduced to Trust target 4% 4% 40,190£

8 If non medical agency spend reduces by 25% 25% 8,493£

9 If medical agency spend reduces by 25% 25% 15£

10 If Theatre utilisation increased by 2%0% -

11 If theatre agency reduced by 25%0% -

General

12 If admin and clerical costs reduced by 5%5% 3,382£

Total 1,480 147,633£

Outpatients

Diagnostics

TheatresInpatient



Productivity

6

Productivity

Metrics Narrative

• High increase in GP referrals

• High increase in cancer / EBUS referrals

• Increased nurse clinic follow-ups

• Improved O/P new : follow-up ratios

• Created new capacity by keeping Follow-

up increase lower than new increase

• Increase in O/P hospital cancellations

primarily due to Industrial Action or bringing

patient appointments forward (e.g. urgent /

cancer)

• Speciality meeting reviewing DNA %

increase to assess themes & provide

actions

Metric 2013/14 2014/15 2015/16

% change

from

2013/14

GP referrals 2,056 2,258 2,750 33.8%

Day Case activity (Bronch/EBUS) 486 576 704 44.9%

Outpatient first appointments 3,248 3,364 4,022 23.8%

Outpatient follow-ups 10,517 11,097 11,625 10.5%

Total new : follow-up ratio 2.74 2.83 2.24 (18.2%)

Consultant new : follow-up ratio 2.33 2.45 1.91 (18.0%)

DNA % 8.0% 7.3% 8.1% 1.3%

Patient Cancellations % 14.2% 14.6% 13.6% (4.2%)

Hospital Cancellations % 6.6% 9.5% 10.2% 54.5%


Specialty Resilience

7


• GP referrals continue to rise

• EBUS referrals continue to rise

• ‘Be Clear on Cancer’ campaign

imminent

• Consultant leaving at end of July,

replacement currently out to advert

(current establishment will cover

Wrightington clinic in the interim

period)

• Increase in specialist nurses required

to support expanding services

• Winstanley Ward nurse staffing gaps

• Outpatient follow-up backlog

continues to rise:

• October 2015 = 59

• June 2016 = 398



Quality Metrics

Metric Mean National Target WWL Position Rating

HSMR / SHMI

etc.

Any mortality audit / mortality

review data???

Complaints Not been made aware of National

targets

2013/14: xx

2014/15: xx

2015/16: xx

Incidents Not been made aware of National

targets

2013/14: 217

2014/15: 190

2015/16: 213

Staff sickness

absence /

turnover

Trust / Divisional targets:

Sickness absence = 4.60%

Turnover = 8.00%

Sickness

absence: Turnover:

Mar-15: 5.79% 7.02%

Apr-16: 5.72% 14.11%

Staff pulse

check

No PULSE check data as

department is not a Pioneer Team

Department has held 2 official

staff engagement sessions in

last 12 months

Quality & Outcome Metrics

8

Skewed as 1

consultant leaver =

20% of dept.

Medical staff = 1.1%

Winstanley = 8.44%


SWOT Analysis

9

Strengths• Number of sub-specialities interests:

• Sleep

• Asthma

• COPD

• Oxygen

• ILD

• TB

• Cancer

• No medical agency usage

• Finance and CIP performance

• Many service improvements with just 4

consultants

• Active in Education, Research & patient safety

Weaknesses

• Decontamination impacts on EBUS and

Bronchoscopy

• Small number of consultants and nurses

• Winstanley Ward nurse staffing cover

• PIU move delay

• Physical space

Opportunities• Wrightington clinic

• 5th full time consultant post

• NW Severe Asthma ODN


• Indwelling Pleural Catheter (IPC) service

• BOC primary care service

• Chronic end-stage Lung Disease joint Palliative

Care clinic (not just financial benefits)

• 1 x Sleep + 1 x Cancer nurse for service

expansion

Threats• Pathway redesign with WBCCG

• Devolution Manchester

• EBUS Bolton

• Expanding service but number of staff need to

follow suit to ensure continued quality, outcomes

and targets are achieved

• Physical space



Improvements: Clinical Variation

10


Area of

focus

• Reviewing ‘Clinical Variation’ is a good idea and the right thing to

do

• BUT – it must be validated and meaningful

• Example: The split between Consultant and Specialist Nurse

activity is different in 2015/16 compared to that used in both

2014/15 and 2013/14, which led to a 3,000 (50%) swing in

Outpatient attendances between each category.

