Background.. 3. NHS National Waiting Times Centre Board (NWTCB) and HEAT Targets 3. The Local Delivery Plan and Financial Challenges 3

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2 Index Page Background.. 3 NHS National Waiting Times Centre Board (NWTCB) and HEAT Targets 3 The Local Delivery Plan and Financial Challenges 3 Local and relevant national HEAT targets Activity and capacity... 5 Beardmore Hotel and Conference Centre 11 Clinical Strategy...13 Beardmore Centre for Health Science. 19 NHS Scotland Objective 1 Health Improvement Early Cancer Detection Lung Cancer 21 NHS Scotland Objective 2 Efficiency and Governance Improvements Reduce Carbon Emissions 24 Reduce Energy Consumption. 24 NHS Scotland Objective 3 Access to Services Delayed Discharge. 26 NHS Scotland Objective 4 Treatment Appropriate to Individuals MRSA/MSSA bacterium:.. 28 C.diff infections

3 NHS National Waiting Times Centre Board (NWTCB) Background The National Waiting Times Centre Board (NWTCB) is an NHS National Board. In 2011/12, we planned to carry out a total of 21,401 inpatient, day case and diagnostic imaging examinations. It is expected that this total will be achieved. The range of services includes: orthopaedic, general, ophthalmic and plastic surgery, bariatric and spinal surgery, minor procedures, endoscopy and diagnostic imaging. This number excludes the heart and lung activity, which is measured through our performance management process. The Board also manages the Scottish National Advanced Heart Failure Service (SNAHFS), the Scottish Adult Congenital Cardiac Service (SACCS) and the Scottish Pulmonary Vascular Unit (SPVU) which are commissioned by the NHS National Services Division (NSD). The theatre suite at the Golden Jubilee National Hospital (GJNH) consists of a total of 15 theatres including one outpatient theatre. Currently six of the inpatient theatres are assigned to the cardiothoracic programme, five to the orthopaedic programme, and three theatres are used flexibly for general and plastic surgery. The existing outpatient theatre reception/waiting area has been redesigned to enhance patient flow and provide improved same-day admission space for minor procedures. This will deliver a level of future-proofing for developments that may emerge from the Clinical Strategy programme. Patients can be referred to the hospital by their NHS Board for cardiothoracic surgery, diagnostic and interventional cardiology, orthopaedic surgery, diagnostic procedures (X-ray, MRI, ultrasound etc.), plastic surgery, eye surgery, endoscopy procedures and other general surgery. We are also the only NHS Board in the UK to have a hotel on site. The Beardmore Hotel and Conference Centre is a four-star facility specialising in conferences, meetings and training courses at special rates for the public sector. National Waiting Times Centre Board (NWTCB) and HEAT targets As a national centre, GJNH receives referrals from all Scottish NHS Boards to enable patients to be treated within the timescales set by the Scottish Government. The Board is also responsible for a range of regional and national heart and lung services. The NWTCB, in discussion with the Scottish Government Performance Division, has agreed a reduced number of Health, Efficiency, Access and Treatment (HEAT) targets, to reflect where it has no direct control to influence that target. It is acknowledged that this situation is under continuous review. The NWTCB is committed to reviewing the relevance of all HEAT targets together with Government colleagues for subsequent Local Delivery Plans (LDPs). The Local Delivery Plan and Financial Challenges Delivery of the Local Delivery Plan and the three year financial plan is based on the planned achievement of all three key financial targets. It is apparent that given the high levels of efficiency targets described in these plans, this period will be very challenging. In particular a number of these projects are dependent on our ability to review and reorganise staff. This may prove difficult where management of the associated human resources issues is constrained by policy. Where these challenges relate to national policy issues, this will require Boards to work in partnership with the Scottish Government to seek resolution. It is also critical that a tighter financial environment requires significant control of expenditure and more emphasis on redesign and delivery of savings for internal investment. This is being progressed through the Board s management teams and we are committed to working through these challenges in partnership with the Board s Partnership Forum. 3

4 The local and relevant national HEAT targets agreed for this Local Delivery Plan (LDP) are as follows: Local targets and priorities L1 Activity and capacity L2 Beardmore Hotel and Conference Centre L3 Clinical Strategy L4 Beardmore Centre for Health Science 1. Health Improvement 1.1 Early Cancer Detection Lung Cancer 2. Efficiency and Governance Improvements continually improve the efficiency and effectiveness of the NHS 2.1 Reduce carbon emissions/ Reduce energy consumption 3. Access to Services recognising patients need for quicker and easier use of NHS services 3.1 Delayed Discharge 4. Treatment Appropriate to Individuals - ensure patients receive high quality services that meet their needs. 4.1 MRSA/MSSA Bacteraemia/ Clostridium difficile infections 4

