NHS TAYSIDE DRAFT CLINICAL SERVICES STRATEGY. Re-shaping clinical services for the future

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1 NHS TAYSIDE DRAFT CLINICAL SERVICES STRATEGY Re-shaping clinical services for the future June

2 1. INTRODUCTION If we are to continue, in partnership with Integration Joint Boards (IJBs), local authorities, third sector and citizens themselves, to provide the high quality health and care local people expect and deserve into the future, achieving for people the best possible outcomes from the care and support they receive, then decisions on future services need to be made within the context of a clear, agreed and prioritized clinical strategy. Scotland s public health record is poor and its people continue to experience significant inequalities, our population is ageing and many are living with complex co-morbidities. This and increasing expectations arising from new drugs, treatments and technologies mean that there is unprecedented demand on services. This document describes the high-level, whole system Clinical Services Strategy for NHS Tayside. The Strategy is intended to provide a coherent, overarching direction for clinical services for the next decade. It sets out our response to the Scottish Government s strategic ambition of Achieving Sustainable Quality in Scotland s Healthcare: a 2020 Vision. It describes the essential building blocks and early priorities that will provide the basis for more detailed planning of specific service models and pathways to deliver sustainable, person-centred, efficient and affordable clinical services, as well as provide the necessary strategic focus for financial and operational plans. There is nonetheless a very clear interdependency between the clinical strategy and social models of care and the strategy is intended to complement and inform the collective planning responsibility of the Integration Joint Boards (IJBs) for health and social care by setting out the clinical advice on what is adopted into the local strategic plans being developed in Angus, Dundee and Perth & Kinross. The strategy is underpinned by principles based on our Visions and Values of patient centred, evidence-based, safe and effective care; a whole system approach - prevention, treatment and support - efficiency and best value and of mutuality, equity and inclusion. We want to build on our efforts to improve health outcomes of local people and enhance the experience that patients have of our services so that it matches what people want to experience a system that delivers more joined up care, that puts them at the centre of decision making and enables them to take better care of their own and their family s health and achieves the demonstrable shift towards a preventative and anticipatory model of care. This will require greater focus on cultural change in the way we work in and across services as well as with patients and communities rather than on the bricks and mortar of where services are delivered. We need to support and enable clinicians in both primary and secondary care to provide the effective leadership required to support behaviour change and deliver care across settings as part of integrated multi-disciplinary and multi-agency, community based teams. The NHS, as with all public services, has to make decisions about priorities within the overall resources that are available. These decisions must be based on the best available evidence and take account of efficiency and best value. We can only meet the changing needs of patients and fund the new services and treatments to keep health services of the highest quality for patients if we are able to change current services and how we invest our resources. The Strategy and the development of the more detailed planning of service models reflect what our patients have told us they value about their local health services and what they would like to see in the future. Engagement with our patients and people in their own communities across Tayside will be central to shaping the future development of health and care. 2

3 We believe that, combined with the assets 1 of our patients and the people living in our communities and the commitment and expertise of our staff, the Strategy will make a sigificant contribution to enabling us to deliver on this ambition. 2. STRATEGIC POLICY CONTEXT There are a number of key policies central to our thinking on the way in which we need to change services so that they truly respond to the needs of our population, are based on the available evidence and able to capitalise on the many advances in clinical care and technology as well as making sure that we make best use of resources to deliver sustainable and affordable services. The Kerr Report, Building a Health Service Fit for the Future, published in 2005 in response to rapidly changing health care needs set out a national framework for service change through a collaborative healthcare model. It advocated a greater focus on providing care in local communities rather than in hospitals; targeted action in deprived communities and an approach to people s care that anticipates and prevents health care crises from happening; the development of an integrated system with investment in pathways of care spanning primary and secondary care and the use of new technology to improve the standard and responsiveness of care. The Report highlighted the need for rational distribution of services between neighbouring hospitals and national planning of complex specialized services. It also recognised the importance of support for patients and their carers to manage their own health care needs and of patients contribution to developing shared solutions for the future of healthcare. Better Health, Better Care set out avision of creating a mutual NHS, where patients and the public are partners in their care rather than merely recipients and where accountability is shared with the Scottish people and with the staff of the NHS. It maintained the policy drive to shift the balance of care from secondary care to the community. The Early Years Framework published in 2008 highlighted the costs of current systems failure and the growing evidence base for early intervention, especially pre-birth and in the earliest years of life to address entrenched inequalities. The Christie Commission report, published in 2010 signalled a significant change in emphasis in public policy to meet unprecedented challenges. It called for a radical, new collaborative culture across public services and a shift towards preventative spending to address deep-rooted inequalities and the increasing demands on public services. It s recognition of the negative impact of fragmentation across public services and the effect that this has on joint working has been instrumental in the Scottish Government s programme of reform to bring about integration of health and social care to ensure that services are joined up and seamless. Tayside s Health Equity Strategy, Communities in Control, also developed in 2010, highlighted the huge disparity in health between the richest and poorest people in our communities and echoed the need for a step change in our action to address generational inequality through targeted intervention, especially in the earliest years of life, and investing in the resilience of communities. Central to this was a commitment to support co-production as a means of promoting the social capital of individuals, families and communities. Its intent was that services should encourage patient and community enablement, so that people take back elements of services that do not need to be delivered by health professionals. In its response to the Christie Commission report, the Scottish Government committed to an approach for public services that combines four key elements: a decisive shift towards 1 The innate, abilities that individuals possess based on their experience and insights 3

