Review and Redesign of Tuberculosis Services in NHS Lanarkshire

Transcription

1 Review and Redesign of Tuberculosis Services in NHS Lanarkshire Wednesday 18 th December 2013 For information on this report contact: Kate Bell, Senior Manager, Change & Innovation Louise Flanagan, Specialist Registrar 1 P a g e

2 Contents Section Page 1. Background 3 2. Current Services 2.1 TB Services in Lanarkshire 2.2 Epidemiology of TB in NHS Lanarkshire 2.3 Case For Change 3 3. Event Programme 5 4. Presentations 4.1 Key Drivers for Change 4.2 Optimum TB Model 4.3 Patient Experience 5. Approach and Methodology 5.1 Short Life Working Group 5.2 Event Commissioning 5.3 Service Change Project Team 5.4 Stakeholder Engagement 6. Option Appraisal Process 6.1 Options for Improvement 6.2 Groupwork - Part I (preferred clinical model) 6.3 Groupwork - Part II (site preference) 7. Analyses and Scoring the Options 7.1 The outcomes preferred clinical model 7.2 The outcomes site preference Next Steps Evaluation 16 Appendix 1 Stakeholder Engagement Participants 19 Appendix 2 Service Change Project Team 20 Short Life Working Group Appendix 3 Six Dimensions of Care for Tuberculosis Services 21 Appendix 4 Participants Score Card AM 23 Appendix 5 Participants Score Card PM 25 2 P a g e

3 1. BACKGROUND This report summarises the stakeholder engagement workshop to review and redesign Tuberculosis (TB) services in NHS Lanarkshire. In 2011, a Scottish Government Tuberculosis Action Plan 1 was published and NHS Boards were asked to implement a number of actions locally (Scottish Government, 2011). The Plan was published with the aim of ensuring that Scotland provides the best quality clinical, laboratory and public health services in relation to TB, which would ultimately lead to a significant reduction in the burden of ill-health caused by this infection. The successful prevention, control and treatment of TB require a multidisciplinary approach. The National Institute of Clinical Excellence (NICE) guidelines, Scottish Guidelines and the national TB Action Plan emphasise the roles of TB clinicians, specialist TB nurses, health visitors and health advocates and their liaison with other primary care, secondary care and local authority resources. A fully integrated clinical and public health approach is essential if treatment, prevention and control are to be successful. The Lanarkshire Tuberculosis Contact Tracing Service (TBCTS) leads in the planning and delivery of care for individuals in Lanarkshire who are infected with or affected by, TB as well as their carers and contacts. 2. CURRENT SERVICES 2.1 TB Services in Lanarkshire TB services are provided on the three acute sites in NHS Lanarkshire and there is currently no dedicated TB clinic. TB patients can initially be seen by clinicians from any specialty although once TB is suspected they are typically seen by respiratory or infectious disease clinicians. Suspected cases may be identified in primary care by GPs and referred to respiratory and infectious diseases (ID) clinics where a diagnosis of TB is made. In secondary care, patients can present with signs and symptoms that are suggestive of a range of conditions and a diagnosis of TB would be made following appropriate investigations. Patients can also be referred into the NHS Lanarkshire TB service via Glasgow hospitals if the patient is a resident in NHS Lanarkshire. There are currently respiratory and infectious diseases consultants across the three hospital sites that see TB cases. The majority of cases are seen at Monklands with Infectious Diseases consultants seeing a similar number of pulmonary cases. 1 TB Action Plan Scotland, Scottish Government, March P a g e

4 The TB service can receive notifications of suspected cases (based on a clinical diagnosis) and confirmed cases (based on laboratory confirmation). There is no standard patient pathway and no specialist service available within NHS Lanarkshire. This results in variations of appointment frequency, potential delays in diagnosis, length of treatment, follow-up times and drug regimens with the potential to disadvantage some residents and widen inequalities within the service. 2.2 Epidemiology of TB in NHS Lanarkshire The epidemiology of TB in NHS Lanarkshire is fairly similar to the rest of Scotland as follows: In Scotland, a total of 408 cases were reported to Health Protection Scotland using the Enhanced Surveillance of Mycobacterial Infections (ESMI) scheme in 2012, equating to an annual incidence of 7.7 cases per 100,000 population. 19 new cases were seen in Lanarkshire in This does not include cases (10) from the Cambuslang and Rutherglen/ Northern Corridor (Cumbernauld/Kilsyth) area and the number of contacts screened. In 2012, 53% cases required hospital admission this figure could vary significantly year on year. 2.3 Case for Change NHS Lanarkshire recognises that the current model of care is unsustainable across three sites and, in order to meet the requirements set out in the national TB Action Plan, a comprehensive service review was required. NHS Lanarkshire Department of Public Health agrees that, in order to meet the requirements set out in the TB Action plan a more suitable model to deliver specialist TB services must be developed. A number of factors including the small number of patients being seen across the three sites, the variations that exist in terms of follow up and the delays in information exchange that affect the public health management of cases have been highlighted in briefing papers to the NHS Board and Modernisation Board of NHS Lanarkshire. It has been agreed that the current service was fragmented, with less opportunities for delivering a patient centred or an effective approach and therefore was no longer fit for purpose. A stakeholder engagement workshop was arranged by NHS Lanarkshire Change and Innovation in collaboration with the Department of Public Health in response to the Scottish Government publication A TB Action Plan for Scotland (March 2011). The Action Plan was published with the aim of ensuring that Scotland provides the best quality clinical, laboratory and 4 P a g e