5 L1 Capacity Planning and Activity for 2012/13 NWTCB strategic lead: June Rogers, Director of Operations The planned activity target for 2012/13 includes capacity for: orthopaedic joints, orthopaedic other (intermediate and minor procedures), general surgery, plastic surgery, spinal surgery, bariatric surgery, ophthalmology, endoscopy and diagnostic imaging. Based on the requests received from referring Boards to date, we will be working towards a total of 22,550 procedures (7,756 inpatients/day cases and 14,794 diagnostic imaging examinations). These numbers exclude activity associated with the Heart and Lung programme which will be managed under waiting list management arrangements and monitored through the Board s Performance and Planning Committee. L1.1 Orthopaedic surgery Orthopaedic expansion Orthopaedic surgery was again in high demand throughout 2011/12, particularly in the fourth quarter of the year. We increased orthopaedic capacity at GJNH in response to the numerous demands that were being made on the service. The Access Support Team made a request for us to explore the possibility of expanding our orthopaedic service by a further 300 joint replacements per year in 2012/13. This expansion represents a significant step up in staffing levels at GJNH. An outline proposal was prepared and presented in December However, requests received from Boards are not currently demonstrating a requirement for this level of increase. We will work on the assumption that flexibility may be required as we progress through the year. NHS Dumfries & Galloway have taken advantage of the GJNH see and treat orthopaedic service for the past three years. This is a process that has been refined over that period of time to the satisfaction of the referring consultants, the GJNH consultants and more importantly the patients. This year, four Boards have requested their orthopaedic patients be seen on a see and treat basis. Approximately 4,300 orthopaedic patients will be seen under this arrangement. The benefits of the see and treat model of care have been tried and tested and benefits have been demonstrated for both patients and referring Boards. These include: High levels of patient satisfaction Reduced waiting times Single pathway of care Reduction in duplication of clinical time Reduction in duplication in administrative processes L1.2 Orthopaedic telehealth clinics Currently a number of NHS Orkney patients are referred to GJNH for orthopaedic surgery via NHS Grampian. There is a requirement for patients to be followed up six weeks post-operatively for knee replacements and 12 weeks for hip replacements. Additionally, there is a requirement for patients to be followed up after one year and then subsequently five years post surgery. Follow up at GJNH is typically carried out by the Orthopaedic Arthroplasty Service which consists of specialist nurses and physiotherapists, with the involvement of consultants as required. 5

6 NHS Orkney expressed concern about the requirement for patients to fly to Glasgow, which in turn incurs an overnight stay, a great deal of travel expense and inconvenience to the patient attending an outpatient appointment. In response to this concern GJNH staff explored options around alternative follow up arrangements. At this point in time the use of telehealth/video linking was thought to be the most effective replacement for face-to-face consultation. Through collaborative working between GJNH and NHS Orkney a process was defined and trialled with patients who all reported a very positive experience. Telehealth clinics for patients from NHS Orkney are now the preferred model for both patients and clinicians. It is expected that in 2012/13 this model will be rolled out to other Boards whose patients experience similar travelling challenges. L1.3 General surgery The availability of a general surgeon 24 hours a day, seven days a week is a prerequisite to support the cardiothoracic programme. It is important, therefore, that general surgery continues to be part of the plan for GJNH. Currently, this service is provided by visiting consultants; the rota is fairly complex and when compounded by the fluctuation we experience in referral flows, this can be a very challenging service. L1.4 Bariatric surgery The National Planning Forum (NPF) commissioned an Obesity Treatment Review which was completed and presented to Board Chief Executives in September Subsequently a short life working group, including representation from GJNH, has been convened to review service provision in the West of Scotland and to examine options for extending capacity in line with the NPF recommendations. While the review was being undertaken, an interim agreement was reached that GJNH would develop a bariatric surgery service for patients from NHS Dumfries & Galloway and the Argyll and Bute catchment area of NHS Highland. By the end of the current financial year 36 patients will have received bariatric surgery at GJNH. L1.5 Ophthalmology GJNH have a full time Ophthalmic Surgeon who has the capacity to deliver 1200 procedures per year. This number is based on the assumption that all referrals will be for cataract surgery. During 2011/12 an agreement was reached with NHS Orkney to supplement the ophthalmology service they currently receive from NHS Highland. The GJNH Ophthalmic Surgeon will provide an outreach service approximately four times per year, at which time he will remain on the island for three/four days to carry out outpatient clinics and theatre lists. The first visit to Orkney took place successfully on 16 th September The expectation is that this arrangement will continue throughout 2012/13. In 2011/12 there were requests for only 30% of the ophthalmology capacity available at GJNH. As we progressed through the year the service became increasingly in demand for both outpatient and surgical capacity. Meeting this demand has presented many operational and workforce challenges, however, by the year end we expect to have exceeded 1200 procedures. L1.6 Plastic surgery We have theatre and ward capacity to deliver 600 inpatient plastic surgery procedures and up to 1000 if cases are local anaesthetic day cases. Surgeon availability has not been as 6