4 prevention; greater integration of public services at a local level driven by better partnership, collaboration and effective local delivery; greater investment in the people who deliver services through enhanced workforce development and effective leadership; and a sharp focus on improving performance, through greater transparency, innovation and the use of digital technology. These key themes are reinforced in Achieving Sustainable Quality in Scotland s Healthcare: a 2020 Vision. The Scottish Government s ambition is that everyone is able to live longer healthier lives at home, or in a homely setting and, that we will have a healthcare system where: we have integrated health and care; there is a focus on prevention, anticipation and supported self-management; where hospital treatment is required, and cannot be provided in a community setting, daycase and short stay will be the norm; whatever the setting, care will be provided to the highest standards of quality and safety, with the person at the centre of all decisions; and there will be a focus on ensuring that people get back into their home or community environment as soon as appropriate, with minimal risk of re-admission. The NHS Scotland Quality Strategy - putting people at the heart of our NHSwith its emphasis on safe, effective and person-centred care and the accompanying Route Map, support the implementation of the 2020 Vision. They build on improvements already being made across health, but highlight the need to focus on evidence-based activities, which yield the maximum benefit and involve the people of Scotland to a greater extent in the co-production of health and healthcare. Integration of adult health and social care is a key part of the Scottish Government s commitment to public service reform. The development of Integration Joint Boards (IJBs) will ensure that health and social care provision is joined-up and seamless, especially for people with long term conditions and disabilities, many of whom are older people. National and regional planning will play a more central role in determining which highly specialised, complex services should be delivered once for Scotland and those that could improve quality and safety by being provided on a networked regional basis. Given the critical role of primary care an estimated 90% of all patient contact happens in this setting - in realising of the 2020 Vision, increasing consideration is being given nationally to a 2020 model of primary care. Prescription for Excellence published in September 2013, describes the strategic direction for pharmacy services for the next 10 years. It affirms the requirement for NHS pharmaceutical care to adapt new, innovative models, signalling an enhanced professional independence of pharmacists working in collaboration with other health and social professionals and the third sector to prevent ill health and to deliver the best possible health outcomes for patients from their medicines. The National Delivery Plan for the Allied Health Professions in Scotland is designed to maximise AHPs contribution and effectiveness by empowering strong professional leadership and enabling the development of integrated teams across health and social care services to support development of innovative new models of care. The emerging vision for general practice also puts greater emphasis on creating extended multidisciplinary primary care teams, with the GP as expert, medical generalists embedded as part 4

5 of the team and focussed on managing people with undifferentiated illness in the community, with other care professionals taking a greater role in health improvement and management of long term conditions such, as diabetes and heart disease. GP practices would continue to provide continuity of care for individuals, but would be expected to collaborate at the level of clusters to deliver a broader and/or more specialised range of services; echoing the locality focus of IJBs. It is clear then that there has been a sustained, coherent drive underpinning health policy in Scotland in the last decade in favour of prevention, more integrated public services, a more prominent role for patients in their own care and a shift in the balance of care from secondary care to the community. Whilst there has been considerable progress made in more recent years to integrate health and social care, we still have a model of healthcare that is largely centred on hospital care where the balance of investment has been skewed rather than in developing alternatives in the community and where there is still too great a separation between primary and secondary care. 3. UNDERSTANDING OUR POPULATION HEALTH Understanding and anticipating population health needs is essential to planning and delivery of responsive and effective clinical services in the future. Demographics The population of Tayside in 2014 was 413,800, just over half (51.5%) were female. The distribution of the population across Tayside s three local authority areas was 116,660 (28.2%) in Angus, 148,260 in Dundee City (35.8%) and 148,880 (36.0%) in Perth & Kinross. The minority ethnic population makes up 3.2% (13,111 individuals) of the Tayside population, ranging from 1.3% in Angus to 6% in Dundee City. The population is expected to increase overall by 14.1%, in the next 25 years, higher compared to projections for Scotland as a whole. During this time, the age profile of our population will continue to change. In common with much of Scotland, there will be a steep rise in the numbers and proportion of older people. The population aged 65 years and over is expected to increase by almost 40,000 (49%) by Chart 1: Projected population change in Tayside between 2012 and 2037 by age group Population Estimate Figure 180, , , , ,000 80,000 60,000 40,000 20, Age Band 2012 Pop.Estimate 2037 Pop. Projection Source: NRS 2012-based population projections This will impact differently across Tayside, with Angus and Perth & Kinross already experiencing significant rises in the number of older people and with those of pensionable age (and particularly those aged 75+ years) predicted to increase the most. 5

