DRAFT version3: 18 th November 2015

Transcription

1 DRAFT version3: 18 th November 2015 NoSPG Regional Clinical Strategy Report from the Clinical Stakeholder Event held 30th September 2015 Woodhill House Aberdeen 1

2 Background context The NHS in Scotland is going through a period of unprecedented change. Our population is getting older and while patient expectation of services is increasing, our ability to meet these increasing demands is being compromised by difficulties in recruitment and financial constraints. The Scottish Government 20:20 Vision for the future of health and social care in Scotland emphasises the need to change the way we care for our patients. Many feel that the NHS in Scotland cannot survive without change. Maintaining the status quo in health and social care is not an option. And we need to start discussing and planning for change now Shona Robison, June 2015 The expansive geography and relatively low population within individual Health Boards has always made it challenging to deliver and sustain high quality health and social care services across all parts of the north of Scotland. Through collaboration between Health Boards, over 25 regional networks have been developed to support a wide variety of clinical services. Very often the impending collapse of a service or a directive form the Scottish Government has been the catalyst for forming such networks and only a minority have developed as part of a long- term strategic planning process. For some services, the evidence increasingly suggests that a critical mass of patients is required to provide optimal care (i.e. specialist cancer surgery, trauma) or to justify the purchase of expensive equipment (i.e. robotic surgery). The provision of sustainable services to this critical mass of over 1 million patients can only be met if all Health Boards in the north work together. Nationally the Shared Services work has identified infrastructure and health support services which may benefit from national and regional models. Underpinning this work is the need to support a health service increasingly working across boundaries and recognising the benefits of planning patient pathways without being tied by traditional boundaries. Due to the above reasons and in order to ensure that we use our valuable staff and resources in the most efficient manner, the Chief Executives from the six north of Scotland Health Boards, at the North of Scotland Planning Group (NoSPG) Executive, discussed and approved the need for the development of a Regional Clinical Strategy, as proposed at the NoSPG Annual Event in November The timing of this fits well with the work being carried out nationally by NHS Scotland with the development of a National Clinical Strategy led by Dr Angus Cameron and local clinical strategy in territorial boards. The development of a North of Scotland Regional Clinical Strategy offers us the opportunity to prospectively plan and deliver services where issues of critical mass, safety or clinician availability mean that a regional solution is the most viable option. This regional solution may not even follow identified regional boundaries but be the most appropriate geographical configuration of the service based on a number of factors (volume, workforce availability etc). It is incumbent on us to collectively plan and deliver these services in the north, reducing duplication and delivering the safest service as close to home as possible. In developing a Regional Clinical Strategy, the aim is to have a full and open discussion with clinicians, planners, Chief Executives and other key decision makers. The Regional Annual Event will be contributing ideas to the Regional Clinical Strategy through patient story workshops, and plenary 2

3 sessions contributing context. The NoSPG Executive on 16th December will get an update on progress and the aim will be to have an early draft of the Strategy itself coming together in early The initial part of this dialogue was a clinical stakeholder event which was held at Woodhill House, Westburn Road, Aberdeen on the 30 th September The event provided the opportunity for clinical leaders from across the professions and Boards, and around 6 people nominated by their Board Chief Executives, to come together and think differently about health services in the North. The event was designed and supported by a group drawn from the NoSPG, the National Leadership Unit (NLU) in NES and Board Organisational Development Leads. (Appendix 1) On the day, 35 participants (Appendix 2) came together with the planning and design group for a whole day event to think creatively and innovatively about future delivery of services in the North of Scotland. The purpose of this report is to capture the thinking from the day in the form of themes drawn from the discussions. The intention of the report is not to analyse or censor the thinking but to ensure that ideas have been captured. Having checked the content for additional input from the attendees, this report will then feed into further discussion and drafting of a Regional Clinical Strategy at the Annual Regional Event on the 25 th November and the NoSPG meeting on the 16 th December. Introduction to the day and scene setting The day was introduced by Cathie Cowan setting out the background context to the day; the importance of challenging the status quo and the need for change and encouraging contribution. The fit of this day with other events and the development of the regional strategy was also set out. Angus Cameron was present for the whole day and he led a brief session to update participants on progress with the National Clinical Strategy and themes which are emerging from the engagement. The intention of the National Clinical Strategy is that it is both transformational and credible with the public, with clinicians and with politicians. High level themes from the work so far include the following: Need for more changes in primary care Requirement to review processes in secondary care to become more efficient, effective and focussed on the patient s journey Need for structural change including centres of excellence for complex conditions Need to plan our services on a population basis to ensure that we get better outcomes for people - thinking about regional services Importance of integration between health and social care delivering transformational change focussed on improved outcomes for people Shift from biomedical models of care to more social models 1 Text drawn from the briefing paper for the event authored by Cathie Cowan and Michael Bisset and circulated 24 th August