7 challenging in 2011/12 as has been the case in previous years. Referral rates also improved this year and the expectation is that this pattern will continue into 2012/13. Further capacity can be created if referring Boards give longer term commitments to activity. L1.7 Endoscopy As for all other procedures, Board requirements for endoscopy in 2012/13 are not yet clear. There is potential to increase this service if Boards are prepared to commit to referrals on a long term basis. At the beginning of 2011/12 the National Waiting Times Centre received requests to provide only 500 procedures. However, by the end of March 2012 we expect to have received and treated approximately 45% more patients than expected at the beginning of the year. We will continue to respond to our referring Boards pressures, however, a more predictable and long term workflow would demonstrate a more efficient and effective use of GJNH capacity and would subsequently demonstrate more benefits to referring Boards. L1.8 Spinal surgery Over the past year visiting spinal surgeons carried out outpatient clinics and surgery on patients referred from NHS Lanarkshire and NHS Ayrshire & Arran. Surgery has now been completed on all patients referred. While this work was ongoing, the NPF commissioned a review of spinal services to understand pathways and capacity. Subsequently, a regional sub group was formed to give consideration to implementing the recommendations contained in the report. While it is not yet clear whether GJNH will continue to be involved in the delivery of spinal surgery, we have representation on the group. L1.9 Management Delivery and Improvement Capacity requests have not been received. Inability to meet projected activity targets. Boards may not require all the capacity we can offer here. Services may not be delivered if longterm commitments are not realised. Management of Letters have been sent to Boards requesting that they complete and return a template detailing their requirements for 2012/13. This will be followed up on a weekly basis until requests have been received and capacity allocated. Face to face discussions between GJNH and Boards have been held at which time requirements for the capacity at GJNH were discussed. As has been the pattern in previous years, this encompassed both short term (2012/13) and longer term arrangements, i.e. three year arrangements. There are challenges in securing longer term utilisation from referring Boards as funding for utilising GJNH activity is currently allocated on a yearly basis. Additionally the current financial climate is encouraging Boards to develop services locally before giving consideration to utilising GJNH. A proposal has been prepared and submitted outlining an alternative funding mechanism for GJNH which is likely to improve planning and utilisation. A series of meetings have been held with Boards at which time their long term requirements will be discussed (we will aim to achieve three year 7

8 agreements). Engagement with Boards regarding our five year Clinical Strategy will also maintain this as a high priority. Workforce Availability of visiting surgeons to provide the service that is being offered to the Boards. Our dependency for plastic surgery, general surgery (including appropriate sub specialty consultants) and endoscopy depends on the availability of visiting surgeons. Long term sustainability of referrals prevents us from recruiting full time specialists in these areas subsequently the dependency on visiting consultants continues. Sustainable referral flows in ophthalmology to keep our full time Ophthalmic Surgeon fully occupied. Availability of radiologists to support the service at GJNH due to the impact of SLA reassessment at host Board. Concerns attached to the provision of appropriate anaesthetic cover due to insufficient staff. Management of General surgery and endoscopy carried out at GJNH is currently provided by a consortium of visiting general surgeons and gastroenterologists. The plastic surgery service is provided by visiting plastic surgeons. Permanent appointments cannot be made due to the short term nature of activity requests. Given that there may be increasing pressures at the home Boards of these consultants their continued availability may be a risk. Close and regular communication with the consultants and their Board is important in managing this risk. See and treat options for cataract surgery will continue to be encouraged with Boards. The opportunity to provide outreach clinics will also continue to be explored. Process in place to recruit substantive Radiologists, although to date this has not been successful. In the short term, re-evaluate elements of the current service e.g. governance arrangements and training programmes. Core general/plastics anaesthetic sessions will be provided through existing job plans, with additional activity resourced through wait list initiative or locum cover. Availability to provide surgical assistants due to reduced availability and changes to Junior Doctors training. Clinical strategy will give long term view of specialties to be delivered enabling substantive appointments to be made. Recruit Specialty Doctors. Recruit Physicians Assistant Anaesthesia. We have three qualified Surgical Care Practitioners with one still in training. These specialist healthcare professionals lighten the burden of the junior surgical staff by assisting the consultant surgeon during surgical procedures. We continue to develop the role and maximise the use of Nurse Practitioners where appropriate. 8