5 public health services in relation to TB, ultimately leading to a significant reduction in the burden of ill-health caused by this infection. The engagement process is consistent with the CEL 4 (2010) Informing, Engaging and Consulting People in Developing Health and Community Care Services guidance 2. A briefing paper summarising the proposed service change and a detailed report of the patient narratives were circulated to all those invited to the event as pre reading. On the day of the event participants received hard copies of all event papers in workshop packs containing: Event Programme Workshop Briefing paper Patient Narratives Participants scoring sheet AM Participants scoring sheet PM Event evaluation sheet 3. EVENT PROGRAMME Participants 3 were welcomed by Kate Bell, NHS Lanarkshire Senior Manager Change & Innovation in place of Dr Harpreet Kohli, Director of Public Health and Executive Sponsor of the review who was unable to attend due to a conflicting event. Kate opened the event by giving a short presentation that outlined the organisation s support for a review and redesign of TB services in Lanarkshire. She described the organisational service change process and the purpose of the stakeholder event as a process to carry out an appraisal of the options for improvement of TB services and to ensure the recommendation is fully informed and based on robust evidence. This is to ensure the stakeholder engagement process arrives at a recommendation of a preferred clinical and service model in consideration of the merits of each of the proposed models. 4. PRESENTATIONS 4.1 Key Drivers for Change Dr Josephine Pravinkumar, Consultant in Public Health Medicine gave a presentation that put the stakeholder event in the context of the services that are being delivered and outlined the key drivers for change including an overview of the TB Action Plan. She gave an overview of the epidemiology of See Appendix 1 for list of participants 5 P a g e

6 TB, current TB services, the existing pathways for the three acute sites in Lanarkshire, current utilisation across all sites and issues surrounding the current service provision for patients with TB. Dr Pravinkumar highlighted the fact that changes to wider services in Lanarkshire would be minimal however the move to a redesigned service would only improve services to patients. The key drivers for change changes according to Dr Pravinkumar were as follows: There are a small number of cases seen across the three sites There is currently no agreed standardised management of patients with suspected TB leading to a lack of continuity of care There is no designated clinic available for referring patients that require assessment out with the normal review pathway TB specialist staff are currently unable to attend all clinics that potential TB patients may present to and are therefore unable to provide opportunistic screening, support and advice Due to the lack of a designated clinic there are often delays in identifying social risk factors that could affect compliance e.g. addictions There are potential infection control issues in relation to management of patients and general awareness of TB Only Monklands hospital has negative pressure facilities which meet the requirements set out in the Health Protection Network (HPN) guidance document (2009) to manage cases of Multi-drug-resistant tuberculosis (MDR-TB) 4. This document provides recommendations on the level of isolation for infection control in hospital settings and states that there should be negative pressure rooms which have air pressure continuously or automatically measured, as defined by NHS Health Facilities Scotland in SHTM There are limited resources to spread services across three sites leading to challenges to coordination and joint working. There is limited availability of clinical staff to attend multidisciplinary team meetings (MDT) due to other priorities Ethambutol hydrochloride, one of the drugs used to treat TB may produce decreases in visual acuity, including irreversible blindness. There are delays in carrying out visual acuity testing which measures how well the patient sees at various distances and describes the acuteness or sharpness of vision (i.e. the ability to perceive small details). Delays in blood tests and other follow up There are delays and problems in prescribing and dispensing medications 4 See page 14 in Tuberculosis: Clinical diagnosis and management of tuberculosis, and measures for its prevention and control in Scotland, Health Protection Network Scottish Guidance, 2009, ( 6 P a g e

