Five Year Business Plan

Five Year Business Plan 2010-2015 1 Amendment Record Version Date Author Description of Change David Forster Joanne Halliwell Status (S/D) S D...
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Five Year Business Plan 2010-2015

1

Amendment Record Version

Date

Author

Description of Change

David Forster Joanne Halliwell

Status (S/D) S D

1.0 2.0

24/02/10

3.0

11/04/10

Joanne Halliwell

D



4.0

12/04/10

D



5.0

15/04/10

Joanne Halliwell Caroline Wood Simon Worthington Joanne Halliwell

D

• •

6.0

16/04/10

Joanne Halliwell

D

7.0

19/04/10

David Johnson Elaine Gibson

D

8.0

20/04/10

D



9.0

24/04/10

Sarah Fatchett Mike Power Simon Worthington

D



10.0

26/04/10

D



11.0

20/05/10

D

• •

S



11.0

Richard Roxburgh Keeley Townend Sarah Fatchett Roger Holmes Joanne Halliwell

• • •

• • • • •

Final version signed off by the Board HR and OD amendments Revision and inclusion of new legislation and DoH documentation / guidance Steve Page amendments to Governance and Risk Section Update of financial tables and information Swot Update Review and re-evaluation of key business risks Updated service improvement plans Demand and population tables updated PESTLE analysis revised References to Digital Radio updated Ambulance station numbers and locations updated PTS demand figures updated Financial projections and associated business impact revised Commentary on plan. Revisions to demand projections, PTS SWOT analysis and PTS activity 09-10 Revise figures p81 Include reference to positive progress re CQC Final version signed off by the Board 18 May 2010

S = Signed Off D = Draft Document Author = Joanne Halliwell This document is controlled. If you would like to suggest amendments to this document please contact the document author.

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Contents Amendment Record… .………………………………………………………………………………………….2 Tables………………… .…………………………………………..………………………………………………6 Figures …… .………………………………..…………………………………………………………8 1 1.1 1.2 1.3 1.4

1.5 1.6 1.7 2 2.1

Executive Summary .......................................................................................................................9 Introduction ………………………………………………………………………………………………. ..9 Foundation Trust Status...................................................................................................................9 Market Assessment........................................................................................................................10 Performance Overview...................................................................................................................10 1.4.1 Financial Performance - Historical .......................................................................................10 1.4.2 Financial Performance Projected .........................................................................................11 1.5.3 Standards and Targets.........................................................................................................12 Summary of Strengths, Weaknesses, Opportunities and Threats (SWOT) Analysis.....................14 Key Risks ………………………………………………………………………………………………. 15 Conclusion ………………………………………………………………………………………………. 16

2.3 2.4 2.5 2.6

Profile of the Trust .......................................................................................................................17 Overview ...................................................................................................................................17 2.1.1 Commissioning Arrangements .............................................................................................18 Range of Services..........................................................................................................................18 2.2.1 Access & Response .............................................................................................................19 2.2.2 Accident and Emergency Operations...................................................................................20 Lifecycle Scheme..........................................................................................................21 BASICS Doctors ...........................................................................................................21 Paramedic and Police Scheme.....................................................................................21 Emergency Care Practitioners (ECP) ...........................................................................21 Community First Responders .......................................................................................21 2.2.3 Patient Transport Service.....................................................................................................21 2.2.4 Emergency Preparedness....................................................................................................22 Activity ...................................................................................................................................23 Finance ...................................................................................................................................24 Standards and Targets Performance .............................................................................................24 Conclusion ...................................................................................................................................25

3 3.1 3.2 3.3 3.4

Strategy ...................................................................................................................................27 Our Vision and Values ...................................................................................................................27 Our Strategy ...................................................................................................................................27 Rationale for Foundation Trust Status ...........................................................................................32 Conclusion ...................................................................................................................................32

4 4.1

Market Assessment .....................................................................................................................33 Description of the Local Health Economy ......................................................................................33 4.1.1 Our Patients .........................................................................................................................34 4.1.2 Our Partners.........................................................................................................................34 Key Factors Driving Future Demand..............................................................................................35 Demand for Services ......................................................................................................35 Population Health & Inequality........................................................................................36 Patient & Partner Expectations .......................................................................................37 Conclusion ......................................................................................................................37

2.2

4.2

3

4.3 Objectives of the Local Health Economy ........................................................................................38 4.3.1 Yorkshire and The Humber Strategic Health Authority ........................................................38 4.3.2 PCT Strategic Commissioning Plans ...................................................................................39 4.4 Major Changes in External Environment/Competition ...................................................................41 Urgent Care Developments ...........................................................................................41 Health Economy Reconfigurations.................................................................................41 Centralisation of Services ..............................................................................................41 4.5 P.E.S.T.L.E. Analysis .....................................................................................................................41 4.6 Competitive Factors .......................................................................................................................45 4.6.1 An Analysis of the Competitive Environment .......................................................................45 4.6.2 Conclusion ...........................................................................................................................47 5 5.1 5.2 5.3

5.4

5.5

5.6

6 6.1

6.2

Service Development Plans ........................................................................................................48 Internal Capability Assessment - SWOT Analysis .........................................................................48 5.1.1 Commentary on our SWOT Analysis ...................................................................................49 Summary of our Service Development Plans ................................................................................50 Access & Response Service Development Plan............................................................................51 5.3.1 Narrative Summary of Plan ..................................................................................................51 5.3.2 Key Strategic Drivers / Benefits ...........................................................................................52 5.3.3 Timescale.............................................................................................................................53 5.3.4 Summary of Activity Projections...........................................................................................53 5.3.5 Conclusion ...........................................................................................................................53 A&E Operations Service Development Plan ..................................................................................54 5.4.1 Narrative Summary of Plan ..................................................................................................54 5.4.2 Key Strategic Drivers / Benefits ...........................................................................................55 5.4.3 Timescale.............................................................................................................................55 5.4.4 Summary of Activity Projections...........................................................................................56 5.4.5 Conclusion ...........................................................................................................................56 Patient Transport Service Development Plan ................................................................................57 5.5.1 Narrative Summary of Plan ..................................................................................................57 5.5.2 Key Strategic Drivers / Benefits ...........................................................................................57 5.5.3 Timescale.............................................................................................................................58 5.5.4 Summary of Activity Projections ..........................................................................................58 5.5.5 Conclusion ...........................................................................................................................59 Emergency Preparedness Service Development Plan ..................................................................60 5.6.1 Narrative Summary of Plan ..................................................................................................60 5.6.2 Key Strategic Drivers / Benefits ...........................................................................................61 5.6.3 Timescales ...........................................................................................................................59 5.6.4 Summary of Activity Projections...........................................................................................61 5.6.5 Conclusion ...........................................................................................................................61 Financial Plans .............................................................................................................................62 Historical Performance Analysis ....................................................................................................62 6.1.1 Income & Expenditure Overview..........................................................................................62 6.1.2 Recurrent Position................................................................................................................63 6.1.3 Historical Cost Improvements ..............................................................................................63 6.1.4 Balance Sheet......................................................................................................................64 6.1.5 Cash Flow ............................................................................................................................65 6.1.6 Capital Expenditure..............................................................................................................65 6.1.7 Historic Financial Summary .................................................................................................66 Five Year Financial Plan ................................................................................................................66 6.2.1 High Level Income and Expenditure Summary....................................................................66 6.2.2 Income Forecast Analysis ....................................................................................................66 6.2.3 Cost Improvement Programme ............................................................................................68 6.2.4 Forecast Balance Sheet.......................................................................................................69 4

6.3

6.2.5 Forecast Cash Flows ...........................................................................................................70 6.2.5 Forecast Capital Expenditure...............................................................................................70 6.2.6 Risk Rating...........................................................................................................................71 Conclusion ...................................................................................................................................71

7 7.1 7.2 7.3

Risks……………………………………………………………………………………………………… .72 Key Business Risks........................................................................................................................72 Financial Impact and Mitigation......................................................................................................77 Conclusion ...................................................................................................................................77

8 8.1 8.2

Leadership and Workforce..........................................................................................................78 Introduction ...................................................................................................................................78 Management Arrangements...........................................................................................................78 8.2.1 Trust Board and the Executive Team...................................................................................78 8.2.2 Management Structure.........................................................................................................79 Workforce Key Performance Indicators .........................................................................................80 Workforce Profile............................................................................................................................81 Sickness Absence..........................................................................................................................82 Recruitment Arrangements ............................................................................................................82 Workforce and Organisational Development .................................................................................82 Professional and Personal Development .......................................................................................83 Conclusion ...................................................................................................................................84

8.3 8.4 8.5 8.6 8.7 8.8 8.9 9 9.1 9.2 9.3

Governance ..................................................................................................................................85 Corporate Governance and Management......................................................................................85 Risk Management ..........................................................................................................................88 Information Management and Technology Strategy & Systems ....................................................89 9.3.1 Strategy................................................................................................................................89 9.3.2 Systems and Support...........................................................................................................89 9.3.3 Information Governance ...........................................................................................90

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Conclusion ...................................................................................................................................91

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References:...................................................................................................................................92

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Glossary…………………………………………………………………………………………………...91

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Tables 1

Executive Summary ........................................................................................................................9 Table 1-a: Summary Income and Expenditure Statement ............................................................10 Table 1-b: Summary of Projected Income and Expenditure Statement ........................................11 Table 1-c: Summary of Annual Health Check Results ..................................................................12 Table 1-d: Summary of our Strengths, Weaknesses, Opportunities and Threats .........................14 Table 1-e: Our Key Business Risks ..............................................................................................15

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Profile of the Trust ........................................................................................................................17 Table 2-a: Commissioning Arrangements.....................................................................................18 Table 2-b: YAS Services ...............................................................................................................19 Table 2-c: Access & Response Assessment of 999 Calls and Response ...................................20 Table 2-d: A&E Demand 2009/10 (incidents responded to in support of each PCT) ....................23 Table 2-e: PTS Forecast Demand 2010/11 (incidents per vehicle type).......................................23 Table 2-f : Historical Financial Performance .................................................................................24 Table 2-g: Summary of Annual Health Check Results..................................................................24 Table 2-h: National Target Results ...............................................................................................25

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Strategy..........................................................................................................................................27 Table 3-a: A Summary of our Strategic Objectives .......................................................................29

4

Market Assessment ......................................................................................................................33 Table 4-a: Summary of Our Patients’ View ...................................................................................34 Table 4-b: Summary of Our Partners’ Views.................................................................................35 Table 4-c: Population (thousands) by PCT 2011 to 2015 .............................................................36 Table 4-d: Demand Projections 2010 to 2015...............................................................................36 Table 4-e: Broad Strategic Themes from Healthy Ambitions Relevant to YAS.............................39 Table 4-f: General Themes from PCT Strategic Commissioning Plans .......................................40 Table 4-g: Market Share Growth in Plan.......................................................................................47

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Service Development Plans .........................................................................................................48 Table 5-a: Summary of our Strengths, Weaknesses, Opportunities and Threats .........................48 Table 5-b: Summary of our Service Development Plans ..............................................................50 Table 5-c: Access and Response Service Development Timescale............................................53 Table 5-d: A&E Operations Service Development Timescale.......................................................55 Table 5-e: A&E Five Year Demand Projection - By PCT ..............................................................56 Table 5-f: A&E Level of Service Performance..............................................................................56 Table 5-g: PTS Service Development Timescale .........................................................................58 Table 5-h: PTS Five Year Activity Forecast Demand Change……………………………………… 59 Table 5-i: Emergency Preparedness Service Development Timescale…………………………. 61

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Financial Plans .............................................................................................................................62 Table 6-a: Summary Income and Expenditure statement.............................................................62 Table 6-b: Normalised Underlying Position...................................................................................63 Table 6-c: Cost Improvements Delivered......................................................................................64 Table 6-d: Historic Balance Sheets...............................................................................................64 Table 6-e: Historic Cash Flows .....................................................................................................65 Table 6-f: Capital Expenditure......................................................................................................65 Table 6-g: High Level Income and Expenditure Summary............................................................66 Table 6-h: Income Growth Analysis ..............................................................................................67 Table 6-i: Detailed Income Growth Breakdown............................................................................67 6

Table 6-j: Planned Cost Improvement Schemes..........................................................................68 Table 6-k: Service Development Plans That Drive Cost Improvements .......................................68 Table 6-l: Forecast Balance Sheet...............................................................................................69 Table 6-m: Forecast Cash Flows ...................................................................................................70 Table 6-n: Forecast Capital Expenditure…………………………………………………………........ 70 Table 6-o: Monitor Risk Rating......................................................................................................71 7

Risks ………………………………………………………………………………………………...........72 Table 7-a: Key Business Risks .....................................................................................................72 Table 7-b: Key Business Risks Analysis .......................................................................................73 Table 7-c: Income and Expenditure Impact Downside Risk..........................................................77

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Leadership and Workforce..........................................................................................................78 Table 8-a: A&E Operational Areas and Ambulance Stations........................................................80 Table 8-b: Workforce Summary as at 31 January 2010................................................................81 Table 8-c Sickness Absence 2006 to 2009-10…………………………………………………….. 82

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Figures Figure 2-a: Ambulance Stations in Yorkshire........................................................................................17 Figure 3-a: YAS Strategic Objectives ...................................................................................................28 Figure 4-a: Yorkshire and Our PCT Partners........................................................................................33 Figure 8-a: Management Structure .......................................................................................................79 Figure 9-a: Internal Control & Governance Committee Structure .........................................................87

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1

Executive Summary

1.1

Introduction The Yorkshire Ambulance Service NHS Trust (YAS) supports the public and patients of England’s largest county. We cover an area of 6000 square miles with a population of some five million; it includes the rural communities of the Yorkshire Dales and Moors and the major cities of Bradford, Hull, Leeds, Sheffield, Wakefield and York. We are constantly developing new and more effective ways of providing care for patients: access and response; accident and emergency; patient transport and emergency preparedness. We strive for excellence in all that we do, to ensure that the people of Yorkshire consistently receive the right response, as quickly as possible, wherever they live. This Business Plan points the way towards continuous improvement in everything that we do. It is written so that our patients, our partners, our staff, managers, commissioners and the public have a clear understanding of where YAS aspires to be over a five year period and how we plan to get there.

Our Vision We aim to deliver an excellent ambulance service for Yorkshire that is clinically focused, financially sound and continuously develops its services to meet the needs of the future

To achieve our vision, we must ensure that the delivery of services, commissioned from us by Primary Care Trusts (PCTs), is safe, efficient and effective, and that everything we undertake is for the benefit of our patients. During 2009-10, two important developments happened which support our plans. First, the NHS Constitution was published. This important change in healthcare means that all providers and commissioners of NHS care are under new legal obligations to consider the rights of public, patients and staff in everything that they do. Secondly, the NHS five year plan ‘NHS 2010 - 2015: from good to great. Preventative, people-centred, productive’ was published.

1.2

Foundation Trust Status This Business Plan will show that we have integrated plans for our clinical and support services, workforce and financial management that are underpinned by strong governance arrangements.

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By adhering to this Plan, the Trust will continuously improve its clinical services to patients, whilst maintaining our financial sustainability. With operational effectiveness and efficiency, we will move to a position from which we can apply for and secure Foundation Trust status. This will empower us with the financial freedoms to develop our services, realise our ambitions and take opportunities to meet the needs of our patients and customers, whose engagement with the Trust will be markedly improved through increased public accountability.

1.3

Market Assessment The local health economy is part of the Yorkshire and the Humber Strategic Health Authority (SHA). We acknowledge the demand for high quality services and our public reputation is good, even though we find it challenging to continuously meet the expectations of all our partners. With an increasing and ageing population, an economy in recession, rising unemployment and significant public health issues across Yorkshire and the Humber, the challenge we face to deliver clinical excellence and value for money is considerable.

1.4

Performance Overview

1.4.1 Financial Performance - Historical In 2007/08, and 2008-09, YAS achieved a breakeven financial position at the end of each financial year. In 2009-10 YAS achieved an operational surplus but a non recurrent technical deficit of £6,453,000 due to revaluation of the estate as required by the Department of Health. Table 1-a: Summary Income and Expenditure Statement 2006/07 Actual £'000

2007/08 Actual £'000

2008/09 Actual £'000

2009/10 Forecast £'000

Income Patient Care Income Other Income

139,227 5,412

150,486 4,524

183,081 3,629

191,973 6,527

Total operating income

144,639

155,010

186,710

198,500

Expenses Pay costs Transport costs Other non pay costs

(109,694) (14,418) (16,493)

(110,794) (15,408) (18,482)

(132,871) (18,222) (25,315)

(143,227) (17,293) (26,702)

Total operating expenses

(140,605)

(144,684)

(176,408)

(187,223)

4,034

10,326

10,302

11,277

384

(212)

3

(6,755) (2,375) 346 (101) (4,467)

(8,004) (2,309) 545 (95) 251

(7,904) (2,648) 507 (109) 151

229 (6,957) (8,670) (2,307) 96 (121) (6,453)

EBITDA Profit/(loss) on disposal of fixed assets Impairment Depreciation PDC Dividends payable Net interest Other finance costs Net surplus/(deficit) for the period

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1.4.2 Financial Performance Projected Table 1-b: Summary of Projected Income and Expenditure Statement 2010/11 £'000

2011/12 £'000

2012/13 £'000

2013/14 £'000

2014/15 £'000

Income

195,716

195,339

196,645

198,043

199,532

Pay Non Pay Total Operating Expenditure

148,668 36,326 184,994

147,665 35,636 183,302

148,007 35,071 183,078

149,934 34,525 184,459

152,400 33,949 186,349

EBITDA

10,722

12,037

13,567

13,584

13,183

Depreciation PDC Dividend Interest Receivable TOTAL

8,515 2,328 (121) 10,722

8,618 2,284 (115) 10,787

8,891 2,284 (109) 11,067

8,903 2,284 (103) 11,085

8,497 2,284 (98) 10,684

0

(1,250)

(2,500)

(2,500)

(2,500)

5.48%

6.16%

6.90%

6.86%

6.61%

(Surplus)/Deficit EBITDA percentage

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1.4.3 Standards and Targets Table 1-c: Summary of Annual Health Check Results

Annual Health Check

2006/07

2007/08

2008/09

2009-10 (Mid year declaration)

2009/10

Quality of Services

Weak

Weak

Weak

Fair

Registered with one condition

Use of Resources

Weak

Fair

Good

Good

From April 2010 the requirements under the Care Quality Commission (CQC) for the regulation and assessment of NHS Trusts have changed. Under the new regulations organisations are required to register to practice with the CQC. To be registered, all organisations must, by law, show that they are meeting new essential standards of quality and safety. The CQC has confirmed that the publication of YAS’ registration status will replace the score for core standards as the mechanism for providing assurance that essential standards of quality and safety are being met. YAS will be registered with one condition relating to the achievement of national response time standards as of April 2010 with a plan to resolve this by October 2010. This position masks the considerable progress YAS has made over the last four years to ensure delivery of high quality clinical care and efficient and effective processes as the summary of annual health check results clearly demonstrates. As of March 2010 YAS was in a position to declare full compliance against all the core CQC standards for the first time. The exact mechanism the CQC will be using to evaluate and report healthcare organisations quality and safety from 2010 onwards has not been finalised as of April 2010.