9 Finance 90% of procedures are paid for in advance as per the service level agreement (SLA). If GJNH is unable to deliver the services that have been paid for then Boards may need to be reimbursed for activity not delivered. Management of Quarterly meetings will be held with Boards to ensure referral flows are continuous and consistent. These meetings will also address case mix complexity, particularly in orthopaedics. Referring NHS Boards are required to put in place appropriate planning systems to ensure the SLA represents an accurate prediction of required activity and that this is available to GJNH early enough to minimise delivery risks. Shortfalls in delivering activity or receipt of referrals will be addressed on a monthly and quarterly basis to ensure that the activity paid for by Boards will be met. Review of funding flows model The Board has been asked to consider a review of the current funding model for the monies received from Health Boards for the marginal costs of the waiting times work. This is currently circa 12m per year (excluding the non recurring orthopaedic expansion). The Board is currently developing options for how this funding would be allocated across the Boards. One option would be to use the last three years average activity requests and base the next three years on this model. However, this approach would need to consider fair and equitable access to all Boards particularly as pressure areas can change between Boards on a yearly basis. The specialties where full capacity is not normally requested at the start of the year are primarily ophthalmology and endoscopy. Inevitably though, during the year, Boards request additional activity resulting in an additional cost to the referring Boards. Any change in the funding model would negate this issue. The Board will submit a proposal on a new funding model to SGHD by the end of February Equalities No risks identified Management of N/A L1.10 Redesign - Maximising Capacity and Utilisation During 2010/11 the Board joined the third year of the HEAT target to reduce the percentage of new outpatient did not attend (DNA) rates and achieved a reduction of 35% from 7.9% in April 2010 to 5.1% in March We recognise that there is a need to be efficient in the use of our clinical resources and have continued to focus on improving the rates of attendance at both new and return outpatient clinics and diagnostic tests, as well as maximising the utilisation of our theatre capacity. As part of the 18 Weeks Referral to Treatment (RTT) programme we identified new ways of working to support these improvements including redesigning booking services for specific specialties which has resulted in improved attendance rates. This includes appointing return patients no more than six weeks in advance of their scheduled appointment and the introduction of telephone reminders to patients. In all patient correspondence regarding hospital appointments we highlight the need for patients to confirm their attendance both for outpatient and inpatient procedures. This has led to a reduction in the number of patients failing to attend particularly for general and surgical day surgery procedures. 9

10 We have reviewed the orthopaedic pathways for patients attending from NHS Grampian, NHS Orkney and NHS Shetland and improved the way that they are pre-assessed for surgery. Initially patients attended the Golden Jubilee for pre-assessment on the day prior to their surgery using referral information about the patient s medical history and any existing medical conditions. This led to a number of cancellations for clinical reasons that could have been identified and resolved earlier in the patient pathway. An agreement has been reached with the referring Boards to pre-assessment the patient earlier either at their local hospital or by telephone assessment, depending on the patient s locality. This process has been modified as further lessons have been learned. This has resulted in a reduced number of late cancellations and lost theatre capacity and minimised unnecessary patient travel improving the overall patient experience. We will continue to develop the model and identify further opportunities to both streamline the processes and make them more effective. We recognise that failure to maximise our clinical capacity through patients not attending hospital appointments or late cancellations results in longer waits for other patients and the loss of valuable resources. The improvements introduced have been demonstrated as sustainable. We will regularly review their effectiveness and, where necessary, tailor these to meet the specific needs of our patients. L1.11 Radiology Development - magnetic resonance imaging (MRI) The Board recently approved a business case for a new MRI scanner. Decommissioning of the old scanner started on 6th February. The new scanner will be available by the end of April Due to the latest technology and faster scan times it is hoped that we will be able to increase activity and offer capacity to other health boards for waiting times patients. We will also be able to scan cardiac patients on the scanner. L1.12 Key Performance Targets Target Date December 2012 January- February 2011 April March 2013 April 2012 onwards Milestone Meetings with NHS Boards to discuss capacity requirements to allow delivery of waiting times for 2011/12. Longer term requirements for the use of capacity at GJNH will form part of these discussions. Submit capacity levels for forthcoming year to National Waiting Times Unit (NWTU) Planning and review of activity by specialty for each Board for each quarter Monitor performance against target activity by specialty on monthly basis to NWTCB 10

11 L2 The Beardmore Hotel and Conference Centre delivering value to the public sector NWTCB strategic lead: Jill Young, Chief Executive L2.1 Delivery and Improvement The Beardmore Hotel and Conference Centre has established itself as a leading conference venue in Scotland and a conference centre of excellence for the NHS and public sector. Attaining all key performance indicators during the period since 2006 and making an annual contribution to NHS Scotland, the Beardmore provides a vital support role to the Golden Jubilee National Hospital (GJNH). Total business from the NHS and the public sector increased to 53% in 2010/11 with a forecast of 47% for 2011/12. Primary Market Usage of Beardmore - NHS/ Public Sector 2005/6 2006/7 2007/8 2008/9 2009/ / / /13 11% 21% 36% 41% 43% 53% 47% forecast 40% The current economic environment presents a challenge for the Beardmore. The use of improved management information technology has supported the introduction of defined processes for marketing campaigns and other developments. This technology also provides valuable customer information leading to enhanced customer experience. Work on a new strategy will commence in late The current Beardmore Strategy seeks to consolidate the Beardmore s position as a conference centre of excellence and to increase its role within the NHS National Waiting Times Centre. The current and future strategies will seek to build and consolidate the NHS, public sector and not for profit sector at a minimum of 40% reflecting the challenging economic landscape. The Beardmore continues to support the adjoining Golden Jubilee National Hospital by providing dedicated sleep room provision for clinical staff and accommodation for patients and patient relatives, to facilitate improved patient access to treatment and reduce waiting times. A key initiative to both enhance the Beardmore s standing as a conference centre of excellence and to showcase the venue is the hosting of informative conferences including the e-factor excellence in event organisation. The Beardmore is seeking to increase medical related business from the commercial sector working closely with the new Beardmore Centre for Health Science combined with the expertise and specialities of the Golden Jubilee National Hospital. The audio-visual links to the Cardiac Catheterisation Laboratories (Cath Lab) and theatres, and the conference and bedroom facilities in the hotel together provide a unique package for the medical and healthcare market. The Beardmore Redesign Group has been established to oversee the next stage of the Beardmore Management Review which includes redesign within Food and Beverage, a detailed review of the Front Office including a potential redesign of the reception area, review of Housekeeping Workforce and the proposed introduction of a trainee management scheme to build capacity and provide career development opportunities and succession planning. The group will provide regular reports on progress to the internal Committees and the NWTC Board. The Beardmore has continued to develop and invest in both the infrastructure and in the level of service required to maintain its position as a conference centre of excellence and to meet the needs of the NHS and public sector, as well as not for profit, commercial and leisure customers. The Beardmore continues to attract leisure business, including weddings and the 11