7 There is often a delay in information exchange e.g. lab results, correspondence, discharge 4.2 Optimum Clinical Model for Tuberculosis in Lanarkshire Dr Pravinkumar gave a presentation in place of Dr Nick Kennedy, Consultant in Infectious Diseases who was unable to attend the morning session due to a conflicting event. She discussed the clinical picture and presented information on possible service redesign options. She covered the six dimensions of quality (see section 5), what an optimum service model would look like and then presented an overview of the three potential future models to be discussed in groups following the presentations. The three models discussed were: Model A: Standardisation of existing clinics - to continue with the current configuration but to standardise management of TB patients Model B: Standardisation - to have a dedicated TB clinic on each site or Model C: Concentrated service, with one centralised clinic Each model requires NHS Lanarkshire to consider a reorganisation of existing services to determine the most suitable model to deliver specialist TB services. 4.3 Patient Experience The final presentation was given by Lesley Ritchie, TB Specialist Nurse in NHS Lanarkshire. She provided information on the patient s perspective following semi-structured interviews with eight patients who were either currently being treated for TB or who had completed treatment within the last two years. In recognition that patients/service users/carers may not be keen to attend the event in high numbers we agreed to develop patient narratives to enable people personally affected by TB to be involved in shaping future TB services. Lesley discussed the barriers associated with TB including stigma, public and professional awareness and a lack of understanding about completing TB treatment. The patients/service users were asked standard questions to place emphasis on the patient voice and perspective regarding what clinical model and service location would provide the optimum care for TB patients. All patients interviewed could see the advantages of a single site model with a focus on continuity of care, early access to TB nurses, less delay between diagnosis and start of treatment and also access to a pharmacy at the hospital. Patients also felt that being able to attend a specialist service would allow them to come into contact with other TB patients and potentially be able to discuss concerns and how they were feeling or coping with it all. 7 P a g e

8 A summary of the anonymised quotes presented are included below: Patient A, a 76 year old female felt that just being in a clinic where other patients who may have had similar issues and concerns and being able to discuss this would be advantageous. Patient B, a 37 year old male felt the current clinic/or single clinics at each hospital site were not advantageous and felt the way forward was one dedicated unit/clinic. Patient C, a 40 year old female felt the disadvantage of the current system was the delay from referral to diagnosis to commencement of treatment. She felt a single clinic on one site was a very positive move and very helpful for TB patients. Having a designated TB clinic with a specialist team, she hopes that time would be saved and things would move faster such as bloods and visual acuity tests. Patient C felt a little disappointed that she met a different doctor at each review and she had to give her history each time and there was little consistency and wondered if having the TB Specialist nurses there would have prevented this repetition as they would be on hand to discuss her history prior to seeing the doctor. Patient D, an 86 year old female felt that collecting her prescription at the hospital instead of obtaining this from a local chemist and having to wait a period would be a bonus. If everything was in the one place and that was all they did all about the TB was ideal and could not see any disadvantages to a single base. Patient E, a 49 year old male said I am not in favour of centralisation of services however in the case of TB patients in Lanarkshire I think it s a good idea due to the small numbers. I would travel to a clinic further away to get the care and to get the questions I had answered. Patient F, a male in his 40s felt that a one stop clinic would hopefully be a timesaver with regards to referral and that vision tests and bloods would be done in the one place. The TB nurses being there would be very beneficial if no other reason than to help with the fear factor in the patients mind. Patient G, a female in her mid-50 s felt that a small team of people caring for patients with TB would be ideal and felt the TB nurses were a good support. She thought having one clinic was advantageous as patients would know where to contact for advice. She could see no disadvantages of the one stop TB clinic and thought this would promote continuity of care. She felt she did not have enough time at reviews to discuss her diagnosis and side effects of the medication and did not feel her questions were answered adequately. She is currently still waiting to have her vision checked and felt that it would definitely be beneficial for the TB nurses to be available at the clinic. 8 P a g e

9 Patient H, a male in his 60 s felt the biggest advantage of a single site clinic was having everything in the one place and being able to get prescriptions from the hospital as he experienced difficulties in obtaining his prescription locally. Patient I, a 41 year old male wasn t sure in the advantages/disadvantages of the current system or having a dedicated TB clinic on the three hospital sites. But did feel having a small team of people looking after TB patients would be good as you get to know people. 5. APPROACH AND METHODOLOGY 5.1 Short Life Working Group An NHS Lanarkshire TB Short Life Working Group (SLWG) with representatives from the Department of Public Health, the current TB service, Communications and the Acute Services carried out a staff workshop 5 in November 2012 to explore the options for change. In recognition of the national TB action plan and local work a proposal for service change was taken to the Modernisation Board (07 October, 2013). 5.2 Event Commissioning Following agreement by NHS Lanarkshire Modernisation Board (October 2013) to proceed with the service change, Change & Innovation were commissioned to support the service change process. The stakeholder engagement event was developed by a project team working together to design and plan the stakeholder engagement event programme. 5.3 Service Change Project Team The TB service change project team included Change & Innovation with representatives from the Department of Public Health, the current TB service and the Communications department in the planning and designing the stakeholder workshop Stakeholder Engagement All interested stakeholders were invited to attend a one day workshop (18 December 2013). 5 See Appendix 3 for list of participants of SLWG 6 See Appendix 2 for service change project team members 9 P a g e

