Creating a Clinical Service Strategy



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|TRUST BOARD MEETING – |Tuesday 31st March 2009 |

|TITLE |Refinement of the Clinical Services Strategy 2008/09 |

|PURPOSE |To inform the Trust Board on the outcome of the Strategic Review 2008/09 |

|FORMAT |Briefing paper |

|THE BOARD IS ASKED TO: |Receive the paper and note the approach to work to be undertaken as an outcome of the review |

| |process |

Introduction

This paper outlines the approach to refine the Trust’s Clinical Services Strategy. The Divisional Strategic Review 2008/09 process endorsed clinical and managerial engagement to assess alignment of the existing strategy to current national and local strategic objectives.

Conclusion

The principle underpinning the review process is to ensure the future direction of the Trust is sufficiently refined to address strategic priorities and to translate into plans for implementation.

Prepared by: Sue Clark, Associate Director Service Development

Presented by: Robert Woolley, Director of Corporate Development

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REFINEMENT OF THE CLINICAL SERVICES STRATEGY 2008/09

CORPORATE DEVELOPMENT

MARCH 2009

|Version |Date |Comments |Action |

|0.1 |18/03/09 |Trust Executive Group |Agree recommendations to the Trust Board |

|0.2 |31/03/09 |Trust Board |Agree the approach to the next steps of the strategic review process|

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REFINEMENT OF THE CLINICAL SERVICES STRATEGY 2008/09

1. INTRODUCTION

This paper was presented to the Trust Executive Group 18th March 2009. It describes the status of the Clinical Services Strategy and advises the Trust Board on the strategic objectives of the Trust following a major strategic review. The paper highlights some significant risks and recommends an agreed approach to the next steps of the strategic review process.

2. CONTEXT

A Clinical Services Strategy was published in March 2006 which underpinned the Trust’s mission and strategic aim to provide patient care, education and research of the highest quality. The strategy was presented in the Integrated Business Plan and submitted to Monitor in 2007 as part of the Foundation Trust application.

The Trust defined its primary objective to be a major specialist provider for Bristol and the South West region and to continue to develop its focus on specialist Cardiothoracic, Cancer, Children’s, Ophthalmology and Dental services.

The core service portfolio also defined the Trusts strategy to provide:

• emergency services for the catchment population identified by patient flows

• general children’s inpatient services for Bristol, North Somerset and South Gloucestershire (BNSSG).

• obstetrics and neonatal services at all care levels.

The Clinical Service Strategy is one component of the overall business strategy for the Trust, which also includes the Trust’s commitment to effective research and development and teaching and training.

The Trust’s strategic aim is to provide efficient and effective services that are affordable to commissioners and desirable to patients and referring clinicians, and to support the principle of local services that are easy to access and provide an excellent, high quality patient experience.

3. PURPOSE

The purpose of the 2008/09 strategic review process was to ensure the future direction of the Trust is sufficiently refined to address strategic priorities and to translate into plans for implementation.

Existing service strategies need to be tested against the comprehensive proposal set out in Lord Darzi’s report NHS Next Stage Review, High Quality Care for All, published June 2008[1], and subsequently endorsed in the NHS South West Strategic Health Authority Strategic Framework for Improving Health in the South West 2008/09 – 2010/2011[2] to raise the overall quality of care and the health of the population.

4. STRATEGIC REVIEW PROCESS

Implementation of the objectives in the NHS Next Stage Review, devolution of care to the community and the centralisation of very specialist services have significant implications for the providers of acute care and present major performance challenges.

The national and local strategic direction will touch all aspects of the Trust’s business and the policies will radically influence strategic priorities. The Trust has to demonstrate how it will put quality at the heart its strategic framework.

To ensure the Trust is responsive to the emerging environment multi-professional staff groups and Governors were invited to attend Divisional Strategic Review workshops. Although Trust-wide specific strategic issues identified during the review process remain relevant attendees at the workshops were asked to reassess their existing strategic plans in the light of national and local policies.