12 Beardmore Health Club and also offers a range of dining options all of which are essential during the quieter non-conference periods. L2.2 Financial implications The financial plan within the approved Beardmore Strategy is based on delivery of a breakeven position year-on-year in addition to making a contribution to the Board s efficiency target. These efficiencies are contained within the Board s efficiency plans for and beyond. L2.3 Workforce planning The Beardmore Management Review examined in detail the financial and workforce framework required to ensure the viability of the Beardmore and delivery of objectives and targets. The next stage of the review will take forward the redesign of Food and Beverage and reviews of Front Office and Housekeeping. The ongoing cost of staff, particularly in our Food and Beverage Department, and the requirement to have an affordable and flexible workforce to meet business demands will continue to be a challenge in 2012/13. In addition to the permanent workforce, the Beardmore uses both casual and agency workers to meet the peaks and troughs of business and to run the business efficiently. These affordable arrangements work well and are essential to the viability of the Beardmore. Any significant change to arrangements in relation to both casual and agency workers would initiate a major cost pressure. L2.4 Management A detailed risk plan forms part of the strategy and identifies areas of commercial risk and the process in place for mitigating these risks. Workforce Failure to meet financial targets due to impact of costs of NHS terms and conditions, including unsocial hours payments and potential changes to the arrangements regarding Casual and Agency workers. Management of Management monitoring and review. Beardmore Management Review and Beardmore Redesign process providing framework for sustainability. Rota management. Utilisation of a flexible workforce to meet additional business needs. Finance Failure to meet financial targets due to decrease in public sector spending. Failure to deliver a flexible workforce to manage the service peaks and troughs. Management of Close monitoring and tracking. Increased flexibility and ability to react. Support from Scottish Government. Diversification into new markets particularly medical, pharmaceuticals, energy. Increased account management. The service model for the Beardmore, as for every other hotel and hospitality venue requires the use of casual workers. If this resource were not available, the hotel would need to consider its financial viability and an overall review of service provision would require to be initiated. The Board approved the continuous use of this flexible business model. 12

13 Equalities No risks identified. Management of N/A L3 NWTCB Clinical Strategy 2010/15 NWTCB strategic lead: Alistair Flowerdew, Medical Director L3.1 Advanced Heart Failure Services The Strategy for the forward vision of the Scottish National Advanced Heart Failure Service (SNAHFS) was agreed with the Scottish Government Health Directorate (SGHD) and approved by the Cabinet Secretary for Health and Wellbeing in December This Strategy describes an integrated approach which will ensure that patients with heart failure throughout Scotland have equal access to a high quality service that provides a full range of appropriate therapeutic options, including heart transplantation, and both long and short term Ventricular Assist Devices (VADs) as a bridge to transplant. It is critically important to recognise that heart transplantation procedures should not be considered in isolation but as one of several options now available for patients with severe heart failure. There has been significant work undertaken in Advanced Heart Failure (AHF) therapies in Scotland. We have identified three key elements in addressing this need. 1) The development of a consistent, equitable, Scotland wide referral pathway for advanced heart failure. 2) A requirement to develop a comprehensive Scottish Ventricular Assist Device (VAD) programme within the Scottish National Advanced Heart Failure Service. 3) Increase the implantation rate of donated organs. The Scottish National Advanced Heart Failure Strategy describes how we will increase the number of heart transplants in Scotland and improve the quality of care for all patients with heart failure in Scotland. The table below describes the number of heart transplants and VADs we will deliver over the next three years. This may increase as the strategy is successfully delivered Increase heart transplants and donors in Scotland The table below shows what we aim to achieve over three year period from /10 actual activity 2010/11 actual activity 2011/12 actual activity 2012/13 planned activity Number of heart transplants undertaken in Total of four heart transplants undertaken in Scotland Total of nine heart transplants undertaken in As at end January, heart transplants undertaken Increase to 11 heart transplants per annum 13