Table 1-d: National Target Results

Target

2007/08

2008/09

2009/10

Category A: 8 minute response

75%

73.5%

69.4%

70.8%

Category A: 19 minute response

95%

96.2%

96.1%

96.7%

Category B: 19 minute response

95%

92.4%

90.6%

91.1%

From the figures above, there appears to be a decline in our performance in 2008/09; however, this is a result of a change in measurement of the national target from 1 April 2008 (now measured from when the call is connected - a difference of approximately 90 seconds from the previous start point). The change in Call Connect measure masks 12

achievements and associated improvements in the response time performance throughout these periods. This plan sets out what is required to ensure that these targets can be consistently delivered going forward.

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1.5

Summary of Strengths, Weaknesses, Opportunities and Threats (SWOT) Analysis The following gives a summary of our SWOT analysis. Table 1-d: Summary of our Strengths, Weaknesses, Opportunities and Threats

Strengths • • • • • • • • •

Weaknesses • • • •

Public confidence in YAS Statutory role as Category 1 responder Statutory role as 999 service provider Good clinical outcomes Very strong market share Region-wide infrastructure and service knowledge Information technology expertise and infrastructure Commitment of staff Commitment of volunteers

• • • •

Opportunities • • • • • • • • • • • •

Registered with condition by the CQC Delivery of key national targets not stable Poor compliance with contract standards Strategic commissioning of services still developing Low commissioner confidence in some services Engagement with commissioners at the local level still developing Management capability Financial viability of PTS service

Threats •

Build on public confidence Enhance resilience for Yorkshire and the UK Develop Yorkshire-wide view of health economy capacity Develop hear and treat Develop see and treat Develop see and refer Improve service design at the local level Develop public health role Match capacity to demand across service lines Develop collaborative patient pathways which support better patient care models PTS moving into urgent care Private and Events expansion

• • • •

14

NHS funding position in 2010/11 and beyond Increased competition from NHS and independent sector Piecemeal tendering of PTS and other services Inadequate commissioning of workforce change Increased contract penalty culture

1.6

Key Risks Our top three business risks are: Table 1-e: Our Key Business Risks O2 Failure to deliver A&E performance improvement plan Likelihood • Performance gains from process improvement yet to be achieved • Front end model yet to be tested in local circumstances Controls • A&E Operations Board • Performance Turnaround process Residual likelihood

Score 5

-2

3 Impact • Failure to achieve key national targets • Regulatory action by the Care Quality Commission Residual risk score O3 Failure to deliver PTS service improvement plan Likelihood • Scale of change very significant • Resistance from some stakeholders • Vehicle efficiency targets very challenging Controls • Change being managed as a corporate programme • Performance Turnaround process • Agree block contracts with activity reduction targets Residual likelihood

5 15 Score 5

-2

3 Impact • Continued service line deficit, reducing funds available for A&E • Reduced resilience • Loss of business Residual risk score H1 Management capability and capacity improvement plan not delivered Likelihood • Leadership review findings • Staff survey results • Operational management capacity issue identified by Peter Bradley Controls • Leading edge management development programme • Investment in operational management capacity Residual likelihood

4

12 Score

5

-2

3 Impact • Sub-optimal performance against objectives / targets

5

Residual risk score

15

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1.7

Conclusion We have outlined our vision for the future. Demand for our services continues to grow and as a service we have already developed from being focused on transporting patients to treatment, to a service that now brings treatment to the patient. The needs of our patients now vary considerably, ranging from primary care needs to those suffering from stroke, heart disease and trauma. Therefore, we must continue to develop and deliver continuous improvements in patient care. To achieve this, it is essential that we have the strategic tools to adapt to the needs of our patients and partners. This summary has set an outline of our vision for the future and is supported by the evidence that demand for our services is set to grow, alongside how we will meet this challenge. The Business Plan that follows provides a more detailed analysis of our performance, leading to a five-year strategy that will help us to move forward, improve patient care and in time realise patient benefits from the opportunities of Foundation Trust status.

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2

Profile of the Trust

2.1

Overview Ambulance services are at the front-line of the NHS; that is why Yorkshire Ambulance Service NHS Trust puts patients and their needs at the heart of its business. From isolated moors and dales to urban areas, coastline and inner cities, the population 1 of Yorkshire is some 5.1 million . YAS has a fleet of over 500 specially equipped emergency vehicles operating from 62 ambulance stations located across the Yorkshire and Humber region to provide twenty four hour emergency and urgent care services. For Patient Transport Services (PTS) we have 466 vehicles across the county. There are two communications centres, in Wakefield and York, from where our emergency response services are activated. Our resources are all available to support major emergencies or crises in our role as a Category 1 Responder. YAS Trust Headquarters is located in Wakefield, West Yorkshire. Figure 2-a: Ambulance Stations in Yorkshire

1

Office for National Statistics estimates as at May 2008. 17

2.1.1 Commissioning Arrangements Our Accident & Emergency (A&E) service is commissioned through a consortium arrangement of the 12 Yorkshire Primary Care Trusts (PCTs), led by Bradford PCT. This accounts for 78% of our income. The Patient Transport Service (PTS) is currently commissioned by a combination of individual PCT and consortium arrangements. It is our aspiration to have a single consortium arrangement for PTS services in the future. PTS accounts for 15% of our income. Our other smaller lines are commissioned by the Department of Health (DoH), PCTs, provider units and the private sector. Combined, these services account for 6% of our income. .

Table 2-a: Commissioning Arrangements

Commissioner PCT North Yorkshire PCT East Yorkshire PCT Hull PCT Bradford PCT Calderdale PCT Wakefield PCT Kirklees PCT Leeds PCT Barnsley PCT Doncaster PCT Rotherham PCT Sheffield Total A&E Income PCT PTS Service Various Other Total all services

2.2

2009/10 Recurrent £000s 23,706 10,196 9,351 14,845 6,532 10,584 12,477 23,128 6,162 7,758 6,294 14,416 145,449 28,614 11,934 185,997

Range of Services We describe our services in four main categories:

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% Total 12.75% 5.48% 5.03% 7.98% 3.51% 5.69% 6.71% 12.43% 3.31% 4.17% 3.38% 7.75% 78.20% 15.38% 6.42% 100.00%

Table 2-b: YAS Services

Service

Output

Access and Response

Accident and Emergency

Handling all emergency calls and deploying the most appropriate service or vehicle to patients. Also, commissioned urgent care and GP out-of-hour calls.

Providing the fastest possible emergency clinical support and transport, activated from one of our two communication centres.

Patient Transport Services

Providing non-emergency transport for people who are referred for treatment to hospital outpatient departments or other treatment centres and also non-urgent transfers between hospitals.

Emergency Preparedness

Category 1 responder to major incidents and the deployment of Hazardous Area Response Teams and/or Urban Search and Rescue teams.

2.2.1 Access & Response Access & Response staff must ensure that when a member of the public calls 999, they receive a timely, professional response that is appropriate for their clinical need. Located at our two communications centres, they handle all emergency calls and deploy the most appropriate staff to meet patient needs. We receive over half a million emergency calls a year, which on average equates to more than 1,500 a day or one emergency call every minute. All 999 calls are assessed as follows: Answering the call within five seconds our communication centre staff • • •

verify the location of the incident apply a non-clinical triage based on a set of structured questions to establish the urgency of the call dispatch the appropriate response.

This whole process currently takes less than 90 seconds on average. The communication centre staff use state of the art telephony and Computer Aided Dispatch (CAD) systems to process the call.

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Table 2-c: Access & Response Assessment of 999 Calls and Response

Category

Criteria

Category A

Life-threatening conditions where speed of response may be critical in saving life or improving the outcome for the patient, such as a heart attack or serious bleeding

• •

Category B

Conditions which need to be attended quickly, but are not life-threatening

• •

First available and nearest resource Double-crew ambulance or RRV

Category C

Non-life threatening conditions and less serious injuries that may be appropriate for referral to an alternative care pathway



Where appropriate a transport response Emergency Care Practitioner response Clinical advice over the phone Directed to another service such as NHS Direct or PCT alternative care pathway

Calls from GPs or hospitals direct to the communications centre



GP urgent and routine transfers

Our Response



• • •

First available and nearest resource Double-crew ambulance or Rapid Response Vehicle (RRV) Community responder backed up by a double-crew ambulance.

Appropriate transport response

Access & Response also provide the GP Out of Hours call handling service for North Yorkshire, East Yorkshire, Hull and Gateshead PCTs..

2.2.2 Accident and Emergency Operations Operating from 62 ambulance stations and a network of stand-by point across Yorkshire, our Accident and Emergency Operations staff operate a fleet of specially equipped emergency vehicles in order to respond as quickly as possible to all 999 calls. Highly skilled staff in double-crew ambulances or Rapid Response Vehicles (RRVs) are trained in the use of the latest medical equipment and respond to all 999 emergencies and GP urgent calls. Our Accident and Emergency staff is over 2,100 and includes: • • • • •

Paramedic Practitioners Paramedics Emergency Medical Technicians Assistant Practitioners Emergency Care Support Workers 20

When dispatched, their aim is to reach patients as quickly as possible and deliver the most appropriate clinical care. In this task, they might work with the Yorkshire Air Ambulance for whom we provide paramedics. We also have other means to reach patients as quickly as possible: Lifecycle Scheme Paramedics in the pedestrianised town centres of York, Leeds and Sheffield with specially adapted bicycles are used to reach patients in the heart of the city and provide emergency care. In other parts of the region motorcycles are used for the same purpose. The bikes carry life-saving equipment such as defibrillators for use in cases of cardiac arrest. BASICS Doctors A network of doctors provides support to ambulance crews at serious road accidents and other trauma incidents. The service is provided on a voluntary basis and all of the specially-trained medics are affiliated to the British Association for Immediate Care (BASICS). Paramedic and Police Scheme We now have four Rapid Response Vehicles (RRV) staffed by a paramedic and a police officer. They work late-night weekend and bank holiday shifts and attend incidents such as drunkenness or domestic violence, where both services are needed. These vehicles currently operate in York and Hull. Emergency Care Practitioners (ECP) An ECP is a paramedic with enhanced skills. ECPs are trained to make full physical assessments, carry out minor medical procedures and prescribe an increasing number of medicines. This enables them to treat many patients in their own home and prevents unnecessary admissions to hospital. It is the intention of YAS to continue to work collaboratively with our partner organisations to develop alternative methods of service delivery to best fit with patient and community requirements. Community First Responders We have over 1,500 community-based volunteers who are trained to provide immediate life-saving treatment at certain emergencies, before the arrival of an emergency vehicle. There are more than 200 community first responder schemes across Yorkshire and each has vital life-saving equipment, including a defibrillator.

2.2.3 Patient Transport Service Our Patient Transport Service is for patients who have been referred for treatment to hospital outpatient departments or other treatment centres, but who are unable to use public transport because of their medical condition. It also provides non-urgent transfers between hospitals. Our PTS fleet incorporates a wide range of vehicles. This enables us to transport patients comfortably whether they require a stretcher, a wheelchair or simply a reassuring hand to help them in and out of a car. All PTS vehicles are designed with 21

patients’ comfort and safety in mind and are crewed by ambulance care assistants who have been trained in first aid, moving and handling techniques and specialist driving skills.

2.2.4 Emergency Preparedness As a Category 1 responder to major emergencies, we form part of the NHS response to major incidents such as flooding, public transport accidents, pandemic flu and chemical, biological, radiological or nuclear incidents. Our Hazardous Area Response Team (HART) programme provides a clinical response within the inner cordon of emergency incidents, particularly where mass casualties are involved. However, one element of the HART initiative is our Urban Search & Rescue (USAR) service of paramedics, the first to be established in the country. This team has the capability to respond to incidents involving entrapments in high rise buildings, underground, collapsed structures and other places that are difficult to reach.

22

2.3

Activity The following shows our A&E and PTS activity in 2009/10. We anticipate A&E demand will increase annually given the ageing population of Yorkshire, its public health issues and the need to meet patient expectations, which are explained in subsequent chapters. Table 2-d: A&E Demand 2009/10 (incidents responded to in support of each PCT)

30120 14601 14956 26513 8892 16228 16950 36309 10763 14290 11735 23556

28669 12796 14988 24985 9091 16461 18050 38521 9992 14549 11434 25612

12190 5438 6182 9482 3323 5474 7042 15035 3712 5638 4451 8835

GP Urgent /Routine 11385 5502 7316 5763 4603 6337 6105 10183 5053 6286 5934 13460

224913

225148

86802

87927

PCT Cat A NORTH YORKSHIRE AND YORK PCT EAST RIDING OF YORKSHIRE PCT HULL PCT BRADFORD AND AIREDALE PCT CALDERDALE PCT WAKEFIELD DISTRICT PCT KIRKLEES PCT LEEDS PCT BARNSLEY PCT DONCASTER PCT ROTHERHAM PCT SHEFFIELD PCT TOTAL

Cat B

Cat C

Total 82364 38337 43442 66743 25909 44500 48147 100048 29520 40763 33554 71463 624790

Table 2-e: PTS Activity 2009-10

PTS Transport Type Code

PTS Transport Type by patient requirement

Code

SC T1 T2 W1 W2 STR CH 3ML 4ML Sub Total Esc Abort Total

Saloon Car Tail lift vehicle with driver Tail lift vehicle with driver and staff member Wheelchair with driver Wheelchair with driver and staff member Stretcher Child 3 man crew required 4 man crew required Patient Escort Journeys Aborted Journeys

23

No of journeys 2009-10 627,901 306,763 62,585 122,838 19,273 20,143 1,728 50 250 1,161,531 226,004 77,463 1,464,998

2.4

Finance The following table describes our turnover and expenditure in the last four years. Table 2-f: Historical Financial Performance 2006/07 Actual £'000

Income Patient Care Income Other Income Total operating income Expenses Pay costs Transport costs Other non pay costs Total operating expenses EBITDA Profit/(loss) on disposal of fixed assets Impairment Depreciation PDC Dividends payable Net interest Other finance costs Net surplus/(deficit) for the period

2.5

2007/08 Actual £'000

2008/09 Actual £'000

2009/10 Forecast £'000

139,227 5,412 144,639

150,486 4,524 155,010

183,081 3,629 186,710

191,973 6,527 198,500

(109,694) (14,418) (16,493) (140,605) 4,034 384

(110,794) (15,408) (18,482) (144,684) 10,326 (212)

(132,871) (18,222) (25,315) (176,408) 10,302 3

(6,755) (2,375) 346 (101) (4,467)

(8,004) (2,309) 545 (95) 251

(7,904) (2,648) 507 (109) 151

(143,227) (17,293) (26,702) (187,223) 11,277 229 (6,957) (8,670) (2,307) 96 (121) (6,453)

Standards and Targets Performance Table 2-g: Summary of Annual Health Check Results

Annual Health Check

2006/07

2007/08

2008/09

2009-10 (Mid year declaration)

2009/10

Quality of Services

Weak

Weak

Weak

Fair

Registered with one condition

Use of Resources

Weak

Fair

Good

Good

From April 2010 the requirements under the CQC for the regulation and assessment of NHS Trusts have changed. Under the new regulations organisations are required to register to practice with the CQC. To be registered, all organisations must, by law, show that they are meeting new essential standards of quality and safety. The CQC has confirmed that the publication of YAS’ registration status will replace the score for core standards as the mechanism for providing assurance that essential standards of quality and safety are being met. YAS will be registered with one condition 24

relating to the achievement of national response time standards as of April 2010 with a plan to resolve this by October 2010. This position masks the considerable progress YAS has made over the last four years to ensure delivery of high quality clinical care and efficient and effective processes. This improvement can be measured through • • • • •

Full compliance against all the “core standards” as of March 2010 Achievement of Risk Management Scheme for Trusts level one Unmatched performance on HCAI as the only ambulance service to get no recommendations after the round of unannounced CQC inspections Achievement of a “Good” rating under the Auditors Local Evaluation Framework Implementation of changes following national lessons learnt reports

The exact mechanism the CQC will be using to evaluate and report healthcare organisations quality and safety from 2010 onwards has not been finalised as of April 2010. Table 2-h: National Target Results

Target

2007/08

2008/09

2009/10

Category A: 8 minute response

75%

73.5%

69.4%

70.8%

Category A: 19 minute response

95%

96.2%

96.1%

96.7%

Category B: 19 minute response

95%

92.4%

90.6%

91.1%

Since its formation, the Trust has had very significant challenges meeting national response time targets. It should be noted that there appears to be a decline in performance in 2008/09, although this is a result of a change in measurement of the national target (now measured from when the call is connected a difference of approximately 90 seconds from the previous start point). Our performance for 2008/09, measured under the old standard was 78.8% for Category A 8-minute response. Ambulance response times in Yorkshire are the best they have ever been. The sustainable delivery of the response time standards has been and remains our number one priority. We have taken every opportunity to learn from good practices in other services and have delivered significant improvement in-year. This plan sets out what is required in order for us to deliver confidently on national targets going forward.