4 Development of a new clinical paradigm - shift away from over diagnosis and intervention to focussing much more on having good conversations with patients and families and understanding what the patients preference is less is more Following Angus input Michael Bisset set the scene for the day highlighting the following_ The day is about thinking together, listening to each other without judgement and generating possibilities Participants in the room were from a variety of clinical backgrounds and levels in the organisation and this had been deliberate to encourage fresh ideas There was no such thing as a daft idea- all ideas are welcome Ground rules around sharing the outputs from the day but operating under a Chatham house rule was agreed Importance of ongoing contribution after the event Bringing the voices of our patients and staff into the room. In preparation for the event a vox pop had been prepared. The vox pop gathered together a collection of diverse opinions from asking a random sample of staff, patients and families/carers about their experiences of health care in the region. The vox pop was played on the day and then the participants were asked to reflect on what they had heard; how they could use what they had heard to stay focussed on the needs of the people in the region as we worked through the day. Thoughts were fed back on post-its from each individual and then themed (with some examples to illustrate) as follows: Communication listening well; sharing information across systems; right information at the right time; informed patients Relationships between staff and patients- speaking up and advocating for our patients; patients and staff understanding each other; Values and behaviours- being brave and challenging the status quo; not being risk averse; mutual respect; trust and confidence in each other Team working- sharing information across teams; working together to help each other focus on the patient; respect each others roles; a sense of team working being diminished / breaking down; undervaluing of the importance of team spirit Caring focus on care not management; who does the caring? Time for care? Time too much time away from patients doing paperwork; taking time to listen and to talk; wanting more time with patients; spending too much time on things that don t seem to add any value Empowerment empowering and valuing staff; feeling pride in our service; empowering from the bottom up to challenge the status quo; empower our patients Patient s journey need to join this up; we need to own the continuity; focus on the person; well planned; pathways Priorities and decision making patient need versus patient want; need to make difficult decisions; need to refocus priorities around patients 4

5 Systems and processes can be helpful and unhelpful; need to stop doing unproductive things; processes have taken over care; staff are disillusioned by processes; too much bureaucracy; systems and processes hold back innovation and improvement Setting up for the rest of the day Hazel Mackenzie led the set up into the rest of the day. A number of inquiry questions had been circulated on the invitation flyer prior to the event. These questions had been clustered into 3 groups. Each group was facilitated using a different OD approach which was appropriate to the question and which would engage participants in a variety of activities. In addition to the 3 planned groups there was one emergent group for any topics on which participants felt they wanted a deeper conversation. There was one such group on the topic of workforce issues. Group 1 Graffiti wall facilitated by Diane McLeish and Gillian Strachan How could we Work across health board areas to continuously improve the quality of clinical care experienced by patients? Redesign and reconfigure our hospital services across the North of Scotland to provide higher quality care? Group 2 Appreciative inquiry facilitated by Anne Inglis and Judith McKelvie How could we. Build on our communities strengths to re-design care across the north of Scotland and promote self management? Promote the health and wellbeing of those who live and work in remote and rural areas? Group 3- dialogue fishbowl facilitated by Sharon Millar and Julie Nicol How could we.. Provide equity of access to all patients across the north of Scotland? Consolidate and expand specialist services for our region s population? Group 4 emergent group workforce How do we attract people to work in the north of Scotland? 5

