Gateshead Health NHS Foundation Trust

Operational Plan Narrative 2018/19

Background to the Trust

Gateshead Health NHS Foundation Trust is a provider of secondary care, community and older persons’ mental health services to a local population of approximately 200,000. Wider populations are served for specialist screening services and gynaecology-oncology services, including South of Tyne, Northumberland, Humberside, Cumbria and Lancashire.

The Trust has a revenue turnover of around £250m and was rated as ‘good’ with outstanding care by the CQC in 2015.

The Trust is now in year two of a Transformation Plan of an £18m contract secured in 2016 for the provision of Gateshead community services working with the Gateshead Care Partnership (GCP). This represents a significant strategic step towards integrating care and increasing the proportion delivered in a community setting.

The draft outturn for 2017/18 is an operational surplus of £2.25m, as a result of delivering a £1m improvement on the Control Total and receipt of additional year end STF funding from NHSI, with a Use of Resources Metric of a 2.

In 2017 the Trust Board set 8 goals for the period to March 2021, which guides our work:

1. Working with partners, we will manage and improve the health of the population of Gateshead, promoting wellbeing and preventing the occurrence and progression of ill-health wherever possible.

2. All the services we deliver will be good or outstanding when assessed against being safe, effective, caring, responsive, and well-led.

3. In all locations and settings of delivery, our patients will experience excellent, timely and seamless care that meets their individual needs.

4. All our services will have a high safety culture in which openness, fairness, accountability and learning from high levels of incident reporting and mortality reviews is the norm.

5. All our services will be effective: we will reduce unwarranted variation, ensure our practice is consistent with recognised best practice 7 days a week, and improve outcomes for patients.

6. We will have an engaged and motivated workforce living the values and behaviours of the organisation, and who are responsive and adaptive to the changing needs of our environment.

7. We will deliver value for money and help ensure the local health and care system is sustainable and well led.

8. We will use our expertise in Pathology, Women’s Cancer, and Screening services for the benefit of the wider NHS working with partners to provide excellent care for patients beyond Gateshead.

Contents

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1. Activity planning 32. Quality planning 53. Workforce planning 134. Financial planning 155. Link to the Sustainability and Transformation Partnership (STP) and

other collaborative health and care system work 196. Membership 217. Appendices 23

(i) Trust 2018/19 Objectives

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1. Activity planning

To prepare for 2018/19 the Trust has undertaken a bottom-up activity analysis and forecasting exercise, working with each service line to agree a realistic plan of activity that is informed by recent trends and takes into acount the changing population, health profile and changes in policy, for example the introduction of demand-reduction initiatives for elective care led by the CCG.

The planned activity levels reflect that Gateshead’s health profile remains challenging, with significant variance in life expectancy and ill-health correlated to high levels of deprivation and unhealthy lifestyle behaviours.

The Trust recognises the importance of aligning demand and capacity in order to safeguard delivery of its operations and secure longer term sustainability of the health economy. Planning capacity on a profiled, seasonal basis to match projected demand will allow us to provide the best quality of care at the lowest cost, by avoiding premium costs wherever possible. In 2018/19, we anticipate particular reductions in outpatient follow-up activity in light of service change, so service lines are working to reduce capacity in those areas.

For key PODs, we anticipate major drivers for change in activity as follows: A&E: we anticipate a growth of 1.3% across our A&E and walk-in centre activity,

reflecting the continuation of trends seen since 2016; Non-electives: overall growth of 0.9% in non-elective activity, but this comprises of a

1.3% rise of activity with a 1 day or greater length of stay, and a 4.9% reduction in activity with a zero length of stay: reflecting the success of the expansion of ambulatory care and other alternatives to admission in the last year. These dynamics mean that the acuity of presenting patients will continue to increase.

Daycases: some reduction in procedures in line with the implementation of value based commissioning demand-management schemes.

Outpatient new attendances: We expect to see continued high demand growth in cancer specialties in line with the national cancer strategy;

Outpatient follow-up attendances: We expect to see a reduction in non-essential follow-up appointments in line with our collaborative work with the CCG to reform pathways, for example by moving to mammographic surveillance instead of routine consultant follow-up for breast cancer patients.

The Trust is continuing to implement the NHS Intensive Support Team’s capacity/demand tools to analyse how capacity meets demand in specific specialties and we are prioritising areas of high-priority/risk.

In Radiology, there remains a recurring level of annual growth in demand which is in line with national trends, and there we will continue to invest in this service in line with the decision we made in 2016.

An expanded mental health liaison service was implemented during 2017 using time-limited funding, and activity is rising reflecting increasing awareness of the ‘Treat as one’ agenda and mental and physical health co-morbidities. We are continuing to discuss the commissioning of liaison psychiatry services with the CCG and NTW, the local mental health

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provider, to ensure this service continues on a permanent basis, in line with the ambitions set out in the mental health Five Year Forward View for Mental Health.

We continue to closely monitor non-elective activity, with evidence suggesting that both volumes and acuity have increased during 2017/18, though at a lower pace than the stated national average. Acuity increases generate a notably higher average level of income per spell, but has also resulted in increased medical bed day demand. We are continuing to iterate our bed modelling and are planning to provide an increased number of medical non-elective beds during 2018/19, again profiled in line with expected demand. Total beds provided will peak in January and we will also convert some surgical bed capacity to medical beds for a short time during this period. These steps will underpin our winter plan.

Throughout 2017/18 and especially over winter, the Trust has demonstrated an ability to flex capacity in order to meet surges in demand. We will continue to plan on the basis of overall full-year changes in activity (the 1.3% increase in non-elective activity) while also recognising that this change in demand will not be distributed evenly throughout the year. For example, in November 2017 we saw a 2.2% reduction in non-elective medical bed demand from the previous year, but the first three weeks of January saw a 6.2% increase in such demand. The Trust is committed to maintaining a full understanding of the variation in demand it faces, with sophisticated modelling of the different scenarios faced underpinning a flexible response. In this way, we will continually iterate our weekly and monthly forward operational plans including use of a flexible number of escalation beds and variation in the amount of elective work undertaken. This work will underpin our plan to deliver comparatively high levels of performance against the headline 4 hour A&E standard , with delivery of 95% planned in line with STF requirements in quarters 1, 2, 3 and in March 2019. In elective care, we expect to continue to deliver RTT and 62 day cancer standards over the year, while progressing our work as an early adopter of the new 28-day cancer diagnostic standard. This is evedienced in our trajectories on the national access standards submitted as requested to NHSI.

