NHSScotland Shared Services

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1 NHSScotland Shared Services Health Portfolio Laboratories Programme Strategy Paper Authors: Heather Bryceland, Janice Archer, Dr Bill Bartlett Contact: Date issued: 18th July 2017 Version: 0.28

2 Programme Title Health Portfolio - Labs Programme Strategy Paper Project Managers Heather Bryceland, Janice Archer Programme Manager Kim Walker Subject Matter Expert Dr Bill Bartlett Programme Director Dr Brian Montgomery Contact Heather.bryceland@nhs.net DOCUMENT HISTORY Revision History Version Number Revision Date Contributors v0.1-v0.4 04/04/17 Janice Archer V0.5 05/04/17 Janice Archer V /05/17-23/06/17 Janice Archer / Heather Bryceland V /06/17 Kim Walker/Janice Archer/Heather Bryceland V0.18IR 26/06/17 Heather Bryceland / Janice Archer V0.18kw 29/06/17 Kim Walker V0.19hb 03/07/17 Heather Bryceland / Bill Bartlett / Brian Montgomery V0.20hb 05/07/17 Heather Bryceland / Bill Bartlett V /07/17-11/07/17 V0.25 Heather Bryceland V /07/2017 Linda Kerr/Emma Smith V /07/17 Heather Bryceland / Bill Bartlett / Emma Smith V /07/17 Heather Bryceland/ Brian Montgomery Strategy Paper I confirm that this Strategy Paper has been approved. Signed by: Brian Montgomery Date: 18 July 2017 Page 2 of 65

3 Table of Contents 1 Executive Summary... 4 What we are asking of the CEs The Strategic Case... 8 The case for change... 8 Current arrangements and challenges Investment objectives and guiding principles A future service model for the delivery of laboratory services...16 Enablers Main benefits criteria Risks Constraints Dependencies Economic Case Commercial Case Financial Case Management Case Readiness to Proceed What we are asking of the CEs Appendix 1 SWOT analysis Appendix 2 PESTLE analysis Appendix 3 Workshop outputs Appendix 4 Laboratories in Scotland Appendix 5 Baseline data Appendix 6 Investment objectives and benefits Appendix 7 Stakeholders Appendix 8 Shared Services and Laboratories Background Page 3 of 65

4 1 Executive Summary The current model of laboratory services delivery across Scotland is not equitable nor is it sustainable in light of the challenges it faces. This paper proposes developing a business case to deliver a future service model for laboratories in NHSScotland. This strategy paper will describe the case for change and provide a high level description of the proposed model emerging through extensive stakeholder engagement. The contention, that there is an opportunity to use the significant resources - workforce, facilities, equipment and finance - available to Health Boards to deliver laboratory services in a way that is more efficient, effective, equitable, resilient and affordable, has been confirmed by stakeholders. Stakeholder consensus has formed around a Distributed Service Model (DSM). The DSM provides the correct volume, range and repertoire of tests reported within an appropriate timescale to support local delivery of front line services. The DSM will deliver an optimal distribution of laboratory services across Scotland with concentration of workloads and sharing of expertise across wider geographical areas. Delivery of the DSM will depend upon coordination across and between laboratories and standardisation of operating procedures across services. In planning terms this will equate to a single virtual service functioning to consistent standards across Scotland while different aspects of service can be delivered by the relevant operational unit at the most appropriate level whether national, regional, Health Board level, individual hospital or community. In many respects this replicates the approach adopted by Scottish National Blood Transfusion Service (SNBTS) in recent years. Guiding principles for a distributed service model have been developed and endorsed by the stakeholder group, and are listed on page 16. The DSM contrasts with the current situation that sees Health Boards providing services that exhibit a high degree of unplanned variation in form, function and capacity. As a consequence the existing model results in unnecessary duplication of services nationally which impacts upon the cost effectiveness and resilience. The existing model also fails to deliver a critical mass in relation to service planning, delivery, workforce and procurement. It is the view of stakeholders that the DSM offers greater sustainability and resilience and will enable us to meet the future needs of NHSScotland. The details including quantified costs and benefits of the DSM now need to be developed through a business case for laboratories. This will not be through a single all-encompassing business case but through a suite of linked cases covering delivery of the identified enablers and redesigned services. The cases will address pressures, priorities and opportunities agreed with stakeholders while being constructed as deliverables of manageable scale and complexity. The net effect will to be incremental delivery of a DSM covering all aspects of laboratory services falling within the programme s remit. Current Situation and Drivers for Change Stakeholders have endorsed the SWOT analysis Appendix 1 and PESTLE analysis, Appendix 2, of the present service model undertaken during workshops following stakeholder engagement (see Appendix 3). These demonstrate inherent weaknesses with the current system and highlight significant drivers for change. These analyses confirm the need for a new service delivery model for laboratories services in NHSScotland: The DSM. Table 1 summarises at a high level drivers for change identified by stakeholders. Page 4 of 65

