Section 1: Context for NHS Foundation Trust Status

Royal Devon and Exeter Healthcare NHS Trust March 2004

Service Development Strategy

Section 1: context for NHS foundation trust status

This section provides the context for the Royal Devon and Exeter NHS Trust’s decision to apply for NHS Foundation Trust status, and for the Service Development Plan for the first five years as an NHS Foundation Trust. It describes:

·  The RD&E, its services, performance and achievements.

·  The local and regional health community within which the RD&E operates.

·  The factors that will influence our position within the local and regional health economy in the next five years.

·  Existing strategic plans that we are currently implementing at the RD&E.

·  The financial context in terms of our financial performance and current position, and the likely financial situation in the next five years.

·  The RD&E estate and capital developments.

·  Our experience of commercial ventures and contracts with third parties.

·  The experience, capability, and approach of the RD&E’s management team who will be leading the transition to NHS Foundation Trust status if it is awarded.

1.1 Profile of the RD&E and role in the local health economy

1.1.1 Overview

The Royal Devon and Exeter NHS Trust (RD&E) provides a full range of acute hospital services principally to the 350,000 people living in the city of Exeter and the surrounding areas of Mid and East Devon. In addition, specialist clinical services are provided to a larger population of around 750,000 people in North Devon, Dorset, Somerset and Torbay. Specialist services include clinical oncology, neonatal services, orthopaedics, spinal surgery, thoracic surgery, head and neck cancer surgery, clinical genetics, cystic fibrosis and renal services. The full range of services is shown in Appendix 3. The Trust has 850 beds and an annual revenue budget of £170 million. The RD&E is the largest local employer (employing over 5,000 people), with a good track record of investment in staff. In an area with a strong sense of identity and loyalty, the RD&E is very much recognised as the local hospital, with strong links to the community.

1.1.2 Performance and achievements

We have been awarded three stars for the last three years in the national performance league tables. This means that the RD&E continues to rank amongst the top hospitals in the country against the criteria that the league tables are based upon (these include access and waiting times, and quality of patient experience). This is in the context of successfully achieving all patient access targets set out in the NHS Plan. This includes aiming to achieve a maximum nine-month wait ahead of time, and continuing to make improvements to the delivery of modernisation targets.

The Preliminary Application for NHS Foundation Trust status gave a more detailed summary of the RD&E’s achievements. The key highlights are summarised below.

Clinical governance and quality

Our mortality rate is lower overall than the national average for both emergency and non-emergency admissions.

CHI gave us a positive report following its routine review of the RD&E in August 2001. CHI commended the following practice in particular:

·  Development of effective clinical risk management structures and systems, and clinical governance seen as a priority.

·  The Health Information Centre which provides a range of free information and healthy lifestyles, illness, disability and treatment in a variety of formats.

·  A clean and well-maintained hospital (the Trust received a PEAT rating of 4).

·  Strong commitment to education and continuing professional development.

·  A motivated and highly committed workforce.

·  A high level of commitment to clinical audit with a substantial amount of clinical audit taking place.

·  A good strategic grasp of the research and development (R&D) programme.

The Department of Health has also rated the R&D programme as high in both quality and relevance. The R&D programme has received external grants totalling £1.9m. National Service Frameworks and NICE reports are increasingly referring to work from Exeter, particularly in diabetes and cardiovascular disease. Clinical governance is seen as a priority at the Trust and benefits from strong leadership from the Chief Executive and a supportive Trust Board. There is recognition that providing services in a way that better meets patients’ needs and improves the patient’s experience requires equal partnerships across the health economy.

The Trust has been involved with the National Patient Safety Agency (NPSA) since its inception in 2001, and is a pilot site for both Phase 1 and Phase 2 of the National Reporting and Learning System, which is a key feature of ‘Building a Safer NHS for Patients’.

Service modernisation

We are performing well against national targets:

·  The Trust total for booked day cases is 93.2%, against a national target of 80%.