6 Deprivation In 2013, 17.3% of the population in Tayside were living in the 20% most deprived areas of Scotland (Scottish Index of Multiple Deprivation). However, there are large variations in deprivation across Taysidewith the majority of severe poverty, ill health and early death concentrated in Dundee. Chart 2: Population of Tayside by SIMD quintile of deprivation 2013 Percentage 50.0% 45.0% 40.0% 35.0% 30.0% 25.0% 20.0% 15.0% 10.0% 5.0% 0.0% 6.8% 37.0% 5.8% 1 (Most Deprived) 17.0% 20.0% 11.9% 24.2% 12.9% 16.8% 38.4% (Least Deprived) SIMD (2012) Quintile Angus Dundee City Perth & Kinross Source: NRS 2013 Mid-year population estimates and SG SIMD2012 Life Expectancy The pattern of inequality is clearly demonstrated in relation to life expectancy where men and women living in Dundee City have the lowest life expectancy in Tayside and lower than in Scotland as a whole. Chart 3: Life expectancy at birth (in years) in Tayside and Scotland Angus Age in years % 44.0% 13.7% 17.0% 21.6% Dundee City Perth & Kinross Tayside Scotland Males Females Source: NRS Life expectancy measures, however, tell us nothing about quality of life. Healthy life expectancy gives an estimate of the number of years an individual can expect to live in good health and varies hugely across different population sub-groups. It is important to acknowledge that care and management of long-term conditions is a significant factor in ensuring people live well throughout their life. Key trends The top 10 causes of death account for 44% of all deaths in Scotland. In Tayside cancer, circulatory disease and respiratory disease accounted for 70% of premature mortality (those dying under the age of 75) in Tayside in Deaths due to substance misuse accounted for 2% of the total. Prevalence and mortality rates of some conditions may be reduced by preventative measures such as not smoking, being a health weight; being physically active; drinking within the recommended limits and eating a healthy diet. 6

7 Smoking rates have reduced in recent years. However, almost a quarter of adults (23.4%) in Tayside are smokers. The health harm is considerable: 1,352 deaths in Tayside were estimated to be attributable to smoking in 2012 and The prevalence of obesity in the UK has more than doubled in the last 25 years and it is estimated that by 2050, 60% of men, 50% of women and 25% of children will be obese 2. In Tayside, more than 66% of adults are overweight or obese and 22.5% of Primary 1 school children are assessed as at risk of overweight or obesity. Being obese or overweight increases the risk of developing a range of serious diseases including type 2diabetes, hypertension, heart disease and some cancers; as well as contributing to premature death. There is now some evidence that obesity is also leading to premature ageing meaning that younger generations can be expected to present with diseases we now view as conditions associated with old age. In Scotland, the total societal cost of obesity and overweight in 2007/08 was estimated to be between 600 million and 1.4 billion, the NHS cost may have contributed as much as 312 million. Nearly half the cost was attributable to obesity-related type 2 diabetes and hypertension. Excessive long-term alcohol consumption can cause serious damage to the liver and brain. Tayside has a high rate of alcohol related deaths (21.5 per 100,000 population in 2012) and local authority comparisons showed that Dundee has amongst the highest rates in Scotland. There is a clear deprivation gradient - people in the more deprived areas are 4.7 times more likely to be admitted to hospital with an alcohol-related condition and alcohol related mortality is four times higher. Illicit drug misuse causes significant social, physical and psychological harm, including transmission of blood borne viruses, specifically hepatitis C, injecting related injuries, and contributes to increased demands on health services. Prevalence of problem drug use in Tayside is higher than the national average. People in the most deprived areas are over 19 times more likely to be admitted with a drug-related to hospital. Dundee City has the highest rate of drug related deaths in Scotland. Breastfeeding is an important element of improving health and attachment of infants, rates in Tayside continue to be lower than the national average and have been stubborn to change. Sexual health is poorer in Tayside than in the rest of Scotland and despite over 50% reduction in teenage conception - a key marker of inequality - rates continue to be high. Tayside is the only Board area outside Glasgow to have 4 deep end practices - the top 100 practices in Scotland in terms of deprivation. High rates basic and/or low level of literacy affect an individual s capacity to look after their own health as well as the way they access services. A recent survey estimated that 49% of people do not have the ability to understand the instructions for using the National Bowel Cancer Screening kit and there is evidence to show that people with low health literacy have a higher risk of hospital admission and higher use of emergency department services. Although rates have decreased in recent years, age standardised rates of psychiatric hospitalisation have been consistently higher in Tayside than the national average. Prescribing for anxiety/depression/psychosis has increased in the last 5 years from 14.7% to 17.1% of the population and is higher than the national average. 96% of all mental health presentations in Tayside are now managed in General Practice Ageing is associated with increased burden of long-term conditions and chronic disease A snapshot from the Scottish Patients at Risk of Readmission and Admission (SPARRA) database in January 2014 showed that there were 5,262 Tayside individuals (or 6.2% of the population) aged 65 years or over found to have a 40% risk of being admitted to hospital as an emergency within a year. 2 Foresight, Tackling Obesities: Future Choices: Summary of Key Messages. The Stationery Office: UK,