14 Scotland Scotland Number of VADs undertaken in Scotland Total of three shortterm and one long-term in 2009/10. Total of six shortterm and three long-term in 2010/11 As at end January, six short-term VADS and four longterm VADS have been implanted. Maintain six short-term VADs and a total of seven long term VADs United Kingdom (UK) Transplant Review We have submitted evidence on our provision of National Heart Transplant services for NHS Scotland as part of the UK-wide review of cardiothoracic retrieval and transplant services. We have described a number of key actions, which we are working to delivery by March 2012 and beyond. These are described below: Maintain a safe and sustainable cardiac surgical transplantation rota (implantation and retrieval). Increase referrals for heart transplantation. Increase use of potential donors. Increase numbers of cardiac transplants performed. Establish Scotland wide transport service for sick patients with advanced heart failure. Consolidate and expand the VAD programme. Expand existing heart failure research into cardiac transplantation and VADs. Explore transplanting patient groups that are not currently transplanted (e.g. adult congenital heart disease). Continue to prioritise robust and exhaustive clinical governance system. Increased interaction with patient groups. L3.2 Rescue Extracorporeal Membrane Oxygenation (ECMO) We are currently recognised as a centre for Rescue ECMO for influenza patients with severe but reversible respiratory failure. At present we have the experience, capability and capacity to provide safe and appropriate clinical care within a robust governance framework for up to two rescue ECMO patients. Glenfield Hospital in Leicester remains the adult referral centre for Scotland and is responsible for deciding on the best placement of the patient, (Leicester, any of the English ECMO centres, Aberdeen or GJNH) as appropriate. The benefits of ECMO treatment for Acute Respiratory Distress Syndrome (ARDS), especially in the management of younger adult patients with acute respiratory failure secondary to influenza, continue to be demonstrated on an international basis. In the interim, options for the medium term provision of adult ECMO for residents of Scotland are being developed, which will take into account access, clinical evidence and the need to ensure a robust system of care across the UK. In January 2012, GJNH ran a four-day standard ECMO course led by the Yorkhill ECMO team and an experienced adult ECMO consultant from Dublin. This was attended by 10 ICU nurses and two intensivists. This course will produce a cohort of nurses, who after suitable shadowing at Yorkhill, will be able to provide bedside care for ECMO-supported patients without immediate perfusionist support. The training focussed on both veno-arterial (circulatory support) ECMO which supports the Advanced Heart Failure Service at GJNH and respiratory ECMO. 14

15 L3.3 Scottish Adult Congenital Cardiac Service (SACCS) Clinical Strategy Review The Scottish Adult Congenital Cardiac Service based at the Golden Jubilee National Hospital is a nationally commissioned service. The service has been considering its way forward in the future delivery of this critical national resource. The service model described in the strategy review document will provide a clinical network that builds on the expertise from the national centre and provides support to the existing regional services. The key drivers and outcome for this strategic review are: to ensure all aspects of the Quality Strategy are considered the delivery of safe, effective and person-centred high quality care across Scotland; to ensure equity of access to specialist care; and to work with local and regional groups to delivery a high quality patient pathway The strategy will deliver: a shared care model that ensures patients are supported by local provision but can access an expert level of care when required; a clinical Adult Congenital Heart Disease (ACHD) network supported and maintained by SACCS and managed through a governance framework; an improved model of effective communication, education and clinical support to ensure the highest quality of clinical care is provided; a sustainable and improvement model for clinical governance ensuring the highest quality of safe, effective and patient centred care; a structured training programme for current and future cardiologists to secure the sustainability of ACHD care; and clinical input at local ACHD clinics by specialists from SACCS. The Scottish Adult Congenital Cardiac Service has developed considerably since designation as a national service. The unit has been successful in achieving recognition as the national centre for treatment of adult congenital heart disease in Scotland. SACCS and is acknowledged as one of the specialist ACHD centres in the UK. SACCS Service Definitions A key component of implementing the ACHD clinical network will be a re-definition of the specialist service definitions to represent current and future activity. This will be essential to ensure efficient use SACCS, to safeguard activity and allow appropriate resourcing to meet the rapidly growing demands placed upon the service. The Strategic Review will recommend that developments in the following four key domains are recognised within the revised designation of the SACCS service: 1. Provision of specialist advanced imaging to include cardiac magnetic resonance imaging (MRI) and Computer Tomography (CT) and congenital cardiac catheterisation: Imaging modalities such as Cardiac MRI play a central role in the assessment of adult congenital heart disease. The performance of such techniques in the setting of ACHD is highly specialist and requires high case numbers to maintain expertise. Similarly, the techniques and expertise involved in congenital cardiac catheterisation fall beyond the experience of most general cardiologists. Both of these techniques are currently recognised to be national roles and need to be reflected within the service definition. 2. Comprehensive multi-disciplinary assessment of adults with congenital heart disease to define an individualised management care plan: The initial service model was dependant upon the referral of patients for congenital surgery and 15