10 In line with NHS Scotland Healthcare Strategy, and A Healthier Future NHS Lanarkshire framework for Strategic Health Planning, the challenge was to ensure the decision-making process was reasonable, transparent and justifiable. The influencing factors used in the group work session are a representation of NHS Scotland Quality Ambitions and are based on The Institute of Medicine Six Dimensions of Care 9, which remain a key foundation of the NHS approach to systems-based, healthcare quality improvement. We agreed to carry out an Option Appraisal as our change and decision making approach for the event. An Option Appraisal is a process that is used when considering a new way to provide services. Option Appraisals allow a wide number of views to be considered and as robust an assessment of options as possible to be created. Option Appraisals look at all the ways in which a service could be provided and the most promising options are then assessed by comparing their benefits, risks and lastly on costs. The aim is to develop the best possible model for TB service in NHS Lanarkshire within the resources available. Participants were divided into three facilitated groups and asked to assess, in a structured way, the proposed models, as described. 6. OPTION APPRAISAL PROCESS (GROUP WORK) Kate Bell gave a presentation to explain the approach to scoring the options. In three separate groups participants discussed the available information, any benefits, disadvantages and risks of each model before applying individual scores against each quality criterion. The three models discussed were: Model A: Standardisation of existing clinics - to continue with the current configuration but to standardise management of TB patients Model B: Standardisation - to have a dedicated TB clinic on each site or Model C: Concentrated service, with one centralised clinic The groupwork session aim was to ensure the preferred model of care would deliver a safe, more patient-centred and effective provision. 6.1 Options for Improvement In 2001, the Institute of Medicine outlined six Aims for Improvement for health care in their report, "Crossing the Quality Chasm: a New Health System for the 21st Century." 10 P a g e

11 Model A: Standardisation of existing clinics Benefits Standardisation of TB patient management on all three sites. Consistent approach for all patients. Easiest option in the short-term (least change). TB clinic closer, for some patients. Disadvantages Very fragmented TB care provision, hence difficult to develop it into a high quality service. Large number of staff seeing small number of patients. Therefore, patients may be seen by a doctor who has limited experience in handling TB cases. TB nurses not able to attend clinics and do joint clinics with the consultants. Issues with communication between all three sites May be difficult to ensure a consistent approach is being delivered at all three sites While there are part time antimicrobial pharmacists on all three sites it may be difficult to ensure that they can deal with TB patients and dispense medication due to their workload. Patients may therefore need to rely on community pharmacists where a delay can occur as TB medication is not regularly stocked in community pharmacies. Lack of access to TB nurses as they will be unable to attend all clinics where a TB patient could attend which will delay the opportunities for early risk assessment to commence direct observe treatment (DOT), screening of close contacts and providing support to the patients Lack of access to other TB patients who they may want to discuss their experience with. Delays in additional testing such as visual acuity tests will remain. Clinical staff unable to attend Multidisciplinary team meetings regularly which could have an impact on the clinical and public health management of patients.. Lack of negative pressure facilities in Hairmyres and Wishaw hospitals. Co-location with the Infectious Diseases unit will only be achieved at Monklands. Model B: Standardisation, with 1 clinic on each site Benefits Designated TB clinic at each site. Should reduce fragmentation somewhat and improve communication. Standardisation of TB patient management with a dedicated TB clinic on all three sites. Consistent approach for all patients. 11 P a g e

12 If a small number of doctors based in all three sites continue to handle TB cases and therefore could remain skilled in this area. Access to specialist physicians and TB nurses. Tests will be quicker with shorter delays and visual acuity will be conducted by TB nurses. Early access to TB nurses who can manage the patient and highlight any issues such as substance dependence which may require them to intervene and start Directly Observed Therapy (DOT) to ensure the patient is taking their medication correctly. Single point of contact for patients as well as clinicians Disadvantages This model still ends up with a limited resource spread over three sites resulting in potentially poor communication. All clinical staff involved might still find it unable to attend Multidisciplinary team meetings regularly which could have an impact on the clinical and public health management of patients Unlikely to get dedicated clinic space at three sites There will be increased demand on the available clinical space on all three sites. Need to consider what might get displaced and to where (implications for consultant job plans). Large number of staff seeing small number of patients. Therefore, patients may be seen by a doctor who has limited experience in handling TB cases. Issues with communication may still occur due to the number of sites. May be difficult to ensure a consistent approach is being delivered at all three sites. While there are part time antimicrobial pharmacists on all three sites it may be difficult to ensure they can deal with TB patients and dispense medication due to their workload. Patients may therefore need to rely on community pharmacists where a delay can occur as TB medication is not regularly stocked in community pharmacies. Increased workload for TB nurses trying to attend the clinics at all three sites. Lack of negative pressure facilities in Hairmyres and Wishaw hospitals. Co-location with the Infectious Diseases unit will only be achieved at Monklands. Model C: Concentrated service, with one centralised clinic Benefits Standardisation of TB patient management with a dedicated TB clinic on one site. Small, dedicated team of specialists - better for maintaining/enhancing skills. Multi-disciplinary clinics, with TB nurses as well as Consultants in attendance. 12 P a g e