8 Dependency ratios are expected to increase from 0.54 to 0.70 over the next 25 years resulting in an increasing burden on the working age population and likely increase on demand for health services. The Alzheimer Research Trust has predicted that one in three people aged over 65 will die from a form of dementia and one in four hospital inpatients will have the disease. In 2013, the main causes of death in Tayside s older population were malignant neoplasms, accounting for 27.0% of deaths to those aged 65+ years, CHD (13.1%), dementia & Alzheimer's disease (12.2%) and cerebrovascular disease (9.5%) were the next most common causes of death in the older population. In recent years, there have been some significant improvements in the health of people living Tayside. Survival rates for many cancers have improved significantly and rates of premature mortality have fallen for cancer, coronary heart disease (CHD), cerebrovascular disease (CVD) and respiratory disease. Nevertheless, there remain significant health challenges relating to an ageing and more obese population as well as in addressing the marked inequalities that still blight many of our communities and contribute higher levels of ill health and early avoidable death. 8

9 4. CURRENT SERVICE CONTEXT 9

10 5. WHAT MATTERS TO OUR PATIENTS The voices of patients, carers, family members and the public all play a vital role in informing the quality of the services we provide. Direct engagement with patients and local people is a central and essential element of planning and delivering services. It is critical to how clinical leaders co-produce service improvement with our patients. People in Tayside have told us what they value about their health services and what they need and want from future healthcare. There are key themes that feature again and again and stress the importance to patients and their families of: caring and compassionate staff and services being treated with kindness by friendly, supportive, and well informed staff who are sensitive to their individual needs and treat them with dignity and respect; a single system characterised by continuity and collaboration between and across services where clinicians work together regardless of which part of the health service they work in a way that feels like one, single care pathway centred around the patient to deliver the right care, support and information at the right time. Fragmentation resulting from organisational boundaries is also where communication can breakdown, causing unnecessary confusion or anxiety and a sense of loss of control; clinical excellence - patients rightly expect that they experience the highest standards of care from well trained and supported staff; prompt, reliable and responsive services long waiting times, cancellations and delays in treatment cause considerable disruption and worry for patients and their families; care is delivered as close to home as possible; shared responsibility for individual and community health and wellbeing; and perhaps most importantly communication and clear explanations about their conditions, keeping them informed during their treatment about what they can expect from their treatment and what will happen afterwards. These concerns need to be central to how we develop specific service models and pathways. We have already identified key principles in our Vision and Values that will support this: Treating patients with dignity and respect by listening and valuing their feedback Getting to know the patient or client as a person (holistic approach as well as individual approach) to enable an asset based approach Sharing of power and responsibility (patient or client as expert in their own health, sharing of decision making, information, the idea of common ground) Accessibility and flexibility (of service provider as a person and of the services provided) Coordination and integration (consideration of the whole experience from the point of view of the service user) Having an environment that is conducive to person-centred care (supportive of staff working in a person-centred way and easy for service users to navigate) Communities in Control made clear the benefits not only of genuinely involving patients in decisions about their health, but also the importance of enabling communities to cocommission, co-design, and when appropriate co-deliver or co-assess public services. This approach has already been successfully adopted as business as usual in some of our services, we now need to consider how we roll out these principles as part of how we continue to shape the future development of health and care. 10