16 catheter intervention from other units. It has become clear that the identification of patients requiring intervention requires specialist assessment tools such as cardiac MRI and cardiopulmonary exercise testing and multi-disciplinary review. Only SACCS can currently meet all of these requirements and referral for assessment has become usual practice. The consequence of this approach is a major increase in their workload that is not recognised within the current service definitions. 3. Participation in shared care arrangements with local services: The Service Level Agreement allows for specialist review of patients as part of a shared care agreement with their local centre. The reality is that a much greater number of patients require shared care than was initially anticipated. Many patients require serial specialist assessment with intervals varying from one to five years and this should form the basis of the national component of their care. 4. Support of local ACHD services: It has become clear that participation in outreach services is important to maintain quality of care and strengthen clinical links between units. The strategy for delivery of care in ACHD recognises this role as a central role for SACCS and work will be undertaken to assess the resource requirement to facilitate this local support. In delivering this strategy, the National Services Division as commissioners of the service, have approved additional resources to enable this to commence. L3.4 Transcatheter Aortic Valve Implantation (TAVI) Aortic Stenosis (AS) is the most common form of acquired valvular heart disease. When patients become symptomatic they require urgent aortic valve replacement. Without surgery the two-year mortality is around 50%. Until recently the only method of replacing the aortic valve was open heart surgery which requires general anaesthesia, cardiopulmonary bypass, post-operative recovery in the intensive care unit, and a 7-10 day ward stay before discharge. The incidence of AS increases with advancing age and frequently occurs in association with other major medical conditions such as coronary artery disease, cerebrovascular disease, respiratory disease, and renal failure. As a result, there is a substantial cohort of patients in whom the risk of Surgical Aortic Valve Replacement (SAVR) is very high. Transcatheter Aortic Valve Implantation (TAVI) is a minimally invasive technique for replacing the aortic valve. It was first performed in 2002 and, since then, has been refined to the point where it can be performed in the catheter lab, percutaneously, under local anaesthesia with a procedural success rate of 98% and an in-hospital mortality rate of 6-7% compared to the predicted mortality of 15-20% if these patients underwent SAVR. In addition, the mean intensive care unit length of stay is 0-1 days versus 6-7 days for conventional surgery and the overall hospital length of stay is 4-5 days versus days. In 2009, NWTCB submitted a full business case to the West of Scotland Regional Planning Group. to establish a TAVI service at GJNH. This proposal was passed to the National Planning Forum for consideration. The current process for access to TAVI was agreed in March 2011 and NHS Boards provide clinical and funding approval on a case-by-case exceptional basis. These patients then have to travel outwith Scotland for treatment. A further review of the evidence and decision from SGHD with regard to the provision of TAVI in Scotland is imminent. Meantime the evidence base for TAVI grows ever stronger. Two randomised controlled trials, both published in the world s leading medical journal, have shown that TAVI is vastly superior to medical therapy in patients with prohibitive surgical risk and at least equal to surgery in patients with high surgical risk in terms of both survival and quality of life. The UK TAVI registry and a separate worldwide registry (SOURCE) have published their results which show excellent outcomes. In total more than 250 original papers on TAVI have been published in the 16

17 past year. As a result of this growing body of evidence the Federal Drug Administration in the USA approved TAVI in December The cost-effectiveness and evidence base for TAVI is being reviewed through a Health Technology Assessment commissioned by the National Institute for Health, the outcome of this review and the other evidence now available is due to be considered by the Cabinet Secretary for Health and Wellbeing. The NWTC currently: has three trained and highly skilled Cardiologists who have extensive personal experience of TAVI having recently undertaken interventional fellowships of at least one years duration in major TAVI centres in London, England, Vancouver, Toronto, and New York. has a multi-disciplinary on-site clinical team who can undertake this procedure. This expertise is already supporting the pre-assessment of these patients within Scotland and performs other complex interventional procedures on a daily basis. has the necessary equipment is in place to perform TAVI (no purchase or upgrade is required). NWTC is one of the largest cardiothoracic surgical centres in the UK. This ensures 24/7 support from cardiac surgeons and cardiac anaesthetists should this be required. We also currently have the skilled specially trained nurses and other clinical staff to support a TAVI programme. manages the Beardmore Hotel which already facilitates the care of a huge number of patients and carers referred from across Scotland. manages three national heart & lung services which not only provides additional expertise and resources but also have in place immediate access to national networks which can be used to facilitate delivery of TAVI. The NWTC has adhered completely to the current position on TAVI, and has ensured that the current agreed referral pathways and authorisation has remained in place. However, we have always advocated that any patient approved for the procedure as an exception should be offered the choice to be treated in Scotland. This is clearly highly cost effective for Boards, and importantly would provide improved quality of care and reduce delay for the patient. L3.5 Management Delivery and Improvement There is a risk that elements of the planned Future Clinical Strategy may not be delivered as a result of national funding and national service delivery constraints. Management of The Board will work with Regional and National Planning Fora and the Scottish Government to ensure that Clinical Strategy outcomes meet the needs of NHS Scotland. Workforce There is a risk that the challenging financial climate will restrict the ability to develop new roles or expand the workforce in developing services. Management of The workforce implications of the Clinical Strategy developments will be fully explored and the Board will seek to develop the existing workforce and deploy staff within services based on a skills, capacity and demand 17