• Our first area of focus is to work with the Data Quality and PMO

teams to ensure the data is meaningful

Consultant

New

Attendances

Follow up

Attendances

Total

Attendances

New to FU

Ratio (no

exclusions) Clinics

Average

patients

per clinic DNAs %

Patient

Cancellations

%

Hospital

Cancellations

%

ASHISH A 507 969 1,476 1.9 144 10.3 5.0% 14.0% 10.8%

AZIZ I 445 781 1,226 1.8 135 9.1 8.4% 14.6% 9.6%

MADI SI 1,469 4,756 6,225 3.2 681 9.1 11.0% 17.1% 10.8%

MEHDI S 241 352 593 1.5 60 9.9 8.6% 14.9% 9.8%

Specialist Nurse 471 3,083 3,554 6.5 716 5.0 2.9% 4.2% 1.1%

SUNDAR R 889 1,684 2,573 1.9 194 13.3 9.0% 13.3% 17.2%

Total 4,022 11,625 15,647 2.9 1,930 8.1 8.1% 13.6% 10.2%


Recommendations

11

Outcome Narrative

Appoint 5th full time

consultant post

• This is necessary to simply meet current cancer and EBUS

demands

Validate variation data

• ‘Clinical Variation’ review is fully supported

• First we must work with DQ and PMO to validate the data

and ensure it is meaningful

• Likewise for SLR - Validate cost build-up and ATC

Reduce cancellation

and DNA % rates

6th consultant post• This post would be necessary to deliver an in-reach service

• It would also allow expansion to the sleep service

Increase Specialist

Nurse support to ILD &

Sleep Services


General Surgery Action Log

Division Name: Surgery

Speciality: General Surgery

Date Actions Log Created: 19 Oct 2016

Date Actions Log Last Updated:

7 Dec 2016

Issue Actions Last Updated By:

Nick Jones

1

11/05/16

Ref Description Comments / Actions Financial Impact (FYE) Owner Due Date

Status Closed Date

1 Formal introduction of ‘hot gall bladder slot’

To prevent unnecessary emergency admissions

Unknown but there are contract condition penalties

Will reduce LOS & readmission rate

Marius Paraoan / MF

Jan 2017 Clinical lead has been appointed and will commence in role in January

Nov 2016

2 Deep dive into reasons for ↑LOS and readmissions

Will reduce LOS & readmission rate

Unknown Marius Paraoan / Nick Jones

March 2017

Delayed due to extra-work from HT meetings

3 Introduction of new middle-grade rota

Maybe further PA reduction

No increase in cost Marius Paraoan / Nick Jones

Oct/Nov 2016

Middle grade appointed and will commence in March 2017 – New job plans have been discussed

4 Drill down on the best practice opportunities – daycase hernias/short stay emergencies

Pre-op process and predictive discharge ‘on the day’

FYE ~£45k ‘lost’ potential income for daycase hernias (mindful that not all will be suitable)

Nick Jones Oct/Nov 2016

Day case rate up – day case lead in post

Nov 2016


Dermatology

ATC £1.10

NB: Benchmark information and ATC based on 2014/15 data



Speciality Overview

22


next two Years?

Team & Services

• In 2015/2016 seen 20465

patients

• Last 3 years 38% Rise in

SCA referrals

• Out to substantive

consultant advertisement

• Exploring option of joint

appointment – Salford

Service out to tender

2014/2015

• Awarded primary provider

status

• Limited shared care

• Consultant Staffing

• Closure to Out of Area

• Service closed on C&B

• Currently 558 patients on

ASI

Key Changes

• Advertising for

substantive consultant

• Outpatient re-design with

CCG – No date for

implementation

• Shared Care

• Increase Team

• Succession Planning

• Open to out of Area


Speciality Overview

33

JOB TITLE CONTRACTED HOURS SUCCESSION PLANConsultant 1WTE Early discussions on retirement plan from November, no plans or agreements in place.

Locum Consultant 1 0.50 WTE Rolling contract, advertisements for substantive consultant unsuccessful, to be re-advertised. Joint appointment with Salford unsuccessful.