The objectives of the review included:

• Updated clinical service strategies, taking particular account of the vision for Cancer services and Diagnostic imaging

• Review of the Integrated Business Plan leading to submission of he first Monitor Annual Plan in May 2009

• Revised site development control plan

• Revised capital investment programme

• Revised Research and Development Strategy

• Priorities identified for the annual planning round for 2009/10

• Evidence of Membership Involvement

Specific Divisional objectives required review in relation to a number of actual or potential developments since 2006, which included:

• selection of North Bristol Trust (NBT) as preferred bidder for provision of Child and Adolescent Mental Health and Community Child Health Services

• selection of the PCT provider are (Bristol Community Health Services) as the ‘lead provider’ for South Bristol Community Hospital (SBCH)

• Cancer Network/PCT review of and anticipated decision about the future configuration of Head and Neck cancer services in Bristol

• independent sector and commissioning developments e.g. development of home chemotherapy services in Bristol, North Somerset and South Gloucestershire.

The review asked the Divisions to reassess the corporate service portfolio and the relevance to the core business of the organisation. The review also made explicit links with the Trust’s capital programme for the re-development of its estate so that service configuration and the physical disposition of the site and clinical services will effectively deliver the Trust’s business strategy.

5. DIVISIONAL REVIEW OUTCOME – 2008/09

The Divisional workshops were of considerable value to generally reinforce the Trust’s priorities as a Foundation Trust and the organisations existing strategic direction.

Core themes emerged as a result of the review process, which have been translated into key strategic objectives for further development, which include:

Quality

In particular driving improvement and taking forward the key priorities of the NHS Next Stage Review:

• Patient safety

• Patient experience

• Clinical effectiveness

The key principles that underpin the strategy are the continuous improvement in clinical outcomes for patients and ensuring systems and practices put the patient at the centre. By focussing on quality and safety, excellent patient experience as a provider of choice and robust financial performance will enable the delivery of a sustainable performance and financial headroom to encourage creativity and innovation.

Partnership Working

Key to establishing partnership working is clinical engagement and participation in community-wide Service Design Groups. The strategy will promote an ethos of shared responsibility and accountability to integrate services and promote different ways of working with primary care, community, secondary and tertiary care.

The premise of an integrated approach to clinical pathway design will support the continuity of care for patients as they move through the healthcare system.

Marketing

The goal is to create value-based relationships with our customers and internal and external partners. To succeed in today’s competitive marketplace, the Trust must be customer focused, attracting customers from competing organisations by delivery greater value. Opportunities for collaboration with the Independent Sector will be taken where there is identifiable benefit.

Teaching and Learning

The Teaching and Learning strategy aims to ensure staff providing clinical care services within the Trust provide a safe, effective and high quality patient care. Development of the strategy aligns to the Clinical Services Strategy and the Research and Development Strategy to enable the Trust to be an employer of choice and to ensure it recruits and retains the best staff.

Research and Development

As the premier secondary and tertiary acute teaching Trust in the South West the organisation is committed to providing high quality clinical care to enhance its reputation with commissioners, referring clinicians, patients and the public. Research is part of the Trust’s core business and it will continue to develop strong partnerships with the Universities of Bristol and the West of England as well as other educational establishments.

The stated values of all the Divisional strategies aspire to put patients first, pursue excellence in patient care and involve and develop staff. Following the review process Clinical Services Strategies have been refined and the key objectives for each Division have been summarised in Appendix 1.

6. STRATEGIC RISKS

Although the review process and subsequent refinement of the Divisional strategies have generally reinforced the Trust’s present strategic direction, the process has highlighted some significant risks arising from:

• patient choice, devolution of care and independent sector competition

• the national quality agenda and regional performance ambitions

• commissioner strategy and increased competitive tendering of services

• potential changes to the Bristol Health Services Plan.

Against these threats, the Trust needs to consider the following risks:

Marketing Strategy

In order to understand the competitive market and the impact of patient choice on future demand for services the Trust needs to have a greater appreciation of its competitive market and provider characteristics which are known to influence choice[3]. The Trust needs to have the resources and skills-base to exploit positive market opportunities arising through its specialist service portfolio and teaching status.

Performance Strategy

Performance and operating issues identified in previous reviews remain relevant but need to be re-assessed in the light of the latest definitions of national, SHA and PCT strategic priorities. Given therefore that the challenging ambitions in the NHS South West Strategic Health Authority Strategic Framework is likely to touch all aspects of the Trust’s business, it is critical it responds proactively. The planned devolution of care out of hospital settings and the centralisation of very specialist services will have significant implications for the future role of acute providers.

Cancer Services Strategy

Concerns have been raised that the Trust lacks a clear Cancer Service Strategy to inform its stance towards service configuration challenges coming from Improving Outcome Guidance, the Bristol Hospital Services Plan (BHSP) and specialised commissioning designation processes. This in turn relates to a perceived weakness in the cancer research strategy.