We have agreed a joint set of principles for transformation with the CCG and recognise that as a Trust we have an important role to play in assisting the health economy to manage demand levels in line with clinical best practice, to avoid low or no value health interventions. Work has progressed to reduce projected activity levels in parts of elective care in particular, with the implementation of Advice & Guidance services and the reform of outpatient pathways. The agreement of a block contract with the CCG for 2018/19 allows for pathways to continue to be reformed without immediate income loss risks as we would face under PBR. This agreement is an important enabler to achieve our shared aspiration of removing waste and non-value adding activity from the system.

As a provider of community services we are now in year two of implementation of a CCG agreed five year transformation plan with clear objectives in years 2018/19 that will help meet the rising need for care due to demographic changes, within existing resource. There is a risk that further budgetary changes and service reductions in the local social care sector may further increase demand beyond existing projected levels. We will continue to work across the health economy to address this as part of the NTWD STP, including reviews of intermediate, mental health and emergency care and transformation of primary care. As community service transformation continues, the opportunity to absorb more traditionally

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acute sector work into a community setting will further increase and we will continue to work with our partners to develop further care models that support the balancing of capacity and demand across the health economy.

2. Quality planning 2.1 The Approach to Quality Improvement

The Trust quality improvement senior responsible officer is Hilary Lloyd, Director of Nursing, Midwifery & Quality. This role is supported by the Deputy Director of Nursing, Midwifery and Quality, and the Assistant Director of Quality.

The Trust was given an overall rating of 'good’, with 'outstanding' for caring overall, and ‘outstanding’ for maternity and gynaecology services, by the Care Quality Commission (February 2016). However, in an inspection of older peoples’ mental health services, reported in June 2017, the Trust received ratings of ‘inadequate’ for inpatient services and ‘requires improvement’ for its older peoples’ community services. The Trust response to this is described below.

In keeping with the Trust’s 2021 strategic goals it is a priority in 2018/19 to continue to deliver a quality improvement plan aimed towards achieving an overall CQC rating of ‘outstanding’ and at the very least maintain a ‘good’ rating.

The Trust’s quality governance structure includes a SafeCare Council (the Trust term for Clinical Governance) and a Risk and Safety Council both of which report to the Quality Governance Committee, which is accountable to the Trust Board. As part of the Quality Improvement Strategy, planning is undertaken within business units, across three domains:

Clinical Effectiveness Patient Safety Patient Experience

These business unit quality improvement plans are monitored by SafeCare Council. Work is ongoing to review these plans to ensure they align with the Trust’s quality priorities and quality improvement strategy.

The Trust has a pro-active quality management culture that reinforces the Trust’s quality priorities and supports continuous improvement and learning. The Trust will continue to strengthen this in 2018/19. Further quality improvement work includes:

Developing a new 2018/21 Quality Improvement Strategy Strengthening the quality governance structure Learning and developing opportunities for further quality improvement Ensuring robust systems for monitoring and assurance Increasing the understanding of risk management Organisational focus on improving incident reporting, investigation and management

Quality governance is achieved through monthly ward to board reporting with the quality and safety dashboard and a report on quality priorities is presented to the board quarterly.

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Quality measurement will continue to be monitored against national and local targets including:

• CQUIN• Performance against the quality priorities• National clinical audit targets• NICE guidance (and other national guidance) National Patient Experience Survey and Friends and Family Test (FFT) National Staff Survey Complaints, PALs and Claims Clinical Staffing Incidents (including falls, pressure damage, medication errors, VTE), serious incidents

and never events Clinical Outcome Review Programmes, including Getting it Right First Time (GIRFT) Mortality Reviews

2.2 Summary of the quality improvement plan

Areas of focus for the quality improvement plan reflect local and national initiatives:

1. Mental Health Improvement Plan The Trust is a provider of Older Persons Mental Health Services. Adult services are provided to Gateshead residents by the Northumberland Tyne and Wear NHS Foundation Trust. In June 2017, the Trust received a rating of ‘inadequate’ for inpatient services and ‘requires improvement’ for community based mental health services. The Trust has a robust quality improvement plan to develop and invest in the service to achieve best practice. A Chief Executive-led Task & Finish group was established to oversee the development and successful implementation of the Mental Health Action Plan. This T&F group has focused on the following improvements:

• Governance Structure• IT Solution • Staffing Model• Staff engagement• Estates Improvement

The Board has approved the business case to support investment in staffing and, estate improvements to ensure an environment that is fit for purpose. Progress against the improvement targets will be tracked throughout 2018/19.

This will remain a priority and the Trust will ensure delivery of the improvement plan and delivery of the 5-year forward view for mental health. It will include improving recognition and care of patients with dementia, delirium and psychosis and the delivery of the Trust action plan for Treat as One, as a Quality Priority for 2018/19.

2. National Clinical Audits (NCA)The NCA Programme comprises of 41 audits that are relevant to the Trust, which cover care provided across a wide range of conditions. The Trust will continue to participate in all NCAs

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for which it is eligible. NCA results will be presented to the appropriate committee within the organisation.

The Clinical Effectiveness team support clinicians and participation is monitored by reports to SafeCare Council. Participation in the NCA Programme, outcomes and actions taken will be presented in the Quality Account.

3. Seven Day Hospital Services The Trust has a plan to deliver against the seven day service standards which is led by the medical director, and participates in the bi-annual national audit. Areas of focus emerging from that include strengthening documentation and information capture to demonstrate improved compliance year on year. In addition where resources allow, investment has been made to enhance service capacity for example in pharmacy prescribing, Sunday trauma capacity and diagnostic capacity, the latter allowing for seven day reporting. The Trust has recently invested in additional consultant staffing in care of the elderly to enhance capacity for timely reviews and support the wider medical team front of house and this will be subject to evaluation in 2018/19. The Trust will continue to review and monitor delivery of services against the standards as reflected in its corporate annual objectives for 2018/19.