Locum Consultant 2 0.50 WTE As aboveSpecialty Doctor 5.5 PA Unable to increase PA’s

Clinical Assistant 1 4.5 PA As aboveClinical Assistant 2 2.25 PA As aboveClinical Assistant 3 1.15PA As above

Locum Specialty doctor 2.50PA As aboveSenior Sister/Skin rash

specialist nurse 33hrs3 clinics per week (psoriasis and eczema new & follow-up patients)Departmental managerial role

Skin Cancer Specialist Nurse 37.5hrs

5 clinics per week:• Benign warts and lesions (new & fol)• SCA• Skin surveillance (fols)• Minor Surgery• Attends plastic surgery clinics as skin cancer SN.

Phototherapy Sister 37hrs Phototherapy sessions, Mon, Weds. Fri.Dressings clinicsSupervises and trains junior staff

3, Band 5 staff nurses 92.5hrsSupervising clinics.DressingsAssisting in theatreMinor surgery

5, Health Care Assistants123hrs

Assisting medical staff within clinics and theatreHousekeeping.

Ward clerk 37hrs Clerical and admin dutiesVACANCIES SICKNESS ABSENCE Consultant 1.91WTEStaff Nurse 0.50WTEHCA 0.27WTE

June 15 – May 16 1.32%



Financial informationDermatology - SLR Data (April 2015 – March 2016)

ATC data (April 2014 – March 2015)

• SLR shows the overall contribution for

Dermatology for 2015/16 was positive £599k

• Adjusted Treatment Cost (ATC) values of more

than £1.00 mean the costs of delivering the

service are more than Lord Carter’s model

hospital.

• ATC’s for Dermatology are available for

Outpatients (OP) and Outpatient Procedures

(OPPROC) – OPPROC have performed well

compared to ATC but OP costs are nearly 50%

greater than those in the model.

• Dermatology is struggling to recruit to its

permanent medical staff Consultant vacancies

which has lead to high agency spend

contributing to this ATC being above model

costs (the agency Consultants have each cost

25% more than the salaried consultant). There

is now difficulty in recruiting through an agency

putting activity and income at risk.

Point of DeliveryNumber of

ActivitiesIncome

Direct &

Indirect

Costs

ContributionContribution %

(2015/16)

ATC

(2014/15)

Outpatients (FA and FUP combined) 17,122 £1,945,470 £1,316,084 £629,385 32% £1.49

Non - Elective 1 £78 £1,120 -£1,043 -1,345%

Outpatient - Procedure 3,190 £406,876 £412,702 -£5,826 -1% £0.83

Outpatient - None Face to Face 364 £25,967 £49,063 -£23,096 -89%

Total £20,677 £2,378,390 £1,778,970 £599,420 25% £1.10


Financial information

Financial Information – ATC data

POD Description ATC Actual CostUnits of

Activity

Expected

CostVariance

Potential

Saving

Consultant Led £1.49 £1,228,866 8,495 £825,300 (£403,566) £403,566

Non Consultant Led £1.22 £3,456 37 £2,844 (£612) £612

Outpatient

Procedures£0.83 £1,014,618 10,463 £1,217,976 £203,358 £0

Diagnostic Imaging

Outpatient£0.77 £2,250 30 £2,932 £683 £0

£1.10 £2,249,189 19,025 £2,049,052 (£200,137) £404,178Dermatology

There is potential to make savings in the region of £400k according to ATC

data, however it is worth noting that this assumes a reduction in costs

including overheads of £648k which clinicians are not able to easily control.