6 Outputs from the groups Over the day participants had the opportunity to take part in each group for one hour. Participants were encouraged to mix the group that they were as they moved between rounds to ensure that conversations didn t get stuck. The outputs from each group are set out below Group 1 Graffiti Wall How could we. Work across health board areas to continuously improve the quality of clinical care experienced by patients? Redesign and reconfigure our hospital services across the north of Scotland to provide higher quality of care? Round 1 Improve communication between primary and secondary provision and across Boards Break down silos Be proactive as a region and challenge thinking in Boards and SG Explore different ways of achieving balance between centralisation and locally delivered Education is central across the region and between primary, secondary and tertiary care Lots of ideas but how do we effect the change? Round 2 One health board real or virtual physical entity or by collaboration Region should be driven by clinical agenda and common aim Develop and test new systems of care before extending Support and recognise role of generalist Improve communication with patients Train clinicians to work in services as they are/could be provided in North of Scotland Round 3 More clarity required around the problem we are trying to solve Need intelligence around quality of care and regional variation Is rationale for change about quality of care or workforce issues, financial pressures, sustainability? 6

7 Are we committed to working as a region? Are we focussed around population? Should volume be driver for centralisation? Quality is about more than clinical outcomes? 7

8 Group 2 Appreciative Inquiry 1. Define (already scoped out for the event) We want to create a society that prioritises positive health and wellbeing We want to build on our communities strengths to re-design health care across the North of Scotland and promote self management We want to promote the health and wellbeing of those that live and work in remote and rural areas 2. Discovery - Questions What is good and valued about living and working in remote and rural areas for members of the community and health care professionals? What is good and valued about how we currently deliver health care? What do you most value about partners/ stakeholders and their contributions? Themes We have great relationships with our communities, patients, and staff We have the potential, and do deliver continuity of care We have a sense of belonging to, working for, and working with our communities We live, work, and deliver care within wonderful environment We are often Multi-tasking which gives an opportunity to increase and broaden skills We take services out to local areas Some of us work as specialists and some as generalists 3. Dream - Questions Imagine it is 2030 and we have vibrant communities. What would you see that is different from now? at community level for staff? for partners? for health care delivery? Themes Strong vibrant communities, who look after their own (all ages), who are involved in planning for their community and community members, and who are outward looking and forward thinking We will have centres of excellence where those who need that level of care will go, but only for care that can only be delivered there, as pre-work and recuperation will be as close to the community as possible Patients will own their own records equal partners in their own care We will have Specialists, but we need to move (back) to having more generalists. There is a need for clarity about what the role of the specialist is and what is delivered in a specialist area 8

9 We will have the balance right between what we can do and what we should do (just because we can does not mean we should less is more - holistic vs. science ) We will have positive partnership relationships and effective structures in place that support that We will be using technology effectively in all our interactions We will be making less use of hospital and increasing the level of activity we put into preventative care We will have staff who feel valued and who are proud to be in profession and the NHS 4. Design - Questions How can we all support the dream and bring it alive? Themes We need to invest differently... not just from secondary care to primary, but into social care and wider We need to re-evaluate how and what we do, and who does it We need to change mindsets and practices & challenge each other and the public/communities/ politicians etc ( but we need the structures to do this) We need to work with politicians We need to hear all the voices and work with our communities and partners 5. Destiny -Questions What would we need to do to create and then sustain the proposed changes? Themes We need to work with politicians We need to engage effectively with our communities, partners and stakeholders We ourselves need to become the change we want to see Appendix 3 sets out the mind maps that were created for each step of the appreciative inquiry, colour coded for each round. 9