11 6. CASE FOR CHANGE The next 20 years will see significant demographic, cultural and technological change. Our population is ageing with a consequent rise in long-term chronic conditions giving rise to an increase in patients with multiple conditions and complex needs. Coupled with the inequalities in health and the continuing public health challenges, specifically the rise in obesity and substance misuse related conditions, demand on the healthcare system will continue to increase. People s expectations of health services have also changed: the digital world has transformed our culture and the way that many of us access information about health and health services. Increasingly, we bring the same expectations of choice about treatments, drugs and therapies and access to health services that we have in most other aspects of our lives. Many of us expect to use that knowledge to exercise a greater role in decisions about our own and our family s health. These demographic and cultural changes mean that health services are already facing significant pressures. Primary care, notably General Practice is facing unprecedented challenges. The average number of consultations has almost doubled in the last 10 years. Demographic change and a shift in specialised care and treatment from hospital to the community has meant that the complexity of the workload has intensified while ten-minute consultation intervals remain the norm in almost all primary care teams. At the same time, the relative share of spending on primary care has decreased, the WTE GP workforce has remained static, and the pace of development of services in the community has been slow. Opportunities for audit, research and personal professional development are scant for many GPs as a result of traditional contracting and service delivery models which contributes to a perception amongst doctors in training that general medical practice is an isolating and unstimulating environment in which to work. Nationally and locally, there is a shortage of GPs; many established doctors are leaving the profession and young doctors do not view general practice as an attractive career option. Combined, these conditions have contributed to major problems in capacity and difficulties in meeting current demand in practice as well as in delivering the out of hours service. We need to resource and develop sustainable models for primary and community services in order to respond to local health needs: not to do so will fatally undermine our ability to achieve the 2020 Vision. The lack of targeted anticipatory care to detect health problems early, coupled with limited options in the community, means that often there is little alternative to admission to hospital, even for more routine diagnostic tests or assessment, and patients have to stay in hospital longer than is necessary to access rehabilitation. Many older people who could have their care provided in their home or in a community setting are instead admitted to hospital for prolonged periods of time, which can lead to institutionalisation and greater frailty and to higher rates of re-admission. This pattern and level of demand in unscheduled or emergency care in turn creates pressure on planned care as these facilities are needed at times of peak demand, resulting in cancellations, inefficient use of resources, increased costs and disruption for patients. We have an out-dated model of healthcare and much of the infrastructure outwith the major hospitals is outmoded and facilities are no longer appropriate to meet the requirements for modern clinical practice. The requirement to reduce working hours as part of the Working Time Directive (WTD) and 11

12 the drive to modernise medical careers, coupled with the extended roles of other healthcare professionals has had, and will continue to have, a profound effect on the way in which we deliver healthcare. Like our population, our workforce is also ageing and we face challenges in recruiting staff in certain disciplines and fields. The demands and expectations on our staff will also change in light of new and emerging models of care, especially health and social integration. Whilst medical care has conferred enormous benefits on us as individuals and as communities, we also need to acknowledge that the increasing medicalisation of our lives carries a downside. The very success of healthcare has led to increasing dependence on health professions. That dependence is known to undermine the natural resilience, which we all have and which is necessary to cope with the stresses we experience throughout our lives. We need to find alternative ways of delivering effective healthcare, based on equal partnership with individuals, families and communities, so that resilience is enhanced rather than compromised. These asset-based approaches or co-production have an increasing evidence base. This was a fundamental tenet of Communities in Control, which recognised and advocated the need for major cultural, professional and organisational change in our relationship with individual patients and communities. While there are a relatively small number of good examples of co-produced, equity-focussed programmes that are successfully tackling health inequalities in Tayside, the ambition of the Health Equity Strategy remains largely unfulfilled. These challenges come at a time of financial constraint. Despite the Government s preferential protection of NHS resources, the higher levels of inflation that affect healthcare, especially new medicines, and increased demand for services are putting significant pressure on budgets. There are undoubtedly significant challenges facing health services, however there are opportunities that, if acted upon, will help us achieve the ambitions laid out in the 2020 Vision and improve quality and outcomes. Evidence to the Christie Commission highlighted that 40 per cent of all spending on public services is accounted for by interventions that could have been avoided by prioritising a preventative approach. Investment in effective prevention and maintaining good health will be paramount if we are to avoid preventable ill health and improve health outcomes, but it will also deliver a more cost effective healthcare system and help us to manage the overall demand for healthcare. Whilst demand for healthcare is set to increase, the Academy of Medical Royal Colleges has also recently pointed to evidence of a considerable volume of inappropriate clinical interventions, acknowledging that the reasons for this are complex and various but form part of a culture of over-medicalisation, which results in sub-optimal care for patients which, at best, adds little or no value and, at worst, may cause harm. Further, it highlights that in a system where resources are constrained it is both unethical as well as inefficient to provide treatments or interventions, which have no clinical value. We subject new investment and developments in services to varying degree of examination. However, our frequent failure to provide the same degree of ongoing scrutiny to existing services and models of care results in opportunity costs: this implicit choice to continue with current service models means we are unable to release funding for investment in more effective interventions and treatment. We need to develop more robust mechanisms to examine the evidence of effectiveness and inform our priorities. Above all, this is about embracing the evidence-base to improve the quality and appropriateness of care and needs to be part of individual interactions between clinicians and patients. 12