Additional

Annual

Activity

Notional saving £

1 If the specialty increased the number of patients seen in OPD by 5% 513 14,416

2 If the specialty reduce DNA rates to Trust target 220 8,085

3 If the new to follow up penalty is reduced by 20% N/A

4 If the specialty reduced drugs expenditure by 5% 23,431

5 If expenditure on diagnostic tests is reduced by 5% 8,190

6 If length of stay is reduced - requires step changes N/A

7 If nursing sickness is reduced to Trust target 4% N/A

8 If non medical agency spend reduces by 25% N/A

9 If medical agency spend reduces by 25% 94,536

10 If Theatre utilisation increased by 2% N/A

11 If Theatre agency reduced by 25% N/A

Ge

ne

ral

12 If admin and clerical costs reduced by 5% 1,098

Total 733 149,756

Ou

tpatie

nts

Diagn

ostics

The

atres

Inp

atien

t


Productivity

7

Productivity

Metrics

Clinical Variation metrics 2015/2016

•Outpatient attendance - 20465

•Hospital cancellations – 5.4%

•Patient cancellations – 12.2%

•First to follow-up ratios – 9:97

•DNA Rate – 6%




8


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3.47

3.24

2.95

2.82

2.81

2.76

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2.23

2.11

2.03

1.99

1.98

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FFU ratio 2015-16

WWL shows the 2nd lowest FFU Rate in the SHA IN 15-16



9


-.Peer (Acute) Attendances FFU Ratio Attendances FFU Ratio Attendances FFU Ratio Attendances FFU Ratio

Blackpool Teaching Hospitals NHS Foundation Trust 34,248 4.21 33,421 3.97 34,602 4.23 38,412 4.84

North Cumbria University Hospitals NHS Trust 14,970 3.8 14,444 3.98 12,957 3.59 16,198 3.47

Salford Royal NHS Foundation Trust 60,637 3.09 62,557 3.11 69,096 3.12 90,880 3.24

University Hospital Of South Manchester NHS Foundation Trust 13,408 2.92 14,565 2.71 14,480 2.52 13,903 2.95

Lancashire Teaching Hospitals NHS Foundation Trust 20,976 2.97 21,096 3.02 23,963 2.6 22,857 2.82

Wirral University Teaching Hospital NHS Foundation Trust 25,899 3.37 23,605 3.29 24,078 2.84 24,912 2.81

St Helens and Knowsley Hospitals NHS Trust 27,765 2.79 30,844 2.6 35,015 2.59 37,865 2.76

University Hospitals Of Morecambe Bay NHS Foundation Trust 20,421 2.22 24,494 2.9 24,940 2.86 26,813 2.74

East Cheshire NHS Trust 12,657 2.9 13,067 2.6 13,729 2.88 10,541 2.7

Central Manchester University Hospitals NHS Foundation Trust 17,678 1.7 20,557 1.82 21,095 2.05 17,507 2.65

Royal Liverpool and Broadgreen University Hospitals NHS Trust 46,549 2.59 48,029 2.77 45,594 2.63 46,024 2.36

Tameside Hospital NHS Foundation Trust 18,433 2.26 19,207 1.87 22,401 2.47 21,673 2.26

Countess Of Chester Hospital NHS Foundation Trust 12,180 2.39 12,680 2.52 12,837 2.24 13,752 2.23

Southport and Ormskirk Hospital NHS Trust 16,450 2.06 18,529 2.07 19,648 2.21 20,482 2.11

Bolton NHS Foundation Trust 12,548 2.07 13,455 2.08 15,011 2.28 14,187 2.03

Wrightington, Wigan and Leigh NHS Foundation Trust 18,226 1.93 20,472 2.02 18,889 1.97 20,465 1.99

Mid Cheshire Hospitals NHS Foundation Trust 13,128 2.18 14,192 2.02 15,052 1.93 17,527 1.98

Stockport NHS Foundation Trust 21,148 3.38 21,367 3.02 19,436 2.33

2013/14 2014/15 2015/162012/13




10


-.

9.69 9.197.06

3.98

8.195.98

9.42 10.25

6.06

13.18

9.87 10.47

4.81 5.667.87 7.76

5.38

27.75

24.89 24.88 24.73

21.3319.11 18.76 18.60 17.59 16.66

13.29

9.86

0.59 0.40 0.00 0.00 0.00

Dermatology Outpatient DNA and Cancellation Rate 15-16 vs SHA Peers

DNA Rate Cancelled Rate

WWL shows the 6th

lowest DNA rate and

the 9th highest

hospital cancellation

rate in 2015/16


Quality Metrics


HSMR / SHMI

etc.

N/A N/A

Complaints Continual Year on Year

Reduction

2015/2016 – 1

Incidents Datix 2015/2016 - 16

Staff sickness

absence /

turnover

Trust Target – 4% 1.32%

Staff pulse

check

Trust Average:

Level of engagement: Average % of positive scores across all

measures of engagement avg for trust =

81.61% ( Oct 15)

84.74 %– Would recommend the trust to friends

and family as a place to work

85.86% - would recommend the trust to friends

and family if they needed care or treatment

Specialist Services Division:

Level of engagement: Average % of positive scores across all

measures of engagement = 80.70% ( Oct 15)

82% of staff would recommend WWL for care,

and 84% would recommend WWL as a place

to work.(Jan 16)

New report due in May 2016 .