Investment Strategy

Uncertainty exists within Divisions about how to translate strategic aims into deliverable plans and to influence the corporate investment strategy accordingly.

7. PROGRAMMES OF WORK

The Trust has established programmes of work to mitigate some of the risks highlighted during the Strategic Review process, which include:

Market Intelligence

The Trust has established a Market Intelligence Group to regularly advise the Trust Executive Group on market intelligence, risks and benefits to the Trust, and to understand the competitive market and the impact of patient choice.

The purpose of this programme of work is to establish effective links with Divisions to support a two-way exchange of market intelligence and to ensure Divisions are equipped with enough data and information to maximise retention and attraction of new customers and identify opportunities for potential service developments.

To ensure the marketing management will support delivery of the Marketing Strategy a framework has been developed that defines the Trust’s six key marketing objectives:

1) To be the first choice by listening and responding to the views of the patients and increase access to information to make informed choice.

2) To be the first choice for GPs, ensure ongoing dialogue and improve the quality of GP information.

3) To build good relationships between primary and secondary care clinicians will help align GPs to the Trust as the preferred provider and improve the patient experience through enhanced continuity of care.

4) To improve the organisations branding and increase the visibility of the Trust through the media by promoting good news stories and a well- develop website.

5) To develop, co-ordinate and evaluate the Trusts marketing activity, and develop a knowledge database of market information to ensure marketing knowledge is cascaded throughout the organisation.

6) To improve partnership working and build relationships with other providers.

Internal Strategic Design Programme

To minimise the risk of non-delivery of local ambitions the Trust has developed a framework to encourage appropriate, controlled and effective service design across the organisation.

The programme of work recognises that the impact of a variety of system reform initiatives is most meaningfully addressed at the level of the patient pathway. Identifying existing and ideal clinical pathways across the whole health system will provide additional benefits in a range of key planning areas for the Trust, which includes:

• annual (operating) plan – the operational impact of contract standards and performance targets should be better understood at service level, as well as the threats and opportunities inherent in Specialised Commissioning designation and clinical network accreditation exercises

• service improvement and Lean – priority-setting should be informed by the service design programme, providing closer alignment with the Trust’s strategic and marketing agenda

• marketing - pathway mapping should provide closer analysis of market opportunities and threats, clearer identification of the Trust’s market position and easier formulation of marketing initiatives

• strategic investment – clearer priorities for service development should result, allowing targeted allocation of resources in the long term financial plan.

Significant elements of this programme of work are also critical to the successful delivery of the estate rationalisation. The programme proposal and pathway design will consider the Trust’s strategic site development plans comprising major capital developments integral to the Bristol Health Services Plan. Strategic site redevelopment will affect the need for long term workforce planning and development, as well as being closely linked to performance management, education and training.

The programme will be centrally planned and co-ordinated to give consistency of approach and to ensure that Trust-wide benefits are achieved.

Service Transformation Strategic Direction

There is growing consensus that the Trust needs a greater focus on the quality of the patient experience, along with a cultural shift which engages all staff in quality improvement, if it is to address current and future performance challenges and so remain attractive to patients and referrers in the NHS market.

Four work streams have been identified as core to creating a successful Foundation Trust and an organisation that is efficient and effective, designs services around patient need and places staff central to success, which include:

1) Patient experience

2) Organisational culture and behaviour

3) Service design – transfer of change techniques to effect productivity and efficiency

4) Communications to support change

Each work stream will have an Executive sponsor and identifiable deliverables and timescales. It is acknowledged that over the last ten years the Trust has achieved considerable success however, to ensure its future status as a ‘world-class’ organisation the programme of work will support the culture of the organisation to work, behave and think differently.

Bristol Health Services Plan - Service Design Programme

The Trust continues to engage with Bristol PCT and North Bristol Trust in the design of clinical pathways and future delivery of the Bristol Health Services Plan.

The Trust has clinical representation on all the Service Design Groups and a Divisional monitoring framework has been developed to ensure the impact of any service and financial risks are appropriately assessed. Identified risks to the Trust are escalated to the Clinical Strategy Group which has reporting responsibility into the Trust Executive Group.

