Community trust’s model behaviour (#DoingOurBit)

by Steve Brown

10 June 2020

Matt Miles, as senior business partner at Lincolnshire Community Health Services NHS Trust, would usually spend his time supporting clinical teams to understand activity and cost data to help them improve services. But during the Covid-19 pandemic he has turned his analytical abilities on to the more pressing issue of understanding the resources the trust might need to meet virus-related demand.

All trusts need to understand whether they have sufficient capacity – or can put that capacity in place – to meet current and future demand. But the speed of infection and subsequent hospitalisations under Covid-19 has meant that trusts have had to develop this understanding rapidly, with only limited experience of exactly what impact the novel virus might have.Doing our bit_Matt Miles portrait

‘Our acute partner – United Lincolnshire Hospitals NHS Trust – had national information to help it to model demand and capacity,’ he says. ‘So it had information to indicate typically how many patients might need to be hospitalised and, of those, how many would need critical care.’

But there was no comparable information to help community trusts to understand exactly how the virus might impact their services. What would they need to meet demand – both in terms of physical infrastructure and human and other resources?  

A number of staff from the finance and business intelligence directorate were quickly redeployed, as the Covid-19 pandemic hit the UK, to support the trust’s incident command centre (ICC). Mr Miles (pictured) was asked to work as part of the joint finance and informatics cell, which subsequently morphed into the central intelligence cell.

One of its chief roles was to co-ordinate the trust’s submission of the daily sitreps, setting out the trust’s specific Covid-19 status. But – with no dedicated capacity planners at the trust, this daily task was added to with the request for support on modelling.

‘We needed to work out – starting with the acute trust’s expectations for the number of patients being discharged into the community – how many would come into our hospital beds, how many might need support from community nursing and how many would not need support,’ says Mr Miles. ‘We just tried to model based on different assumptions and the actual numbers of admissions and discharges from the acute. Doing this helped us to plot our community nursing staffing needs and case load numbers.’

Before Covid-19, the trust had 102 beds spread across six wards in four community hospitals. Its initial response to the request to expand capacity led to a target of having 140 beds open for patients. However, as the outbreak has developed and the trust has seen both the local and national trends in terms of the demand placed on health services, it has been able to scale this back.

Modelling the required bed capacity, alongside joint system work streams to rapidly improve discharge processes from both community and acute hospitals, means that the trust is now looking at a minor increase of just two additional beds, with the potential to open up to 122 if a second wave makes that necessary.

‘Initially everybody was on high alert the whole time,’ says Mr Miles. ‘We redeployed everyone as much as possible and retrained people for different roles to ensure we had the capacity. But we needed to get to a point where it was more sustainable.

‘Looking at our beds and our community nursing numbers, our aim was to ensure that our current team could manage the forecast amount of patients and, if not, to decide what more resources we would need,’ he adds. This could have involved using extra bank staff and increasing the bank pool or recruiting extra staff where possible – processes that often need time to deliver results.

The modelling has helped give the trust confidence that it does in fact have the resources based on current assumptions to meet demands placed on it in the coming months. Mr Miles says his costing background – with a good understanding of the resources involved in delivering the trust’s various services – helped him with his modelling role. However, he also says that having other finance colleagues in the central intelligence cell meant the team was good with numbers and comfortable with spreadsheets and data manipulation. An informatics colleague with a mathematics- and statistics-focused degree also proved a real asset.

There have been a few surprises along the way. For example, the trust’s peak in community nursing demand came before the peak in demand for its community hospitals – with demand starting to fall off at a time when the trust expected it to keep increasing. Having the modelled scenarios enabled the trust to track against these daily and make adjustments to staffing numbers once patient demand patterns crystallised.

Following central guidance, the trust also suspended or reduced a number of services, with remaining services focused on the most urgent cases and a major expansion of virtual consultations. In the early part of 2019/20, the trust was implementing video consultations as an option for clinical service delivery, where there was generally a limited uptake (on average around six per month). However, in the three months since March it has done over 2,000 e-consultations. The trust is keen that this change is hardwired into service delivery post Covid-19.

While reducing services helped to ensure the trust could focus on more immediate demands, the task now is to look at reinstating or expanding these activities back to the pre-Covid-19 levels. ‘We are going through discussion now about planning for business as usual,’ says Mr Miles. ‘Some services didn’t step down, but of those that did scale back – including allied health professionals, children’s services and our specialist services – we need to understand what the implications are.’

This involves knowing where redeployed staff are currently working and how services could be delivered safely while the trust retains its ability to care for patients on a Covid-19 pathway, as well as retaining the ability to scale up Covid-19 capacity again if necessary.

‘Personal protective equipment (PPE), workforce and estates are the really big factors to consider,’ says Mr Miles. ‘Have you got sufficient PPE to see all the patients, do you have the staff and is the estate compliant and fit for purpose?’

Clinicians are understandably keen to restart comprehensive services although the trust is still working through exactly how many beds it can allow to be occupied by non-Covid-19 patients and the segregation that needs to be followed for different pathways.

Just over half the 15 strong finance team have taken on a role supporting the trust’s emergency response structure, leaving a core finance team to successfully deliver the year-end accounts submission and audit to the original deadlines, in addition to supporting core duties such as ensuring new PPE suppliers were checked and paid promptly. As with most trusts this year, these processes have been delivered while working remotely.Doing our bit_Simon Burrows portrait

However, the trust has also found an innovative way to communicate and update the key messages from its month one reporting – recognising that face-to-face meetings with budget holders were not going to be able to happen. Simon Burrows (pictured), head of financial accounting, although currently supporting the trust as part of the tactical silver response role, explains.

‘Primarily, as a team, we wanted a way to say thank you for collectively landing the 2019/20 position,’ he says. ‘But we also wanted to recognise that these are uncertain times. We know that people may have heard about the suspension of contracting and pausing of efficiency requirements, so we just wanted to explain what this means for them as budget holders.’

The team decided the best way to deliver this message was using a short animated video featuring trust finance director Sam Wilde, in the first of what is likely to be a series of #Sambites episodes.

The video simply underlines that budget holders just need to keep doing what they have done previously, while providing the latest information on the approach to income and efficiencies. The key principles outlined were that budget managers should commit costs within budget levels, ensure value for money, review budget statements, adhere to standing financial instructions and flag up any increased costs incurred resulting from Covid-19 changes in delivery.

Mr Burrows says the short video just helps to remind budget holders that the finance team is still there to help, even if it is now more dispersed and not able to visit clinical teams. He recognises that there will need to be a transition back to business as usual, both clinically and in terms of financial control. Maintaining our effective relationships with budget holders is the best way to prepare for the resumption of efficiency requirements and whatever contracting, financial control and monitoring mechanisms are put in place as the year develops.