2.6

Conclusion We have a range of emergency and patient transport services, supported by a comprehensive communications infrastructure, which allows us to support patients across the entirety of Yorkshire and beyond. We have an established reputation as a 25

Category 1 responder and have built upon the advantages that were secured when YAS was established. The achievement of the national response time standards remains an area of focus for us and we will continue to improve our performance in these areas. We are financially sustainable and continue to develop our future strategy to improve our clinical support to patients whilst consistently improving our financial position.

26

3

Strategy 3.1

Our Vision and Values

Most people in Yorkshire will need an ambulance service at some point in their lives. When they do, they expect and deserve an excellent service. Our Vision and Values describe our ambition to achieve this. Our Vision

We aim to deliver an excellent ambulance service for Yorkshire that is clinically focused, financially sound and continuously develops its services to meet the needs of the future

Our Values

3.2

Clinically Focused Everything every one of us does is for the patient

Responsive We listen and we respond quickly

One Team We work together to provide the best patient service

Exemplary Service Skilled, professional, working to high standards and passionate about improving patient healthcare

Our Strategy

We will move toward our vision over the next five years by achieving eight strategic objectives. These have been agreed by the Trust Board after a comprehensive analysis of our services and the environment in which they operate. This analysis included a market assessment, SWOT analysis, PESTLE analysis and consideration of service development and financial plans.

27

Figure 3-a YAS Strategic Objectives

The following strategic drivers were also considered: •

Our NHS, Our Future (NHS Next Stage Review – Lord Darzi’s Review 2007-2009)



Taking Healthcare to the Patient (The Bradley Report 2005 - Transforming NHS Ambulance Services)



Healthy Ambitions (Yorkshire and the Humber Strategic Health Authority 10-Year Vision, May 2008)



The Operating Framework – High Quality Care for All (High Quality Care for All, Department of Health, December 2009)



Standards for Better Health (Health Care Standards for Services under the NHS, Department of Health 2004)



Our Health, Our Care, Our Say (A New Direction for Community Services, Department of Health 2006) 28



National Standards Local Action (Health & Social Care Standards and Planning Framework 2005/06-2007/008, Department of Health 2004)



Civil Contingencies Act 2004



NHS Constitution and the Health Act 2009



NHS Carbon Reduction Plan (Saving Carbon, Improving Health NHS Carbon Reduction Strategy for England Department of Health 2009)



NHS Five Year Plan (NHS 2010 - 2015: from good to great. Preventative, people-centred, productive Department of Health 2009)

Our Strategic Objectives are examined in more detail in the following table. Table 3-a: A Summary of our Strategic Objectives

Strategic Objective 1 CLINICAL EXCELLENCE Rationale Measure of Success

Timeline Risk

Strategic Objective 2 RESILIENCE Rationale

Measure of Success

Timeline Risk

Ensuring that everything we do leads to patient benefit, excellence in clinical care and access to the most appropriate and timely care for all our patients. This objective is crucial in ensuring that we use all of our resources efficiently and effectively to maximise patient benefit. • Continuously improve our clinical practice so that we are recognised as leaders in the field • Exceed our partners’ expectations for timely and emergency response • Exceed our partners’ expectations for the effectiveness of our nonemergency patient transport services Short term • Management capacity and capability development plan not delivered • Excessive demand / severe weather • A&E service improvement plan not delivered • PTS service improvement plan not delivered

Maintaining business continuity at all times, whilst having the capacity and ability to respond appropriately to emergencies or crises. This objective is to ensure that we meet our commitments to our patients whilst also having the capacity and ability to support the wider community in times of emergency or crisis, meeting our obligations as laid down in the Civil Contingencies Act 2004. • Capacity and ability to support emergencies or crises whilst maintaining business continuity • Successful execution of resilience and emergency preparedness plans • Collaborative planning with other emergency services and civil contingency organisations Short term • Large scale uncompensated loss of PTS business • Management capacity and capability development plan not delivered • HART not commissioned • Excessive demand / severe weather • Major IT failure

29

Strategic Objective 3 OUR PATIENTS Rationale

Measure of Success

Timeline

Putting the patient at the heart of our work by ensuring that every policy and practice supports their physical and mental well-being. This objective puts the patient at the heart of all our work as a clinically focused organisation. • Systematic process for capturing patients’ views • Improvement based on lessons learnt from patient feedback • Patient participation in our planning and governance structure Medium term •

Risk

Strategic Objective 4 OUR PARTNERS

Rationale

Measure of Success

Proactively working together with our partners to deliver integrated services that meet current and future standards for world class healthcare. This objective underpins the core services we provide, by helping us to appreciate the needs of our partners and, therefore, our patients. It allows us to develop our services to meet these needs. • Improvement in partners’ experiences and satisfaction • Improve engagement with our partners to help deliver integrated services

Timeline • Risk • •

Strategic Objective 5

Management capacity and capability development plan not delivered

Medium term Management capacity and capability to development plan not delivered A&E service improvement plan not delivered PTS service improvement plan not delivered

Embedding the principles of Quality throughout the Trust to deliver continuous improvements in all our services.

QUALITY

Rationale

Measure of Success Timeline

This objective helps us not only to critically assess what we actually do to support patients and all of our business activities, but how we do it. Therefore, we can seek to provide the very highest quality of service to our patients and in how we undertake all aspects of our business. • Continuous improvement as measured by the Care Quality Commission assessment • Achieve Foundation Trust status Medium term • Management capacity and capability development plan not delivered

Risk

30

Strategic Objective 6 OUR PEOPLE

Rationale

Measure of Success

Timeline

Recognising that the excellence, professionalism, well-being and personal development of our staff and volunteers are key to the success of everything that the Trust does. The commitment and professionalism of all our staff, including volunteers, are critical to our success in delivering clinically focused and excellent patient care, and also our reputation. This objective is pivotal to our securing the best people in a competitive employment market. • Demonstrable leadership and management qualities to deliver the Trust Vision • Provision of training and development to meet the needs of the Trust and our staff • Improvement in staff satisfaction Medium Term • Management capacity and capability development plan not delivered

Risk

Strategic Objective 7

Creating a high quality, efficient and safe workplace that reduces our negative environmental impact.

ENVIRONMENT

Rationale

Measure of Success Timeline Risk

Strategic Objective 8

This objective seeks to establish the Trust as an environmentally and highly efficient user of its resources in line with the national strategies to reduce our carbon footprint and contribute more widely to the environmental policy agenda. • Year-on-year reduction in our corporate carbon footprint • Continuous improvement and development of the Trust’s estate and fleet Medium term • Market conditions prevent sale of surplus assets • Carbon improvement plan not delivered

Delivering sound financial management and value for money.

FINANCE

Rationale

Measure of Success Timeline Risk

Managing our finances in the very best way will ensure the viability of the Trust and afford our people the best opportunity to deliver excellence in patient care, thus securing our future and allowing us to develop and improve further as we move towards Foundation Trust status. • At a minimum, sustained financial viability • Recognised as ‘Excellent’ in our use of resources Short / Medium term • • • • • •

Large scale loss of PTS business HART not commissioned by PCTs Market conditions prevent sale of surplus assets Carbon improvement plan not delivered Cash Releasing Efficiency Savings target not delivered Inflation / other cost pressures greater than planned

31

3.3

Rationale for Foundation Trust Status Our ambition to improve the service we provide is clear from our Vision, Values and Strategic Objectives. Becoming a Foundation Trust will support the delivery of our Vision by ensuring:

3.4



Improved business processes that will drive improved quality of services. In particular, in order to be authorised as a Foundation Trust we will need to ensure sustainable delivery of key national targets, full compliance with core standards and stakeholder agreement with key strategic objectives. This Business Plan will help us to achieve an increased performance across all areas of the Trust, whilst maintaining our financial viability. With these improvements being built upon year-on-year, we will move to a credible position from which we can apply for Foundation Trust status.



Improved public engagement through the membership and Board of governors. With Foundation Trust status giving us more financial independence, we need to reassure our patients and the public that the core NHS principle of free care, based on need and not ability to pay, will continue. This will be achieved not only by an improvement in our services, but through greater engagement with the public, who will be invited to become members of the Foundation Trust. Indeed, this form of public ownership and accountability will help to ensure that our services, which are at the front-line of NHS emergency care, reflect the needs, expectations and aspirations of the people we serve.



Improved stakeholder engagement. We have identified a need to improve significantly the reputation of the Trust with some of our partners whose appreciation of the professionalism and fine reputation of our staff is limited. Therefore, we need to articulate better the benefits of the Trust by way of the range of services we can provide and the excellence of our staff. Work to improve our relationships with our partners has already begun and with greater independence from Foundation Trust status we will be in an even stronger position to promote the brand that is Yorkshire Ambulance Service.



Independence and enhanced financial strength. Independence will best allow us to protect and build upon our reputation with the public. Also, whilst the NHS Trust financial regime has been made more like that of Foundation Trusts, there remains enhanced freedom under the Foundation Trust regime. Foundation Trust status provides a strong incentive for all of our staff to deliver the most costeffective services and to identify ways to reinvest in new developments.

Conclusion Our Vision and Strategic Objectives are focused to ensure that we continue to deliver excellence in patient care, whilst meeting our contractual and civil obligations, and consistently improving our financial performance. This will afford us the opportunity to secure Foundation Trust status and develop further our services for the benefit of our patients and community.

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4

Market Assessment

4.1

Description of the Local Health Economy Our local health economy is the entirety of England’s largest county, covering some 6000 square miles and with a population of over five million. Our partners include 12 PCTs, five Acute and Mental Health Trusts and one Strategic Health Authority, serving an extensive rural community as well as the large and diverse urban populations of Leeds, Sheffield, Bradford, Rotherham, Hull, Doncaster, Wakefield and York. Figure 4-a: Yorkshire and Our PCT Partners

33

4.1.1 Our Patients The patient experience 2 of our services is nearly always positive, albeit with some recognised concerns and a lack of appreciation of alternative urgent care pathways: Table 4-a: Summary of Our Patients’ View

Our Service

Patients’ Views

Access & Response

• • • •

Valued and appreciated Responsive and skilled staff who are calm and helpful Staff convey a clear message of reassurance Surprised to learn of alternative urgent care pathways such as NHS Direct or even referral to GP

Accident & Emergency

• • • •

Almost universally positive Fast response times Professional, caring and friendly crews Great confidence in ability to treat and transport to hospital

Patient Transport Service

• •

Professional, friendly and caring staff Usually on schedule, but not always

4.1.2 Our Partners Our partners appreciate the challenges we have faced and addressed since 2006. However, they are critical of aspects of our performance, whilst wishing to engage with us better for mutual benefit and most importantly for our patients. They have an increasing need for on-demand/flexible transport, which is challenging to our current pathway focus. Even so, they have confidence in our Trust and wish to improve engagement with us to identify the processes that need to be implemented so that alternate pathways can be adopted and necessary communication established.

2

Quadrant Consultants – Market Analysis & Review of Yorkshire Ambulance Service, 11 November 2008. 34

A summary of their views is as follows: Table 4-b: Summary of Our Partners’ Views

Positive

Negative



Professionalism and commitment of staff





YAS services do not reflect the changing needs of PCTs and patients

Established infrastructure to provide a responsive and successful ambulance service



Contractual commitments not always met



Perceived reluctance to change



Fail to respond to patient choice agenda and demand for more flexible non-urgent care transport services



Appreciate YAS organisational challenges since 2006



Supportive of YAS major effort to improve Category A response time targets



Strong commitment to engage better with YAS for mutual and patient benefit



Too often inflexible and unable to meet short notice requests for non-urgent transport



Engagement improved



Inflexibility results in poor delivery times and patients enduring long delays, being collected early and returned home late

4.2

Key Factors Driving Future Demand Demand for Services We commissioned research 3 to make demand projections for emergency incidents over the next five years. Using historical trend information for emergency calls across the county’s former Ambulance Trusts 4 , as well as YAS, the research produced an overall expectation of future demand. From the results, we can conclude the following: •

Demand will increase annually for A&E services.



There is a high correlation between demand and population at the PCT level.



The Yorkshire population will increase by around 3.75% between 2009 and 2013.

The research concluded that there is no relationship between the age profile of a population and its propensity for generating emergency demand. Focus groups identified that younger age groups were more likely to call for an ambulance, citing their right to do so and belief that arriving at a hospital in an ambulance would guarantee treatment more quickly. Nevertheless, there is a high correlation between demand and 3

ORH Research – Emergency Demand Projections for Yorkshire Ambulance Service, 13 October 2008. West Yorkshire, South Yorkshire, and the North Yorkshire and East Yorkshire part of Tees, East & North Yorkshire Ambulance Service (TENYAS). 35

4

population at the PCT level. Therefore, differential rates of increase in population at PCT level can be expected to result in corresponding differential rates of increase in emergency demand. Demand projections for each category of emergency demand were produced based on the following population projections. Table 4-c: Population (thousands) by PCT 2011 to 2015

PCT Barnsley Bradford and Airedale Calderdale Doncaster East Riding of Yorkshire Hull Kirklees Leeds North Yorkshire and York Rotherham Sheffield Wakefield District TOTAL

2011

2012

2013

2014

2015

230.6 526.7 207.7 295.4 350.0 266.8 411.7 799.8 825.2 259.9 544.0 329.8 5047.6

232.2 533.7 209.8 296.6 354.0 269.1 414.7 809.6 833.6 261.4 547.6 331.9 5094.2

233.8 540.8 211.8 297.9 358.0 271.3 417.7 819.0 842.0 263.0 551.1 334.0 5140.4

235.5 547.7 213.9 299.2 362.1 273.6 420.8 828.3 850.3 264.6 554.5 336.2 5186.7

237.2 554.7 215.9 300.6 366.2 275.8 423.8 837.5 858.7 266.2 558.0 338.5 5233.1

The PCTs with our largest patient populations, North Yorkshire and York, Leeds and Bradford and Airedale are projected to have the largest population increases in the next five years, all with rises expected to be above 1%. The demand projection is as follows: Table 4-d: Demand Projections 2010 to 2015 Category

2010/11

2011/12

2012/13

2013/14

2014/15

Cat A Cat B Cat C Urgent/Routine Total

227,497 243,870 90,458 87,931 649,756

239,749 256,762 95,123 90,421 682,055

250,639 268,658 99,461 89,762 708,520

261,624 280,013 103,995 88,436 734,067

272,221 291,909 108,235 87,110 759,475

The projected demand increases are lower than those experienced in recent years and assume a degree of success in demand management by commissioners in partnership with YAS.

Population Health & Inequality An ageing population, health behaviour and significant health inequalities across Yorkshire, will give us a different and more challenging mission in the years ahead.

36

Life Expectancy. Some parts of Yorkshire have the lowest life expectancies in England 5 . In the past ten years, there has been an increase in life expectancy by over two years for men (76.6) and one year for women (81.0). However, this remains below the national average life expectancy in England of 77.3 years for men and 81.6 years for women. This reflects the significant public health issues and the consequences of many forms of poverty in certain areas. A baby born in Bradford is almost three times more likely to die before their first birthday than a baby born in Hambleton. Health Behaviour. The biggest avoidable threats to the health of the Yorkshire population continue to be the prevalence of smoking, alcohol abuse and rising obesity. If current trends continue, by 2010 Yorkshire is likely to have the highest number of obese or overweight girls aged 11-15 in England. Alcohol Consumption & Smoking. The Yorkshire population has some of the highest levels of alcohol consumption in the country and with just under one in five deaths in Yorkshire attributable to smoking, there are still high levels of smoking compared with the national average, with a consequent impact on the likelihood of disability and premature death.

Patient & Partner Expectations Patients. We have an ageing population and younger people with significant lifestyle health issues who demand an ambulance service as a right; therefore, patient expectations are increasing. They expect a fast, responsive and personal service that reflects significant increases in health spending in recent years. They know about patient choice and wish to see this implemented throughout the NHS. Partners. Our partners deem efficient ambulance services as critical to their reputation. They face increasing pressure to deliver continuous improvements, offer more patient choice, reduce usage of hospital beds and respond to competition, whilst still meeting regulatory standards. Hospitals have more complex transport and logistical needs to match the complexity of their business and their service reconfigurations which we must respond to. Also, the centralisation of some clinical services, such as Accident and Emergency and for stroke patients, brings a changing expectation of our service provision which we must take into account.

Conclusion The expectations of our patients and partners are increasing and they expect a consistently reliable, flexible, responsive and continuously improving range of services.

5

Yorkshire and The Humber Strategic Health Authority, ‘Healthy Ambitions – High Quality Care for All in Yorkshire and The Humber’ 2008 37

4.3

Objectives of the Local Health Economy 4.3.1 Yorkshire and The Humber Strategic Health Authority ‘Healthy Ambitions’ sets out the work that the Yorkshire and The Humber Strategic Health Authority has led to take forward the ‘Our NHS, Our Future’ review established by Lord Darzi in 2007. In his final report, ‘High Quality of Care for All’, the key themes are: •

High quality care for patients and the public, with an NHS that works with partners to prevent ill-health and provides care which is personal, effective and safe.



A focus on the quality of everything we do which includes patient safety, the patient experience and the effectiveness of care.

From this, the SHA has outlined its vision for Urgent Care that impacts directly on YAS. Alongside the requirement to meet all existing national targets, the SHA has noted the following in its vision: •

A single point of contact for urgent care should be introduced.



More options for treatment at a scene by skilled staff.



After initial assessment or face-to-face contact, a wider range of referrals across the health care system should be available to make best use of all services.



Ambulance bypass protocols should be developed for patients with stroke, acute MI, major trauma and paediatric emergencies where or when appropriate to ensure patients have access to the best treatment.

The SHA requires each PCT to produce a strategic commissioning plan and a delivery plan for ‘Healthy Ambitions.’ Alongside the SHA’s vision for Urgent Care, we have identified ten broad strategic themes from ‘Healthy Ambitions’ that have implications for YAS and our delivery of clinically-focused services.

38

Table 4-e: Broad Strategic Themes from Healthy Ambitions Relevant to YAS

Serial Number

Strategic Theme

i

A focus on the quality of our services as well as access.

ii

The impact of centralisation of some services into specialist units.

iii

The repatriation of patients from centralized units to local hospitals.

iv

A responsibility to consider the well-being and health of our staff.

v

An appreciation of existing and developing opportunities in mobile scanning.

vi

Our capacity to screen patients for a wider rage of conditions.

vii

The ability of our current and future ICT systems to link to the rest of the health and social care system.

viii

A responsive ICT system that can quickly identify the particular needs of patients.

ix

The opportunity to compete to provide a broader range of patient services.

x

The ability to access the broader range of care pathways that are to be developed.