13 An example of this suboptimal care is the over-reliance on medication to treat self-limiting illnesses or problems that have their root in social or individual life circumstances and the use of poly-pharmacy where patients are prescribed a range of medicines - that instead of alleviating conditions can instead contribute or exacerbate problems of ill health. The Quality Strategy makes clear that developments in technology and in information and communications technology in particular, give us the tools to fundamentally reshape how healthcare is delivered. More widespread use of telehealth and telecare services will enable us to deliver services more locally and offer remote care and support for people at homethat could improve outcome sas well as reduce the number of physical visits to healthcare facilities. Improved monitoring systems and better access to information and support will provide opportunities for people living with long-term conditions to manage their own conditions effectively. Through our links to the University of Dundee and our role as a tertiary centre for specialist care, Tayside has built up a strong track record of research, development and innovation. The creation of the Academic Health Sciences Partnership will develop on this in the coming decade and will provide greater opportunities to enhance the evidence base and benefit quality of care for local people. There are opportunities to share services across board boundaries as part of regional or national networks. Clustering of services that provide treatment for extremely rare or highly complex conditions and/or where a specialty relies on specialist highly infrastructure teams of expert clinicians with access to appropriate equipment not only offer better value, but will improve patient safety and individual outcomes. The growing recognition of the need to shift from reactive, hospital-based treatment of acute conditions to one that is more preventative and community based combined with developments in technology is expected toreduce our reliance on property and buildings to deliver care and release more money for investment in direct patient care. New models of care will require new skills and ways of working that span community and hospital settings. Building on the skills of a wide range of healthcare professionals will help make sure that we have sufficient staff with the right skills, values and behaviours to work in the most appropriate settings to deliver care for our patients. All of this means, that NHS resources and services need to be reshaped to reflect a different pattern of service, with the balance of investment shifting from acute care to primary and community care. This rebalancing of resources needs to include a shift of some traditionally hospital based staff and services being relocated into the community. At every stage we should be looking to ensure capacity exists to allow the patient to be managed by the most efficient and effective services, and avoiding overflow into more expensive areas.for this to be achieved successfully, new service models, working relationships and career development opportunities will be necessary to power the change. It is not only the challenge of limited resources and changing demographics that forces this change, but equally compelling, are the opportunities to take advantage of evidence supporting models of care that focus on prevention and anticipatory care. By adopting these models we satisfy the challenges facing the existing services as well as our desire to improve the quality of services and outcomes for patients. Despite our aspiration to achieve the 2020 Vision, all too often our focus has been on tackling the immediate symptoms rather than on addressing the underlying causes of the problems. 13

14 If we are to meet mounting pressures of demand, the expectations of our patients and keep pace with advances in clinical care to realise the vision of modern healthcare for the 21 st century, there is no option but to change the way we deliver services. 7. EMERGING MODELS OF CARE NHS Tayside has already made progress in the direction of the 2020 Vision. Nevertheless to fully realise the ambitions of the 2020 Vision for care and promoting better health and reduce health inequalities, we need to take a more integrated, whole system approach to strategy and delivery. A workshop of senior clinicians from across the healthcare system considered the drivers for change and the emerging evidence of best practice, to inform the development of the strategy. We also drew on existing work to create the Tayside rich picture, as well as more detailed service planning led through the Older People s Board, Shaping Surgical Services Programme and by the Director of Primary Care. This resulted in the development of a driver diagram a logic model that seeks to describe a strategic corporate-level vision for health in Tayside. The driver diagram aims to set out the strategic vision and describe the key elements that need to be in place to deliver the radical change in the model of care as well as the associated generic, cross cutting actions. The driver diagram will inform the more detailed service planning for individual work streams, but will also act as a reference point against which all future strategic decisions by NHS Tayside will be judged. The overall strategic aim is to make sure that we have a healthcare system that enables people to live longer, healthier lives, which promotes health equity, individual empowerment and puts patients at the centre of all decisions; and we deliver integrated health services where community provision is the norm and that are sustainable safe, effective and affordable. This will require a radical departure from the current model of care. In order for it to be achievable there are a number of critical changes that we need to make; these centre on: a focus on prevention, maintaining existing health through anticipation, coproduction and self-management; joined up pathways of care between primary and secondary care and between clinical services; enhanced community provision; preventing hospital admissions or keeping them as short as possible and enabling people to go home as soon as it is appropriate; safe, effective, high quality and person-centred care; and making sure that we have the infrastructure, workforce and organisational culture with the capacity and capability to support and enable the necessary step change to deliver the 2020 Vision. 14