4. Reducing Variation Work during 2018/19 will include undertaking a focused programme of reducing variation in clinical practice using the Getting it Right First Time (GIRFT) methodology. GIRFT is a national programme to improve medical care within the NHS by reducing unwarranted variations. This programme is led by frontline clinicians who are expert in the areas they are reviewing which means that the data underpinning the methodology is being reviewed by the people who lead and understand these services. The quality department will work with the Business Units and the wider Trust to ensure that these reports are received in a co-ordinated approach and to ensure any actions for the speciality and Business Unit are shared and owned by the wider clinical teams. The Trust’s re-launch of its service improvement framework and RPIW programme, the Gateshead Way, will enhance both the processes and culture of engagement within which required changes to reduce variation and continuous service improvement can be achieved

5. Safer Staffing To sustain and improve the quality of our services, we need to ensure the right people, with the right skills, are in the right place at the right time. The Trust recognises the challenge of maintaining the clinical workforce and identifies this as a key risk. Our plan includes:

• Plans for recruitment and retention of nursing, AHP and medical workforce• Medical and specialist nurse job planning• 12 monthly review of nurse establishments as per National Quality Board guidance• Pursuing opportunities to develop new roles e.g. nursing associate• Development of apprenticeship routes into healthcare• Transformation plans for clinical services in line with the reconfiguration of clinical

pathways and wider workforce planning as part of CNE STP work streams including Optimising the Acute Workstream, Local Maternity Systems work and clinically-led Regional Vulnerable Services work stream.

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The Carter Review recommended that Care Hours per Patient Day (CHPPD) data is collected to ensure that workforce and financial plans are consistent in order to optimise delivery of clinical quality and use of resources. The Trust reports the CHPPD in the monthly staffing report to Board. In addition, data is used to inform the review and setting of staffing establishments, help ensure efficient rostering, and draw links with quality data on patient harm and experience.

6. Better Births: Improving outcomes of maternity services in England The recommendations from this report underpin the Trust priorities for maternity services over the next two years and beyond. The Trust has undertaken a gap analysis against the seven themes identified and this has been shared with commissioners and incorporated into the maternity strategy. The Trust already complies in a number of areas as reflected in our CQC assessment of 2016, where the Trust’s maternity services were rated as outstanding. In 2018/19 these plans will include increasing the number of births to reflect national guidance on the critical mass required to remain clinically sustainable in the longer term whilst sustaining quality, though the Trust remains mindful of the national debate on sustainability of multi-local centres in the longer term and will collaborate across the CNE STP in this area.

7. End of Life In 2018/19 we will focus on the roll out of the care of the dying document to enhance patient and family experience at the end of life. This will guide health professionals to consider important conversations and acknowledge choices as well as ensuring symptoms are controlled and a peaceful death is achieved. The Trust aims to develop the current ‘social’ model of day care towards a more targeted and effective patient centred model to achieve better patient outcomes and more effective use of resources.

8. Cancer Key areas of work for 2018/19 will include:(i) Early diagnosis –• Working collaboratively with Commissioners • Working with primary care to flag risk factors for patients and promote early

interventions• Agreeing how to access ‘hard to reach’ groups working with primary care and Public

Health • Improving screening rates (bowel and cervical) • Roll out of the FIT test• Streamlining of pathways to support early diagnosis in line with national optimal

pathways. Work on implementing the optimal pathways for colorectal and prostate will commence in May, building on the achievement of the introduction of Colorectal Direct to Test

• Preparation for the 28 day faster diagnosis target (2020). The Trust will be shadow monitoring to develop processes and systems to deliver on the target (i.e. development of tracking and follow-up processes for various pathways). A data base is already in place to support this.

(ii) Living with and beyond cancer The Trust will continue working in collaboration with commissioners to enhance post- discharge support. This will include development and evaluation of a patient workshop involving the Charity Fighting All Cancers Together (FACT).

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Gateshead Community Based Care, the local GP federation is supporting the Living With and Beyond Cancer agenda and working alongside Trust cancer nurse practitioners.

9. Mortality, serious incident investigation and learning During 2017/18, the Trust reviewed its systems and processes for investigations and reviews including improving the quality of mortality reviews and serious incident investigations; learning and sharing lessons learned. This work included a highly successful Rapid Process Improvement Workshop (RPIW) that highlighted and addressed recommendations including:• Standardising approach to mortality reviews across the Trust • including data capture and documentation • Access to information for professionals• Enhancing methodology for sharing lessons learned/• Improving relatives information and engagement via the bereavement services• Staff training and awareness An electronic mortality review database was developed to manage and monitor outcomes from mortality reviews, which has been rolled out to all wards within the Trust. This allows consultants and ward teams to analyse their own data. Specialist level mortality reviews were presented to the Mortality & Morbidity Steering Group to support shared learning. Good progress has been made during 2017/18 in the number and quality of reviews undertaken. In 2018/19 investigation training will be continued to be rolled out to all staff and the Trust will continue to improve on the targets set for 2017/18. There is a process in place for level 2 reviews and sharing lessons learned and further work will focus on this.

10. Infection prevention and control (IPC) Ensuring preventative measures and reducing infection is important to the quality of patient care and our improvement plan for 2018/19. Whilst infections are monitored and followed up for patients during their stay, some key indicators such as Meticillin resistant Staphylococcus aureus (MRSA) and Clostridium difficile Infection (CDI) are used nationally to benchmark and measure performance.

Acute Trusts are required to report all cases of MRSA BSI, Meticillin sensitive Staphylococcus aureus (MSSA) BSI, Escherichia coli (E. coli) BSI and CDI to Public Health England. Reporting in 2017/18:

MRSA post 48hr BSI: The Trust reports 0 cases with a Zero rate per 100k bed days MSSA post 48hr BSI: The Trust report 8 cases with a 4.64 rate per 100k bed days CDI post 72hr: The Trust reports 31 cases to date against 2017/18 objective of 19 (6

cases have been upheld following appeal, representing 25 cases against the quality premium)

A national ambition to reduce healthcare associated Gram negative Blood Stream Infections (GNBSI) by 50% by March 2021 was introduced from April 2017 with a specific focus on reducing E. coli BSI by 10% for 2017/18 and again during 2018/19 across the whole health care economy. In 2017/18, for Gram negative blood stream infections (GNBSI):

Escherichia coli (E.coli): The Trust reported 38 post 48hr E. coli cases and 182 pre 48hr/community related GNBSI cases.

Pseudomonas aeruginosa: The Trust reported 4 post 48hr cases with a rate of 2.3 per 100k bed days and 13 pre/community 48hr P. aeruginosa GNBSI cases

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Klebsiella spp: The Trust reported 9 post 48hr cases with a rate of 5.2 per 100k bed days and 40 pre/community 48hr Klebsiella GNBSI cases.