‘Healthy Ambitions’ affords the Trust an opportunity to work together with our partners in order to address their common requirements and also their differences as a result of local priorities. Understanding local health commissioning priorities, timescales and impact will enable us to respond using this intelligence in a planned and coherent way.

4.3.2 PCT Strategic Commissioning Plans Each PCT has produced its draft strategic commissioning plan and a delivery plan for ‘Healthy Ambitions’ which the Trust must appreciate. The general themes from these plans are as follows:

39

Table 4-f: General Themes from PCT Strategic Commissioning Plans

Theme

Implications for the Trust

Reducing Health Inequalities & Increasing Life Expectancy

The geographical variation on achievement of this target generally favours the urban areas which tend to have greater levels of deprivation and, therefore, poorer life expectancy. Further detailed work through the SHA is to be undertaken to increase understanding of demand, identifying particular areas where both life expectancy and response times are lower.

Tackling the Major Killers (Heart Disease Cancer & Stroke)

Opportunity for YAS to work on regional, sub-regional and local care pathway/service development and model the service implications. This will allow the Trust to forecast, plan, assess the need for increased clinical skills and identify transport arrangements to specialist care centres.

Delivering Care Closer to Home

All PCTs want to maintain independence, care for people closer to home and reduce unnecessary admissions, although different language and delivery mechanisms are identified within their plans. All PCTs have identified a shift in some planned and unplanned services to community settings. This is supported by the aim to reduce conveyance to hospital i.e. reduction in A+E attendance which for YAS will be delivered by increased clinical skills and better information about and access to, primary or community based services.

Prevention of Ill Health and the Public Health Agenda

Prevention of Ill Health is new for ambulance services but via the Public Health Agenda, YAS will gain an opportunity to deliver health improvement at an individual and population level and through our day-to-day patient contact. This is an area where YAS could bring added value to population health improvement.

End of Life Care

Better clinical skills will be required to assess risk and manage people at home, combined with a better system for support from community services.

Consistent Themes: • Commissioning additional community services • Shifting specific acute services into community locations • Increasing access to primary care services either through additional GP-led Health Centres / Darzi Centres, enhancing Out of Hours Services or additional GP Practices • Increasing disease management for people who have a long term condition Engagement with PCTs is imperative to identify information on the local pathway/service development that will be fundamental to enable YAS to deliver local PCT pathways as part of their emergency/urgent care strategies. 40

4.4

Major Changes in External Environment/Competition Urgent Care Developments The consequence of urgent care developments is that it is likely that we will face increased competition for the delivery of urgent care ambulance services. This will focus upon our Access & Response and Patient Transport Services in particular. PCTs wish to separate out emergency (acute) care from urgent care, with an intent to enable patients to be cared for at or closer to home, rather than unnecessary hospital attendance or admission. Each PCT is seeking to commission a responsive service which is sufficiently consistent to be efficient whilst minimising risk. The PCTs are considering four elements of Urgent Care that we will have to respond to: •

Initial Call Handling and Triage Systems



Knowledge of Existing Services, Pathways and Hospital Service Capacity



Clinical Skills



Urgent Care Centres

Health Economy Reconfigurations Health economy reconfigurations can be a major impact on demand for transport. Significant demand growth has occurred recently as a result of changes in hospital configuration. Reconfigurations that are likely to occur over the life of the plan have been considered. Demand estimates have been calculated where there is sufficient information to do this.

Centralisation of Services The centralisation of clinical services such as stroke, whilst improving clinical outcomes, increase ambulance cycle times and require appropriate additional resources to be commissioned. For the purpose of the plan, it is assumed that all such impacts will be appropriately commissioned in time for the relevant workforce to be put in place.

4.5

Political, Economic, Social, Technology, Legal and Environmental (PESTLE) Analysis We have conducted a PESTLE analysis based on our market assessment and other research. The key themes that have emerged are: •

The financial health of the UK economy and its impact on investment in public services.



A changing health policy environment, taking into account potential political change and initiatives focused on patient choice. 41



A need to work closely with our PCTs and other organisations to address socioeconomic issues, in particular public health.



An increasing focus on the environmental impact of public health organisations and an expectation of significant carbon footprint reductions

Political The political agenda is dominated by two key factors: a General Election in May 2010 and the state of the UK economy. The consequences of which are: •

Uncertainty in future levels of public spending on healthcare beyond 2010-11



Increasing pressure to: o o o o

Expand patient choice Increase the quality of clinical care provided Achieve better value for money Secure Foundation Trust status

The short to medium-term prospects for the economy are extremely challenging and difficult; however, there is a broad political consensus that the amount of public investment in health must demonstrate an increase in both output and accountability. The Foundation Trust initiative has cross-political party support and will continue to be a focus for change within the NHS, whatever the result of the next General Election. This, alongside initiatives to expand patient choice and deliver a wider range of services will, therefore, continue to dominate the health agenda. There is also an increasing focus within all parts of the public sector to achieve better value for money. Following significant investment in health over the past decade, which will not be matched in the short to medium-term, the political pressure both nationally and locally for better performing NHS Trusts will be considerable. Our Response. • •

We will embrace fully the quality agenda and seek to embed the culture of continuous improvement throughout the Trust. We will move forward as quickly as possible to place ourselves in a position to secure Foundation Trust status.

Economic The 2010-11 Operating Framework clearly identifies the following A future without funding growth. In 2010-11 PCT’s receive an average of 5.5 per cent growth, 1% to be retained as surplus, 2% allocated to non recurrent schemes. In addition, PCT’s and SHA’s are to reduce costs by 30% over the next four years with ‘most progress’ on this to be made during 2010-11 and 2011-12. The emphasis is clearly on more efficient and productive functions within the same or less financial envelope. This will be reflected in the commissioning arrangements. Marginal Funding and Tariff Pricing. In 2010-11 the Operating Framework clearly identified a move to 30% marginal funding for acute secondary care 42

above threshold limits. Although this has not been explicitly linked with Ambulance Services for 2010-11 this remains a potential area of risk. Within the 2010-11 Operating Framework there is a signal to move towards tariff as maximum price not guaranteed price. This may increase YAS financial risk as organisations with high reference costs will be adversely impacted. Health Expenditure. Along with the cost of servicing government debt, the squeeze on public spending will be considerable for the foreseeable future and this is being accompanied by an unprecedented drive to secure efficiencies across all areas of the public sector. Although health spending is expected to grow in real terms, from 2010 it is now expected to fall as a share of national income, which is a significant change from the large budget increases of the past decade. Inflation. There is no inflationary uplift to the tariff during 2010-11, this assumes a 3.5% efficiency saving. It is highly likely that this will be the case in 2011-12. Our Response •

We will continue to be financially sustainable and improve our use of resources. We have revised our assumptions regarding the cost improvement plans required and are forecasting savings of £55m over the life of the plan.



We are assuming zero inflation uplift in the last three years of the plan.

Social The economic context will have a significant impact on social changes amongst the Yorkshire population, already facing major public health issues. Demand for Services. With an increasing and ageing population, the demand for ambulance services will increase and the Trust must identify initiatives that respond positively to the patient choice agenda, with clinical care likely to be delivered much closer to patients’ homes. Whilst we have noted that there is not a correlation between an ageing population and their likelihood to call for an ambulance, this will be negated to some extent by their increased health requirements. Public Health Impact. We must be aware of any negative impact upon the health of our patient population due to the deteriorating economy. Increased unemployment and homelessness often leads to more instances of alcohol abuse and a general deterioration in public health and this is likely to occur when Yorkshire already faces significant challenges in this area. Our Response •

We will work with our partners to help develop strategies and utilise our resources to best effect in order to help tackle the major killers of heart disease, cancer and stroke.

43

Technology Information Management and Technology developments are key to the Trust improving its responsiveness and patient care. With a large geographical area to support, the Trust must continue its initiatives to exploit to the full its range of technological resources. Crucial to this will be our financial viability to help deliver these improvements, as well as staff training to realise maximum benefit from technology. It is also likely that technological advances in clinical care will be one of the drivers of change in patient treatment and where this can be delivered. This will enable PCTs to respond positively to the patient choice agenda with inevitable consequences for the Trust in how we respond to different patient needs. Our Response • •

We will continue with our Information Management & Technology strategy in order to modernise our services. We will use technology to help our partners manage their capacity to meet demand.

Legal The 2009 Health Act and the associated NHS Constitution places a legal burden on healthcare providers, staff and patients in that all providers and commissioners of NHS care are under a new legal obligation to have regard to the NHS Constitution in all their decisions and actions. This Constitution brings together what staff, patients and public can expect from the NHS.

Our Response •

We will ensure that the NHS Constitution forms a central part of our decision making, policy generation and communication plans throughout the Trust

Environmental The NHS currently contributes approximately 3 % of England's total carbon dioxide emissions. The Carbon Reduction Strategy commits the NHS to reduce these emissions by 60 per cent by 2050 in all areas, including procurement, travel and building energy use.

Our Response •

A five year Carbon Management Plan, written in collaboration with the Carbon Trust will commence in 2010-11 with a view to significantly reducing our carbon footprint.

44

4.6

Competitive Factors

4.6.1 An Analysis of the Competitive Environment We have reviewed the competitive forces that we face within the local health economy and the key findings are as follows: •

YAS is the dominant provider of ambulance services across the county.



There is significant potential for competition across all services, albeit limited for A&E Cat A and B services at present.



Whilst challenging and expensive for a new organisation to establish the necessary infrastructure to provide a full and competing range of ambulance services across the county, opportunities exist for both the private sector and NHS competitors to provide many key services including Access & Response, A&E urgent care services and patient transport.



The SHA’s market strategy seeks to open services to more competition with possible county-wide contracts that offer significant advantages through economies of scale, thus providing opportunities for both YAS and its competitors.



The financial focus of PCTs and the need to secure value for money and quality of service means that they are increasingly reliant on efficient and flexible patient transport.

45

Figure 4-b: Analysis of the Competitive Forces in the Local Health Economy 6

New Entrants • • •

Difficult to establish full range of ambulance services Opportunities to provide niche/selective services to PCTs Potential competitors already in the market, or considering how they can expand their business: eg. NHS Direct for Access & Response services, private transport providers for Cat C urgent transfers and patient transport, competitor NHS ambulance services in county border areas

Threat of Competition

Buyers • • •



PCTs are powerful buyers of services, supported by influential commissioners Patient choice agenda increases Buyers’ power Increased focus on value for money and flexible transport services from PCTs SHA market strategy for possible county-wide services will increase competition

Competitive Rivalry

Supplier Power

Competitors from the private sector and within NHS. Increasing rivalry for provision of Access & Response, A&E urgent transfers and patient transport services.

Buyer Power

Suppliers •







6

YAS dominance across county in ambulance services market YAS market reputation weakened by overall quality of service YAS offers established countywide infrastructure and professional staff Private transport services tried and tested across the public sector, eg. Local government, Police Authorities, Prison Service

Threat of Substitutes

Substitutes • • • •

Limited substitutes, if any, for Cat A and B A&E services Established and proven private sector providers for Cat C urgent transfers Established NHS Direct infrastructure and service could compete for provision of Access & Response services to PCTs Patient Transport market already exploited by private sector, eg. 18% of Yorkshire PTS already with non-YAS providers

This framework follows Porter’s Five Forces Analysis, developed by Michael E Porter in 1979. 46

4.6.2 Conclusion Having finalised our market analysis, we have concluded that it is appropriate to plan for an ongoing demand increase in A&E. Our approach to PTS is that we will manage demand on behalf of our commissioners and retain our present contracts. Due to the revised financial context we are not planning to increase our market share in any services. There may even be possible contraction of some service levels depending on the commissioning profiles moving forward. YAS will continue to develop plans to address opportunities as they arise, but given the anticipated scarcity of market development opportunities in the present financial climate these have not been included in the base plan. Table 4-g: Market Share Growth in Plan

Estimated Market Share (%)

Competition

Potential Market Share Growth

Potential Market Share Growth in Plan

Access & Response 999 Call Handling and Dispatch Urgent Care - Cat C Triage Urgent Care - GP Out of Hours Urgent Care - Other Call Handling

100 52 28 0

None Significant Significant Significant

None None Limited Medium

No No No No

A&E Operations A&E Initial Response A&E Transport - Cat A/B A&E Transport - Cat C, Urgent , Routine ECP's

100 100 95 17

None None Some Significant

None None Limited Large

No No No No

Patient Transport Services

82

Significant

Limited

No

Emergency Preparedness HART Team Other EP

100 100

None None

None None

No No

Despite a diverse and geographically large county with an increasing and ageing population, many of the challenges that the Trust will encounter focus on the need to deliver better and more flexible services, that are responsive to patients’ needs and give value for money. The economic outlook is negative for the short to medium-term and the pressure to deliver a more efficient service with less public funding is considerable. To achieve this at a time when the public health of the county might deteriorate further places an even greater emphasis on the need to embrace a culture of continuous improvement, respond innovatively to the demands of the PCTs and our patients and secure Foundation Trust status. 47

5

Service Development Plans

5.1

Internal Capability Assessment - SWOT Analysis Table 5-a: Summary of our Strengths, Weaknesses, Opportunities and Threats

Strengths • • • • • • • • •

Weaknesses • • • •

Public confidence in YAS Statutory role as Category 1 responder Statutory role as 999 service provider Good clinical outcomes Very strong market share Region-wide infrastructure and service knowledge Information technology expertise and infrastructure Commitment of staff Commitment of volunteers

• • • •

Opportunities • • • • • • • • • • • •

Registered with condition by the CQC Delivery of key national targets not stable Poor compliance with contract standards Strategic commissioning of services still developing Low commissioner confidence in some services Engagement with commissioners at the local level still developing Management capability Financial viability of PTS service

Threats

Build on public confidence Enhance resilience for Yorkshire and the UK Develop Yorkshire-wide view of health economy capacity Develop hear and treat Develop see and treat Develop see and refer Improve service design at the local level Develop public health role Match capacity to demand across service lines Develop collaborative patient pathways which supports better patient care models PTS moving into urgent care Private and Events expansion

48

• • • • •

NHS funding position in 2010/11 and beyond Increased competition from NHS and independent sector Piecemeal tendering of PTS and other services Inadequate commissioning of workforce change Increased contract penalty culture

5.1.1 Commentary on our SWOT Analysis This analysis, alongside our market assessment, demonstrates that although there are some significant challenges for us to overcome we are in a good position to deliver our Vision. Research conducted by the NHS in Yorkshire and The Humber, along with our own market assessment, have demonstrated that we enjoy high levels of public confidence, far in excess of other NHS organisations in the region. The strength of our brand with the public is built on the commitment of our staff and volunteers. This, along with our unique statutory position and dominant market share in some areas, give us a very strong foundation from which to develop our services. We have demonstrated good progress in dealing with the issues we faced at the start of our organisation in 2006 and have managed successfully a significant programme to achieve financial recovery, whilst delivering major improvements in service quality. Although ambulance response times in Yorkshire are the best they have ever been, they need to improve further. Our service delivery plans clearly address the weaknesses identified in the analysis. We will continue to engage with the lead commissioner to develop the strategic commissioning of our services, including PTS, and this is essential to ensure that we have commissioner support for our long term plans. The overall economic situation and its consequent impact on NHS funding is a significant threat. This is addressed through our cash releasing efficiency plans as well working with commissioners to establish a pricing framework consistent with the NHS Operating Framework. We recognise that many of our services operate in a highly competitive market with significant independent sector competition. Our objective is to ensure that we provide value for money whilst working with commissioners to agree processes that ensure that market testing is undertaken in a way that does not destabilise the 999 service and our emergency preparedness infrastructure. The focus of the organisation over the next five years will be managing the demand increases in A&E services within the financial context of the NHS, and maintaining PTS contracts. The challenge is to ensure that these activities are valued by our commissioners and appropriately commissioned in line with our strategic objectives. We believe our service development plans clearly support our Vision and that our Vision is one that will be supported by our commissioners and other partners.

49

5.2

Summary of our Service Development Plans Our four Service Development Plans are described in the following table. Table 5-b: Summary of our Service Development Plans

Service Line

Access & Response

Supported Plans • • • • • • •

Accident & Emergency Operations

• • • • • • • •

7

Change capacity in line with managed demand Achieve continuous improvement in activation time Achieve continuous improvement in deployment of resources 7 Support the Front End Model Demand Management: Hear & Treat/alternative pathways Ensure all staff practice safe and effective healthcare Develop A&E resources for Cat B

YAS Ambition • • •

Implement a capacity management system for Yorkshire Develop further urgent care call handling and telephone advice Establish a resilient communication centre in York

Provide emergency services that exceed national performance standards Change capacity in line with managed demand by implementing the A&E workforce plan Improve clinical practice and skill mix Implement new ways of working (Front End Model) Continue to develop alternative pathways Integrate patient transport services into the above Ensure all staff practice safe and effective health care Develop A&E resources for Cat B

The Front End Model that we intend to implement is a new way of working to ensure the appropriate delivery of care and treatment closer to home or in the home, thus improving the patient experience of our service and the NHS. 50

Service Line

Patient Transport Services

Supported Plans • • •

• • •

Emergency Preparedness

• • • •

5.3

YAS Ambition

Ensure financial viability Manage demand Develop the service in line with patient case mix by: a) increased use of cars and b) integrating high end work with A&E Create a regional communications centre Automate processes within PTS Ensure all staff practice safe and effective health care



Maintain Hazardous Area Response Team (HART) Ensure the Trust has well rehearsed business continuity plans Ensure that the Trust has the capacity and capability (including specialist teams) to respond to major emergencies Ensure all staff practice safe and effective health care





Manage eligibility criteria on behalf of commissioners Resilience recognised in contract specifications

Implement other new services as required by the centre

Access & Response Service Development Plan 5.3.1 Narrative Summary of Plan The Access & Response service development plan covers the following key areas. Communication Centre staffing profile will be continually reviewed to ensure capacity is aligned with demand. Demand management through activation of appropriate alternative services to mainstream A&E will continue to be developed. Also, strategic work with commissioners and health partners on demand management will continue to be developed. Implementing technological and process improvements, along with ongoing staff training, will ensure that we continue to deliver reductions in the time taken to answer 999 calls, verify the location of the caller and effectively dispatch the nearest resource. This is crucial to the ongoing achievement of key national targets as well as our efficiency plans.