13 Better communication within team as well as with patients, GPs and others. Clinic could be co-located with inpatient TB facility. Consistent approach for all patients. Tests will be quicker with shorter delays and visual acuity will be conducted by TB nurses at an early stage. Early access to TB nurses who can manage the patient and highlight any issues such as substance dependence which may require them to intervene and start DOT to ensure the patient is taking their medication correctly. Single point of contact for patients as well as clinicians MDT meetings will be easier to organise and to manage. Disadvantages A number of patients will have to travel further to access a clinic. This will depend on the site chosen. Therefore there may be travel/transport issues for some patients. Consultants not providing the clinics could become de-skilled in TB management. The two sites with no TB service may be disadvantaged. There will be increased demand on the available clinical space on the chosen site, though there will be an associated reduced demand on the other two sites. Need to consider what might get displaced and to where (implications for consultant job plans). There may be additional pressures on the Patient Transport Services/Scottish Ambulance Service. Some patients who are diagnosed with TB as an in patient will require transfer to the site where the service is provided and this might have an impact on the current management of other co-existing medical conditions The next part of this report provides a summary of the output from across the three groups. 6.2 Groupwork - Part I (preferred clinical model) Each group had a dedicated facilitator and lead subject matter expert. Participants were given the opportunity to ask questions about the current service and the proposed options. The six quality dimensions (safe, effective, and person centred, efficient, timely and equitable) were utilised as quality criteria with definitions and notes shared on the participants scoring template to inform the groupwork process and ensure transparency. (See Appendix 4) The facilitated groupwork session captured participants individual scores on the three proposed models. 13 P a g e

14 Participants were asked to reflect on the presentations delivered by the Presenters (topic experts), the briefing paper and the information contained within the patient narratives and consider the extent to which each model would deliver against the 6 quality dimensions. Each group considered and scored each of the 6 dimensions in turn. Individual participants then allocated a score to each model using the following scoring system: 5 Strongly agree that the model delivers this element 4 Agree that the model provides this element 3 Neutral neither agree or disagree that the model 2 Disagree that the model provides this element 1 Strongly disagree that the model provides this element The scores from each group were collated and the weightings applied in an electronic master score card. The weightings applied to the factors, which were determined by a separate process ahead of the stakeholder event, were as follows: Table 1: Quality dimensions and weightings used in analysis FACTORS WEIGHTING Safe 2.0 Effective 1.8 Patient-centeredness 1.6 Efficient 1.5 Timely 1.4 Equitable 1.2 The morning session resulted in the one-site model being identified as the preferred model. 6.3 Groupwork - Part II (site preference) Kate Bell gave a presentation to explain the approach to ranking the options and Dr Nick Kennedy highlighted the factors that influence the optimum clinical model that focuses on patient-centeredness and the features of the site and team that will be required to deliver the service. Each group was asked to consider which site would be best to locate this TB service. Each individual was asked to consider which site (Wishaw, Hairmyres or Monklands) would be able to meet the essential, important and desirable factors using an individual score sheet (see appendix 5) designed for the purpose by the project team. Participants were asked to choose one site but given the 14 P a g e

15 option to choose more than one site if they felt multiple sites would meet this criterion. These factors were: Essential 1. Accommodation: Space for clinic 2. MDT working faster decision making, improved communication, improved communication, quality of care 3. Consistent management of cases enhanced MDT working 4. Specialist Nurse Input in attendance at all clinics, one stop MDT inputs, screening of contacts or contact tracing 5. Access to negative pressure facilities co-location with Infectious Diseases Unit Important 1. Access to other disciplines BBV staff at ID Unit, Pharmacist 2. Accessibility clinic available within NHS Lanarkshire 3. Training opportunities audit, shared practice, consistent approaches, standardises operating procedures 4. Multi agency working Dungavel, Shotts Prison local authorities, Port Health Authorities, other health boards Desirable 1. Opportunities for Continuous Improvement future developments 2. TB Nurses to be based on acute site 7. ANALYSES AND SCORING THE OPTIONS 7.1 The outcomes preferred clinical model A total of 20 individuals participated in this scoring exercise. Each individual scored the options on a scale of 1-5 using a scoring sheet that had been designed for the purpose i.e. a matrix showing both the options to be scored and the factors against which each option would be considered. The individual scores for each group were transcribed onto a master score card by the group facilitators. This allowed the pre-determined weightings of the factors to be applied and a final score to be calculated. The final scores from group master score cards were then aggregated to give the overall final ranking of the options. Both the individual scoring sheets and the group master score cards for the morning session have been retained for the purpose of audit. The scores came out as follows: 15 P a g e

16 Table 2: Scores indicating preference of model for TB services Group No. of Model A Model B Model C Scorers Group Group Group Overall Outcome: Model C Concentrated service, with one centralised clinic scored highest in all 3 groups. The scores from each group resulted in a one-site model being identified as the recommended/preferred model. 7.2 The outcomes site preference (Wishaw, Hairmyres or Monklands) The individual scores for each group were transcribed onto a master score card by the group facilitators. This allowed the pre-determined weightings of the factors to be applied and a final score to be calculated. The final scores from group master score cards were then aggregated to give the overall final ranking of the options. Both the individual scoring sheets and the group master score cards for the afternoon session have been retained for the purpose of audit. The scores came out as follows: Table 3: Scores from the afternoon session indicating site preference for the TB service Group 1 Wishaw Hairmyres Monklands Group 2 Group 3 Total Group 1 Group 2 Group 3 Total Group 1 Group 2 Group 3 Essential Important Desirable Total 80 Total 86 Total 162 Table 3 provides an account of all scores across all factors. The methodology is designed to provide a clear preferred site on essential criterion only. Outcome: Monklands hospital was ranked highest by all groups using the essential criteria. The process resulted in Monklands being identified as the preferred site. 8. NEXT STEPS Total 16 P a g e