5 Drivers for Change Multiple factors challenging the sustainability of the current model (see SWOT Appendix 1) Increasing demand on health care service as a consequence of ageing populations and increasing prevalence of long term conditions delivering increased demand for laboratory services. Need to support evolving models of care as a consequence of the NHSScotland National Clinical strategy and in response to the Health and Social Care Delivery Plan. New and emerging technologies that will enable service transformation and increased clinical effectiveness and efficiencies. Emergence of personalised medicine and need to deliver companion diagnostics Need to address intrinsic variation in service delivery and extrinsic variation service utilisation across the current model for laboratory services. Challenges in delivery of a sustainable and competent work force appropriately structured to meet the current and evolving requirements of NHSScotland Need to address inequity of service delivery across NHSScotland Need to deliver affordable laboratory services to NHSScotland that are optimally configured to deliver maximum whole system benefit by enabling access of the right test, in the right place at the right time. Table 1: High Level Drivers for Change Addressing the drivers is hampered by current arrangements where Health Board level accountability has created a number of barriers which will have to be surmounted to realise the full potential of the DSM. Much of this relates to intrinsic variation, that is, variation within and between laboratories where there is no standard approach across Health Boards to operating procedures covering planning, delivery, IT systems, procurement or employment. This results in: Inequitable access to testing across boards; No NHSScotland standard approach to data; Standalone IT systems which are expensive to maintain and which do not connect with other clinical systems. Nor do they connect with systems in other laboratories within and between Health Boards; Failure by several Health Boards to achieve critical mass in relation to laboratory services; Service duplication; Unutilised or underutilised capacity within laboratory facilities buildings and equipment; High risk of single points of failure, both within specialist analytical areas and within discipline specific IT staff; Workforce planning not linked to national requirements; Difficulties providing opportunities for training and career progression; Difficulties in succession planning; Difficulty in workforce recruitment and retention; Board level capital plans to maintain and develop facilities and capacity within laboratories; in the face of ageing real estate and ageing IT infrastructure; Different local priorities; and, Variation in the achievement of accreditation standards between Health Boards. A further challenge for the current configuration of laboratories is meeting the required standards for accreditation and regulation. This is costly and complex in terms of both time and resource. However there is the potential for some rationalisation by moving from accreditation of individual laboratories to accreditation of Health Boards. This could potentially be taken further once the DSM has been established and there is greater clarity around regional delivery and accountability. This is dependent upon what constitutes the legal entity responsible for the facility being accredited. The significant work that has been done since the Laboratories Positioning Paper was submitted to the Chief Executives (CEs) in November 2016 has allowed greater understanding and Page 5 of 65

6 quantification of the issues outlined in that paper 1. The paper identified four enabling projects necessary to ensure that maximum benefit is derived from the DSM 1. Benchmarking 2. IT 3. Standardisation 4. Innovation Table 2: Enabling Projects The development of robust and consistent benchmarking data to enable service planning and improvement. This work is being taken forward by all Boards in partnership with Keele University. Definition of the IT specification required to support delivery of the DSM. An initial workshop has been held and a shared understanding of the future requirements for an IT connected DSM have been agreed by stakeholders. Alignment of laboratory practices and procedures to reduce unwarranted variation of laboratories service provision and promote consistency and connectivity between Board level services. Exploring innovative solutions to support the efficient and effective delivery of laboratory services through the DSM. Digital Pathology is being progressed as an initial pilot supported by funding secured from Scottish Government. As with other service areas covered by the Shared Services Health Portfolio, realising the full potential of the solution proposed in the business case will depend upon addressing extrinsic variation; the variation in the practice of clinicians and others who access the testing services provided by laboratory disciplines. There is significant variation in demand for certain tests between Health Boards which needs to be understood and, where appropriate, addressed. This will require further engagement with the wider clinical community through Medical and Nurse Directors, the Diagnostic Steering Group (DSG) and the various Diagnostic and Clinical Networks. The approach must also link to the ethos of Realistic Medicine and the Demand Optimisation Group. Anticipated Benefits A number of anticipated benefits have been identified by stakeholders and now require to be developed further as part of the business case. Anticipated benefits of the DSM A laboratories model capable of supporting emergent front line clinical models Service model that is focussed on delivery of Triple Aim benefits Greater adherence to the concept of delivery of the right test, right place, right time Equity of provision Greater sustainability and resilience More efficient and effective use of resources facilities, equipment and finance Reduced requirement for capital to refurbish and develop facilities Greater critical mass with benefits in areas such as the application of clinical expertise and in procurement Improvements for workforce including improved workforce planning with delivery of training opportunities, better career structure and improved recruitment and retention Consistent application of new technology to improve efficiency and effectiveness IT connectivity with the ability to match demand and capacity through remote working Streamlined more efficient approach to accreditation Table 3: Anticipated benefits 1 The Shared Services Laboratories Position Paper was presented to the Chief Execs when they met on 8th November 2016 Page 6 of 65