51

Support the implementation of the ‘Front End Model’, which is explained in the A&E Operations Service Development Plan. Automatic dispatch will also be developed and implemented. We will ensure that Access & Response staff practice safe and effective healthcare across the full range of quality indicators, including those which relate to the Care Quality Commission, NHS Litigation Authority, Health and Safety and other statutory legislation and guidance: • • • •

Reduction in serious untoward incidents Providing safer services to patients Improved risk management systems Equity of access maintained for all communities

We will be prepared to respond effectively to the expected procurements of urgent care call handling and telephone advice.

5.3.2 Key Strategic Drivers / Benefits The key benefits of delivering this service development plan are: •

Delivering improved clinical care and patient outcomes



Achieving and exceeding response time targets



Managing forecast increases in demand



Delivering the required efficiency savings



Delivering health economy benefits through reduced transport to hospital

52

5.3.3 Timescale Table 5-c: Access and Response Service Development Timescale Access and Response Service Development – shaded areas indicate active plans 10/11 Manage capacity and demand Activation improvements Deployment improvements Support the front end model Safe end effective practice

11/12

12/13

13/14

5.3.4 Summary of Activity Projections See section 5.5.4

5.3.5 Conclusion This Service Development Plan describes how Access & Response will deliver its contribution to the Trust’s Vision by providing excellent activation and deployment of resources from a resilient base.

53

5.4

A&E Operations Service Development Plan 5.4.1 Narrative Summary of Plan The A&E operations strategy covers a number of key objectives, these are: To continue to provide emergency services for life threatening (Category A) and serious calls (Category B) measured against national performance standards. • • •

Implementation of Status Systems Management tool to deploy vehicles more effectively (right place right time). Improved performance management culture Revised deployment procedures for more effective mobilisation of emergency responders.

Strive to improve clinical practice, delivering high class care and treatment as measured against national Clinical Performance Indicators and other local indicators where agreed. • • •

Continue to develop Clinical Team Educator (CTE) scheme. Develop clinical leadership programmes and mentoring schemes. Improve our capability to deliver evidence based outcomes and revise clinical practice.

Continue to develop and implement new ways of working (Front End Model) to ensure the appropriate delivery of care and treatment closer to home or in the home improving the patient experience of our service and the NHS (See and Treat). •

Continue to develop the Paramedic/ Paramedic Practitioner cadre in order to roll-out the ‘Front End Model’ providing the ability to treat and refer patients to appropriate centres to resolve their clinical needs.

Working with our health partners, develop alternative care pathways to ensure those patients who do not require an emergency response (Category B and Category C) receive an appropriate response to resolve their needs which might include, telephone advice, as in NHS Direct or transport to an NHS walk-in centre (Treat and Refer/Hear and Treat). This will be implemented in line with our Urgent Care Strategy. • •

Increase capacity and capability of the clinical hub. Continue to work with NHS Direct develop links for clinical triage.

Integrate the Patient Transport Service into the above developments to maximise transport, care and cost options. •

Evolve PTS services into a high dependency transport tier available to clinical hub and Access & Response for Category C and urgent patients.

54

Continue to implement the A&E Workforce Plan which provides the skill mix and training to meet future developments as outlined above. • • • •

Staff numbers will be altered in line with demand after accounting for efficiency savings. This is likely to mean that front line staffing numbers will remain broadly static. Improved skills escalator Staff development needs met Flexible and responsive workforce

Ensure that staff in operations practice safe and effective healthcare across the full range of quality indicators, including those which relate to the Care Quality Commission, NHS Litigation Authority, Health and Safety and other statutory legislation and guidance: • • • • •

Improved compliance with infection control procedures Reduction in serious untoward incidents Providing safer services to patients Improved risk management systems Equity of access maintained for all communities

5.4.2 Key Strategic Drivers / Benefits The key benefits of delivering this service development plan are: • • • • •

Delivering improved clinical care and patient outcomes Achieving and exceeding response time targets Managing forecast increases in demand Delivering the required efficiency savings Delivering health economy benefits through reduced transport to hospital

5.4.3 Timescale The timescales for this plan are illustrated below: Table5-d: A&E Operations Service Development Timescale A&E Operations Service Development - shaded areas indicate active plans 10/11 11/12 Exceed national performance standards Flex capacity in line with demand Improve safe and effective clinical practice Implement the front end model Alternate Pathways Integrate PTS delivery – urgent / Cat B / Cat C Develop ECP’s Develop public health role 55

12/13

13/14

5.4.4 Summary of Activity Projections Table 5-e: A&E Five Year Demand Projection - By PCT

NORTH YORKSHIRE AND YORK PCT EAST RIDING OF YORKSHIRE PCT HULL PCT BRADFORD AND AIREDALE PCT CALDERDALE PCT WAKEFIELD DISTRICT PCT KIRKLEES PCT LEEDS PCT BARNSLEY PCT DONCASTER PCT ROTHERHAM PCT SHEFFIELD PCT Grand Total Year on Year Growth %

2010/11 86,457 40,573 45,670 69,526 26,123 45,413 50,232 102,123 30,923 42,044 35,324 75,347 649,756 2.0

2011/12 94,496 42,925 47,001 72,602 26,685 48,198 52,790 105,788 32,079 43,515 36,265 79,712 682,055 4.7

2012/13 98,509 45,384 48,632 75,691 27,350 49,152 54,656 109,360 33,234 45,174 37,408 83,970 708,520 3.7

2013/14 102,632 47,696 50,214 78,801 27,987 49,853 56,268 112,809 34,359 46,586 38,515 88,347 734,067 3.5

2014/15 106,560 50,114 51,700 81,715 28,624 50,857 57,880 116,367 35,483 48,012 39,523 92,640 759,475 3.3

5.4.5 Conclusion This service development plan is designed to deliver the following level of service performance from 2010/11.. will also reduce unnecessary transports to hospital by 10% by 2012/13.

Table 5-f: A&E Level of Service Performance

NORTH YORKSHIRE AND YORK PCT EAST RIDING OF YORKSHIRE PCT HULL PCT BRADFORD AND AIREDALE PCT CALDERDALE PCT WAKEFIELD DISTRICT PCT KIRKLEES PCT LEEDS PCT BARNSLEY PCT DONCASTER PCT ROTHERHAM PCT SHEFFIELD PCT Total

Cat A 8 Mins (%) 75 75 85.2 75 75 75 75 75 75 75 75 75 75.9

56

Cat A 19 Mins (%) 95 95 100 95 95 95 95 95 95 95 95 95 95.4

Cat B 19 Mins (%) 95 95 98.1 95 95 95 95 95 95 95 95 95 95.3

5.5 Patient Transport Service Development Plan 5.5.1 Narrative Summary of Plan Our overall plan is to redesign the service model into one Yorkshire-wide PTS service, align service management across functional rather than geographical boundaries and use automation and technology as a key driver for efficiency and quality improvement. This will support the delivery of a service model that: • • • • • • •

Develops the service in line with patient case mix Creates a workforce of band 2 staff working in cars with high volume of activity Creates a regional support centre (single PTS communication function) Automates processes within PTS Manages eligibility criteria on behalf of commissioners Develops a public health advice service Has the role that PTS plays in delivery of resilience plans valued in contracts

PTS is aligning its service to the core business of the Trust, the provision of emergency and medical transport services. The overall service strategy, therefore, is to align demand with supply and offer a skill mix and vehicle base that matches this demand and the commissioned activity over the next five years. This will impact on the skill mix and vehicle mix of the service over the five year plan. Service alignment is planned for urgent work across the Trust that is clinically appropriate for this tier of staff. The plan will ensure there is a regular cycle of staff recruitment and that the Trust can mitigate against contract losses in PTS by ensuring staff can be profiled into core Trust activity on a planned basis. We will ensure that PTS staff practice safe and effective healthcare across the full range of quality indicators, including those which relate to the Care Quality Commission, NHS Litigation Authority, Health and Safety and other statutory legislation and guidance: • Reduction in serious untoward incidents • Providing safer services to patients • Improved risk management systems ƒ Equity of access maintained for all communities

5.5.2 Key Strategic Drivers / Benefits The key benefits of delivering this service development plan are: • •

High quality, safe, effective and patient focused Patient Transport Service Sustainable business model that is financially viable, providing funds to invest in service development 57

• • •

Business continuity and emergency preparedness Yorkshire Right price, right skill, right time Deliver capacity and recruitment pathway to A&E

support

to

5.5.3 Timescale Table 5-g: PTS Service Development Timescale Patient Transport Services Service Development - shaded areas indicate active plans 10/11 Financial Viability Manage demand Capacity aligned to case mix Create regional communications centre Automate processes Manage eligibility criteria Resilience recognised in contract specifications Safe and effective practice

11/12

12/13

13/14

5.5.4 Summary of Activity Projections Table 5-h: PTS Five Year Activity Forecast

PTS 5 Year Activity Forecast Mobility Saloon Car Tail lift with driver Tail lift with driver and staff member Wheelchair with driver Wheelchair with driver and staff member Stretcher Child 3 man crew required 4 man crew required Sub Total Escort Journeys Aborted journeys Total

2010/11 583,647 285,143 58,174 117,251

2011/12 525,283 256,628 56,720 114,320

20012/13 472,754 230,966 55,302 111,462

2013/14 425,479 207,869 53,919 108,676

2014/15 382,931 187,082 52,571 105,959

18,878 19,730 1,693 60 300 1,084,877 187,475 72,004 1,344,356

19,350 20,224 1,650 72 360 994,607 159,354 64,803 1,218,764

19,834 20,729 1,609 86 432 913,175 135,451 58,323 1,106,948

20,330 21,248 1,569 104 518 839,711 115,133 52,491 1,007,335

20,838 21,779 1,530 124 622 773,436 97,863 47,241 918,541

58

Table 5-i: PTS Five Year Activity Forecast Demand Change PTS 5 Year Forecast Demand Change Mobility 20010/11 Saloon Car -7% Tail lift with driver -7% Tail lift with driver and staff member -7% Wheelchair with driver -5% Wheelchair with driver and staff member -2% Stretcher -2% Child -2% 3 man crew required 20% 4 man crew required 20% -7% Sub Total Escort Journeys -17% Aborted Journeys -7% -8% Total Notes:

2011/12 -10% -10%

20012/13 -10% -10%

2013/14 -10% -10%

2014/15 -10% -10%

-3% -3%

-3% -3%

-3% -3%

-3% -3%

2% 2% -3% 20% 20% -8% -15% -10% -9%

2% 2% -3% 20% 20% -8% -15% -10% -9%

2% 2% -3% 20% 20% -8% -15% -10% -9%

2% 2% -3% 20% 20% -8% -15% -10% -9%

2010/11 Loss of North Lincolnshire/North East Lincolnshire PTS accounted for 2010/11 Application of Eligibility Criteria expected to reduce activity

5.5.5 Conclusion This service delivery plan describes a patient-focused, financially sustainable, Patient Transport Service. We will deliver value for money by providing highly effective services that also support the resilience and service development of Accident & Emergency.

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5.6

Emergency Preparedness Service Development Plan

5.6.1 Narrative Summary of Plan The Emergency Preparedness service development plan covers a number of key objectives: •

The implementation of the Hazardous Area Response Team (HART) was completed in 2009. The team have been operational since September 2009 providing a valuable contribution to the management of hazardous incidents as well as bringing pre-hospital healthcare to patients within these environments. In addition we will implement additional services as required by the national service specification for emergency preparedness, given appropriate funding and resources are secured through the commissioners.



Ensuring that the Trust has well-rehearsed business continuity plans in place and maintains the capacity and capability (including specialist teams) to respond to major emergencies or crises. In particular, we will ensure: • • • • •



ICT critical infrastructure resilience All department have business continuity plans Emergency preparedness training plan implemented HART Team available for operational deployment Flu pandemic plans in place and tested

Ensuring that Emergency Preparedness staff operate effective healthcare across the full range of quality indicators, including those which relate to the Care Quality Commission, NHS Litigation Authority, Health and Safety and other statutory legislation and guidance: • • • • •

Improved compliance with infection control procedures Reduction in serious untoward incidents Providing safer services to patients Improved risk management systems Equity of access maintained for all communities

• In addition the Ambulance Chief Executives Group through the Emergency Preparedness Board developed in 2009 a five strategy approach for the delivery of emergency preparedness matters nationally covering six key areas: • • • • • •

Commissioning and Funding Education and Development Resources and Equipment Special Operations Business Continuity Management Policies and Procedures

It is the intention of YAS to use these strategic principles in future business plans.

60

5.6.2 Key Strategic Drivers / Benefits The key benefits of delivering this service development plan are: • • •

Improved ability to respond to major / catastrophic incidents in Yorkshire and the UK Compliance with the Civil Contingencies Act (2004) Compliance with the NHS Emergency Preparedness Guidance (2005)

5.6.3 Timescales The timescales for this plan are illustrated below: Table 5-j: Emergency Preparedness Service Development Timescale Emergency Preparedness Service Development 10/11

11/12

12/13

13/14

Compliance with national requirements Capacity and Plans Safe and effective practice

5.6.4 Summary of Activity Projections Not applicable.

5.6.5 Conclusion This service development plan will ensure that the people of Yorkshire and the UK receive significant additional support in the event of a major emergency or crisis.

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6

Financial Plans 6.1

Historical Performance Analysis

6.1.1 Income & Expenditure Overview In our first year of operation, 2006/07, we faced major financial challenges as a result of a NHS Employers National “Unblocking” panel decision on the banding of technicians in the West Yorkshire area. This caused a £5.4m in-year pressure and was combined with a number of other pressures that pre-existed or resulted as a consequence of the reconfiguration of the previous ambulance services. YAS incurred a deficit of £4.5m in its first year of operation. Due to technical issues relating to the phasing of the in-year merger that created the Trust, this deficit did not have to be recovered in future years; however, it did mean that we were rated as ‘Weak’ on Use of Resources in our first year of operation. Through rigorous financial control and the implementation of our voluntary financial turnaround process our original underlying deficit on three of four major service lines was eliminated at the start of 2008/09 financial year. There remain issues with the PTS service. A small operating surplus was delivered in 2008/09 and 2009/10. The deficit reported in 2009/10 is technical in nature, resulting from the revaluation of the estate based on new DoH guidance. This deficit is a non recurrent, non cash movement that has no impact on our financial standing or statutory duty to balance income and expenditure taking one year with the next.

Table 6-a: Summary Income and Expenditure statement 2006/07 Actual £'000 Income Patient Care Income Other Income Total operating income Expenses Pay costs Transport costs Other non pay costs Total operating expenses EBITDA Profit/(loss) on disposal of fixed assets Impairment Depreciation PDC Dividends payable Net interest Other finance costs Net surplus/(deficit) for the period

62

2007/08 Actual £'000

2008/09 Actual £'000

2009/10 Forecast £'000

139,227 5,412 144,639

150,486 4,524 155,010

183,081 3,629 186,710

191,973 6,527 198,500

(109,694) (14,418) (16,493) (140,605) 4,034 384

(110,794) (15,408) (18,482) (144,684) 10,326 (212)

(132,871) (18,222) (25,315) (176,408) 10,302 3

(6,755) (2,375) 346 (101) (4,467)

(8,004) (2,309) 545 (95) 251

(7,904) (2,648) 507 (109) 151

(143,227) (17,293) (26,702) (187,223) 11,277 229 (6,957) (8,670) (2,307) 96 (121) (6,453)

£15.5m of the increase in income in 2008/09 is non-recurrent additional capacity funding associated with improving performance against key national targets. £13.5m of this funded additional direct staffing, whilst £2m funded the costs of providers.

6.1.2 Recurrent Position We have continually monitored our recurrent position through the medium term financial planning process that has been in place since 2006. The following table describes the change in the underlying position. Table 6-b: Normalised Underlying Position

Normalised @ start of year CRES to reduce deficit New recurrent issues Normalised @ end of year Non Recurrent Income Pay Non Pay Outturn

2006/07 £'000 (4,526) 2,151 (4,706) (7,081)

2007/08 £'000 (7,081) 5,004 (303) (2,380)

2008/09 £'000 (2,380) (1,017) (3,397)

2009/10 £'000 (3,397) 1517 (3,451) (5,331)

£'000 1,000 1,614 0 (4,467)

£'000 1,441 1,002 188 251

£'000 1,100 2,297 151 151

£'000 13661 -4157 (10,626) (6,453)

We started with a significant recurrent issue which was exacerbated by the agenda for change banding issues. Significant progress was made in 2007/08 to reduce our underlying deficit. The residual deficit in 2008/09 relates to the Patient Transport Service. Some new issues arose in 2008/09 as result of non-pay inflation being significantly higher than funding. The increase in underlying deficit in 2009/10 relates to the Trust Board agreeing to recruit at risk additional A&E front line staff to ensure there was sufficient operational capacity in place at the start of the 2010/11 financial year to deliver key national targets. These costs are covered by recurrent income in the 2010/11 A&E contract

6.1.3 Historical Cost Improvements Over the last four years we have made £17.8m real cash releasing savings. £7.2m of these savings, generated through the first two years when we were in voluntary financial turnaround, were largely used to offset the underlying recurrent deficit (see table 6b above). In 2008/09 and 2009/10, savings have been used to pay for unavoidable cost pressures and developments.