17 Kate Bell, brought proceedings to a close by thanking all participants for their views, ideas and suggestions and confirming that the recommendation from the stakeholder event will be taken by the Director of Public Health to the NHS Board for approval. 9. EVALUTION More than 6 weeks prior to the event a total of seventy-one people were invited to attend the event with forty-two confirmed as attending. The stakeholder event was attended by twenty-nine stakeholders included clinicians and managers, TB service users and public and patient representatives from Public Partnership Forums (PPF). A representative of the Scottish Health Council attended the event to observe the process. Event Presentations by: Kate Bell, Senior Manager, Change & Innovation Dr Josephine Pravinkumar, Consultant in Public Health Medicine Lesley Ritchie, TB Nurse Specialist Dr Nick Kennedy, Consultant in Infectious Diseases Analysis of evaluation responses 15 of the 20 individuals who scored (75%) returned completed evaluation forms as follows: 2 PPF 1 Patient 6 NHS Lanarkshire clinicians 5 Non Clinicians 1 National Voluntary Organisation Format Overall, the format for the event was well received. The venue (location, refreshments, acoustics and comfort) was rated by 8 respondents (53%) as very good and by 7 individuals (46%) as good. Feedback about the presentations The content, relevance/interesting, visual readability, clarity, avoidance of jargon and timing for all presentations were rated by all 15 respondents (100%) as either very good or good. 17 P a g e

18 One reply (7%) gave a rating of poor against the use of plain English, and keeping to time Feedback about the review process The Stakeholders noted that they had been invited/nominated by the Board (departments), Managed clinical networks and through the TB nursing staff. 14 respondents (93%) felt that the event clearly explained why the review was necessary 11 (73%) participants felt that sufficient information was shared to enable and support full participation 3 (20%) people commented that some of the information was not easy to understand. All 15 (100%) respondents felt they had been given the opportunity to ask questions and were supported to participate All 15 respondents commented that the service model recommended reflected the group discussions. General comments The majority of group members noted that the event and group work was well explained and felt encouraged to take part; also seeing attendance at the event as a good use of their time. In general, people attending the event felt they had received enough notice of the event and sufficient correspondence ahead of the event. For further information on the implementation of this service change please contact: Dr Josephine Pravinkumar, Consultant in Public Health Medicine Dr Nick Kennedy, Consultant Infectious Diseases 18 P a g e

19 Appendix 1: Table 4: Stakeholder Engagement Workshop (Dec 18 th Participants) Attended for morning session only Name Designation Location 1 Stephanie Dancer Consultant Microbiologist Monklands Hospital 2 Pali Mahal General Practitioner Cumbernauld 3 Andrew Smith Consultant, Respiratory Medicine Wishaw General Hospital 4 Catherine Thomson Senior Nurse Dungavel IRC 5 Donald Inverarity Consultant Microbiologist Monklands Hospital Attended all day 6 Eddie Docherty Communications Officer Kirklands Board HQ 7 Lindsay Guthrie Senior Nurse, Health Protection Kirklands Board HQ 8 Kathleen Macarthur Pharmacist, Infectious Diseases Monklands Hospital 9 Kathleen McCandless Antimicrobial Pharmacist Wishaw General Hospital 10 Janice McLaren Biomedical Scientist 2 Hairmyres Hospital 11 Louise McNally Biomedical Scientist 1 Hairmyres Hospital 12 Ruth Nisbet Consultant Occupational Hamilton Therapist Health Physician SALUS 13 Sudipta Roy Consultant Respiratory Physician Hairmyres Hospital 14 Hina Sheikh Equality and Diversity Manager Law House 15 Gillian Ventura Local Officer, Scottish Health Council Service Users and Public Representatives (Attended all day) Beckford Street, Hamilton 16 Jean McMillan PPF 10 Representative North Lanarkshire 17 Hugh McMillan PPF Representative North Lanarkshire 18 Bernadette Al-Hilli Service User Coatbridge 19 Dr Chakrabarti Treasurer, LEMAG 11 Hamilton Attended afternoon session only 20 Soong Tan Consultant, Respiratory Medicine Wishaw General Hospital 21 Nick Kennedy Consultant in Infectious Diseases Monklands Hospital 22 Lawrence McAlpine Consultant Respiratory Physician Monklands Hospital 10 Public Partnership Forum 11 Lanarkshire Ethnic Minority Action Group 19 P a g e