Tackling antimicrobial resistance continues to form part of the National CQUIN for 2018/19. The Trust will continue improvement work to reduce total antibiotic consumption per 1,000 admissions and to promote prescribing of narrow spectrum agents where appropriate.

11. Improving Patient Safety Culture The Trust is committed to reducing avoidable harm and utilises local intelligence systems, for example incidents, complaints, patient feedback and clinical audit. Part of our quality improvement includes: Falls: Implementation of the inpatient falls reduction strategy will be driven by the newly

developed Strategic Falls Reduction Group. The Trust aims to maintain or reduce its harmful ‘in hospital’ falls rate of 2.60 per 1,000 bed days

Sepsis: Building upon quality improvement work in preventing deaths as a result of sepsis, the Trust will continue to improve the recognition and timely treatment of patients presenting with Sepsis by ongoing development of the sepsis screening process and implementation of the six element sepsis care bundle

Pressure Ulcers: The Trust has participated in the regional patient safety collaborative to reduce pressure damage to patients. Pressure damage in the Trust remains low and the Trust aims to achieve year on year improvements in reducing harm to patients

Medicines Management: Continuous improvement plan to reduce omitted doses of critical medicines

Complaints: Embed RCA methodology across all investigations including complaints MapSaF: Measure the Trusts Safety culture

12. Patient Experience

In 2018/19 the Trust will implement its new patient, public and carer involvement and experience strategy 2018-21: “ Your Care, Your Voice”. The strategy aligns to the Trust’s vision and values that places the patient at the centre of all that we do and striving for excellence. The delivery framework identifies key priorities for 2018/19 that include the following:

Refresh our face to face real time patient survey programme Develop a patient survey programme for elderly mental health services Work in collaboration with patients and carers to identify Always Experiences

(Always Events). With an initial focus in elderly mental health services, we will co-design and implement reliable processes of care utilising the Model for Improvement to achieve this.

Determine a programme of engagement and involvement work for governors members, partners and stakeholders

Continue to support John’s Campaign Develop new and innovative posts for volunteers to support staff in delivering high

quality care.

13. National CQUIN The Commissioning for Quality and Innovation (CQUIN) national goals was introduced in 2009 to deliver clinical quality improvements and drive transformational change for

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specified area of patient care, as identified by NHS England. This supports the Five Year Forward View and links to the NHS Mandate. The Trust undertook an assessment against the CQUIN schemes for 2017/19 and identified that there was some risk to delivery within existing resources/capacity. The Trust has worked hard to try to achieve these challenging schemes and can advise, currently, that it forecasts to achieve 82.7%. These Quality Improvements will continue for 2018/19.

CQUIN is actively managed by the Quality Governance Committee and monitored on a quarterly basis at Trust Board meetings.

14. Research and Development (R&D) The Trust is a research active organisation, which ensures that our patients have access to the very latest treatments and technologies. The Trust has a reputation for delivering on research studies and is a ‘green light’ site for Novartis Ltd. in relation to Cardiology studies.

The Trust is a partner organisation of the Clinical Research Network: North East and North Cumbria (CRN NENC) and has a long and successful relationship with the network. The R&D Department works closely with the CRN NENC to deliver National Institute for Health Research (NIHR) portfolio studies across a range of specialties.

Our aim for 2018/19 is to continue to build on our success and to further increase the number of research projects and develop our reputation as a research active Trust, increase nursing and AHP research and provide high quality research opportunities for patients.

2.3 Summary of the Impact Assessment Process

The Trust has an effective risk based Quality Impact Assessment (QIA) policy in line with NQB guidance and is endorsed by the Trust's Financial Sustainability Programme Board. The QIA process assesses schemes against a scoring framework to assess risk to quality and there is a process to ensure that cost reduction programmes (CRPs) are assessed during their development, implementation, and following implementation.

All schemes are managed through the PMO and presented to the Financial Sustainability Board. QIAs cover safety, clinical outcomes and patient experience. QIA meetings are led by the medical director and director of nursing, midwifery and quality, to ensure the formal consideration of each QIA and all schemes are reviewed against the self-assessment tool.

The Trust intends to continue to utilise this established process for all proposals to significantly change services, including transformation schemes and business cases as well as the CRP programme. It will align quality and safety with business and financial planning underpinned by the role of the PMO.

2.3 Sustainability and Transformation Plan

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The Trust has been an active partner in the existing Northumberland, Tyne & Wear and North Durham (NTWD) STP, and the more recent work that is being carried out across the wider Cumbria & North East footprint. Progress to-date and implications for 2018/19 are set out in section 5.0 of this plan.

2.4 Triangulation of indicators and use as part of Trust governance

The Board receives reports directly that support triangulation of indicators for quality, finance, workforce, activity and performance. Board committees also receive reports where points raised by the Board can be explored in greater detail and provide onward assurance to Trust Board. The Board committees comprise:⁻ Finance and Performance ⁻ Human resources⁻ Quality Governance⁻ Audit ⁻ Charitable Funds

This is underpinned by an infrastructure that includes: Corporate Management Team – weekly meeting of the Trust Executive team Clinical Policy Group – a monthly meeting chaired by the Medical Director and

comprising membership of all Clinical Heads of Service, provides a platform for senior clinical engagement, scrutiny and policy

Financial Sustainability Programme Board comprising Executive and business unit Associate Directors reviews the effectiveness of the Trust Efficiency and Productivity Programme and accompanying QIAs to receive assurance from the managers responsible for efficiency schemes regarding their impact on quality

A robust Board Assurance Framework (BAF) is in place underpinned by the Trust risk register and processes that bring together planning and quality governance and risk. During 2017/18 the Trust strengthened its approach to planning and risk to inform decisions on investment. Board Assurance reports on the latter are more closely aligned with quarterly monitoring of the Trust corporate objectives and 2021 goals to ensure that:

Areas of identified risk are escalated to the Board for effective and timely consideration. Adequate progress is being achieved against corporate plan, benefits realised, and any

slippage / re-adjustment of objectives are accounted for.

In parallel, executive members of Trust committees ensure issues arising from committee discussions are addressed via the appropriate executive forum and reported back.

The Trust’s audit programme is also used to explore opportunities for improvement with learning picked up and progressed following an annual work plan.

As part of the delivery of the Community Services Transformation Plan the Trust is developing a suite of reporting mechanisms to improve capture of information that will reflect true demand, utilisation of resources and service outcomes. This work will continue to be developed in 2018/19 and will provide a robust baseline upon which the Trust can

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effectively model capacity requirements and evidence the productivity and quality outcomes proposed through the Transformation Programme.