SWOT Analysis

12

Strengths

Service Reputation

Specialist Nursing Team

Weaknesses

Shared Care

Use of off licence drugs

Opportunities

Out of Area Income

All Other Providers closed to out of

area

Collaborative working with Salford

Biosimilars

Threats

Outpatient Service Redesign

Consultant Staffing


Recommendations & Improvements

13

Recommendation Action Timescale

Continue focus on

substantive

consultant

recruitment

Job plan awaiting Royal

College Approval

SPA increased to 2.5

Attractive job plan

Ongoing

Reduce drugs

expenditure

Work with CCD Shared

care

Implement IFR process

Ongoing – awaiting

GMMMG approval

Increasing

Outpatient Dept

efficiency

Review Current Practice Ongoing


Dermatology Action Log

Division Name: Specialist Services

Speciality: Dermatology

Date Actions Log created: 8th December 2016

Date Actions Log last updated:

Issue Actions last updated by

1

11/05/16

Ref Description Comments / Actions Financial Impact (FYE)

Owner Due Date Status Closed Date

1 Continue focus on substantive consultant recruitment – reduce agency Drs

Job plan awaiting Royal College approval SPA increased to 2.5 Attractive job plan

Joanne Bark On-going Job plan finalised and advertised. As of yet no applicants

2 Reduce drugs expenditure Work with CCD Shared care Implement IFR process. Awaiting GMMMG approval

Joanne Bark On-going Still awaiting GMMMG approval

3 Increasing Outpatient Dept efficiency

Review Current Practice Joanne Bark On-going Slot utilisation flexed on a weekly basis to manage capacity effectively. Negated need for FT locum.

4 Explore the sector based solution to recruitment and acute service

Previously advertised for joint appointment with Salford – no applicants. Trying to recruit WWL consultant

5 Unfunded / unlicensed drugs – explore replacing with Biosimilars

1. Attend CIP assurance meeting with Mike Parks to explore the options

Joanne Bark 1. On-going

Biosimilars not currently used in sector in Dermatology Not viable options at the moment.


Respiratory Medicine

ATC £1.03

NB: Benchmark information, Staff Costs and ATC based on 2014/15

data



Speciality Overview

2


next two Years?

Team:

4 consultants + 0.50 shared with Acute

Medicine (leaving and out to advert)

2 Registrars

5 Sleep Nurses (4.49 WTE)

3 Asthma / ILD Nurses (2 WTE)

5 COPD Nurses (4.80 WTE)

2 Oxygen Nurses

2 Bronchoscopy Nurses

2 Cancer Specialist Nurses

Services provided:

- Day Case / Elective (c700 p.a.):

- EBUS & Bronchoscopy

- Outpatients (> 15,600 p.a.):

- Sleep

- Asthma / ILD

- COPD

- Oxygen

- TB

- Cancer

- Inpatients (Ince & Winstanley Ward):

- Ward rounds (5 day senior

cover)

- Acute Medicine on call rota

Internally driven:

- New consultant post

- Initiation of Wrightington O/P clinic

- New : follow-up ratio (2.83 in 14/15 >

2.24 in 15/16)

- GM lead for EBUS

- Chronic Recurrent Admissions MDT

(reviews patients with 3+ admissions

in 12 months)

Externally driven:

- Breathlessness Service (community)

changes from Health First to BOC

- NICE Cancer Guidance

Internally driven:

- New Cancer pathway being trialled

- 5th Consultant post

- IPC service

- Ideally in-reach but would need 6th

consultant

Partnerships:

- NW Severe Asthma ODN

- NW ILD Network (Specialist

Commissioned)

- International Medical Fellow (Sept >)

- NW Research Network & 2 multi-

national trials

Notable successes:

- Finance & CIP performance

- New to Follow-up ratios

- 4 Consultant service

- 3 x Royal College & Undergraduate

assessors

- Finalists for Patient Safety Award &

represented Trust nationally

- Effective contributor for IHI meeting

Externally driven:

Pathway redesign with WBCCG

‘Be Clear on Cancer’ campaign

imminent

Notable successes continued:

- Regional level services (EBUS,

Sleep, ILD, Home NIV)

- Combined Rheumatology clinic


Service Change

Business Cases

etc.