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16 Each of these critical elements - or primary drivers - is fundamental to achieving our strategic aims. We looked at each of these in turn to identify the key cross cutting actions, which are supported by evidence and/or best practice, and that NHS Tayside needs to put in place. 7.1 Focus on prevention, maintaining existing health through anticipation, coproduction and self-management The NHS Board has already endorsed a range of far reaching recommendations in our Health Equity Strategy Communities in Control to address inequalities in health and which in turn drive up demand for services and result in poorer outcomes. Its stated objective was to eliminate health inequalities in Tayside within a generation. Although the objective remains ambitious, there is clear evidence from around the world that it is achievable if everyone acts together to achieve the goal at a local and national level. Locally, the actions required were: targeting of health improvement programmes towards those most in need, particularly towards our most socioeconomically-deprived communities and families; targeting of health and other service in the same way. similar targeting of 'co-production' and 'asset-based approaches' by public sector agencies in partnership with the communities of Tayside; and early intervention, especially from pre-birth and in the earliest years of life. Whilst there are numerous examples of encouraging progress, improvement has been inconsistent and remains too limited. We need to re-energise our equity-focused work so that it becomes a core part of how services, including hospitals, work in a day-to-day basis. This will not happen unless NHS Tayside commits to a far-reaching programme that brings the culture of our organisation into line with that goal. Currently, the dominant culture favours investment and prioritisation around on dealing with ill health, downstream when increasingly sophisticated and costly interventions are required in acute secondary care settings. By shifting the focus upstream to prevention, co-production and community based primary and social care services these downstream costs can be avoided, overall health improved and control over health placed in the hands of individuals, families and communities. If we are to effectively target inequalities as well as plan health services for the future that meet changing population needs and are rooted in evidenced-based practice, we need to be able to develop and act on robust population health data and health intelligence. In addition, to sustaining existing health intelligence capacity in Public Health, effective service planning also needs to be able to access health economics expertise to inform decisions on best value. This same evidence-based approach needs to underpin the development of an overarching, prioritised Public Health Plan. Making sure that every health contact is a health promoting opportunity and that we adopt asset or strength-based approaches is also central to delivering services, which enable individuals to both improve and manage their own health. This will require a change in the investment focus of NHS Tayside in the coming years away from its traditional spending pattern towards an increase in the proportion of new and existing resources committed to prevention, anticipatory care, and co-produced community and primary care based services. 16

17 7.2 Joined up pathways of care between primary and secondary care and between clinical services The development of patient focussed whole system pathways of care that encompass prevention, treatment, care and support is key to making sure patients receive evidencebased interventions and/or treatment at the earliest opportunity and to achieving the goal of the perfectly prepared patient, the prepared process and the prepared professional. Progress has been made in designing joint integrated pathways between primary and secondary care, but as yet these are limited to a relatively small number of diseases/conditions and their impact has been at the margins of the healthcare system. In order to reshape the way that clinical care is provided, pathway development needs be supported by the whole system and become business as usual and be based on a genuine collaboration of expertise from across the healthcare system that brings a depth of understanding of both primary and secondary care. For this to happen we will need to release the clinical time necessary to their development and evaluation. Initial development should focus on areas including: frail elderly, dementia, assess to admit and complex care and where there is evidence of waste, variation and harm. Care pathways need to include a greater role for pre-habilitation : a targeted approach to interventions that anticipate individuals needs based on collective information from a range of sources, including non-health services and friends and family. The information and predictors can be individually tailored or linked to known population groups or particular conditions and used to guide support for people to maintain and maximise their health and wellbeing and to promote self-management of long-term conditions. For pathways to be an effective means of delivering the 2020 Vision, professionals in health, social care and third sector organisations will be required to work as single integrated multidisciplinary teams across healthcare settings that enable most efficient deployment of staff. 7.3 Enhanced community provision Alternatives to hospital care and ways to reduce unscheduled care are critical to achieving the 2020 Vision. Work commissioned by the Royal College of General Practitioners suggests that in the short term, improved access to general practice has the potential to release savings of between million per year in the UK by reducing demand on acute admissions, A&E and ambulance call outs. To put this in a local context, this would release between 2-3 million each year in Tayside. Longer term, through providing more emphasis on lifestyle factors such as smoking, alcohol consumption and exercise it is estimated that there is the potential for primary care to generate savings of million per year in the long term through smoking cessation, and million through reduced alcohol consumption 3. Community provision should include more services organised around GP practices, and clusters of practices serving larger populations, delivering a broader range of services in keeping with the emerging locality focus of health and social care. This model of delivering primary care, along with the development of community hubs needs to be underpinned by: the creation of extended multi-disciplinary primary care teams; 3 Deloitte the economic case for improving access to general practice, Nov