10 Group 3 - Dialogue 1. What can be done to provide equity of access to all patients across the North of Scotland? What equity of access are we aiming for? All three rounds supported the emphasis on providing equity of health and wellbeing outcomes rather than access. Impediments - geography, human resources, time factor, political appetite, transport infrastructure and IT infrastructure contribute to inequalities in remote and rural. A structural solution might be to move to having one Health Board for the North of Scotland Region We all have different interpretations of the terms frequently used (e.g. access, outcomes, interventions). We need to share how each of the stakeholder groups interpret or define terms to understand different perspectives and draw conclusions about levels of tolerance of risk. More honest conversation with the population to manage expectations. Model of care should be tiered up from the population. Support self management. Principle All areas have mechanisms to consider outcomes. Principle New models of care should be tested against the range of impediments and peoples tolerance for risk. Principle If we can deliver National standards locally do it! 2. Which specialist services could we consolidate and remodel to reach our region s population? How does the North of Scotland Regional agenda relate to local and the National clinical strategy? Need to clarify boundaries and responsibilities of different centres and responsibilities to support each other. Need to clarify language e.g. what do we mean by consolidation? Are we consolidating services or interventions? Consolidate does not mean centralise. Evidence (of good and poor outcomes) should frame the enquiry into consolidating and redesigning specialist services (where does it matter/ based on what?) Need North of Scotland Regional pathways and protocols for care. Hold a risk register at Regional level. Pathways need to be easy to follow. Central hub we need to be equipped to support the spokes (education, communications, network of support) Outreach/in reach model clinicians move rather than patients. There are real tensions particularly around follow up. Recruitment and sustainability means moving from specialist services to a robust generalist role. Change is very uncomfortable need to offer support. Clinician s roles and how they perceive their roles needs to change. Network systems of support are essential between primary and secondary care. They are based on relationships which are built on trust. Principle Clinicians share responsibility for all patients in the North of Scotland For photos of the flip charts from each round please contact the National Leadership Unit (NLU) (see Appendix 4). 10

11 Group 4 Emergent group focussing on workforce issues One group emerged over the day to focus on workforce issues. The inquiry question was about how we recruit to post in the North of Scotland? The following themes emerged Provision of island allowance Provide housing Look at variety of experience and bespoke packages Need to think about making the job attractive alongside a package Offer opportunity to work for a period and then move on to something else Secondment / Sabbatical from other Boards for a fixed period Present the opportunities of working in the North Consider support with CPD Other general themes / thoughts which emerged over the day During the day Hazel Mackenzie moved around the groups to capture any general quotes / thoughts. These are summarised below Equity is not just about access, it is something else. It is about equity of outcome. Maybe we should be talking more about that It is hard to talk about what needs to be different when I don t think we even understand what the issues are that we are trying to resolve We don t want everything to be focussed around a medical model, we need to think more radically than that We are limited by our own professional background and silo There is a dynamic about focussing on our own patch- we need perhaps to come together in a different way. We could be much more active about trying out things i.e. an educational trial.trial it in a small way in one area pick something that is troubling us; trial it in a small way as one pathway looking at the whole system.go about it deliberately. It is the notion of redesigning the plane while flying it! I don t know how to think about this differently There is an advocacy about an NHS Board but if we could really think about services for the North of Scotland- through that lens- then I think we would come up with something different /a better solution There will be failures in trying something new.how up for that are we? We are faced with problems that we just can t resolve locally so we need to look collectively How do we shift create enabled communities. In a sense we have disabled our communities so where this has happened how do we shift this back? 11

12 Conclusion to the day Cathie Cowan brought the day to a close by providing some broad reflections. She commented on the high level of energy and commitment over the day and reflected that over the course of the conversations she had not heard anyone suggest that what we currently have will be sufficient to deliver into the future. So a key message to take forward was that there is a pressing need to really focus on what needs to be different. Angus Cameron also provided some reflections from the day. He commented on there being a lot of consistency with the discussions that have emerged in relation to the national clinical strategy. The need for primary care to be taking on a much broader role is emerging. This needs to be focussed on communities and working with partners to do this. And the future will require a big shift in the way secondary care is delivered. There is a strong move away from over medicalisation of care and this is becoming a global conversation. Finally Angus reflected on how much he had enjoyed and valued the day and emphasised that to move forward it was important not to abandon things because they seemed too difficult. Cathie Cowan closed the event by encouraging participants to continue the conversation, hold other events around the questions locally and feed into the discussions. The next steps were summarised as providing a write up and summary of the day and checking this out with the participants by the end of October. A commitment was made by Cathie to ensure that the themes and key messages from this day were fed into the annual event in November and the development of the Regional Clinical Strategy. 12