·  With a 65.7% Trust total for booked inpatients, we are well on the way to achieving the national target of 66.7% by March 2004.

·  We are achieving the one-month wait target in 100% of cases for paediatric and testicular cancers, and acute leukaemia.

·  100% of patients with a suspected cancer are receiving appointments within two weeks of urgent GP referral.

·  The Trust has consistently achieved the 90% A&E target this year.

We are one of nine pilot sites for the National Theatre and Pre-Operative Assessment Project. Through this work, we are now rebooking 100% of cancelled patients within 28 days, and are now achieving at least 80% theatre list utilisation.

‘Action On’ programmes are in place in ENT, Dermatology, and for cataract surgery. These have resulted in:

·  Patients with a suspected cataract being referred directly to a consultant by their optician. This has reduced waiting times from 15 to 9 weeks.

·  Increasing use of local community facilities for ENT services.

·  A teledermatology service being established.

We have been selected as one of nine pilot sites for the Ideal Design of Emergency Access Project. We have also been involved in the Enabling Excellence Pilot Project working with the NHS Clinical Governance Support Unit applying a modernisation approach across health and social services. Both of these projects have delivered direct benefits to patients and staff.

The North and East Devon health community, including the RD&E, was selected as a pilot site for the Modernisation Agency’s ‘Pursing Perfection’ (P2) programme[1]. This is in recognition of the progress that has been made to date in adopting and applying modernisation techniques for improving services. In its first year, the programme concentrated on two main project areas – treatment of stroke and delayed discharges. Six additional areas have now been incorporated into the programme (emergency care, diabetes, attention deficit hyperactive disorder, day surgery, diagnostics and transport). Lessons from these two projects are being used to improve big system working, and internal organisational working arrangements, as well as the delivery of specific NHS Plan targets.

Performance and efficiency

The Trust has benchmarked its performance with that in other Trusts. For example, the Acute Hospital Portfolio demonstrated that compared to other Trusts:

·  A high proportion of emergency admissions are made within four hours of arriving in A&E.

·  There are few inter-ward transfers.

·  Very good overall theatre efficiency for both elective and emergency lists (as evidenced in the 2002/03 District Audit annual letter).

·  Good 13 and 26 week waits in outpatients.

·  Low new to follow up ratios for outpatients

·  Low did not attend rates in clinics.

However, the audit also noted that there was significant scope to undertake more day surgery, and reduce length of inpatient stay, including by providing more diagnostics and other clinical support at weekends to facilitate discharges.

The Trust’s financial position is summarised in Section 1.4 below. The District Audit annual letter (2002/03) commented particularly on:

·  A sound internal control environment, including the development of governance arrangements.

·  Prompt and clear working papers to support the accounts.

·  The achievement of financial stability during a period of significant change within the local health economy.

·  Good working relationships with finance staff.

In the data quality and spot check reviews undertaken by the Audit commission in 2001/2002, the Trust was classified as low risk in many areas. In particular, the spot check review found robust waiting list policies and corporate processes in place, for example:

·  Clear accountability for waiting time performance.

·  Waiting list policy issued on 16 October 2001.

·  Performance is monitored and controlled through the Waiting List Management Group.

·  Clear audit trail for central returns.

·  Validation of patients on the waiting list.

Conclusions

The RD&E is a high performing organisation with stable senior management a good track record, and a consistent history of meeting targets. The factors that have led to our success can be summarised as:

·  Well trained, committed and highly capable staff delivering excellent clinical standards.

·  Good external relationships with GPs, commissioners and other healthcare providers, with our three main PCTs providing a considerable degree of commissioning stability

·  Very strong internal relationships particularly with clinicians, and a good history as an employer, with a stable workforce.

·  Efficient and adaptable working environment, with good building stock and low capital requirements

·  Strong research, development and academic links, including teaching hospital status providing undergraduate medical education.