8. NEXT STEPS

The strategic review process is part of the Trust’s annual business planning cycle. While the 2008/09 process was a major three-yearly review of Divisional strategies, there is a clear opportunity to use the next review period (from April to August 2009) to examine further some of the cross-cutting risks identified in this paper and, in particular:

• the cancer services strategy

The objectives of this work-stream would be to:

• understand likely market changes, particularly for chemotherapy and radiotherapy provision

• assess the strategic implications for the Trust of the national Cancer Reform Strategy

• anticipate the outcome of commissioner designation processes for major cancer surgical specialties

• consider the alignment of service and research strategies for cancer.

• the corporate investment strategy

This work-stream would comprise the following:

• the capital investment policy is subject to annual review, which should be undertaken as part of this process. It is proposed that a revenue investment policy is also developed.

• given uncertainty about future changes to the national tariff and in the current absence of a service line reporting framework, it is not possible to undertake a standard portfolio analysis of Trust services. It is recommended, however, that consideration is given to constructing a high-level portfolio analysis as an aid to decision-making, recognising that this will require future refinement.

• review of site development strategy in the light of capital and revenue affordability constraints.

9. CONCLUSION AND RECOMMENDATION

The Trust Board is asked to note the outcome of the Strategic Review process and agree the approach to the next steps of the strategic review process.

Written by:

Sue Clark

Associate Director Service Development

Presented by:

Robert Woolley

Director of Corporate Development

March 2009

Appendix 1: Divisional Clinical Services Strategy Refinement 2008/09

|Division |Strategic Vision |Strategic Aims and Objectives |

|Women’s and Children’s Services |To be a world class Women’s and Children’s |A key strategic objective of the Division is to consolidate its position as a provider of secondary services to the |

| |service provider with a national and |BNSSG area for maternity services, general paediatrics, paediatric emergency care and specialised paediatric |

| |international profile. |services. |

| | | |

| | |The strategy is to maintain high clinical standards of tertiary women’s and children’s services, regionally and |

| | |supra-regionally, supporting the centralisation of Specialist Paediatric services from North Bristol Trust and the |

| | |development of gynaecology services across the community. Over the next five years the Division will deliver |

| | |services in a local setting, such as the South Bristol Community Hospital (SBCH) and health centres closer to home |

| | |and extent the provision of outpatient clinics through the South West to support local access to care for women, |

| | |young people and children. |

| | | |

| | |The Division has particular concerns regarding dedicated facilities for young adults and is committed to the review |

| | |of options to agree a seamless transitional model of care from children to adult services. |

|Medicine |To maintain the position as a provider of high |The Division recognises its role as the provider treatment for the acutely ill and adult medical patients for South |

| |quality emergency care. |and Central Bristol and the provision of a well regarded outpatient service. |

| | | |

| | |The Divisional strategy focuses on developing a better understanding of the balance of acute care and long-term |

| | |chronic disease to strengthen partnership working with key community stakeholders to develop an urgent care vision |

| | |and model of care. Participation in the development of a community hospital will ensure the closure of the Bristol |

| | |General Hospital and align the Divisions strategic objective to close the Old Building, develop an Integrated |

| | |Assessment Unit and support the reconfiguration of the existing services to improve the patient experience and |

| | |improve patient care. |

|Surgery, Head & Neck |To provide the highest quality service for |The Division delivers a full range of highest quality emergency and elective surgical services; from simple day case |

| |emergency and elective surgical patients based |and outpatient services to complex tertiary and clinically dependent patient care. The Division’s strategic |

| |on excellence in clinical outcomes and against |framework is based on excellence in clinical outcomes and against performance targets. Strategic priories include |

| |performance targets. |developing tertiary services that support the Trust’s core service portfolio and developing services to reduce length|

| | |of stay. |

| | |The Division’s strategic intent is to reduce the amount of low dependency surgery, increase major surgery throughput |

| | |and rationalise the number of specialties. The aim is to centralise all emergency surgery on the main BRI site, to |

| | |centralise the assessment and admissions area for emergency surgical patients and the Dental School expansion. The |

| | |Division aims to transfer breast surgery to St Michaels Hospital as well as reorganise services to move low |

| | |dependency and day surgery. |

| | | |

| | |The expansion of anaesthesia and critical care is required to accommodate more centralisation of complex elective |

| | |surgery and the medical inpatient demographic demand. |

|Specialised Services |To be the premier provider of Cardiac Surgery, |Cardiac Services. Services will be delivered in a modern purpose built centre under the brand of the Bristol Heart |