63

Table 6-c: Cost Improvements Delivered 2006/07 Actual £'000 0 0 1870 523 730 0 3123

Area Income Access & Response A&E Operations PTS Management & Support Departments Non Pay Total

2007/08 Actual £'000 540 799 458 0 2923 645 5365

2008/09 Actual £'000 156 350 958 189 612 110 2375

2009/10 Forecast £'000 0 0 4738 706 1500 0 6944

6.1.4 Balance Sheet The main movement on the balance sheet over the years have been working capital balances – these reflect better management of debtors and creditors and Non Current Assets, which reflect the impact of revised revaluation methodology as well as the impact of the global economic downturn on landing building values. Table 6-d: Historic Balance Sheets

Total Non Current Assets Current Assets Stock & work in progress Debtors Cash at bank and in hand Total Current Assets Total Current Liabilities Net Current Assets (Liabilities) Total Assets less Current Liabilities Creditors: amounts falling due after more than one year Provisions for liabilities and charges Total Assets Employed Taxpayers' Equity Public dividend capital Retained Earnings Revaluation reserve Donated asset reserve Other reserves (Government grant reserve etc.) Total taxpayers' equity

2006/07 Actual £'000 76,087

2007/08 Actual £'000 81,240

2008/09 Actual £'000 75,922

2009/10 Forecast £'000 72,262

927 19,073 469 20,469 (11,391) 9,078 85,165

902 10,437 3,650 14,989 (8,020) 6,969 88,209

1,062 11,769 5,002 17,833 (14,888) 2,945 78,867

1,542 10,003 3,357 14,902 (12,246) 2,656 74,918

0 (6,276) 78,889

0 (4,665) 83,544

0 (5,151) 73,716

(5,375) 69,543

73,190 3,099 2,282 318 0 78,889

73,319 3,350 6,596 279 0 83,544

74,001 (2,817) 2,342 190 0 73,716

74,094 (8,462) 3,830 81 69,543

Please note that the 2006/07 balance sheet has yet to be restated to International Accounting Standards. Also the reduction in retained earnings between 2007/08 and 2008/09 was due to revaluation of the estate based on revised DoH guidance. This 64

change was dealt with as a change to opening balances so did not pass through the Income and Expenditure Account.

6.1.5 Cash Flow The table below summarises our cash flow for the last three years. In order to manage our cash position in 2006/07 we took out a loan for £2.9m. This was repaid in 2007/08. Table 6-e: Historic Cash Flows 2006/07 Actual £'000 4,034 (107) (2,636) 1,291 (9,492) 1,356 (6,845) 0 346 5,993 2,908 (2,375) 27 442 27 469

EBITDA Excluding non cash I&E items Movement in working capital Cash flow from operations Capital expenditure Cash receipt from asset sales Cash flow before financing Movement in long term creditors Interest received on cash balance Public dividend capital received Loan movement Dividends paid Net cash (outflow)/inflow Opening cash balance Net cash (outflow)/inflow Closing cash balance

2007/08 Actual £'000 10,368 765 1,696 12,829 (8,180) 3,054 7,703 0 566 129 (2,908) (2,309) 3,181 469 3,181 3,650

2008/09 Actual £'000 10,338 (118) 4,428 14,648 (14,031) 2,194 2,811 0 507 682 0 (2,648) 1,352 3,650 1,352 5,002

2009/10 Forecast £'000 10,532 (108) (1,312) 9,112 (9,194) 608 526 0 96 93 0 (2,360) (1,645) 5,002 (1,645) 3,357

6.1.6 Capital Expenditure Capital expenditure over the last four years in line with our fleet, estates and information technology strategies: Table 6-f: Capital Expenditure

Asset Land Buildings Plant and Machinery Transport Equipment Information Technology Total

2006/07 Actual £'000

2007/08 Actual £'000

109 1,608 62 6,331 948 9,058

0 2,108 330 5,312 731 8,481

65

2008/09 Actual £'000 1,290 3,983 234 7,020 1,876 14,403

2009/10 Forecast £'000 0 4,857 180 3,271 1,863 10,171

6.1.7 Historic Financial Summary We dealt with the very significant financial challenges that we faced in our first two years through a robust voluntary financial turnaround process, delivering income and expenditure balance in the last two years whilst generating significant cash surpluses. Although we have a residual underlying deficit, the next section of the plan identifies how this will be managed.

6.2

Five Year Financial Plan 6.2.1 High Level Income and Expenditure Summary Forecast income and expenditure for the next five years is set out below. Surpluses are expected to be generated form 2011/12 onwards. Table 6-g: High Level Income and Expenditure Summary 2010/11 £'000

2011/12 £'000

2012/13 £'000

2013/14 £'000

2014/15 £'000

Income

195,716

195,339

196,645

198,043

199,532

Pay Non Pay Total Operating Expenditure

148,668 36,326 184,994

147,665 35,636 183,302

148,007 35,071 183,078

149,934 34,525 184,459

152,400 33,949 186,349

EBITDA

10,722

12,037

13,567

13,584

13,183

Depreciation PDC Dividend Interest Receivable TOTAL

8,515 2,328 (121) 10,722

8,618 2,284 (115) 10,787

8,891 2,284 (109) 11,067

8,903 2,284 (103) 11,085

8,497 2,284 (98) 10,684

0

(1,250)

(2,500)

(2,500)

(2,500)

5.48%

6.16%

6.90%

6.86%

6.61%

(Surplus)/Deficit EBITDA percentage

6.2.2 Income Forecast Analysis Critical to understanding the risks inherent in the plan is the need to understand the income forecast. At the time of writing, we are still negotiating the 2010/11 outcome for all contracts. For purposes of the plan a reasonable worst case outcome for these negotiations has been assumed. This results in relatively “flat” income projections going forward.

66

Table 6-h: Income Growth Analysis Income Forecast

195,716

195,339

196,645

198,043

199,532

Additional Income Source Generic Inflation Based on current agreements Assumed negotiations Non recurrent - negotiation

2010/11 £'000 72 1,089 8,557 0

2011/12 £'000 (3,900) (992) 4,515 0

2012/13 £'000 (4,032) 0 5,338 0

2013/14 £'000 (4,173) 0 5,572 0

2014/15 £'000 (4,324) 0 5,813 0

9,719

(377)

1,306

1,399

1,489

Key points to understand the income position; a) Inflation funding in 2010/11 is effectively zero and after that time is expected to be negative (2% reductions per year). This is expected as a result of DoH guidance on the likely generic uplifts in the acute sector “tariffs”. This reflects the impact of the global economic downturn on public finances. b) There is some residual non recurrent funding in the 2010/11 position which will reverse out in 2011/12 c) Other increases are due to assumed activity increases in A&E (plus Commissioning for Quality and Improvement Schemes CQUINS in 2010/11) Table 6-i: Detailed Income Growth Breakdown

Base Income Income 1 Demand increase 2 Cquins 3 2009/10 Demand income 4 2010/11 PTS Demand income 5 South Yorks PCT Commissioning 6 WDC Trainer Relief 7 Loss of Kirklees & Calderdale Para Scheme 8 Other Total Income Change 9 Inflation funding Recurrent Funding Total Non recurrent income Total Total Change in Year Income Forecast

2010/11 £'000 185,997 £'000 2,220 2,311 4,439 0 (850) 831 (394) 1,089 9,646 72 9,719 2009/10 £'000 0 0 9,719 195,716 67

2011/12 £'000 195,716 £'000 4,110 0 0 (587) 0 0 0 0 3,523 (3,900) (377) 2010/11 £'000 0 0 (377) 195,339

2012/13 £'000 195,339 £'000 5,914 0 0 (576) 0 0 0 0 5,338 (4,032) 1,306 2011/12 £'000 0 0 1,306 196,645

2013/14 £'000 196,645 £'000 6,136 0 0 (564) 0 0 0 0 5,572 (4,173) 1,399 2012/13 £'000 0 0 1,399 198,043

2014/15 £'000 198,043 £'000 6,366 0 0 (553) 0 0 0 0 5,813 (4,324) 1,489 2013/14 £'000 0 0 1,489 199,532

6.2.3 Cost Improvement Programme The following cost improvement programme is set out to move us into recurrent balance and to ensure that we will be able to live within the zero inflation uplift environment that is anticipated from now onwards Table 6-j: Planned Cost Improvement Schemes CRES 2010/11 £'000

2011/12 £'000

2012/13 £'000

2013/14 £'000

2014/15 £'000

Chief Executive Medical Directorate Stds & Compliance HRD Finance A&E Operations PTS Operations IM&T Total

96 57 141 458 4,146 6,395 2,983 1,284 15,560

75 44 111 256 2,228 5,365 1,145 1,012 10,236

69 40 102 239 1,922 5,070 1,036 970 9,447

66 39 98 231 2,199 5,050 972 960 9,616

59 36 89 211 2,555 4,738 857 892 9,437

% of Expenditure

8.10%

5.35%

5.10%

5.27%

5.22%

The major elements of the cost improvement plans fall out of the service development plans of our high level service lines. Table 6-k: Service Development Plans That Drive Cost Improvements

Service Line

Access & Response

Supported Plans • • • •

Accident & Emergency Operations



• •

Change capacity in line with managed demand Achieve continuous improvement in activation time Achieve continuous improvement in deployment of resources Support the Front End Model

Change capacity in line with managed demand by implementing the A&E workforce plan Improve clinical practice and skill mix Implement new ways of working (Front End Model) 68

YAS Ambition

Patient Services

Transport



Continue to develop alternative pathways

• • •

Ensure financial viability Manage demand Develop the service in line with patient case mix by a) increased use of cars and b) integrating high end work with A&E Create a regional communications centre Automate processes within PTS

• •



Manage eligibility criteria on behalf of commissioners

6.2.4 Forecast Balance Sheet Table 6-l: Forecast Balance Sheet Forecast Balance Sheet

Total Non Current Assets CURRENT ASSETS Stocks & Work in Progress Debtors Cash at bank & in hand Total Current Assets Total Current Liabilities Net Current Assets/(Liabilities) Total Assets Less Current Liabilities Creditors - amounts due after more than one year Provisions for Liabilities and Charges Total Assets Employed

Taxpayers' Equity Public Dividend Capital Revaluation Reserve Donated Asset Reserve Income & Expenditure Reserve Other reserves (Government grant reserve etc.) Total Taxpayers' Equity

Year End Year End Year End Year End Year End 10/11 11/12 12/13 13/14 14/15 £'000 £'000 £'000 £'000 £'000 71,174 71,174 71,174 71,174 71,174 1,554 7,361 3,101 12,016 (10,043) 1,973 73,147 0 (5,168) 67,979

1,554 6,184 4,752 12,490 (9,324) 3,166 74,340 0 (5,125) 69,215

1,554 6,184 7,252 14,990 (9,324) 5,666 76,840 0 (5,125) 71,715

1,554 6,184 9,752 17,490 (9,324) 8,166 79,340 0 (5,125) 74,215

1,554 6,184 12,252 19,990 (9,324) 10,666 81,840 0 (5,125) 76,715

74,094 3,830 47 (9,992) 0 67,979

74,094 3,830 33 (8,742) 0 69,215

74,094 3,830 33 (6,242) 0 71,715

74,094 3,830 33 (3,742) 0 74,215

74,094 3,830 33 (1,242) 0 76,715

The value of the estate is assumed to remain constant through the period. Increasing cash balances are a result of the planned income and expenditure surpluses

69

6.2.5 Forecast Cash Flows Table 6-m: Forecast Cash Flows Forecast Cash Flow EBITDA Excluding non cash I&E items Movement in working capital Cash flow from operations Capital expenditure Cash receipt from asset sales Cash flow before financing Movement in long term creditors Interest received on cash balance Public dividend capital received Loan movement Dividends paid Net cash (outflow)/inflow Opening cash balance Net cash (outflow)/inflow Closing cash balance

2010/11 £'000 10,722

2011/12 £'000 12,005

2012/13 £'000 13,471

2013/14 £'000 13,433

2014/15 £'000 12,977

10 10,732 (8,515) 0 2,217 0 121 0 0 (2,328) 10 3,091 10 3,101

401 12,406 (8,618) 0 3,788 0 125 0 0 (2,262) 1,651 3,101 1,651 4,752

0 13,471 (8,891) 0 4,580 0 175 0 0 (2,255) 2,500 4,752 2,500 7,252

0 13,433 (8,903) 0 4,530 0 225 0 0 (2,255) 2,500 7,252 2,500 9,752

0 12,977 (8,497) 0 4,480 0 275 0 0 (2,255) 2,500 9,752 2,500 12,252

6.2.5 Forecast Capital Expenditure Table 6-n: Forecast Capital Expenditure

Asset type Land/Buildings Plant Transport IT Medical Equipment Total Cash source Opening Capital Cash Depreciation NBV Disposals Total Internal Capital Cash Balance

2010/11 £'000 831 61 5201 1491 931 8515

2011/12 £'000 855 192 5355 1371 845 8618

2012/13 £'000 868 214 5496 1342 971 8891

2013/14 £'000 896 235 5031 1432 1309 8903

2014/15 £'000 926 262 4917 1397 995 8497

8515

8618

8891

8903

8497

8515

8618

8891

8903

8497

0

0

0

0

0

Forecast capital expenditure is in line with the fleet, estates and information technology strategies. Expenditure is financed from depreciation. No land or building sales are assumed..

70

6.2.6 Risk Rating The base financial plan delivers a Monitor risk rating of four for each year, on the assumption of a 30-day working capital facility being in place. Table 6-o: Monitor Risk Rating Indicator 2010/11 2011/12 2012/13 2013/14 2014/15 Achievement of plan 4 4 4 4 4 Underlying performance 3 3 3 3 3 Return on capital employed 5 5 5 5 5 I&E surplus margin 3 3 4 4 4 Liquidity (assuming 30 days WCF) 4 4 5 5 5 Overall risk rating 4 4 4 4 4 Liquidity improves from 12/13 onwards due to increase in surplus from £1.25m to £2.5m For underlying performance to move to 4 would need 8% EBITDA

6.3

Conclusion

The base financial plan clearly supports the delivery of our Strategic Objectives. The scale of the financial challenge facing us over the next five years is significant.

71

7

Risks 7.1

Key Business Risks

Our risk management structure is described in Chapter 9. We have reviewed our assurance framework and risk register and identified potential risks through the PESTLE and SWOT exercise. We have also taken into account statutory and regulatory requirements. The table below describes the key issues that could jeopardise the delivery of our plans.

Table 7-a: Key Business Risks Strategic

Score

S3 Competition - large scale loss of PTS business S4 Competition - large scale loss of urgent care business S5 HART not commissioned by PCTs Operational

9 5 3 Score

O1 Excessive Demand / Severe weather O2 Failure to deliver the A&E service improvement plan O3 Failure to deliver the PTS service improvement plan Financial

10 15 12 Score

F1 Market conditions prevent sale of surplus assets F2 Carbon improvement plan not delivered F3 Cash releasing efficiency plan not achieved F4 Inflation / other cost pressures greater than plan Information Technology

4 4 10 5 Score

I2 Major IT failure

5

Human Resources

Score

H1 Management capacity and capability improvement plan not delivered H3 Abstraction rate not managed

Our top three risks are: •

Failure to deliver the A&E service improvement plan



Management capacity and capability improvement plan not delivered



PTS service improvement plan not delivered

The following explains the risk score for each of our key business risks.

72

15 10

Table 7-b: Key Business Risks Analysis S3 Competition – large scale loss of PTS business Likelihood • Low commissioner satisfaction • Strong competition / low barriers to entry • Changes in PTS commissioning guidance • Yorkshire-wide tender likely from 2010/11 Controls • PTS service improvement plan • Negotiate capacity review criteria in standard contract Residual likelihood

Score

5

-2

3 Impact • Reduced major incident resilience • Non recurrent exit costs • Fixed cost issues Residual risk score

3

9

S4 Competition – large scale loss of urgent care business Likelihood • Low commissioner satisfaction • Strong competition • PCT urgent care strategies Controls • A&E service improvement plan • Urgent care strategy • Improved engagement with PCTs Residual likelihood

Score 4

-3

1 Impact • Reduced major incident resilience • Loss of economy of scale • Non recurrent exit costs • Fixed cost issues Residual risk score

5

5

S5 HART not commissioned by PCTs

Score

Likelihood • DoH funding ends by 2011/12 • DoH may not fund inflation • Challenging NHS financial position expected at that time Controls • HART included in mandatory service specification in standard contract Residual likelihood

3

-2 1

Impact • HART not available Residual risk score

3 3

O1 Excessive demand / severe weather

Score

Likelihood • Pandemic Flu • Large scale / protracted major incident

4

73

• Instability of other providers (e.g. West Yorks urgent care) • Demand Impact of extreme weather • Road conditions impact of extreme weather Controls • Pandemic Flu Plan • REAP Levels / business continuity plan • Major Incident Plan • Standard contract “excusing” clauses • Cost and volume contract Residual likelihood

-2

2 Impact • Prolonged period of poor performance against national targets Residual risk score O2 Failure to deliver A&E performance improvement plan Likelihood • Performance gains from process improvement yet to be achieved • Front end model yet to be tested in local circumstances Controls • A&E Operations Board • Performance Turnaround process Residual likelihood

5 10 Score 5

-2

3 Impact • Failure to achieve key national targets • Regulatory action by the Care Quality Commission Residual risk score O3 Failure to deliver PTS service improvement plan Likelihood • Scale of change very significant • Resistance from some stakeholders • Vehicle efficiency targets very challenging Controls • Change being managed as a corporate programme • Performance Turnaround process • Agree block contracts with activity reduction targets Residual likelihood

5 15 Score 5

-2

3 Impact • Continued service line deficit, reducing funds available for A&E • Reduced resilience • Loss of business Residual risk score F1 Market conditions prevent sale of surplus assets Likelihood • Economic downturn has already impacted on some sales • Poor market conditions likely to persist for some years Controls • Minimise number of sales necessary to finance estates plan Residual likelihood

4

12 Score 5

-1 4

Impact • Changed balance between new build and refurbishment of buildings Residual risk score F2 Carbon improvement plan not delivered

1 4 Score

74

Likelihood • Delivering changes in driver behaviour / vehicle based technologies • Necessary estates changes Controls • Carbon reduction plan Residual likelihood

3

-1 2

Impact • Failure to deliver Carbon element of CRES • Reputation impact Residual risk score

2

F3 Cash releasing efficiency targets not achieved

4 Score

Likelihood • 20% cash releasing savings required over the life of the plan 5 Controls • Well established process for delivering CRES operationally • 100% of savings identified to schemes • Business Delivery Committee, ET Focus Residual likelihood

-3

2 Impact • Requirement to trigger mitigation plan to maintain financial viability Residual risk score F4 Inflation / other cost pressures greater than plan Likelihood • Inflation has been volatile over last two years • Impact of recession Controls • Monitor forecast inflation as part of finance process