7 The work on laboratories has also identified several examples where investment in new investigations could significantly alter care pathways with benefits to patient experience and efficiencies which can be realised as savings or capacity and performance gains. An example would be the introduction and consistent application of B-type natriuretic peptide (BNP) testing, (table 19 refers) which would provide patients with faster, more accurate diagnosis of heart failure and reduce demands on cardiac imaging and cardiology outpatient appointments. Such initiatives will be most effective if introduced as part of standardised national clinical management pathways in line with the National Clinical Strategy, Demand Optimisation and Realistic Medicine. There is the opportunity to improve efficiency, effectiveness, equity, resilience and affordability of laboratories services pan Scotland. Stakeholders overwhelmingly agreed that progression to the DSM for laboratories in Scotland is the most appropriate way to achieve this and to support future development. What we are asking of the CEs The CEs are asked to: a) Give authority for the laboratories programme to develop a business case(s) outlining options for a distributed service model with key components for Scotland in accordance with the guiding principles; and, b) Ensure support from the NHS Boards to assist with enabler projects / pilots; and, c) Ensure that any future capital investment and re-procurement plans considered necessary to sustain business as usual are aligned with the work of the Laboratories Programme and comply with the guiding principles for a distributed service model (as listed on page 17) d) Support the next steps of the Laboratories Programme. Next steps To enable the ongoing process of a successful design of the DSM, a programme delivery group will be established. This will include multidisciplinary representation from: 1. Territorial Health Boards; 2. Relevant Special Health Boards; 3. Managed Diagnostic Networks; 4. Diagnostic Steering Group; and, 5. Partnership. Page 7 of 65

8 1. The Strategic Case The Case for Change In 2015 a Shared Services visioning exercise facilitated by Deloitte identified the advantages of delivering Shared Services within NHSScotland. Laboratory services were recognised as one of the elements of the emerging programmes for diagnostic services which is now embedded within the Health Portfolio. This section of the Strategic Paper sets out a compelling case for change to design the DMS for Laboratory Service delivery to NHSScotland. The DSM is required to enable delivery of an efficient, effective, resilient and affordable service to meet future national and local requirements. National Drivers for Change Drivers for change, in terms of relevant policies, strategies and reports are summarised in table 4 below. Policy / Driver Requirements Delivering Value: Services should be organised and delivered at the level where they can provide the best, most effective service for individuals. Regional, and in some case, national, centres of expertise and planning should develop for some acute services to improve patient care. Health and Social Care integration: Delivering the right test and the right place and the right time. Primary and Community Care: Health and Social Care Delivery Plan (January 2017) 2...to enable those waiting for routine check-up or test results to be seen closer to home by a team of community health care professionals enable GPs to have more access to hospital-based tests so that people can be referred to the right clinician first time. Realistic Medicine: reduce unwarranted variation... [to]... support a workforce that can find more effective and valued ways of delivering medicine NHS Board reform: Review the functions of existing national NHS Boards to explore the scope for more effective and consistent delivery of national services and the support provided to local health and social care system for service delivery at regional level. Ensure that NHS Boards expand the Once for Scotland approach to support functions 2 Page 8 of 65