The Trust does also rely on excellent communication channels from wards/services upwards and invests a significant amount of time into ward and site visits to ensure it can triangulate indicators with feedback and local intelligence. The Trust ward accreditation programme (CQAF) measures progress with delivery on the nursing and midwifery strategy against quality indicators.

The measures described above are used to support the delivery of the Trust’s ongoing drive for clinical and service excellence.

3. Workforce planning 3.1 Workforce planning methodology

The Trust has recently begun to utilise the ‘Six Steps’ Skills for Health approach to workforce planning which ensures workforce decisions are embedded within operational planning and are underpinned by a purpose, plan and ownership, and triangulated with financial, quality and activity factors. The methodology asks each defined area to describe what it will look like in the future, where we are now, and how do we close the gap with a robust plan. Given the service priorities all feed from the Trust’s Goals and Objectives, the workforce plan does similarly. Further work is required within the Trust to embed this methodology

3.2 Workforce strategy

The Trust developed its People Strategy throughout 2016. Signed off by Trust Board in June 2016, it encompasses key themes of Diversity and Inclusion, Health and Wellbeing, Recruitment and Retention, Learning & Development, Organisational Development and Reward & Recognition. The work plan for delivery is overseen by the Trust’s HR committee and is progressing as planned.

3.3 Governance processes and alignment with service plans

The Trust continues to strengthen reporting dialogue and process with each business unit and service. This will include measures designed to ensure that, workforce, quality financial and productivity plans are aligned and are on track to be delivered. Performance against workforce KPIs and plans will continue to form part of these meetings. Workforce risks at service and trust level are reviewed through the risk register and Board Assurance Framework, via the Board Committee structure.

Workforce performance reports are considered monthly by business units and quarterly by the HR Committee to track performance and address areas where necessary in relation to retention, absence, appraisals and core training. Assurance reports in relation to certain staff groups are discussed at Trust Board (e.g. Nurse staffing levels and junior doctor exception reporting in line with the new contract via the Guardian of Safe Working).

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3.4 Workforce efficiency – STP and CRPs

The Trust’s PMO monitors a range of workforce efficiency schemes (for example, review of non-ward based nursing, consultant job-planning and effective use of administrative services).

3.5 Workforce transformation

The Trust continues to try to balance workforce supply and demand through on-going demand management, capacity reviews and intelligence gathering. We will continue to develop alternative methods of service delivery where workforce supply is challenging (for example nurse specialists in paediatrics to mitigate against junior medical staffing gaps, utilisation of therapists in care closer to home wards to bridge the gap between acute nursing and community/social care, development of nurse endoscopists and international training opportunities to mitigate against consultant level vacancies). The Community Services Transformation Programme (see section 1) involves new roles and ways of working across health, social care, primary and acute boundaries (e.g. the extension of Older Persons Nurse Specialists to all nursing and residential homes in Gateshead).

3.6 Workforce initiatives and seven day services

The Workforce Advisory Board in the North has been established and commenced discussions about workforce planning, supported by an emerging workforce advisory group and forums such as the North East Social Partnership Forum to ensure early engagement with partners such as NHS England, HEENE, CCGs, social care and trade union colleagues.

Robust governance processes will continue to limit the use of agency workers to critical areas of service only, within wage and price caps. Supply of medical staff at all grades remains a challenge and this is our one area where reliance on agency workers remains. The Trust is one of five Trusts in the North East piloting a regional medical staffing bank led by the regional Lead Employer Trust, with a stock take due in June 2018.

The Trust became an employer-provider under the Apprenticeship Levy in 2017 and has commenced partnerships with local further education providers for joint delivery of a range of apprenticeship programmes in leadership, health, administration, therapies and scientific roles. Early plans identify new roles within audiology, cardiology diagnostics, pathology and theatres which will mitigate some of the risks due to national and/or local supply issues.

The general and mental health nursing workforce remains a challenge reflecting the national position. Significant work continues under the People Strategy umbrella to ensure existing staff are valued, developed, their health & well-being is a priority, and therefore retained. The Trust has also become part of national Nurse Associate pilot which goes into its second year in 2018/19 and we have also entered into discussions with the Open University regarding in-house programmes to develop and train support staff into nursing roles.

In 2018 a new e-rostering and time and attendance system will be rolled-out within the Trust, which will strengthen existing practices around rostering and efficient working.

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As part of the Trust’s active role in the NTWD STP and the Newcastle Gateshead local health economy system redesign, there will be a need to align workforce structures to new models of care across health and social care. The Trust will ensure its work programme responds effectively to this challenge under the leadership of the Deputy Director of Workforce.

As described in section 2.2, the Trust continues to deliver seven day services. Service transformation forms a key element of this work alongside underpinning workforce plans to deliver the essential capacity and support new ways of working. The realisation of these plans is in part dependent upon both financial resources and staff availability and a number of the proposals are subject to ongoing cost benefit analysis. Further work in this area is expected to emerge through the optimising the acute sector work stream of the NTWD STP.

4. Financial planning 4.1 Financial forecasts and modelling

The 2018/19 financial projections build on the actual financial performance delivered in 2017/18 (the first year of the current 2 year plan) and take account of the activity, workforce and performance requirements, as well as the impact of the signed contracts agreed with commissioners and the national changes to the STF/PSF and Control Totals for 2018/19.

The financial model for 2018/19 is based on:

Detailed internal capacity and demand modelling that has been shared and agreed with Commissioners and factors in the impact of CCG QIPP schemes where granular level detail is available.

Currently excludes the impact of the 18/19 AFC pay settlement on both I&E over and above the 1% in the tariff.

Recurrent and non-recurrent infrastructure has been set to try to ensure delivery of performance targets and to maintain the quality of services.

Workforce levels informed by the above to limit reliance on agency staffing within the NHSI Agency cap, continuing the Trust’s low agency use as outlined in section 3.

Efficiency and cost reduction plans derived from the detailed work of the Trust’s PMO and ongoing monthly Financial Control meetings. The Trust is also increasingly utilising the suite of information and indicators available via the Model Hospital portal, linked to the national and local GFRT reviews, though it should be noted that our work to date suggests that there are no easy wins/ immediate cash releasing financial benefits to be derived from this work.