20 Appendix 2 Table 5: Service Change Project Team and event roles Facilitators Role Role during the event Dr Josephine Consultant in Public Health Event organiser and presenter Pravinkumar Medicine Dr Nick Consultant Infectious Disease Event Planner and presenter Kennedy Kate Bell Service Change Process Lead Event organiser, presenter, facilitator and report author Louise Flanagan Subject Matter expertise, programme development Event attendee, inputting data from master score cards and compilation of report Lesley Ritchie TB Nurse specialist input/patient narratives Event planner and presenter of patient experience Christine Weir TB Nurse specialist input/patient narratives Event Planner and groupwork lead Lorraine Forrest Planning & Development projects officer Stakeholder management and event planning Alison McAndrew Administrative support Event planning and event reception Karon Hamilton Communications Event Planning Loretta Barr Medical secretary Inputting data from master Marjorie McGinty Tasmin Sommerfield 20 P a g e Programme Manager, Reshaping Care for Older People and Long Term Conditions Consultant in Public Health Medicine Table 6: B Short Life Working Group score cards Groupwork Facilitator Groupwork Facilitator Title First Name Surname Designation Dr Ken Dagg Consultant in Respiratory Medicine Ms Louise Flanagan Specialty Registrar in Public Health Dr Nick Kennedy Consultant in Infectious Diseases Dr Ken Liddell Consultant Clinical Scientist/Head of Microbiology Dr Lawrence McAlpine Consultant Respiratory Physician Ms Allison McAndrew Higher Clerical Officer Ms Rachel Nicholls TB Nurse Specialist Dr Josephine Pravinkumar Consultant in Public Health Medicine Ms Lesley Ritchie TB Nurse Specialist Dr Sadipta Roy Consultant Respiratory Physician Ms Beth Smith Higher Clerical Officer (BankAid) Ms Marysia Waters Communications Manager Ms Christine Weir Lead TB Nurse Specialist

21 Appendix 3 Six Dimensions of Care for Tuberculosis Services Definition Avoiding injuries to patients from the care that is intended to help them. Providing services based on scientific knowledge to all who could benefit and refraining from providing services to those not likely to benefit (avoiding under use and over use). Doing the right thing for the right person at the right time. Description A safe TB service would provide Safe inpatient isolation facilities leading to reduced risk to cases, contacts and the public from TB especially MDR-TB, TB nurses would be in attendance at clinics and on site available to provide opportunistic screening and advice. Early assessment and implementation of Direct O Therapy. The optimal model would provide consistent management of confirmed and suspected cases, a consistent approach to prescribing and dispensing, early identification of any problems with treatment, management of side effects with smooth transition to step down treatment An effective TB service would improve the quality of care through Multi-disciplinary team working and the benefits provided by co-located teams. A Nurse-led function - TB specialist nurses would be available at clinic to provide support and undertake blood tests, visual acuity testing, early assessment of compliance, ensure appropriate prescribing and dispensing and opportunistic screening of contacts. Added Effectiveness is delivered through co-location of Antimicrobial pharmacist, a single concentrated service would lead to better facilitation of audits, aid administrative support for multidisciplinary team working including access to results on test samples Providing care that is respectful of and responsive to individual patient preferences, needs and values, and ensuring that patient values guide all clinical decisions. Avoiding waste, in particular A patient-centred TB service would be delivered through access to a small, dedicated team of specialists, a dedicated TB service providing continuity of care and follow up with specialist TB nurses and clinicians, clear and well-defined patient pathway, consistent management of confirmed and suspected cases including choice of appropriate method of follow up to suit patient needs. Good communication both verbal and written. Nurse-led hospital and community TB clinics with TB specialist nurses able to attend clinic and offer early support. Visual acuity screening and bloods could be done simultaneously on site reducing the number of appointments An efficient TB service is best described as follows: 21 P a g e

22 waste of equipment, supplies, ideas and energy. Reducing waits and sometimes unfavourable delays for both those who receive and those who give care. Direct referrals to clinic, reduced waiting times due to increased clinic frequency and rapid access to clinic if required with TB service being able to ensure appropriate referrals to clinic Prompt diagnosis of TB cases, appropriate management of cases and contacts and reduction of PH risks Better allocation of resources and planning services Improved facilitation of audits Improved links with other agencies e.g. Dungavel and direct access to clinic if required Improved management of cases with complex and/or specialist needs e.g. interpreter services Streamlining of services for new entrant screening Better coordination of multi-disciplinary team working Improved teaching and learning opportunities for staff A timely TB service would provide Direct referrals to clinic, reduced waiting times due to increased clinic frequency and rapid access to clinic if required, Prompt diagnosis of TB cases, appropriate management of cases and contacts and reduction of PH risks and streamline services for new entrant screening. Visual acuity screening and bloods could be done simultaneously on site and avoid the need for multiple appointments Providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location and socio-economic status. An equitable TB service is best described as seeing the right person, at the right time and in the right place. improved management of cases with complex and / or specialist needs e.g. interpreter services including better coordination of services amongst various agencies, consistent management of confirmed and suspected cases. 22 P a g e