9 Policy / Driver Requirements National Health and Social Care Workforce Plan (NHSCWP) : The NHSCWP will take forward the commitment to a sustainable workforce Research and development, innovation and digital health: Digital technology. The time is right to develop a fresh, broad vision of how health and social care service processes in Scotland should be further transformed making better use of digital technology and data. The Christie Commission Report 3 National Clinical Strategy 4 Healthcare Quality Strategy 5 A future Laboratories Service model will be tackling fragmentation and complexity in the design and delivery of the service. Laboratory Services to be planned and delivered nationally and regionally, based on evidence supporting best outcomes for the populations those services will serve. Effective collaboration between clinicians, patients and others. Continuity of Care. NHSScotland faces a challenge with regard to sustaining a suitably trained workforce over the next five to ten years. 7 day working Ageing population and increase in long term conditions Financial pressures/shrinking budgets across the health care system Scottish Healthcare Science National Delivery Plan ( ) 6 The Scottish Government Seven Day Working Taskforce has been asked to identify the optimal service models and consider what is needed to deliver them. The resulting increase in workload cannot be supported within the current laboratories structure. A future service model for Laboratories will increase efficiency, reduce waste through identifying unwarranted variation and demonstrate whole system benefit. Demand Optimisation: This is defined as the process by which diagnostic test use is optimised to maximise appropriate testing which in turn optimises clinical care and drives more efficient use of scarce resource. The process needs to consider: Minimising over-requesting and under-requesting, both of which can be damaging to optimal patient care. Reducing unnecessary repeat requesting. Ensuring appropriate and useful test repertoires are universally available across all healthcare outlets. The development of a future service model is driven by the desire for Page 9 of 65

10 Policy / Driver Requirements demand optimisation. IT: The Future of Pathology Services (Nuffield Trust, June 2016) 7 There is widespread agreement on the need for better supported IT that is interoperable so patients and other institutions can easily access data. The National Laboratory Medicine Catalogue is an important foundation for this work. Effective laboratory information management systems are also critical for the delivery of high-quality, safe pathology services. As the quantity of digital information increases, the ability to store, retrieve and analyse data will become increasingly important. Workforce: Table 4: National Drivers for Change The Royal College of Pathologists identified that 40% of pathologists are over 55 and most are expected to retire in the next five years. Training pathways will not generate sufficient people to replace them, which pose a significant risk to service delivery. Local Drivers for Change The PESTLE analysis was completed: Appendix 2. The key points from this analysis are summarised in table 5 below. Policy/Driver Increasing demand and new models of care Industry regulation Workforce sustainability Increasing need for big data analysis Themes relevant to Labs Laboratory Services existing configuration will be unable to respond to either due to ageing IT, other existing infrastructure and continued working in silos. Evidencing compliance with ISO through UKAS accreditation visits is more challenging for clinical and scientific staff in smaller NHS Boards. MHRA and other bodies place a regulatory framework around elements of service delivery that are challenging to deliver and maintain. Due to the current silo environment, role development and skills mix are becoming increasingly challenging to manage. New technologies are challenging existing role boundaries. Increasing the focus on the data information, information and knowledge management is also identifying the need for new roles. Current disparity between both laboratory software and data means that meaningful cross border analysis is not currently possible. There is a wide variation in form and function of services across Health Boards Table 5 Local drivers for change This forms a barrier to cross border collaboration and lab to lab communication. 7 Page 10 of 65

11 Number of laboratory services Current Arrangements and Challenges At this time, laboratory services in Scotland appear to be unbroken to users. Historically service providers across the Health Boards have evolved largely to meet their local Health Board requirements. This has led to high degrees of intrinsic and extrinsic variation in form and utilisation of service. The development of local services has been tempered by competition / demand for resource. Therefore, variation in service form and function arise as a consequence of competing local priorities for investment across the wider system at Health Board level. This is a major cause of intrinsic variation across the country which needs to be managed in order to deliver sustainable and equitable services in the future. Laboratory Services in Scotland Laboratory services in Scotland are complex, varied and wide reaching. This map in Appendix 4, is indicative of the location of laboratories in NHSScotland in Current situation In order to verify and qualify data obtained from Scottish Health Service Costs 8 (Cost Book) the following baseline data was gathered in April 2017 from laboratory services across Scotland in the form of a questionnaire. This involved input from Shared Services leads and designated laboratory representatives from the Health Boards. This data demonstrates significant variation and range of services provided in each locality. The following figures demonstrate the extent of variation in laboratory services by location and by service configuration. Thus blood sciences departments are made up of three disciplines in some Health Boards and two in others. There is further variation at hospital level within services delivered across Health Boards which is shown in Appendix 5: Table A1: Baseline data - Service Component delivered by location Monklands Hairmyres Wishaw GJNH Vale of Leven Airdrie East Kilbride Gartnavel General Glasgow RI Queen Elizabeth Stobhill Ambulatory Care Victoria Ambulatory Care Inverclyde Royal Royal Alexandra FV Royal Ayr Crosshouse DGRI Galloway University Community Wishaw Clydebank Alexandria Glasgow Greenock Paisley Larbert Ayr Kilmarnock Dumfries Stranraer Stornoway Western Isles Site and Location Blood Sciences Chemical Pathology Genetics Haematology Histocompatibility and Immunogenetics Histopathology Immunology Medical Microbiology Neuroimmunology Andrology Figure 1: Laboratory services by location, West of Scotland (NHS Greater Glasgow & Clyde, Golden Jubilee, NHS Ayrshire & Arran, NHS Lanarkshire, NHS Dumfries & Galloway, NHS Western Isles, NHS Forth Valley) 8 Page 11 of 65