The following sections summarise the key movements between the 2017/18 draft outturn and 2018/19 plans and the key risks, sensitivities and mitigations to delivery:

The draft outturn for 2017/18 is an operational surplus of £2.25m, (increasing to £6.1m due to the impact of the technical reversal of previous year impairment). The Trust received an additional £4.1m of year end STF payments as a result of exceeding the Control Total and receiving £1.0m of £ for £ matched funding and a further £3.1m of incentive and bonus funding - offset by non-achievement of the Q4 performance fund of £574k due to marginally missing the A&E 4 hour target. This excellent result for the

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year was in in no small part a function of delivering a programme of £12.1m (95%) of the planned cost reduction / income generation programme.

After stripping out the non-recurrent STF of £8.77m the surplus reverts to an underlying deficit of £6.52m and further deteriorates to a starting deficit for 18/19 of £12.42m after adjusting for other non-recurrent items (including CRP delivery) and full year effects.

The impact of the national tariff inflator of 0.1%, incorporating a 2% efficiency requirement; the impact of cost pressures and the costs of delivering planned activity associated with maintaining the excellent performance standards that the Trust continued to deliver during 2017/18 (primarily increased access to diagnostics to support earlier diagnosis, improved patient flow and progress on 7 day working) equates to £6.9m which increases the recurrent deficit to £19.32m.

The impact of the movement in the Control Total from a deficit of £2.34m to a surplus of £742k results in a gross challenge of £22.3m for 18/19. The financial gap is reduced to a net gap of circa £15.1m (6.1% of turnover) based on sign up to the control total assuming full receipt of the STF of £7.28m.

The net CRP target for 2018/19 will be extremely challenging to deliver, especially in light of the CRP that has been delivered over the last 5 years and the relative efficiency of the Trust as per the latest RCI.

The SOCI, SToP and STCF in the financial model that are derived from the revenue and capital plans (see section 7.4) result in the following key metrics for 2018/19:

£8m retained cash at 31/03/19, with no recourse to distressed finance during the year – this is a significant risk and very dependent upon delivery of the challenging CRP programme;

Operational surplus of £740k in line with notified Control Total; CRP requirement of £15.1m (6.1%).

4.2 Efficiency Savings for 2018/19

The Trust continues to use the PMO team to identify scope and help deliver efficiency savings but it is increasingly clear that medium term clinical and financial sustainability is dependent upon both transformational change across the care boundaries and structural change and realignment of clinical serves between acute providers.

Accordingly the Trust has both realigned the focus of the PMO team much more towards identifying and supporting transformation projects and has also relaunched the Gateshead LEAN approach to support identifying and delivering efficiency. It should be noted that although there will be some tangible, cash releasing benefits identified and released in year this approach is fundamentally about delivering medium term sustainability.

To compliment this approach the Trust continues to hold monthly Financial Control meetings designed to maximise in year savings, which helped to produce the excellent delivery in 17/18.

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Carter Model Hospital Efficiency Programme / GRFT Programme – The Trust is increasingly focusing its PMO resource towards the potential areas of efficiency and savings that the Model Hospital and GRFT programmes are flagging as outliers.

In addition, the pathology workstream of the Cumbria & North East STP/ICS footprint has recommended that the South of Tyne Pathology hub that the Trust operates (and that currently provides hot and cold services to the 3 local trusts and direct access work for the same footprint) will be the hub for the NTW patch for non-specialised pathology. It should be noted however that the timescale for this project is not likely to deliver saving until 19/20.

The Trust recognises the need to ensure cost effective delivery of back office functions. In January 2018 the Trust transferred its Payroll function to a joint NHS payroll consortium and will continue to explore further options to deliver back-office efficiencies.

Intrinsic across all of the efficiency / cost reduction measures that the Trust is pursuing is a rigorous Quality Impact Assessment process to ensure the current levels of quality and performance are not compromised. The Trust Board is very clear that it is not prepared to put financial delivery ahead of patient care but is committed to delivering that care in the most cost effective and efficient way.

The Trust is committed to continuing to reduce reliance on external agency staff and the consequent premium cost associated there with. The Trust has very low levels of reliance on agency nursing, the primary usage is to support winter/surge bed capacity. The Trust has started to implement the GDEFF programme and it should be noted that there is a significant requirement for temporary programme management support to ensure delivery of the programme which has the potential to add significant pressure to this target for the next two years.

4.3 Capital Planning

The 5 year capital programme is based on utilising cash from internal depreciation, net of loan / interest payments, supplemented by the GDE FF national funding designed to deliver digital care over the next two financial years. In addition to this the capital programme is primarily designed to:

maintain current estate condition status replace essential medical equipment and service developments maintain and replace IT infrastructure, further developing robust systems to support

community services and the OOH pathway transformation agenda that are essential prerequisites of the Gateshead Care Pilot, progress the interoperability of patient data between secondary and primary care as well as the key GDE FF programme referenced above.

The 2018/19 programme is based on retained cash from internal depreciation of £5.3m, less £1.4m of loan principle repayments, resulting in a net internal capital resource for 2018/19 of £3.9m. In addition to this the national GDE FF funding of £2.5m increases the programme to £6.4m.

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The level of funding to support the draft programme for 2018/19 is now at a level where the Trust will continuously have to reprioritise the programme in year as new clinical risks present, as will inevitably be the case with an ageing asset base of equipment and buildings and infrastructure.

4.4 Financial risk

There are a number of significant risks to delivering the plan. At this juncture there appears to be very limited upside sensitivity available other than the potential for additional income from repatriation of work from the private sector (that has a cost neutral impact on the CCG) or pathway changes resulting from service vulnerability in other local health economies e.g. breast care services. There are no material non recurrent sources of income from land sales etc. that are sufficiently developed to include in the plan at this point.

The key risks inherent in the 2018/19 plan are as follows:

Delivery of front of house A&E performance and back of house bed capacity during winter 2017/18 was very challenging and led to non-receipt of the Q4 performance element of the SFT. A similar or worse winter period in 18/19 has the potential to impact on both the cost base and performance and associated risk to Q4 STF.

Delivery of CRP/ efficiency savings – The base case scenario in the financial plan and summarised above requires the Trust to generate a minimum of £15.1m of recurrent CRP savings in 2018/19. This equates to circa 6.1% of turnover and when related to spend that can be directly influenced in the short term, this translates to nearer 20% which the Board is concerned has the potential to compromise quality and performance targets. Significant focus is being given to this challenge and the programme of schemes outlined in section 2 will be vigorously pursued via the Trust’s Financial Sustainability Board chaired by the Chief Executive and with a robust approach to quality impact assessment led by the Medical Director and Director of Nursing. Midwifery and Quality. This presents a significant risk.

