Agenda item

(This item provides an update on the Lincolnshire Recovery Programme, the purpose of is to oversee the delivery of the NHS Constitutional Standards; improvements in the quality of care; and actions to address financial balance within the Lincolnshire health economy.  The reports lists the outcomes from Programme over the last year. 

Jim Heys, Locality Director, Midlands and East (Central Midlands) NHS England, and Ian Hall, Senior Delivery and Development Manager, NHS Improvement, will be in attendance)

Consideration was given to a joint report by NHS England and NHS Improvement which provided an update on the Lincolnshire Recovery Programme, the purpose of which was to oversee the delivery of the NHS Constitutional Standards; improvements in quality of care; and actions to address financial balance within the Lincolnshire health economy.  The report included outcomes from the Programme over the last year.

Jim Heys (Locality Director – Midlands and East (Central Midlands) NHS England) and Ian Hall (Senior Delivery and Development Manager – NHS Improvement) were in attendance for this item.

The context of the Lincolnshire Recovery Board, jointly chaired by NHS England and NHS Improvement, was explained for the benefit of the Committee by providing the background.  The Lincolnshire Recovery Programme (LRP) had been developed to provide a senior level coordinating programme structure which supported performance improvement and further development of a clinically safe and financially sustainable health and care model across Lincolnshire.

The aims of the Lincolnshire Recovery Programme were noted:-

·       Improve United Lincolnshire Hospitals NHS Trust's (ULHT's) performance against the NHS Constitutional standards so that all required targets were achieved;

·       Continue to improve quality within ULHT and across the health community;

·       Develop a financial strategy and plan to deliver improvements to the financial position across Lincolnshire; and

·       Design an underpinning workforce/organisational development strategy and plan.

It was reported that no regulatory action had been necessary over the last 12 months and that the relationship and dialogue between commissioners and providers was much improved.  The group membership had also evolved and included only accountable officers and Chief Executives.  Although it had been agreed that the Lincolnshire Recovery Board would oversee the Lincolnshire Health and Care (LHAC) plan, this had now expanded to include the Sustainability and Transformation Plan (STP). 

The current view was to continue with the Lincolnshire Recovery Board and consider strategic operational progress in addition to financial performance.

NHS England led the National Health Service (NHS) in England, setting the priorities and direction including strategies such as the Five Year Forward View.  NHS England was organised into four regional teams, each providing support to Clinical Commissioning Groups (CCGs) in areas such as healthcare commissioning and delivery.  Additionally, they provided professional leadership on finance, specialised commissioning, human resources and organisational development and worked closely with local authorities, health and wellbeing boards and GP practices.

Since the last meeting it was explained that the Trust Development Agency and Monitor had integrated to become one operational model known as NHS Improvement.  NHS Improvement also included Patient Safety, the National Reporting and Learning System, the Advancing Change Team and the Intensive Support Teams.  NHS Improvement was responsible for overseeing foundation trusts, NHS trusts and independent providers.

Chief Executives from the seven NHS organisations had undergone a Lincolnshire Leadership Programme facilitated by an external body.  The benefit of the programme was to gain a sense of joint ownership and understanding of the issues and had been successful in the cessation of silo working.

The purpose of the Lincolnshire Recovery Programme Board was noted:-

1.    To oversee achievement of the programme aims for an initial period of twelve months from July 2015, after which time those responsible for health and care system delivery would be in a position to no longer require this level of intervention;

2.    To agree a programme structure that holds senior leadership from all represented organisations to account and oversee high level intervention and support;

3.    To ensure that the boards of each organisation represented were signed up to the LRP aims and programme structure;

4.    To accept recommendations from the Operational Programme Group with regards to the scope and expected outcomes from the programme work streams;

5.    To act upon exception reports and items for escalation from the Operational Programme Group, in order to ensure the programme aims were achieved;

6.    To ensure that dependency issues between the LRP and the Lincolnshire Health and Care (LHAC) Programme were managed in a manner that avoids duplication between the programmes or adverse impacts on either programme; and

7.    To identify the need for additional support to facilitate achievement of the Programme aims and agree approaches for securing support.

The outcomes for the programme to-date included:-

·       Outcome 1 – Improved working relationships between the constituent NHS organisations, and a new focus on joint action, led by new Lincolnshire Leaders working group.  Evidenced by prompt signature of the 2016/17 contract between ULHT and its lead commissioner;

·       Outcome 2 – Consistent delivery of the Referral to Treatment (RTT) incomplete standard of 92%;

·       Outcome 3 – Consistent delivery of the national target for diagnostic waiting times;

·       Outcome 4 – ULHT was currently off track against the Quarter 1 trajectory for the 62 day cancer standard.  Improvement progress was monitored on a weekly call between NHS Improvement, NHS England, ULHT and Lincolnshire CCGs and an improvement trajectory agreed;