12 Number of laboratory services Gilbert Bain Balfour Aberdeen RI Aberdeen Dr Gray's Belford Raigmore Caithness Sexual General Health Clinic Lerwick Kirkwall, Orkney Lorn and Islands Ninewells Perth RI Victoria Edinburgh RI RHSC Western General Aberdeen Elgin Fort William Inverness Wick Oban Dundee Perth Kirkcaldy Edinburgh Livingston Melrose St John's Borders General Site and Location Blood Sciences Chemical Pathology Genetics Haematology Histocompatibility and Immunogenetics Histopathology Immunology Medical Microbiology Neuroimmunology Andrology Note: Genetics service at NHS Highland Raigmore Hospital is reported under NHS Tayside Figure 2: Laboratory services by location, East of Scotland (NHS Borders, NHS Tayside, NHS Lothian, NHS Grampian, NHS Fife, NHS Highland, NHS Orkney, NHS Shetland) There are also examples where some Health Boards are providing laboratory services for other Health Boards: Appendix 5, Table A2 Tests provided and received for the period April December 2016 (within Scotland). Based on Cost Book data 2015/16 the current laboratories situation is detailed within Appendix 5, Tables A5 and A6: 27 laboratory sites Containing 87 laboratories Covering 16 Boards (14 territorial and 2 special) Approximately 3759 FTE staff Annual Costs estimated at million million staffing costs 72.7 million non-staffing costs These services may be provided under Service Level Agreements (SLAs) following historical arrangements. There is variation in the level of cross charging for these transferred workloads. These arrangements have often been ad-hoc reflecting local specialist interests or more structured when commissioned as national services. Ad hoc arrangements by their very nature are unplanned in the context of NHSScotland as a whole. They can be expensive and raise issues in terms of equitable access to specialist testing. The current laboratory service in NHSScotland is therefore challenging in its complexity and variability in its various aspects of form and function across the Health Boards. Page 12 of 65

13 IT Systems The IT infrastructure in place to support the delivery of laboratory services in NHSScotland displays an unacceptable level of variation. In most cases there is limited standardisation within the IT systems employed in the laboratories. This is reflected in the systems used and the way that the systems are configured. See table 6 below. The detailed breakdown of this is found in Appendix 5, within Table A3: LIMS systems by Board and Discipline and A4: Order Communication System. Variation of IT Systems (15 Boards -not including SNBTS) Laboratory Information Management System (LIMS) Eleven different LIMS Supplied by nine different system providers Three Health Boards using multiple systems Where Health Boards are using the same systems they are using different software versions Electronic Ordering (Order Comms) Eight different systems Only five offer between Health Board communication Most Health Boards use different systems for primary and secondary care. The IT system employed by SNBTS has not been universally adopted by all boards delivering a degree of complexity around the management of blood products. Table 6: Variation of IT Systems The challenge within IT systems in the laboratories in NHSScotland is due to the high degree of variation they do not facilitate cross border working and lab to lab communication. This variation carries significant overhead in terms of management and delivery of critical systems and delivers complex interface with laboratories. It will also impact on the ability of services to respond nimbly to national initiatives dependent upon IT configuration. Workforce Many of the workforce issues identified in the DSG Workforce Report of 2013 are still prevalent and evolving. The stakeholder workshops identified a consensus that the current workforce configuration does not provide the resilience required for the future. More information relating to workforce will be gathered through completion of the Keele questionnaires data from 2016/17. There was significant consultation and constructive discussion around the form of these questionnaires with stakeholders within the data / benchmarking enabler project. At this stage major workforce challenges were identified as follows: Ageing workforce with poor succession plans; Workforce model is expertise heavy; Recruitment and retention issues; and, Sustainability of specialist disciplines. The DSM for service delivery and technological developments will have a major impact on workforce planning. Page 13 of 65