The only material area of “discretionary Investment” in the 2018/19 plan again relates to increasing diagnostic capacity, primarily in the radiology modalities of MRI, CT and Ultrasound that are considered essential to providing the capacity needed to ensure that patient flow and waiting times are maintained and are a direct consequence of the increasing volumes of activity and increasing provision of 7 day services. This is a continuation of the programme of investment from 2017-18. Consideration was given to deferring this investment by the Board prior to sign off the operational plan but the risks to quality and performance outweighed the financial investment and would expose the Trust to increased operational risk.

4.5 Summary

Delivery of the 2018/19 financial plan is dependent upon the delivery of an extremely challenging internal efficiency target as well as system wide transformational changes, both of which will be essential to ensure the Trust can maintain financial viability and enable the Trust and LHE partners the time and head room to develop realistic and deliverable services across primary, community and secondary care.

The Board has taken due account of the financial challenges and risks inherent in the operational plan for 2018/9 and has signed up to the control totals based on the knowledge

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of the significant risks to said plan. The Trust appreciates the financial challenge to the main CCG and is committed to working in partnership with them to jointly manage the dual risk to delivering the local health economy’s plans.

5. Link to the ‘Sustainability and Transformation Partnership’ (STP) and other collaborative health and care system workThe Trust has been an active partner in the existing Northumberland, Tyne & Wear and North Durham (NTWD) STP, and the more recent work that is being carried out across the wider Cumbria & North East (CNE) footprint.

The regional health and social care system has some of the highest performing providers in the country, however the health and well-being gap remains high. Poor population health is reflected in high use of intensive services, primary and social care and service models/investment that focus largely upon ‘treatment of ill-health’ and this in turn is a contributor to the finance and efficiency gap our area faces. The Trust recognises the need to continue to work with all NHS and local authority organisations across the region.

The Trust is working with particular intensity to address population health and integration of care services within the place of Gateshead, building on our work as part of the Gateshead Care Partnership with the Council, Northumberland, Tyne & Wear NHS Foundation Trust, Newcastle Hospitals, CBC Health (a local GP provider group) and the emerging GP Federation.

In addition we continue to work to ensure that acute services are sustainable and reflect best practice for the future across Newcastle – Gateshead through joint collaboration work with the Newcastle upon Tyne Hospitals NHS Foundation Trust.

5.1 Trust work as part of the Cumbria & North East system

The Trust continues to play a prominent role in key CNE workstreams including pathology and workforce.

Within the Cumbria & North East work on ‘Optimising the Acute Sector’ the NTWD work programme is being led by the GHNT Director of Strategy and Transformation with the Medical Director acting as medical director sponsor for one of the pathways being developed.

Further collaborations are undertaken with other providers across CNE around specific services where there is joint interest and patient benefit in doing so – e.g. Breast services and Older Persons Mental Health.

Collaboration is already underway with local mental health providers on the Deciding Together, Delivering Together initiative being led by Newcastle Gateshead CCG.

5.2 Trust work to develop the Gateshead health and care system

The Trust continues to participate in a joint transformation programme with Newcastle-Gateshead CCG, which includes

o Elective demand management including Value Based Commissioning approaches

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o Application of RightCare principleso Introduction of advice & guidance serviceso Intermediate care reviewo Transformation of community serviceso Exploring new models of care

Further development of the existing Gateshead Care Partnership, with transformation of the collaboratively provided community services including interface with Transformation programmes for Gateshead Primary Care and delivery of the Gateshead Intermediate Care service (the development of ‘step up; step down’ care and review of community teams)

Developing work to build integration and collaboration within Gateshead as a place. We are working jointly with commissioning, local authority and provider partners to develop:

o a common view of what long-term outcomes we should be targeting for Gateshead,

o how the commissioning infrastructure will evolve to focus delivery on these outcomes and reduce transactional commissioning,

o the governance and architecture that is needed to support place-based deep collaboration, including joint financial and risk arrangements

o the Gateshead provider network and the scope of services it can provide collaboratively.

5.3 Trust work on acute collaboration with Newcastle Hospitals

An acute services collaboration programme is in place with Newcastle–upon-Tyne NHS Foundation Trust (NuTH), and work continues on priority clinical pathways that includes:

o Vascular services – implementing a hub and spoke model in line with the regional review of Vascular services;

o Interventional radiology – in line with work across the region and in light of workforce scarcity.

o MSK services – successful contract award for the tendered Newcastle Gateshead MSK service, to go live October 2018;

o Paediatrics – exploration of opportunities to improve local services in Gateshead, potentially involving some shared consultant posts with NuTH.

o Stroke – further development of the stroke pathway following the centralisation of hyper-acute stroke care at NUTH in November 2016

o Informatics – GHNT has been selected as the fast follower of NUTH as a Global Digital Exemplar, and a significant level of collaboration is in place to share systems and best practice.

6. Membership

6.1 Annual elections

Elections in both public and staff constituencies are undertaken on behalf of the Trust by the Electoral Reform Ballot Services Limited. This year’s elections to the Council of Governors

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began in October 2017 and the results were declared on 13 th December 2017. The election was to fill seven posts; five public and two staff. Election results were as follows:

Year Vacancies Filled2017/18 7 62016/17 12 102015/16 9 7

In past years Governors have been recruited through a number of channels including membership newsletters, local council news and other local publications. In 2017/18 the Trust carried out on-line elections as well as a postal option. This included the distribution of postcard invitations to all of our members (both public and staff). An internal comprehensive induction programme is provided for newly appointed Governors that includes:

The role of our regulators; Introduction to finance; Preparing the Annual Plan; Quality indicators.

All governors are invited to visit services across the Trust and have access to a development programme including, for example, quality governance; accountability; making engagement meaningful and quality accounts. In addition individual governors have attended events including the regional governors’ forum, NHS Providers Governor Focus Conference and external events such as those held by Gateshead HealthWatch.

6.2 Communication and involvement of members

A comprehensive communications approach includes: A joint members and Trust staff newsletter circulated electronically and by mail

featuring service developments, departmental information, membership information and governor activities/calendar of events;

The Trust’s website, members’ page; ‘Medicine for Members’ seminars, attended by 147 members in 2017/18 on topics

including Sepsis, Liver Disease and AAA Screening; Governors attend local community groups to engage directly with members.