23 Appendix 4 Participants Score Card Each INDIVIDUAL should make use of all the information available (presentations, benefits/risks group work), discuss the models in relation to the factors listed, consider to what extent each model supports these and SCORE APPROPRIATELY (1 5). NAME... DESIGNATION... GROUP... Factors Dimensions of quality definitions Notes Model A Model B Model C 1 Safe Avoiding injuries to patients from healthcare that is intended to help them 2 Effective Providing services based on scientific knowledge 3 Patient Centeredness 23 P a g e Providing care that is responsive to individual personal preferences, needs and values and assuring that patient values guide all clinical decisions Safe inpatient isolation facilities leading to reduced risk to cases, contacts and the public from TB especially MDR-TB TB nurses on site to provide opportunistic screening and advice Early assessment and implementation of DOT Consistent management of confirmed and suspected cases Consistent approach to prescribing and dispensing, early identification of any problems with treatment, management of side effects with smooth transition to step down treatment Improved quality of care Multi-disciplinary team working and co-located teams Nurse-led function - TB specialist nurses available at clinic to provide support and undertake blood tests, visual acuity testing, early assessment of compliance, ensure appropriate prescribing and dispensing and opportunistic screening of contacts Co-location of Antimicrobial pharmacist Single concentrated service will lead to better facilitation of audits, aid administrative support for multidisciplinary team working including access to results on test samples Access to a small, dedicated team of specialists Continuity of care and follow up with specialist TB nurses and clinicians Clear and well-defined patient pathway Consistent management of confirmed and suspected cases including choice of appropriate method of follow up to suit patient needs Good communication both verbal and written Nurse-led hospital and community TB clinics with TB specialist nurses able to attend clinic and offer early support

24 4 Efficient Avoiding waste, including waste of equipment, supplies, ideas, and energy 5 Timely Reducing waits and sometimes harmful delays for both those who receive care and those who give care. 6 Equitable Providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location or socio-economic status Please tick one as appropriate Visual acuity screening and bloods could be done simultaneously on site reducing the number of appointments Direct referrals to clinic, reduced waiting times due to increased clinic frequency and rapid access to clinic if required with TB service being able to ensure appropriate referrals to clinic Prompt diagnosis of TB cases, appropriate management of cases and contacts and reduction of PH risks Better allocation of resources and planning services Improved facilitation of audits Improved links with other agencies e.g. Dungavel and direct access to clinic if required Improved management of cases with complex and/or specialist needs e.g. interpreter services Streamlining of services for new entrant screening Better coordination of multi-disciplinary team working Improved teaching and learning opportunities for staff Direct referrals to clinic, reduced waiting times due to increased clinic frequency and rapid access to clinic if required Prompt diagnosis of TB cases, appropriate management of cases and contacts and reduction of PH risks Streamlining of services for new entrant screening Visual acuity screening and bloods could be done simultaneously on site and avoid the need for multiple appointments Seeing the right person, at the right time and in the right place Improved management of cases with complex and / or specialist needs e.g. interpreter services including better coordination of services amongst various agencies Consistent management of confirmed and suspected cases Patients will travel to concentrated services for high quality clinical interventions [ ] Patient [ ] Carer [ ] Member of the public [ ] Public Partnership Forum representative [ ] NHS staff (clinician) [ ] NHS staff (non clinician) [ ] Local Authority staff [ ] Local voluntary organisation/charity [ ] National voluntary organisation/charity 24 P a g e

25 Appendix 5 Participants Score Card PM Consider each essential factor in turn. Place an X in those hospital boxes that you consider can deliver that factor. Repeat this process for each important factor and then for each desirable factor. NAME DESIGNATION GROUP [ ] FACTORS TO CONSIDER SITE CAPABILITY Essential 1. Accommodation: Space for clinic WISHAW GENERAL HAIRMYRES MONKLANDS 2. MDT working faster decision making, improved communication, improved communication, quality of care 3. Consistent management of cases enhanced MDT working 4. Specialist Nurse Input in attendance at all clinics, one stop MDT inputs, contact screening 5. Access to negative pressure facilities co-location with Infectious Diseases Unit Important 1. Access to other disciplines BBV staff at ID Unit, Pharmacist 2. Accessibility clinic available within NHS Lanarkshire 3. Training opportunities audit, shared practice, consistent approaches, standardises operating procedures 4. Multi agency working Dungavel, Shotts Prison local authorities, Port Health Authorities, other health boards Desirable 1. Opportunities for Continuous Improvement future developments 2. TB Nurses to be based on acute site Please tick one as appropriate [ ] Patient [ ] Carer [ ] Member of the public [ ] Public Partnership Forum representative [ ] NHS staff (clinician) [ ] NHS staff (non clinician) [ ] Local Authority staff [ ] Local voluntary organisation/charity [ ] National voluntary organisation/charity [ ] Staff Partnership representative [ ] Other (Please specify) P a g e

26 26 P a g e