·       Outcome 5 – The A&E standard (95% within 4 hours) varied by site and was the subject of intense support from all parties.  A revised trajectory for delivery had been agreed by NHS Improvement and NHS England.  Performance in April 2016 was better than the agreed monthly trajectory and performance in May and June was likely to be on or around the trajectory agreed.  Current year to date delivery was 81.4% (at 17 June 2016);

·       Outcome 6 – ULHT delivered its revised deficit target for 2015/16, recording a year end deficit of £57 million, (original planned deficit was £40 million).  The Trust's control total for 2016/17 was a deficit of £48 million.  Year to date (April and May 2016), ULHT had delivered a deficit of £8 million, a position that was £0.4 million better than plan.  The STP included a section on "closing the finance" and efficiency gap", describing in outline the approach being developed to address the current circa £60 million deficit and the financial gap forecast for 2020/21, if no remedial actions were taken;

·       Outcome 7 – The Lincolnshire Health and Care (LHAC) Programme also reported on progress to the Lincolnshire Recover Programme Board, although LHAC was subject to a separate governance and decision making structure.

Members were invited to ask questions, during which the following points were noted:-

·       Outcome 4 (cancer standards) had not been met since January 2016 and there was a number of ways in which these concerns could be escalated.  There had been a significant increase in referrals within recent months and the Trust had also reported significant referrals for spot check cancer.  Further impact had been a significant turnover in consultant oncologists which had caused some disruption to clinics.  The Cancer Committee was scheduled to meet where a trajectory would be agreed that the Trust was expected to meet over the next few months;

·       Although it was acknowledged that 50% of people who presented at A&E did so inappropriately, it was reported that this was a national issue.  There had been a significant decrease in performance in this area but those inappropriately presenting at A&E were generally found to be complex cases.  Lincolnshire had significant gaps in the workforce and the inability to secure locum cover was a continued problem.  Consideration was to be given to other options to fill the gaps as this was a mitigating factor in not meeting performance targets;

·       The Ambulatory Care Clinic had improved performance in some areas but it was noted that unless the channels for release or transfer of patients from A&E improved, clinics such as ambulatory care were not the whole solution.  National work was underway to discuss these areas;

·       Presentation to A&E between April and June 2016 was greater than January to March 2016 and it was unclear as to why the "winter" period was quieter than subsequent months;

·       Other Trusts across the country were also in a similar position in relation to Outcome 6 (financial sustainability).  Commissioners and providers were developing an understanding of each other's position;

·       In relation to Outcome 7 (workforce development), workforce was key to the working of the system and the Lincolnshire Recovery Programme was to devise a workforce model which was fit for purpose.  In doing so, a stocktake had been undertaken across all providers to understand the workforce including numbers, skills and experience.  Services required were then considered and the competencies required for those services listed, following which an exercise was undertaken to see if the current workforce matched that;

·       It was highlighted during the process that A&E did not have the required workforce and model to sufficiently support the service.  Consideration was being given to patients being seen by other professionals rather than the requirement for doctors to treat everyone, for example nurses, pharmacists or paramedics;

·       Although it had been anticipated that the workforce modelling would be completed by June 2016, it was accepted that the increased presentation to A&E between April and June had delayed this process and further identified the fragility of the service;

·       The concept of Neighbourhood Teams had been changed slightly but had been rolled out with the associated workforce in place;

·       The report indicated that the Lincolnshire Recovery Programme would continue beyond the initial twelve months, although this had not yet been agreed.  It was anticipated this decision would be made on 12 August 2016;

At 2.37pm, Councillor C J T H Brewis, Vice-Chairman, left the meeting and did not return.

·       A&E performance was monitored by the provider and based on the population however it was acknowledged that it was difficult to work out performance in each District Council area by population;

·       Work was ongoing to understand why people presented to A&E as part of the workforce modelling as it may be found that by having a senior doctor on shift to undertake first triage, this would signpost people more quickly to  the most appropriate care;

·       In relation to Outcome 5 (A&E standards), it was noted that one of the main reasons for delays was the requirement for diagnostic work in other departments and waiting for results to be provided;

·       Clarification was given that the £64 million deficit referred to in Outcome 6 incorporated £16 million allocated for the Sustainability and Transformation Plan (STP),  and the actual deficit was £47.9 million;

·       A suggestion was made to change road signs when services changed in hospitals as this may contribute to patients presenting inappropriately.  This was acknowledged and would be given further consideration;

·       Workforce modelling across Adult Social Care in addition to NHS partners was also underway as part of the stocktake.  This included the extraction of data from Lincolnshire County Council (LCC) systems followed by individual providers;

The Committee was not reassured following the presentation of the report and requested that an update be presented in January 2017 when it was thought more progress would have been made.

RESOLVED

1.    That the report and comments be noted; and

2.    That a further update be presented to the Health Scrutiny Committee for Lincolnshire at its meeting in January 2017.