6.3 Membership strategy

In 2017 we again focused on young members, visiting local schools and engaging them in the Trust’s second successful careers event held by staff. This strengthened our relationship with local schools. We also held our first Annual Trust Open Day in November 2017 with over 150 members visiting a number of information stands, with staff from across the hospital showcasing their services and skills.

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1 2 3 4 5 6 7 8

1

Join up care across primary, community and acute settings

1. Delivery of Community Transformation Plan to planned timescales. 2. Roll-out of agreed Trusted Assesment process and documentation across clinical teams in line with 18 month plan.3. Development of discharge to assess model

y y y

Associate Director, Community Services

2

Promote health by delivering our 'Make every contact count' plan.

1. Complete mapping of MECC activity within Trust2. Agree MECC plan3. Additional measures in place for health promotion areas other than alcohol and tobacco

1. Patients receiving alcohol brief interventions / signposting2. Patients receiving tobacco brief interventions / signposting

y

Director of Nursing, Midwifery and Quality

3

Improve patient flow through our wards by embedding right place, right time care.

1. Roll-out of SAFER/red-green approach2. Assessment / plan for further 7 day staffing 3. Arrangements to monitor and manage patients with a length of stay of >7 & >28 days 4. Development of front of house geriatrican interface model5. Discharge audits6. Evaluation of 7 day frailty model

1. Reduced length of stay 2. Reduced average bed occupancy levels 3. Reduced rates of emergency re-admissions within 30 days 4. Reduced percentage of critical care patients not discharged within 4 hours

y y y

Associate Director, Medicine

4

Improve our Older Persons Mental Health services in line with agreed plans.

1. Delivery of business cases / improvement plans to agreed milestones, including improvements to staffing, estate & informatics as detailed in business case

1. Assessment against CQC standards for OP MH inpatient & community services y y

Associate Director, Medicine

5

Treat physical and mental health 'as one' with parity of esteem, by improving the availability of mental health support and expertise across our services.

1. Implementation of mental health screening questions and associated training2. Completion of Trust-wide training needs analysis, 3. Implementation of identified training requirements 4. Protocols in place to use IT systems to identify patients with known / current mental health issues that are presenting to QEH5. Delivery of the A&E CQUIN. 6. Review of quantity and quality of referrals to liaison psychiatry and associated response

y y

Medical Director

Trust goalsIn 2018-19 we will work to: Milestones that will demonstrate progress in our work

Measures that will demonstrate the impact of our workNot all objectives have existing measures we can use to guage impact. These will continue to be developed in-year

Responsible Director

Trust 2018/19 ObjectivesAppendix 1

1 2 3 4 5 6 7 8

6

Deliver national access standards and plan to reduce the time taken to diagnose or give the all-clear following a cancer referral.

1. Develop measurement of 'diagnose within 28 days' emerging cancer standard 2. Develop options to increase speed of diagnosis for required tumour sites

1. A&E 4 hour2. Cancer 62 days 3. RTT4. Diagnostic standards

y y

Director of Strategy & Transformation

7

Implement our patient experience and involvement plan.

1. Implement our patient experience and involvement plan2. Introduce mental health and community surveys

1. National patient experience benchmarking Y

Director of Nursing, Midwifery and Quality

8

Continue to improve our patient safety culture and reduce avoidable harms

1. Undertake Patient Safety Culture Assessment (MapSaf)2. Delivery of integrated learning report3. Implement new national guidance for serious incidents and never events4. Increase Human Factors training 5. Deliver programme of patient safety campaigns including pressure damage, falls, sepsis, delirium, mortality; nutrition and hydration, medication errors, gram negative organisms

1. Incident reporting rate2. Achieving and sustaining 80% target for mortality reviews

y

Director of Nursing, Midwifery and Quality; Medical Director

9

Reduce unwarranted variation in clinical practice and work to deliver 7 day services

1. Presentation of action plans to Safe Care Council from specialties who have received GIRFT review2. Delivery of actions arising from services examined under GIRFT in previous year.

1.7 day services audit outcomes against priority standards y

Medical Director

10

Build our quality and service improvement capacity to support our teams to improve care while reducing waste

1. Re-launch of Gateshead Lean improvement methodology including plan and governance 2. Delivery of refresher training for previous certified leaders and training to develop new certified leaders 3. Development of RPIW Programme and delivery of 6-8 improvement events

y y

Medical Director

11

Deliver the People Strategy work plan, including developing a plan for our future workforce, using information to drive performance and introducing values based recruitment.

1. Healthroster implementation as per plan2. Embedded ESR manager self-service3. Value Based recruitment introduction

1. Selected staff survey and workforce metrics

y y y

Director of Strategy & Transformation

Responsible Director

In 2018-19 we will work to: Milestones that will demonstrate progress in our work

Measures that will demonstrate the impact of our work

Trust goals

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1 2 3 4 5 6 7 8

12

Transform through Health Informatics, making progress towards delivering digital healthcare by 2021

1. Implement our Global Digital Exemplar Fast Follower Plan, milestones as per GDE funding agreement

y y

Director of Finance & Informatics

13

Meet the Trust's financial requirements, hitting our control total by reducing costs and improving efficiency

1. Quarterly review of Monitor plan against actual to inform receipt of the STF. 2. Achievement of CRP, monitored monthly. 3. Meeting monthly spend profiles as set out in plan

1. Financial position against plan2. Efficiency of Trust as measured through model hospital metrics y

Director of Finance & Informatics

14

Plan a sustainable future for all services including collaborative models as required

1. Robust winter plan in place 2. Written plans developed and implemented for each service in line with collaboration discussions taking place across the STP and with NUTH. To include delivery of: - Existing breast expansion agreement- Pathology commercial plan - Approval/implementation of revised pathway for Vascular services in collaboration with NuTh- Maternity growth in light of South Tyneside pathway changes

y y y y

Associate Directors

15

Integrate our information and reporting of operational, financial, workforce and quality metrics to strengthen assurance and decision making.

1. Production of integrated service line reporting packs. 2. Introduction of integrated Board report3. Development of data quality assurance across indicators

y

Director of Strategy & Transformation

16

Develop the Gateshead Health and Care System with our partners

1. Cross-system workshops to develop local system proposals2. Proposals to boards of organisations3. Alignment of system development work with CNE ICS discussions

y y y

Director of Strategy & Transformation

In 2018-19 we will work to: Milestones that will demonstrate progress in our work

Measures that will demonstrate the impact of our work

Trust goals Responsible Director

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