Summary of Purpose Latest position / benefits

realisation

Service Change review (last 3 years)

3

Trial of 5th consultant (half

Respiratory / half Acute Medicine)

Implementation of Wrightington clinic

Increase activity and income levels

Demand management & resilience in

Respiratory and Acute Medicine

Wrightington clinic activity 62% out of

area.

Activity levels (O/P first and EBUS)

increased.

Research involvement

Involvement in Research Network

Multi-National trials

Commercial & non-commercial studies

£24,000 in last 2 years

2 commercial drug trials running &

several non-commercial studies

Regular flow of expressions of interest

for potential new respiratory studies

Combined Rheumatology ILD clinic

at Wrightington

66 patients in 2015/16

£4,611 profit in SLR



Financial information – SLR DataRespiratory Medicine - SLR Data to Q4 (April – March 2016)

• This is the SLR Data for Respiratory Medicine

for April 2015 – March 2016 – Overall

Contribution is positive £1.2m.

• ATC values of less than £1.00 mean the costs

of delivering the service are less than the

national average – Outpatients are performing

well compared to ATC.

• Based on the Department of Health trust saving

drill down there is potentially £640k savings

opportunity in respiratory medicine including

overheads, (£767k), which are largely

uncontrollable by the clinical team.

• Day case ATC is higher than the national

average by £0.27, meaning there is 27% more

cost incurred than the national average – offset

by lower costs in outpatients.

• Respiratory as a whole is performing well

posting an ATC very close to the national

average.

• DZ06Z : Minor Thoracic Procedures , is

currently loss making in SLR (£21k)

• SA13A : Single Plasma Exchange,

Leucophoresis or Red Cell Exchange, 19 years

and over, is currently loss making in SLR (£21k)4

Point of Delivery Number of Activities Income Direct Costs Indirect Costs Direct & Indirect Costs Contribution Contribution % ATC

Day Case 706 £1,317,618 £466,249 £86,305 £552,553 £765,065 58% £1.27

Outpatient - Follow Up 8,883 £1,620,925 £896,448 £385,582 £1,282,031 £338,895 21% £0.70

Elective 82 £173,307 £82,147 £31,664 £113,811 £59,496 34% £0.69

Outpatient - First 3,973 £1,152,443 £836,349 £270,733 £1,107,081 £45,362 4% £0.70

Outpatient - None Face to Face 2,531 £229,366 £198,174 £28,788 £226,962 £2,404 1% £0.70

Outpatient - Procedure 187 £34,088 £31,331 £9,147 £40,479 -£6,390 -19% £0.92

Total 16,362 £4,527,749 £2,510,699 £812,218 £3,322,917 £1,204,831 27% £1.03




Additional

Annual

Activity

Notional

saving £

1 If the specialty increased the number of patients seen in OPD by 5%628 14,346£

2 if the specialty reduce DNA rates to Trust target 851 16,754£

3 If the new to follow up penalty is reduced by 20% 0 -

4 If the specialty reduced drugs expenditure by 5%5% 13,016£

5 If expenditure on diagnostic tests is reduced by 5%5% 31,462£

6 If length of stay is reduced by 2% - requires step changes 2% 19,975£

7 If nursing sickness is reduced to Trust target 4% 4% 40,190£

8 If non medical agency spend reduces by 25% 25% 8,493£

9 If medical agency spend reduces by 25% 25% 15£

10 If Theatre utilisation increased by 2%0% -

11 If theatre agency reduced by 25%0% -

General

12 If admin and clerical costs reduced by 5%5% 3,382£

Total 1,480 147,633£

Outpatients

Diagnostics

TheatresInpatient



Productivity

6

Productivity

Metrics Narrative

• High increase in GP referrals

• High increase in cancer / EBUS referrals

• Increased nurse clinic follow-ups

• Improved O/P new : follow-up ratios

• Created new capacity by keeping Follow-

up increase lower than new increase

• Increase in O/P hospital cancellations

primarily due to Industrial Action or bringing

patient appointments forward (e.g. urgent /

cancer)