We still face a number of challenges in maintaining and improving upon current levels of performance:

·  Comparatively, the RD&E has the best day case rates in the South West Peninsula but there remains the need to improve further, and to achieve 75% of day case rates in line with national plans.

·  Inpatient and outpatient waiting times need to reduce further in line with NHS Plan targets for 2008.

·  Managing the growth in emergency admissions will require continued and focussed management by the RD&E, PCTs social services and other local partners. New and innovative ways of working are being developed via the P2 project, and new models of care are emerging.

·  There is still further scope for reducing delayed discharges from hospital.

·  We need to improve information management and technology to:

- improve patient access to services, and available information about those services.

- support service planning and new ways of working.

- ensure financial flows are in line with the activity we undertake.

1.1.3 Local and regional context

Our range of services illustrates how our role and purpose is defined both by our position within the local health and social care community around mid, North and East Devon, and within the wider South West Peninsula region.

The RD&E is part of the North and East Devon health and social care community, which includes the following partners:

·  East Devon, Mid Devon, North Devon, and Exeter PCTs.

·  Northern Devon Healthcare NHS Trust.

·  Devon Partnership Trust.

·  Devon County Council Social Services.

·  Local District Councils covering Devon.

·  Westcountry Ambulance Service.

The RD&E has links to neighbouring health communities in South Devon, Dorset and Somerset, and is part of the South West Peninsula strategic health community.

The figure below shows the health community within the South West Peninsula.

Figure 1: South West Peninsula health community

The South West Peninsula (covering the counties of Devon and Cornwall) has a population of 1.6 million people. It is essentially self-sufficient in the provision of health services with a large enough resident population to sustain a strong district general hospital and community hospital infrastructure, and a regional specialist centre (Plymouth Hospitals NHS Trust). The South West Peninsula now has its own undergraduate medical school (established in 2002).

This self-sufficiency is particularly important given that the resident population is dispersed across a large geographical area with relatively long travel times and distances. Referrals out of the region are only necessary for very specialist, nationally organised services, such as burns and liver transplantation. Bristol is the nearest national centre.

Acute services in the North and East Devon health community are provided in the context of a high number of community hospitals and a good primary care infrastructure. Three of the local PCTs received two stars in this year’s performance ratings, and Exeter PCT received three stars.

Some of the key issues arising from this local and regional configuration of health services are considered in the next section.

1.1.4 RD&E position within local and regional context

A number of factors and trends over the next five years will have clear implications for the RD&E and our role in providing acute healthcare.

Enhanced district general hospital roles

The population within Devon and Cornwall is dispersed, with some centres of population around the main cities of Exeter, Plymouth and Truro. Smaller centres of population form around the extensive network of market towns. They have a strong sense of local community and a desire to maintain the economic and social well being of the locality. A significant proportion of the population however live in geographically and socially isolated communities and face significant challenges.

Within the South West Peninsula district general hospital services are currently provided within the main population centres of Exeter, Barnstaple, Torbay, Plymouth and Truro. Traditionally, each of these hospitals has enjoyed a loyal following from the resident population, and patients have no history of seeking treatment, other than very specialist care, away from their local service. This practice is beginning to change with the development of greater sub-specialisation of services and clinical expertise becoming focused in networked services across the region. The implementation of the Choice Initiative may encourage people to consider travelling further to access more timely care and may have an impact on traditional patterns of service. In 2003/03 an orthopaedic waiting list initiative with the private sector resulted in only 12.5% of patients offered the chance of early treatment elsewhere, choosing to do so. The Trust will work proactively with the population it serves to ensure the service profile delivered continues to meet expectations and will regularly review with partners the impact of potential changes in patient preference for location of care.

The RD&E has the significant benefit of being supported, in its delivery of acute hospital care, by a network of community hospitals. The community hospitals are managed by the local PCTs but form part of the network of health and social care local people benefit from. The hospitals are at the heart of many of the local market town communities. The RD&E will continue to develop these links with local community hospitals and look for ways of further expanding the linked services it delivers within a community hospital setting.