18 analysis. Finance Income required from the Scottish Government to deliver the third year of the SNAHFS strategy is not received Unfunded creeping clinical developments may result from the Clinical Strategy There is a risk that restrictions to capital and revenue spend in the forthcoming years may place a constraint on service developments. Management of The activity associated with the strategy model would need to be adjusted with a cap on transplants and VADs. Patients would be referred to England for treatment. Additional funding options would also be explored through discussion with NSD. It is anticipated this risk would be relatively low given the current controls within the organisation. Any significant service change would be discussed through the National and Regional planning groups. The Board has a robust capital and service planning process and will review and assess the priority of identified service developments. We have also provided a number of staff with enhanced change management and service improvement skills to maximise service improvement within existing resources. Equalities There is a risk that access to some of our developing specialist services will be restricted by referring Boards due to funding constraints. Management of We will continue to work with referring Boards to increase referral levels and seek to develop sustainable referral flows. L3.6 Key Performance Targets Target Date Milestone Autumn 2012 Explore options for sub-speciality Orthopaedic provision March 2012 Delivery of E-Health Strategy supporting clinical service provision April 2012 Approval of the SACCS Clinical Strategy by NSD and NWTCB March 2013 Deliver the planned clinical interventions described within the Advanced Heart Failure Strategy L4 Beardmore Centre for Health Science NWTCB strategic lead: Alastair Flowerdew, Medical Director L4.1 Background The Beardmore Centre for Health Science (BCHS) is unique in that it combines a specialist NHS facility with a purpose-built Clinical Skills Centre and Clinical Research Facility, and a four star hotel. The first course took place in the Clinical Skills Centre on the 9 th May 2011 and the first patient was seen in the Clinical Research Facility in mid July The Centre was officially opened by the Cabinet Secretary for Health Wellbeing and Cities Strategy on the 19 th September The BCHS ensures that staff across NHS Scotland have access to a clinical skills area with inbuilt audio visual links to the Golden Jubilee s theatres, cardiac catheterisation laboratories and diagnostic imaging suite. Within the Clinical Research Facility (CRF) there are four outpatient rooms, a Research Support Office (a hot desk facility for researchers to use while looking after 18

19 patients) and a patient waiting area. The Clinical Skills Centre has five training rooms designed for the following primary uses: manual handling/resuscitation; patient simulation; surgical skills training and corporate training. All rooms are flexible and can be used for a variety of training and meeting purposes. The Clinical Skills Centre is used in the main for training by NWTCB trainers and staff. However, a key objective is to attract clients out with the Board with a charge being made depending on the client type (public or commercial). The venue has already hosted Scotland s first ever training course for doctors on single lung ventilation using a patient simulator. Experts from across the United Kingdom and the United States have also met there to learn innovative techniques for opening blocked heart arteries. The NWTC Board Research and Development Office have to date approved a total of 92 research projects with 23 of these having been completed. Along with the University of Glasgow, the hospital has recently been awarded 3.9M from the Medical Research Council and British Heart Foundation for a study on how to prevent the failure of heart bypass grafts. The Board is required to conform to the Research Governance Framework for Health and Community Care (SGHD 2006) and achieved a Level Three in the last Research Governance Self Assessment Exercise. This is an improvement on our previous level and provides an assurance to the NWTC Board that the research hosted conforms to the quality criteria set out in the Framework. The Centre has entered into a Service Level Agreement with the Royal College of Surgeons to host the surgical and dental examinations for the College through the year. L4.2 Objectives A number of key performance indicators were defined in the business case and form the basis of quarterly reports to the Board s Performance and Planning Committee. These are as follows: Percentage use of the Clinical Skills Centre and the Clinical Research Facility Number of attendees per course New business developed as a result of the facility Income received through external marketing of the Clinical Skills Centre Income for the Beardmore Hotel and Conference Centre Number of research projects and income generated. L4.3 Management Delivery and Improvement Failure to secure business from external users. Management of Develop close working relationship with key users. Aggressive marketing of venue. Robust scrutiny of management information. Workforce The Centre Management Team comprises three full-time individuals: Research and Development Manager (Centre Lead); Centre Manager, and an Administrator who provides support Management of The Centre Management Team will establish operating policies and procedures. Working arrangements and weekly team meetings will enable members of the team to carry out the essential requirements of all roles. 19