• Speciality meeting reviewing DNA %

increase to assess themes & provide

actions

Metric 2013/14 2014/15 2015/16

% change

from

2013/14

GP referrals 2,056 2,258 2,750 33.8%

Day Case activity (Bronch/EBUS) 486 576 704 44.9%

Outpatient first appointments 3,248 3,364 4,022 23.8%

Outpatient follow-ups 10,517 11,097 11,625 10.5%

Total new : follow-up ratio 2.74 2.83 2.24 (18.2%)

Consultant new : follow-up ratio 2.33 2.45 1.91 (18.0%)

DNA % 8.0% 7.3% 8.1% 1.3%

Patient Cancellations % 14.2% 14.6% 13.6% (4.2%)

Hospital Cancellations % 6.6% 9.5% 10.2% 54.5%



7


• GP referrals continue to rise

• EBUS referrals continue to rise


imminent

• Consultant leaving at end of July,

replacement currently out to advert

(current establishment will cover

Wrightington clinic in the interim

period)

• Increase in specialist nurses required

to support expanding services

• Winstanley Ward nurse staffing gaps

• Outpatient follow-up backlog

continues to rise:

• October 2015 = 59

• June 2016 = 398



Quality Metrics


HSMR / SHMI

etc.

Any mortality audit / mortality

review data???

Complaints Not been made aware of National

targets

2013/14: xx

2014/15: xx

2015/16: xx

Incidents Not been made aware of National

targets

2013/14: 217

2014/15: 190

2015/16: 213

Staff sickness

absence /

turnover

Trust / Divisional targets:

Sickness absence = 4.60%

Turnover = 8.00%

Sickness

absence: Turnover:

Mar-15: 5.79% 7.02%

Apr-16: 5.72% 14.11%

Staff pulse

check

No PULSE check data as

department is not a Pioneer Team

Department has held 2 official

staff engagement sessions in

last 12 months


8

Skewed as 1

consultant leaver =

20% of dept.

Medical staff = 1.1%

Winstanley = 8.44%


SWOT Analysis

9

Strengths• Number of sub-specialities interests:

• Sleep

• Asthma

• COPD

• Oxygen

• ILD

• TB

• Cancer

• No medical agency usage

• Finance and CIP performance

• Many service improvements with just 4

consultants

• Active in Education, Research & patient safety

Weaknesses

• Decontamination impacts on EBUS and

Bronchoscopy

• Small number of consultants and nurses

• Winstanley Ward nurse staffing cover

• PIU move delay

• Physical space

Opportunities• Wrightington clinic

• 5th full time consultant post

• NW Severe Asthma ODN


• Indwelling Pleural Catheter (IPC) service

• BOC primary care service

• Chronic end-stage Lung Disease joint Palliative

Care clinic (not just financial benefits)

• 1 x Sleep + 1 x Cancer nurse for service

expansion

Threats• Pathway redesign with WBCCG

• Devolution Manchester

• EBUS Bolton

• Expanding service but number of staff need to

follow suit to ensure continued quality, outcomes

and targets are achieved

• Physical space




10


Area of

focus

• Reviewing ‘Clinical Variation’ is a good idea and the right thing to

do

• BUT – it must be validated and meaningful

• Example: The split between Consultant and Specialist Nurse

activity is different in 2015/16 compared to that used in both

2014/15 and 2013/14, which led to a 3,000 (50%) swing in

Outpatient attendances between each category.