5 10 Score 3

-1

Residual likelihood 2 Impact • Trigger mitigation plan to deal with shortfall Residual risk score

3 6

I2 Major IT failure

Score

Likelihood • ALERT CAD system needs replacing • Some examples of major issues in last year (for short periods only) Controls • IT strategy • Disaster recovery planning Residual likelihood

3

-2

1 Impact • Potential significant service degrade / financial penalties Residual risk score H1 Management capability and capacity improvement plan not delivered Likelihood • Leadership review findings • Staff Survey Results • Operational management capacity issue identified by Peter Bradley Controls 75

5 5 Score

5

• Leading edge management development programme • Investment in operational management capacity in 2009/10 Residual likelihood

-2 3

Impact • Sub-optimal performance against objectives / targets Residual risk score H2 Workforce plan not delivered

5 15 Score

Likelihood • Current workforce gap in A&E • Significant skill mix change required over life of plan Controls • A&E Workforce Plan / A&E Workforce Group • Additional investment secured • PTS service improvement plan Residual likelihood

4

-2

2 Impact • Service targets not achieved • Health economy efficiencies not achieved Residual risk score

5 10

H3 Abstraction Rate not Managed

Score

Likelihood • Current abstraction rate 25% greater than plan Controls • A&E Operations Board • Sickness management improvements Residual likelihood

5 -3

2 Impact • Service targets not achieved • Regulatory action by Care Quality Commission Residual risk score

5 10

76

7.2

Financial Impact and Mitigation Table 7-c: Income and Expenditure Impact Downside Risk

S3 S3 S4 S5 O1 O2 O3 F1 F2 F3 F4 I2 H1 H3

Year 1 £'000 1,250 4,000 4,000 0 600 6,395 2,983 0 350 5,832 267 100 0 3,147 28,924

Year 2 £'000 3,000 8,000 4,000 2,637 600 5,365 1,145 0 0 3,726 200 100 0 3,147 31,920

Year 3 £'000 5,000 0 4,000 150 600 5,070 1,036 0 0 3,341 200 100 0 3,147 22,644

Year 4 £'000 5,000 0 4,000 150 600 5,050 972 0 0 3,593 200 100 0 3,147 22,813

Year 5 £'000 5,000 0 4,000 150 600 4,738 857 0 0 3,842 200 100 0 3,147 22,634

Available mitigation: No performance impact - £ Service impact - £ Total imapct - £

3,500 5,595 9,095

3,500 1,484 4,984

3,500 1,484 4,984

3,500 1,484 4,984

3,500 1,484 4,984

No performance impact - % Service impact - % Total impact - %

12.10 19.34 31.44

10.96 4.65 15.61

15.46 6.55 22.01

15.34 6.51 21.85

15.46 6.56 22.02

Competition - loss of PTS business - recurrent Competition - loss of PTS business - redundancy provision Competition - loss of Urgent Care Business - recurrent HART not commissioned by PCTs Impact of severe weather Failure to deliver the A&E service improvement plan Failure to deliver the PTS service improvement plan Market conditions prevent sale of surplus assets Carbon improvement plan not delivered Other cash releasing efficiency plans not delivered Inflation/other cost pressures greater than plan Major IT failure Management capacity and capability Abstraction rate not managed Total

The financial impact of the various business risks are identified above. The mitigation for these risks is in three parts •

As part of the plan a £2.5m risk reserve has been established. Use of this reserve to mitigate financial risk will have no detrimental impact on service performance.



The Trust’s operational budgets contain £1m of spend on discretionary expenditure ( items that can be deferred in the short term without immediate impact on service performance / compliance)



This expenditure is required to maintain service performance however it could be suspended if necessary to avoid a deficit. The overtime budget reduces after the first year of the plan.

On this basis the Trust could mitigate £9m of financial risk in the first year of the plan. This drops to £5m in the years there after

7.3

Conclusion A clear mitigation plan is in place to deal with a defined level of financial risk. If this risk level is exceeded in year a recovery plan would need to be put in place based on bringing forward the Trust’s CRES programme. 77

8

Leadership and Workforce 8.1

Introduction

To deliver our Vision, recruiting and retaining staff is critical. Also, with pay accounting for 73% of our total expenditure, it is imperative that we lead and manage our people effectively in order to maintain financial sustainability and continue to improve our financial performance. Working at the front-line of the NHS, often being the very first contact with patients, we have a good reputation amongst the general public and our range of services offers a variety of challenging career opportunities for people with different skills and talents. The aim of our Human Resources Strategy is to support the Trust in delivering its Vision by recognising that the excellence, professionalism, wellbeing and personal development of our staff and volunteers, are key to the success of everything that we do. It aims to achieve a high quality workforce that responds to the challenges of rising demand, increased patient expectations and changes in national and local strategy and policy. The strategy is focused on quality and is patient-centred, clinically driven, flexible and locally led.

8.2

Management Arrangements

The Trust Board is our key decision-making committee, approving strategies and policies to ensure that we achieve clinical, operational and financial targets.

8.2.1 Trust Board and the Executive Team • • • • • • • • • •

Dr Nick Varey Martyn Pritchard Roger Holmes Nancy Murgatroyd Richard Roxburgh Nina Wrightson Paul Osborne Simon Worthington Dr Alison Walker Keith Prior



Wendy Foers

Chairman Chief Executive Non-Executive Director Non-Executive Director Non-Executive Director Non-Executive Director Non-Executive Director Deputy Chief Executive & Director of Finance Medical Director Operations Director - Accident & Emergency (Acting) Director of Organisational Development & HR (Acting)

The following Directors attend Trust Board meetings but are not voting members of the Board: • •

Sarah Fatchett Keeley Townend

ƒ ƒ

David Forster Steve Page

Operations Director - Patient Transport Services Director of Information, Communication & Technology Director of Policy and Strategy Standards and Compliance Director 78

8.2.2 Management Structure The following diagram shows our Executive Team and divisional structure. Figure 8-a: Management Structure

Chief Executive

Operations Director

Operations Director

Accident & Emergency

Patient Transport Services

Medical Director

Clinical Business Unit

Clinical Business Unit

Clinical Business Unit

Clinical Business Unit

Clinical Business Unit

North Yorkshire

Hull & East Yorkshire

Bradford Calderdale & Kirklees

Leeds & Wakefield

South Yorkshire

Deputy Chief Executive & Director of Finance

79

Director of ICT

Director of OD & Human Resources

Standards and Compliance Director

Director of Policy Strategy

From an operational perspective, A&E Operations is divided into five Clinical Business Units (CBUs) which operate from 61 ambulance stations across Yorkshire and are served by two communications centres in York and Wakefield: Table 8-b: A&E Operational Areas and Ambulance Stations

Clinical Business Unit

Number of Ambulance Stations

Ambulance Stations

North Yorkshire

20

Bainbridge, Ingleton, Settle, Grassington, Skipton, Richmond, Pateley Bridge, Northallerton, Ripon, Thirsk, Harrogate, Wetherby, York, Haxby, Selby, Kirkbymoorside, Malton, Whitby, Scarborough, Filey

Hull & East Riding

13

Bridlington, Driffield, Pocklington, Hornsea, Beverley, Goole, Brough, Willerby, Sutton Fields, Hull East, Hull West, Preston, Withersea

Bradford, Calderdale & Kirklees

9

Keighley, Bradford, Todmorden, Halifax, Brighouse, Huddersfield, Honley, Dewsbury, Menston

Leeds & Wakefield

9

Bramley, Leeds, Leeds General Infirmary, Seacroft, Gildersome, Castleford, Wakefield, South Kirkby, Sherburn in Elmet

South Yorkshire

11

Penistone, Barnsley, Doncaster, Bentley, Hoyland, Wath, Middlewood, Rotherham, Longley, Maltby, Batemoor

8.3

Workforce Key Performance Indicators We are currently developing Human Resources Key Performance Indicators (KPIs) for three workforce themes: • • •

Workforce Information Education & Training Leadership

Our intent is to develop integrated HR KPIs to benchmark overall performance within the service in conjunction with other performance data, in particular that for finance and activity.

80

8.4

Workforce Profile As at 31 January 2010, we employed 4483 staff in 3890.12 Whole Time Equivalent posts. We regularly monitor our workforce to ensure that turnover and sickness absence levels do not exceed an appropriate level. In addition, we review the makeup of all our staff considering their age, gender and ethnic profile. Of the staff in post as at 31 January 2010, 41% were female and 59% male. The Trust employs 65 staff with disabilities, as recognized under the Disability Discrimination Act, which represents 1.45% of the total workforce and we have 164 staff from groups identified as other than White British, which represents 3.6% of the total workforce.

Table 8-c: Workforce Summary as at 31 January 2010

SIP, WTE and BME by Directorates Corporate

Est

Chief Executive Division

WTE

9.6

8.60

Vac

1.00

No Of Emp

No Of ESR Assg

9.00

9.00

Male %

56%

Female %

Full Time % Part Time %

44%

89%

11%

A White British

9

Other

BME

0

0.00%

Disabled

0

Non Executives Division

6

6.00

0.00

6.00

6.00

67%

33%

100%

0%

6

0

0.00%

0

Clinical Division

20.8

19.58

1.22

23.00

23.00

30%

70%

70%

30%

23

0

0.00%

0

Urgent Care Division

5

2.00

3.00

2.00

2.00

100%

0%

100%

0%

2

0

0.00%

Neonatal Division

11

10.00

1.00

10.00

10.00

80%

20%

100%

0%

10

0

0.00%

0

Total Corporate

52.40

46.18

6.22

50.00

50.00

52%

48%

84%

16%

50.00

0.00

0.00%

1.00

Bradford & Calderdale CBU

427.52

446.68

-19.16

483.00

483.00

58%

42%

86%

14%

450.00

33.00

6.83%

3.00

Leeds & Wakefield CBU

448.40

459.52

-11.12

484.00

484.00

61%

39%

89%

11%

473.00

11.00

2.27%

4.00

North Yorkshire CBU

389.40

381.88

7.52

395.00

404.00

67%

33%

92%

8%

392.00

3.00

0.76%

EY & Hull CBU

326.16

330.92

-4.76

352.00

354.00

69%

31%

90%

10%

346.00

6.00

1.70%

7.00

South CBU

509.97

526.20

-16.23

558.00

611.00

66%

34%

88%

12%

543.00

15.00

2.69%

7.00

Network Response Division

16

18.55

-2.55

19.00

19.00

53%

47%

89%

11%

ECP Division

24

19.19

4.81

21.00

21.00

67%

33%

81%

19%

20

1

4.76%

0

Air Ambulance Division

20

16.90

3.10

17.00

17.00

82%

18%

94%

6%

17

0

0.00%

0

1

Operations

19

0

0.00%

8.00

1

Clinical Trainees Division

0

0.00

0.00

0.00

0.00

0

0

Emergency Planning Division

16

11.53

4.47

12.00

12.00

75%

25%

92%

8%

12

0

0.00%

1

HART Division

44

43.00

1.00

43.00

43.00

79%

21%

100%

0%

39

4

9.30%

0

#DIV/0!

#DIV/0!

#DIV/0!

#DIV/0!

#DIV/0!

0

Operations Division

0

0.00

0.00

0.00

0.00

0

0

Total Operations Business Development & PTS PTS Central

2221.45

2254.37

-32.92

2384.00

2448.00

64%

36%

89%

11%

2311.00

73.00

399.45

395.03

4.42

506.00

515.00

55%

45%

58%

42%

477.00

29.00

5.73%

6.00

PTS North

146.48

146.64

-0.16

240.00

243.00

71%

29%

54%

46%

238.00

2.00

0.83%

5.00

292.00

299.00

72%

28%

51%

49%

286.00

6.00

2.05%

2.00

#DIV/0!

#DIV/0!

#DIV/0!

#DIV/0!

#DIV/0! 3.06%

0 31.00

PTS South

190.04

181.58

8.46

PTS Mgmt - Control Division

12.8

16.60

-3.80

17.00

17.00

29%

71%

88%

12%

16

1

5.88%

0

PTS Mgmt - Operations Division

41.8

41.41

0.39

43.00

45.00

47%

53%

81%

19%

41

2

4.65%

0

1

16.67%

PTS Commisioning Team Division

6.00

-3.00

17%

100%

PTS Project Development

0

7.00

-7.00

7.00

7.00

43%

57%

100%

0%

7

0

0.00%

0

Private and Events Division

16.66

3

14.00

2.66

23.00

6.00

23.00

6.00

78%

83%

22%

61%

39%

0%

23

5

0

0.00%

1

Business Development Division

0

1.00

-1.00

1.00

1.00

100%

0%

100%

0%

0

Total PTS

810.23

809.26

0.97

1135.00

1156.00

63%

37%

57%

43%

1093.00

1 100.00% 42.00

3.70%

0

0 14.00

Finance Finance Division

35.98

34.24

1.74

39.00

39.00

36%

64%

79%

21%

30

9

23.08%

0

Ambulance HQ Division

14.51

9.85

4.66

11.00

11.00

18%

82%

64%

36%

10

1

9.09%

0

Procurement Division

20.5

15.13

5.37

16.00

16.00

56%

44%

81%

19%

16

0

0.00%

0 0

Estates Division

13.43

9.23

4.20

10.00

10.00

90%

10%

80%

20%

10

0

0.00%

Ancillary Division

77.23

54.63

22.60

82.00

84.00

40%

60%

32%

68%

81

1

1.22%

1

Hull Logistics Division

29.55

20.51

9.04

23.00

23.00

91%

9%

57%

43%

23

0

0.00%

1

Fleet Maintenance Division

102.4

95.53

6.87

96.00

96.00

82%

18%

99%

1%

91

5

5.21%

0

Programme & Project Management Division

5.6

5.60

0.00

6.00

6.00

67%

33%

83%

17%

6

0

0.00%

0

Total Finance Human Resources Human Resources Division

299.20

244.72

54.48

283.00

285.00

60%

40%

70%

30%

267.00

16.00

5.65%

2.00

30.5

23.53

6.97

26.00

26.00

15%

22

4

15.38%

Training Division

55

47.12

7.88

59.00

61.00

59%

41%

75%

25%

58

1

1.69%

1

Organisational Development Division

0

4.64

-4.64

5.00

5.00

40%

60%

80%

20%

5

0

0.00%

0

8%

92%

85%

2

Occupational Health Division

6.56

6.15

0.41

7.00

7.00

0%

100%

57%

43%

6

1

14.29%

1

Total HR Standards & Compliance Corporate Governance Division

92.06

81.43

10.63

97.00

99.00

40%

60%

76%

24%

91.00

6.00

6.19%

4.00

5

3.00

2.00

33%

67%

100%

0%

3

0

0.00%

0

PR & Communications Division

6.23

3.03

3.20

4.00

4.00

0%

100%

50%

50%

4

0

0.00%

0

Health, Safety & Risk Division

9.64

8.73

0.91

10.00

10.00

60%

40%

70%

30%

10

0

0.00%

1

Legal & Compliance Division

6.91

4.91

2.00

5.00

5.00

20%

80%

80%

20%

5

0

0.00%

0

Patient Services Division

7

7.00

0.00

7.00

7.00

0%

100%

100%

0%

7

0

0.00%

0

Risk Team

4

2.00

2.00

2.00

2.00

100%

0%

100%

0%

2

0

0.00%

3.00

3.00

0

Infection Prevention and Control Division

2

1.00

1.00

1.00

1.00

100%

0%

100%

0%

1

0

0.00%

0

Total Standards & Compliance ICT and Access & Response Access & Response 999 Division

40.78

29.67

11.11

32.00

32.00

34%

66%

81%

19%

32.00

0.00

0.00%

1.00

347.75

321.48

26.27

361.00

369.00

25%

75%

78%

22%

340

21

5.82%

9

ICT Division

38.6

36.60

2.00

37.00

37.00

73%

27%

97%

3%

34

3

8.11%

Business Intelligence Division

46.53

43.99

2.54

47.00

47.00

32%

68%

83%

17%

44

3

6.38%

2

Access & Response OOH Division

30.28

22.43

7.85

57.00

84.00

11%

89%

9%

91%

57

0

0.00%

1

0

Total ICT

463.16

424.50

38.66

502.00

537.00

28%

72%

72%

28%

475.00

27.00

5.38%

12.00

Combined Totals

3979.28

3890.12

89.16

4483.00

4607.00

59%

41%

77%

23%

4319.00

164.00

3.66%

65.00

81

8.5

Sickness Absence

Table 8-d

2006 2007 2008 2009 +/-

: Sickness Absence 2006 to 2009-10 Apr

May

Jun

July

Aug

Sep

Oct

Nov

Dec

Jan

Feb

Mar

N/A 5.57 6.81 4.90 -1.91

N/A 5.64 6.77 4.58 -2.19

N/A 4.71 6.31 4.49 -1.82

4.83 5.41 6.2 5.91 -0.29

4.78 5.95 5.65 6.01 0.36

4.96 6.18 5.74 5.85 0.11

4.84 6.89 5.70 6.50 0.95

5.72 7.76 5.34 6.23 0.89

5.06 8.65 5.98 5.91 0.07

6.44 8.05 6.22 5.51 -1

6.76 6.78 5.02

6.08 6.64 4.63

Since the cessation of staff incentive payments in June 2009, the Trust has experienced an increase in sickness levels. This increased to 6.5% in October 2009 when action was taken across all directorates to manage absence better and more quickly. Since then, there has been a steady decline in absence. The average sickness rate for Ambulance Trusts is 6%, which is above that for the Trust. Even so, the sickness absence rate is above the level experienced during the incentive payment scheme and the NHS Trust average of 4%. In 2010/11, the Trust will aim to reduce its sickness rate to at least the NHS Trust average.

8.6

Recruitment Arrangements Recruitment is coordinated from within our Human Resources and Organisational Development Directorate. Since 1 April 2008, the Trust has recruited an additional 1317 new members of staff. Of these, 429 joined A&E Operations, 170 Access and Response, 514 Patient Transport Services and the remaining 180 joined support departments. We will continue to actively recruit where demand justifies a position and funding can be identified for the post.