| |Cardiology, Oncology, Haematology and |Institute (BHI) and reflect the full integration of clinical and academic cardiac activity. The BHI will follow |

| |Homeopathy. |national guidance by becoming a major centre for the delivery of 24/7 Primary Angioplasty. The strategic objectives |

| | |are to provide a comprehensive secondary cardiology service and tertiary cardiac service, develop non-invasive |

| | |cardiac imaging and expand the cardiovascular research programme. The strategic purpose of the service is to reduce |

| | |mortality and improve service efficiency by reducing the length of stay and service costs. |

| | | |

| | |Haematology and Oncology Centre: The unit offers secondary, tertiary and regional haematology services. A key |

| | |strategic objective is to improve the environment for patients and staff. The co-location of Adult BMT service with |

| | |the rest of adult haematology service is a key priority for the Division. This approach has cross divisional support|

| | |and will release much needed space in the Children’s Hospital. The department will work in close partnership with |

| | |primary care to provide certain services ‘nearer to the patient’. A strategic aim is to implement NRAG |

| | |recommendations by increasing general radiotherapy capacity and provide a facility that meets future service demand |

| | |and to successfully manage the transfer of 30% of the current oncology workload to the new centre in Taunton. |

| | | |

| | |Palliative Care: High quality supportive and palliative care is part of the core service and the Divisions strategic|

| | |direction is to establish a supportive care strategy for cancer patients at all stages of their illness. |

| | | |

| | |Homeopathy: To achieve a sustainable service within the Trust and to be the specialists in the provision and |

| | |development of medical homeopathy in South-West England, South Wales and the Midlands. The service will build on the|

| | |current existing success of providing outreach services in the community and continue to develop and foster a whole |

| | |person care approach across the clinical services within the Division. |

|Diagnostics & Therapies |To deliver a start of the art, high quality and|Over the next year the Division will continue to integrate and by bringing together the various services to produce a|

| |efficient service across all specialties |brand which reflects its common ethos. By early 2009 the Division will implement and roll out an |

| | |order-communications package for electronic requesting and reporting of pathology and radiology tests by users both |

| | |within the acute Trust and in primary care and implement digital mammography for the Avon Breast Screening Unit. |

| | | |

| | |In order to ensure we can provide high-end diagnostics to a large tertiary centre it is crucial to ensure appropriate|

| | |investment in diagnostic equipment including a scheduled rolling capital replacement programme. Investment plans |

| | |over the next five years include a number of recommendations from the Sg2 Diagnostic Review. |

| | | |

| | |The Division will deliver pathology modernisation through implementation of a managed service contract (MSC) with a |

| | |single provider of major equipment, associated consumables and supplies, maintenance and critical support. The |

| | |modernisation of the laboratory medicine department will be achieved by re-configuring the current laboratories on |

| | |levels 8 and 9 of the Queens Building, to optimise opportunity offered by the managed service contract. |

| | | |

| | |The Division will continue to modernise pharmacy services through the use of robotics, which will enable increases in|

| | |work volume, space and workforce constraints to be managed through efficiencies brought about by the new technology. |

| | | |

| | |Current diagnostic imaging wait times will be reduced to two weeks to meet existing cancer targets and 7-day working |

| | |will be championed to support improved patient flow and increase capacity to aid the implementation of national |

| | |targets. |

| | | |

| | |There is very clear and increasing demand for all services under the broad heading of therapy services. The |

| | |development of community based models of care and the shift of activity into community settings brings challenges to |

| | |the way therapy services are delivered and managed but they also bring opportunities for partnership working. |

| | | |

| | |Many of the core services within the Trust could not operate without the support of Medical Physics and |

| | |Bioengineering. To match the Trust strategy to provide increasingly complex and specialised services in the face of |

| | |growing competition from the independent sector, there will be a growing need to strengthen and consolidate the |

| | |scientific and technological workforce base, as recognised by the Cancer Peer Review. |

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[1] .uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH

[2]

[3] using the Report of the National Patient Choice Survey, July 2006, and publicly available information from nhs.uk

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Objective: To collaborate with Commissioners and other stakeholders

Objective: To support research of national and international excellence

Objective: To enhance the Trust’s reputation as a teaching and learning organisation

Objective: To gain market leadership

Objective: To focus on getting the essentials of the organisation right

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