• Our first area of focus is to work with the Data Quality and PMO

teams to ensure the data is meaningful

Consultant

New

Attendances

Follow up

Attendances

Total

Attendances

New to FU

Ratio (no

exclusions) Clinics

Average

patients

per clinic DNAs %

Patient

Cancellations

%

Hospital

Cancellations

%

ASHISH A 507 969 1,476 1.9 144 10.3 5.0% 14.0% 10.8%

AZIZ I 445 781 1,226 1.8 135 9.1 8.4% 14.6% 9.6%

MADI SI 1,469 4,756 6,225 3.2 681 9.1 11.0% 17.1% 10.8%

MEHDI S 241 352 593 1.5 60 9.9 8.6% 14.9% 9.8%

Specialist Nurse 471 3,083 3,554 6.5 716 5.0 2.9% 4.2% 1.1%

SUNDAR R 889 1,684 2,573 1.9 194 13.3 9.0% 13.3% 17.2%

Total 4,022 11,625 15,647 2.9 1,930 8.1 8.1% 13.6% 10.2%


Recommendations

11

Outcome Narrative

Appoint 5th full time

consultant post

• This is necessary to simply meet current cancer and EBUS

demands

Validate variation data

• ‘Clinical Variation’ review is fully supported

• First we must work with DQ and PMO to validate the data

and ensure it is meaningful

• Likewise for SLR - Validate cost build-up and ATC

Reduce cancellation

and DNA % rates

6th consultant post• This post would be necessary to deliver an in-reach service

• It would also allow expansion to the sleep service

Increase Specialist

Nurse support to ILD &

Sleep Services


Respiratory Medicine Actions Log

Division Name Medicine

Speciality Respiratory

Date Action Log created 25/07/2016

Date Action Log last updated 09/12/2016

Action last updated by Chris Ellison

1

11/05/16


Owners Due Date Status Closed Date

1. Appoint 5th full time consultant

Change advert from half Respiratory / half Acute Medicine consultant to full Respiratory. Post currently out for advert – no applicants as yet.

TBC Abdul Ashish Chris Ellison

31-Dec-16 Open -

2. Validate and investigate ATC data to determine high cost base

Service Line Reporting - Review POD’s with higher than average ‘ATC’ costs (looks to be only day case).

TBC Abdul Ashish Chris Ellison Ian Roberts Stephen Holt Boby Raja

31-Dec-16 Open -

3. Narrow clinical variation (specific)

Understand and address variations, e.g.

Outpatient clinic templates

New to Follow-up ratio

Outpatient DNA rates

Outpatient Hospital Cancellation rates

Outpatient Patient Cancellation rates Incorporated as part of the 16/17 CIP Plan for Respiratory with a focus on reducing DNA and Cancellation Rates.

TBC Abdul Ashish Chris Ellison Boby Raja

31-Dec-16 Open -




4. Investigate 6th consultant post

Identify benefits from appointing 6th full time

consultant.

Agreed to park this at the moment until

CCG Commissioning Intentions and income

growth implications are clear – currently

unsure of how income is going to

commissioned next year.


31-Dec-16 Open -

5. Increase Specialist Nurse support to ILD & Sleep Services

Build up business case of additional staffing

resource required vs additional activity,

financial and non-financial benefits.

ILD Business Case out for signatures but will

be dependent on CCG Commissioning

Intentions and income growth implications.

Sleep Service – currently being written

TBC Abdul Ashish Salem Madi Chris Ellison

31-Dec-16 Open -

6. Sleep Service - Explore commencement of NIV clinic

Identify additional resource requirements vs anticipated benefits from having a NIV clinic. Sleep Service – currently being written

TBC Salem Madi Chris Ellison

31-Dec-16 Open -

7. Severe Asthma ODN Continue discussions with Salford & Bolton re: commencing joint sector wide Severe Asthma clinic.

Identify potential start date.

Identify additional resource requirements vs anticipated benefits.

TBC Imran Aziz Sandra Dermott Chris Ellison

31-Dec-16 Open -

8. Nurse-led clinics for COPD

Explore potential of clinics in the Community

to fit in with ‘Care closer to home’ and

WBCCG agenda.

TBC Imran Aziz Joanne Wright Chris Ellison

31-Dec-16 Open -




9. ILD nurse-led clinic Linked to reference number 5. Complete business case to show anticipated benefits accruing from a 15 hours per week increase in nurse staffing hours. ILD Business Case out for signatures but will

be dependent on CCG Commissioning

Intentions and income growth implications.

TBC Abdul Ashish Sandra Dermott Chris Ellison

31-Dec-16 Open -

10. COPD / Respiratory Review Unit (reduces LOS)

Identify additional resource requirements vs anticipated benefits from having a full respiratory review unit at RAEI.

TBC Abdul Ashish Imran Aziz Chris Ellison

31-Dec-16 Open -

11. IPC service Review potential to commence IPC service at WWL.

TBC Ram Sundar Chris Ellison

31-Dec-16 Open -

12. Explore Bronchoscopy at Leigh

Identify additional resource requirements vs anticipated benefits from commencing Bronchoscopy services at Leigh as well as RAEI. Investigations have been undertaken with regards availability of clinic space at Leigh. This will be dependent on CCG Commissioning Intentions and income growth implications


31-Dec-16 Open -

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