8.7

Workforce and Organisational Development We recognize that one of the key factors to our success is our people. As such, a key focus for the Trust is the professional and personal development of all our staff and volunteers. Therefore, we seek to engage staff in our organisational development work. Our Organisation Development strategies aim to develop the Trust into one that is confident, empowering and inclusive, aligning behaviour, systems and procedures with our Values to help deliver our Vision. The Trust has worked with its recognised staff side representatives (UNISON and Unite) to 82

develop and implement a YAS Partnership Agreement. The agreement is a framework which outlines how we, as partners, will work together to promote effective partnership working on workforce/organisation issues. The agreement recognises respective roles and responsibilities established shared values and common purpose and set some key principles for effective joint working. It provides the basis for a continually improving partnership which will lead to longterm workforce solutions that work both for staff and, more importantly, for patients.

8.8

Professional and Personal Development Alongside the considerable amount of statutory and mandatory training that we deliver for our staff, we have policies and initiatives that seek to improve their personal well-being and develop further their professional skills. Some key policies/initiatives that support our Strategic Objectives are summarized below: •

Leading Edge Leadership Development. In 2008, the Trust participated in a national review of management and leadership capacity and capability in the ambulance sector. In line with the recommendations of the review, YAS has developed a comprehensive programme of leadership & management development known as ‘Leading Edge.’ This programme provides leadership development through a 360º assessment and feedback process so as to develop leadership style and behaviours. It also provides access to accredited and non-accredited management and leadership programmes, in-house modules, departmental programmes, access to coaching & mentoring training, and regional talent management programmes for managers at all levels throughout the Trust.



A&E Workforce Plan. Fundamental to achieving our Vision is having the right number of staff with the right skills to do their jobs. Therefore, our A&E Workforce Plan outlines how we aim to increase numbers of frontline staff and their clinical skills. The plan is based on the principle that a new workforce model should be focused on quality, patient-centred, clinically driven, flexible and locally led. Workforce issues in PTS and Access & Response in particular will be impacted upon by the A&E workforce model and the implications will be addressed for each of these service areas. Our A&E staff requirements for future years have been assumed to grow in proportion to demand and this began in 2009/10.



Professional Registration and Membership Policy. With this policy, we seek to recognise the professional skills and development of our staff. It aims to ensure that the Trust identifies posts which, due to their responsibilities, legislative or professional requirements require the post holder to hold and maintain registration and/or a specified level of membership of a particular professional institutions.



Employee Well-being and Support at Work Policy. The working environment for our staff, and in particular those supporting patients at the front-line of our service, can be traumatic. Therefore, we have in place mechanisms through which staff can be given personal support, for example following attendance at a particularly serious scene and who 83

may feel traumatised to a level which may affect them personally and/or professionally. •

Employee Wellbeing Forum. The Trust is adopting a holistic approach to employee wellbeing and has established the Employee Wellbeing Forum. This Forum demonstrates our commitment to employee health and wellbeing and is responsible for implementing an on-going action plan that strives to engage with employees to ensure that workplace wellbeing is integral to organisational culture. As such, the Forum supports directly the Trust’s Strategic Objective ‘Our People – recognizing that the excellence, professionalism, wellbeing and personal development of our staff and volunteers are key to the success of everything that the Trust does’



Annual Staff Survey. This survey is a key part of our effort to engage with staff and appreciate their views, which the Trust Board take into account when determining policy and future direction. We gather the views and opinions about a wide range of issues that affect them and their working environment. The findings of the 2009 Staff Survey identified three organisational priorities: (1)

Increase the number of staff having well-structured appraisals.

(2)

Reduce the amount of work pressure felt by staff due to demands of the job.

(3)

Deliver a focussed management development programme and clearly link personal objectives to strategic and operational objectives

The 2009 staff survey showed a marked increase in the number of participants and a positive impact of the initiatives which had taken place during 2008/09. The Listening Watch initiative where Directors regularly set aside a day to visit departments outside their own directorate is continuing with feedback from the visits forming part of the directorate improvement plans. The Annual Staff Survey will continue to play an important part in capturing the views of staff and identifying initiatives that we can take forward to improve their management and well-being.

8.9

Conclusion We are confident that our leadership and management of our people are underpinned by coherent policies that respect their skills, diversity and wellbeing. Working together with our staff to achieve our Vision will establish a working culture that will afford us the opportunity to achieve our Strategic Objectives and ambitions.

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9

Governance 9.1

Corporate Governance and Management

In 2008, we commissioned Deloitte to undertake a review of our Board Committee structure. The principal objectives of the review were to: •

Undertake a ‘fit for purpose’ assessment of each committee to assess whether it operates in accordance with the existing Governance and constitutional arrangements of the Trust.



Assess the relationships between committees and working groups.



Review the individual terms of reference for each committee and working group.



Assess how membership of each committee and group is determined and whether this is tracked and analysed.

Our intention was that any proposed revision to the governance structure should serve to strengthen our overall governance arrangements and enable us to move forward to Foundation Trust status. Whilst recognising the valuable work undertaken by the Governance Committee structure, the report recommended that a future governance structure should be more aligned with the Trust’s Vision and Strategic Objectives. A revised governance framework was introduced in October 2009. We will regularly review and refine this framework, in the light of new national guidance and learning from key enquiries into governance failures, as we continue to improve our performance and develop the organisation, in preparation for Foundation Trust status. Following the Foundation Trust diagnostic evaluation concluded in December 2009, an action plan has been developed which will be delivered during 2010-11. This will include reviews of present governance structures, constitution and reporting and audit arrangements.

Internal Control & Responsibility The Trust Board is accountable for internal control. As the Accountable Officer, the Chief Executive has responsibility for maintaining a sound system of internal control that supports the achievement of the Trust’s Vision. The Chief Executive also has responsibility for safeguarding the public funds and the Trust’s assets for which he is personally responsible, as set out in the Accountable Officer Memorandum. Whilst the Chief Executive has overall responsibility for risk management, the following Directors maintain key positions in the corporate governance structure of the Trust: •

Medical Director. The lead for clinical governance, including clinical risk management.



Finance Director. Responsibility for financial and estates-related risk management. The Finance Director is also the lead executive supporting the Audit Committee.

85



Standards and Compliance Director. Responsibility for co-ordinating risk management activities and quality issues including the Care Quality Commission registration programme (working closely with the Medical Director in relation to clinical governance), and for the work of the Integrated Governance Committee and its sub-committees.

Current Committees of the Trust Board The Board is supported by a series of sub-committees, each of which is responsible for a key area of the Trust’s activities and processes. The sub-committees are chaired by a Non-Executive Director and draw their membership from senior management, specialist staff and trades union representatives. Key areas of business are attributed to each of the level 2 committees to enable an appropriate level of focus, with processes in place to ensure effective communication and co-ordination for any cross-cutting issues. The principal committees of the Trust are: •

Audit Committee. Independent from the Trust Board and comprising NonExecutive Directors, Executive Directors and representatives from external and internal auditors, the Audit Committee is established in accordance with the Trust’s Standing Orders. Its purpose is to provide an independent and objective view of internal control. It is a statutory, non-executive committee of the Board and has no executive powers, other than those delegated in its Terms of Reference. Even so, it exercises influence by its review of the effective system of integrated governance, risk management and internal control across the whole of the organizations activities, both clinical and nonclinical. The Committee seeks these assurances via the Integrated Governance Committee and Business Delivery Committee, which work in support of and in partnership with the Audit Committee. The Committee is authorised by the Board to investigate any activity within its remit and to seek any information it requires from employees, who are directed to co-operate with all requests. It can also obtain outside legal or other professional advice and to secure the attendance of outsiders with relevant experience and expertise if it considers this necessary. Two key functions of the Committee are Internal Audit and External Audit:



Internal Audit. The Committee ensures that there is an effective internal audit function established by management that meets the mandatory NHS Internal Audit Standards and provides appropriate independent assurance not only to the Audit Committee itself, but to the Chief Executive and the Board.



External Audit. The Committee reviews the work of the External Auditor that is appointed by the Audit Commission and considers the implications and management responses to their work.



Integrated Governance Committee. Responsible for assurance and all clinical governance, quality and risk management activity within the Trust. Chaired by a Non-Executive Director, and co-ordinated by an Executive Director lead, it has representation from across the functional areas of the organization, as well as Non-Executive Directors and Executive Directors. Its work alongside and in support of the Audit Committee is a key part of the Trust’s Integrated Governance Strategy.

86



Business Delivery Committee. Chaired by a Non-Executive Director, and supported by and Executive Director lead. Responsible for monitoring achievement against the Trust’s strategic objectives, and for overseeing the performance management of the Trust’s operating systems and procedures, that help deliver operational success and achieve value for money.



Remuneration and Terms of Service Committee. As a formal subcommittee of the Board, the Committee is responsible for reviewing all aspects of pay and terms of service for Directors and senior managers.



Charities Committee. This Committee is responsible for the income and expenditure of the Trust’s charitable funds. It reports on income from sources such as donations and legacies, on the main areas of expenditure and on how the Trustees of the charity manage income from charitable donations.

Figure 9-a: Internal Control & Governance rnance Committee Structure

Trust Board

Audit Committee

Risk and Assurance

Business Delivery Committee

Integrated Governance Committee

Remuneration Committee

Charities Committee

Clinical Governance

Information Governance

Infection Prevention and Control

Health and Safety

Patient Safety

Clinical Effectiveness

Patient Experience

Safeguarding – children and adults

87

9.2

Risk Management

Our system of internal control is designed to minimise risk to a reasonable level, rather than to eliminate all risk of failure, in order to achieve our Vision and Strategic Objectives. It can, therefore, only provide reasonable and not absolute assurance of effectiveness. The system of internal control is based on an ongoing process that is designed to: •

Identify and prioritise the principal risks that may impact on the achievement of the Trust’s Strategic Objectives and policies.



Evaluate the likelihood of those principal risks being realised and the impact should they be realised, and to manage them efficiently, effectively and economically.

Given that risk mnagement is a corporate responsibility, the Trust Board maintains ultimate responsibility to lead on this and ensure that effective processes are in place. Leadership is exercised through a Trust Board-approved Risk Management Strategy and Assurance Framework within which the Trust Board, Directors, Managers and staff can operate effectively. The Risk Management Strategy itself contains a programme of action and embraces the following issues: • • • • •

Risk management structures Roles and responsibilities Types of risk Risk identification, analysis, control and review Monitoring and assurance

The identification of risk in the Trust is both reactive and proactive. We monitor risks which are identified through a wide range of reactive processes, both clinical and nonclinical. Proactive processes allow the identification of risks via risk assessments, business planning processes, external assessments and internal self-assessments. All risks are graded using a matrix of likelihood and impact, with any identified risks placed on the Risk Register, which is a live document. Processes are in place to escalate risks from both reactive and proactive sources where appropriate, to Executive level for action and to the Board and its sub-committees for assurance. The Integrated Governance Committee oversees and receives assurance on risk management processes within the Trust, and is supported in this function by the recently established Risk and Assurance Group. Through the risk management structure, the work of the Integrated Governance Committee links Clinical Governance, Controls Assurance, Corporate Governance, Standards for Better Health, external risk standards and existing internal financial controls to develop and implement a comprehensive system of risk management in line with best practice and national guidance. The Committee ensures that significant risk management concerns are appropriately considered and communicated to the Board on a regular basis and that decisions are taken on how to deal with those concerns and how they should be monitored. Recommendations on the actions to be taken by the Trust Board in relation to principal risks are reported at Trust Board meeting for approval.

88

9.3

Information Management and Technology Strategy & Systems

9.3.1 Strategy As a service, we rely on modern IT systems and infrastructure to enable us to respond quickly and effectively to patient needs across a large geographical area. Indeed, the best use of IT to support modern working practices and aid rapid communication is at the heart of our plans and future ambitions. Therefore, our IM&T strategy is supported by five principles which describe how IM&T investment must: • • • • •

Transform positively the patients’ experience and access to the NHS Support the work of staff in achieving the Trust’s Vision Ensure sufficient flexibility to enable response to change Assure the availability, security and transparency of data within the context of Information Governance Support internal process and performance improvement

The Strategy has been developed to ensure the Trust’s IM&T Team is in a position to fully support the developments planned at the organisational, local health community and national level.

9.3.2 Systems and Support The Trust is supported by a wide range of IT systems, which are key enablers for all operational and support services from ambulance operations to financial management. Explained below are the key services that are provided and managed by the IM&T team. •

CAD. The swift activation of A&E services by our Access & Response staff depends significantly upon our Computer Aided Dispatch (CAD) system. During 2009-10 we successfully integrated the legacy systems inherited as a result of the formation of the trust into a single CAD system. This will allow significant improvements in the efficiency of the service. Such is the importance of CAD that we have an alternate ‘Comms Server’ with an interface to the CAD systems that will enable us to continue business if a major IT failure degrades our IT systems.



CLERIC. Patient Transport Services benefits from the CLERIC system, a market leader in computer systems for the booking of transport services. It is a crucial tool for all PTS operations and will be a significant asset when we compete across the county for PTS contracts in the years ahead. Like our CAD system, we have business plans to maintain CLERIC in the event of a major IT failure.



Network. The Trust’s Wide Area Network (WAN) covers nearly 100 sites. These sites are linked using a variety of methods depending on ‘best fit’ and is based on a “Hub & Spoke” design. Resilience is built in to the Network with multiple access points to the NHS net via N3, Distributed Domain Access, File Servers, Off-site backup, firewalls, virus protection and Local e-mail servers. 89

Application servers and network infrastructure is located in secure Computer Rooms with battery, generator backup and air conditioning. Critical servers have built in redundancy and mirrored fallback. •

Telecommunications. We have two Accident and Emergency communications centres along with a centre that supports Urgent Care services. The Trust intends to rationalize these into two larger ‘flag ship’ emergency and urgent care Access & Response Communication Centre facilities for the entirety of Yorkshire that are integrated with the wider health economy with opportunities for new services linked to telemedicine and alternative care pathways. Telecommunications will be at the heart of supporting the delivery of this intent and we are currently implementing a flexible infrastructure for a virtual call centre (VCC). The Information Management & Technology team also manages a telephone switch with resilience across 3 sites. The switch is capable of VoIP and the Trust currently has over 30 VoIP connected sites.



Radio. The Trust uses the National Digital Radio network procured and managed by a Department of Health (DH) team. This system is new to the Trust and the ICT team are supporting with developing the way it interfaces to other systems in Access and Response and Patient Transport Services. The Trust is also rolling out a lone worker safety solution that makes use of the digital radio hand portable devices and network infrastructure.

9.3.3 Information Governance The Trust currently uses Connecting for Health (CfH) guidance and the Information Governance toolkit to manage Patient Confidentiality and Information Security. The Trust’s Information Governance Group oversees this and reports to the Trust’s Integrated Governance Committee.

90

10

Conclusion We are ready to move forward and deliver our Vision of an excellent ambulance service for Yorkshire. By establishing this five year business plan we have taken a major step forward in our business processes. We can demonstrate: •

A clear vision for the future



Measurable strategic objectives



An understanding of our market and our stakeholders plans



Realistic but ambitious service development plans



Sound financial plans



Clear appreciation of business risk and mitigate its impact



A rationale for Foundation Trust status

The plan will be implemented through the annual business cycle of the Trust. It will be refreshed on an annual basis so that we always have a five year view of the future. The first refresh of the plan will be the Integrated Business Plan that will support our Foundation Trust application.

91

11

References

Our NHS, Our Future (NHS Next Stage Review – Lord Darzi’s Review 2007-2009) Taking Healthcare to the Patient (The Bradley Report 2005 - Transforming NHS Ambulance Services) Healthy Ambitions (Yorkshire and the Humber Strategic Health Authority 10-Year Vision, May 2008) The Operating Framework – High Quality Care for All (High Quality Care for All, Department of Health, December 2009) Standards for Better Health (Health Care Standards for Services under the NHS, Department of Health 2004) Our Health, Our Care, Our Say (A New Direction for Community Services, Department of Health 2006) National Standards Local Action (Health & Social Care Standards and Planning Framework 2005/06-2007/008, Department of Health 2004) Saving Carbon, Improving Health (A Draft Carbon Reduction Strategy for the NHS in England, July 2008) Civil Contingencies Act 2004 Quadrant Consultants – Market Analysis & Review of Yorkshire Ambulance Service (11 November 2008) HM Treasury – Forecasts for the UK Economy A Comparison of Independent Forecasts (January 2009) NHS Carbon Reduction Plan (Saving Carbon, Improving Health NHS Carbon Reduction Strategy for England Department of Health 2009) NHS Five Year Plan (NHS 2010 - 2015: from good to great. Preventative, people-centred, productive Department of Health 2009)

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12.

Glossary

ARRP A&E A&R CAD CBU CfH CRES CTE DoH ECP EBITDA EP GP GPOOH HART HR IFRS IT ICT IMT I&E JCNC KPI MINAP MRSA NBV NHS NICE NPSA OD PBL PCT PDC PEST PR PTS REAP RPI RRV SLA SHA SWOT UK GAAP USAR VAT VCC VoIP WAN YAS

Analogue Radio replacement Programme Accident and Emergency Access and Response Computer Aided Dispatch Clinical Business Unit Connecting for Health Cash Releasing Efficiency Savings Clinical Team Educator Department of Health Emergency Care Practitioner Earnings Before Interest, Taxes, Depreciation and Amortization Emergency Preparedness General Practitioner General Practitioner Out of Hours Hazardous Area Response Team Human Resources International Financial Reporting Standards Information Technology Information Communication Technology Information Management Technology Income and Expenditure Joint Negotiating and Consultative Committee Key Performance Indicator Myocardial Ischaemia National Audit Project Methicillin-resistant Staphylococcus Aureus Net Book Value National Health Service National Institute for Clinical Excellence National Patient Safety Agency Organizational Development Prudential Borrowing Limit Primary Care Trust Public Dividend Capital Political Economic Social & Technology Public Relations Patient Transport Service Resources and Energy Analysis Programme Retail Price Index Rapid Response Vehicle Service Level Agreement Strategic Health Authority Strengths Weaknesses Opportunities and Threats United Kingdom Generally Accepted Accounting Principles Urban Search and Rescue Value Added Tax Virtual Call Centre Voice Over Internet Protocol Wide Area Network Yorkshire Ambulance Service 93