13 Appendix 1- Membership of the Event planning and design group Cathie Cowan, Chief Executive and Vice Chair of NoSPG Michael Bisset, Regional Medical Director, NoSPG Jim Cannon, Director of Regional Planning Kerry Russell, Associate Director of Regional Planning Emma Watson, Director of Medical Education, NHS Highland Hazel Mackenzie, Head of the national Leadership Unit (NLU) NES Sharon Millar, Leadership Consultant, NLU, NES Gillian Strachan, Leadership Consultant, NLU, NES Anne Inglis, Head of Organisational Development, NHS Grampian Judith McKelvie, Head of Learning and Development, NHS Highland Diane McLeish, Organisational Development Lead, NHS Tayside Julie Nicol, HR Manager, NHS Orkney Sally Hall, Organisational Development NHS Shetland 13

14 Appendix 2 Attendees Regional Cinical Strategy Clinical Stakeholder Event 30th September 2015 NHS Grampian Nick Fluck Medical Director Malcolm Metcalfe Acute Sector Associate Medical Director Paul Bachoo Divisional Clinical Director for Surgery June Brown Jenny Gibb Associate Director of Nursing Associate Nurse Director Royal Cornhill Hospital Mustafa Osman Mike Greaves Susan Carr Manoj Kumar Susan Webb Graeme Smith Duff Bruce Steve Wilkinson Anne McKenzie Consultant Paediatrician Combined Child Health Head of College & Vice Principal College of Life Science & Medicine Associate Director of Allied Health Professionals Consultant Surgeon Surgical Acting Director of Public Health Director of Modernisation Consultant Surgeon Consultant Physician (DCD) AHP Sector Lead, Moray NHS Highland Rod Harvey Paul Davidson Ian Rudd Pat Tyrell Findlay Hickey Medical Director Clinical Director N & W Director of Pharmacy Deputy Director of Nursing Lead Pharmacist NHS Orkney Martinus Roos Alison Hughes Judy Sinclair Paul Cooper Moraig Rollo Wendy Lycett Charlie Siderfin NHS Shetland Ralph Roberts Dr Sarah Taylor Dr Roger Diggle Medical Director Consultant Physician Lead Nurse Lead Clinician/Consultant Anaesthetist Lead AHP Principle Pharmacist Lead GP Chief Executive Director of Public Health/Planning Medical Director 14

15 NHS Tayside Karen Anderson Caroline McQuillian Interim AHP Director Associate Nurse Director NHS Dumfries & Galloway Angus Cameron Medical Director NoSPG Cathie Cowan (Orkney) Mike Bisset Kerry Russell Emma Watson Jim Cannon Sami Shimi Chief Executive Regional Medical Director Associate Director of Regional Planning Director of Medical Education NHS Highland Director of Regional Planning NOSCAN Lead Clinician OD Design/Facilitation Group Hazel Mackenzie Sharon Millar Gillian Strachan Anne Inglis Judith McKelvie Diane McLeish Julie Nicol Head of NLU Leadership Consultant Leadership Consultant Head of Organisational Development Head of Learning & Development Organisational Development Lead (Staff Engagement) HR Manager 15

16 Appendix 3 Group 2 mind maps setting out themes for each stage of the appreciative Inquiry and the rounds (by colour code) Discovery (double click on image to view) Dream (double click on image to view) Design (double click on image to view) Destiny (click on image to view) 16

17 Appendix 4 Group 3 flip chart pictures from each round are available on request from the National Leadership Unit nlu@nes.scot.nhs.uk 17