18 the GP as expert medical generalists embedded as part of the team and focussed on managing people with undifferentiated illness in the community, with other care professionals taking a greater role in health improvement and management of long term conditions; an enhanced primary care model, which combines predictive and targeted intervention for those at greatest risk of admission; improved home care; better community based access to diagnosticsthrough 7-day access to appropriate specialist advice, assessment and a range of common diagnostics; expanded range of services where patients can self-refer in the context of effective triage, these could include online booking and direct access to more specialist services as part of a mutually agreed care plan; specialist NHS medical and nursing skills supporting local and community based services, including outreach out-patient services where this is cost effective; increased use of technology to improve access to specialist support particularly in rural areas so less face to face contact including innovative consultation styles including Skype and e-consult; an enhanced role for community pharmacy; investment in infrastructure buildings fit for purpose, including GP practices, community hospitals and hubs and linked IT based on a single electronic record that can be accessed by all relevant organisations; and a programme of public engagement about the benefits and added value of delivering more care in primary and community settings. Development of hubs should be used to provide a focus for co-ordination of holistic step up and step down care to meet complex needs that cannot be met in home, community settings, or within traditional general practice, but that do not require traditional care in acute hospital settings. Allied Health Professionals would be key to delivering pre-habilitation, step up and step down care: working at the top of their licence to provide continuity and coordination across the whole system. Hubs can also be the focus for delivering of wide range of community-based provision, including women and children s services. Organising services and teams in this way would require a shift from reactive, and traditional medical models of care, but could offer much needed and more appropriate care, avoiding unnecessary hospital admission as well as enabling earlier, safer discharge from hospital. This will require us to scale up effective programmes, such as the enhanced care model, and reconsider how we engage with independent practitioners to agree and develop models of service delivery. It will also require a rebalancing of investment and a shift from acute care to primary and community care. 7.4 Preventing hospital admissions or keeping them as short as possible and enabling people to go home as soon as it is appropriate Referral patterns show considerable variation across Tayside, some of which can be attributed to differences in practice populations and in particular higher levels of deprivation, but for others there is no clear explanation. Development of integrated pathways of care and alternatives to hospital admission are expected to have the greatest impact on referral patterns. However, the introduction of evidence-based admission criteria developed and referral management services as part of integrated care pathways would also support a more consistent approach to hospital admission and help ensure that acute inpatient services are only for those with needs that require them to be in hospital. 18

19 There is a large body of evidence suggesting ways to reduce hospitalisation and readmission, which centres on effective chronic disease management, remote patient monitoring, and improved home care. Chronic disease management is well established in primary care, however despite the growing potential of telehealth, remote patient monitoring is less well developed in Tayside. Access to improved home care, including the availability of rapid response in situations of deteriorating health from community nursing and allied health professionals is essential if we are to reduce hospital admission. Preventing or reducing admission to hospital will also require a greater emphasis on access to rapid diagnosis, assessment and care planning to facilitate shorter hospital visits and stays. This should enable better community-based access to diagnostics, including provision of enhanced 7-day access to common diagnostic investigations by primary care, as well as access to a broad range of services, including outpatients, pre and post operative assessment, complex wound management, phlebotomy, monitoring, access to community resources and a networking and shared learning resource. Access to these services needs to made available in each of the three HSCI areas Ambulatory care provides access to diagnosis, assessment, treatment, and rehabilitation on an outpatient basis. It is increasingly well established as a way of managing planned care that avoids the need for an overnight admission nearly two-thirds of all day case activity in Tayside is managed at the ambulatory facility at Stracathro. For day surgery to be the norm (rather than inpatient surgery), we need to maximize our use of existing ambulatory care capacity and extend its provision as a core element of planned care. Ambulatory Emergency Care is a more recent innovation for managing patients who present to hospital urgently or as an emergency and who would traditionally require admission for investigation and management. Instead, they are treated in an ambulatory care setting and discharged the same day. The Royal College of Surgeons of England has recently stated that Ambulatory Emergency Care has the potential to have a similar impact on emergency care as day surgery has had on planned care. The College highlights that ambulatory emergency care results in high levels of patient satisfaction, avoidance of unnecessary admissions and a reduction in the number of emergency bed days used. It is particularly well suited to older patients, as it maintains people s wellbeing and avoids the deterioration associated with longer hospital stays. Planned and Emergency Ambulatory Care is consistent with the model of care envisaged in the 2020 Vision, confer significant benefits for patients and make more effective use of resources. The current pattern and level of demand in unscheduled or emergency care has a large impact on the use of beds, theatres and staff for planned care and in turn on waiting lists. Medical emergencies in particular tend to overflow into facilities intended for elective care, resulting in cancellations, in efficient use of resources, increased costs and disruption for patients. In addition the steps needed to tackle the underlying causes of these pressures by prioritising development of enhanced community services and expansion of ambulatory care, we can also improve patient experience, achieve a more predictable workflowand increase efficiency by separating elective surgical services from emergency admissions wherever possible. Evidence suggests that approximately 98% of elective surgery could be safely undertaken in a dedicated elective environment. High-volume specialties, such as general and orthopaedic surgery are particularly suited to separating the two strands of work. This should include: 19