14 Specialities The map in Appendix 4 highlights the Health Board distribution of the five main laboratory services in NHSScotland and displays a breakdown of a range of specialties (as identified by the Cost Book). The Royal College of Pathologists 9 identifies on their website that they oversee training of pathologists and scientists working in 19 specialities which include cellular pathology, haematology, clinical biochemistry and medical microbiology. As demonstrated in Figures 1 and 2, there is variation in the distribution of specialities. Laboratory services need to make provision to enable sustainable delivery of these 19 specialities across NHSScotland. This delivers concerns regarding sustainability of the current model due to challenges highlighted under workforce and general issues identified in the SWOT analysis: Appendix 1. The emerging challenge for laboratory services is delivery of a resilient infrastructure that will enable supply of the required laboratory outputs from the 19 specialties that meets evolving user requirements. Technology and Innovation Technology and innovation will shape future laboratory service delivery. Within the current model adoption and deployment of new technology, innovation and best evidence is challenging. Coordinated responses across Health Boards, in the main, can only be achieved at this point in time through consensus and/or compromise where funding streams are locally based. Local interests and strategies may deliver ad-hoc and piecemeal adoption of new approaches to service delivery. This limits the potential benefits realisation, to the population of Scotland that may be achievable through a more coordinated delivery. An example of new technology that will clearly enable a new approach to service delivery is provided by Digital Pathology. A pilot project is in an advanced stage of development delivered by collaborative working between NHS Greater Glasgow & Clyde and NHS Lothian, with wider involvement of the Cellular Pathology Networks and Shared services. This was identified under the innovation enabler project as a key development in this speciality. The challenge following a successful delivery of this project will be national deployment of the technologies across all Health Boards faced with competing priorities for pressurised resource. Digital Pathology highlights the feasibility of a Once for Scotland approach involving multiple stakeholders in its delivery and at the same time identifies the need to develop a service model that will enable sharing. Other examples which could be considered important at this point in time and potentially game changing includes (not exhaustive): Molecular testing in infectious diseases; Robotics (delivery of multidisciplinary workloads in high volumes); Emergence of techniques to support the delivery of personalised medicine; Development in mobile technologies and Point of Care Testing (POCT); and, Information, data and knowledge management. 9 Page 14 of 65

15 Summary It has been highlighted that the current service model faces many challenges that will impact on its long term sustainability. These challenges have been recognised and validated by multiple stakeholders who proposed the delivery of a future service model that would be best placed to meet these. The proposal is that a distributed service model (DSM) would deliver a framework to respond to current challenges and meet future service need. The stakeholder consensus is that the DSM approach is best suited to delivering services that are efficient, effective, equitable, resilient and affordable. Investment Objectives and Guiding Principles The investment objectives identify what is needed to be achieved to overcome the problems with the existing arrangements. The key investment objectives for this proposal are listed in table 7 and were developed using outputs from stakeholder workshop 1 (the visioning workshop) which was held on the 15 September The investment objectives were accepted by stakeholders at workshop 2, held on 14 December They have been widely circulated with no objections received in response. Each investment objective has been selected in response to the need for change outlined above and to align with stakeholder ambitions for what we could achieve through applying the DSM to laboratory services. Effect of the cause on the organisation Existing configuration is currently unable to respond to increasing demand and new models of care, mainly due to ageing IT systems and the fact that both disciplines and Boards work in their own silos Risk of failure as the current service model is not resilient There is an imminent risk to service sustainability due to the workforce Change is required to support the delivery of the NHSScotland Clinical Strategy, by refreshing outdated technology/ageing infrastructure and spreading the good practice which is currently happening in silos Due to shrinking budgets and competing demand for revenue and capital, we need to make savings to meet CRES targets at a time when investment is needed Table 7: Investment Objectives What needs to be achieved to overcome this need? (Investment objectives) To put in place a flexible, scalable configuration of facilities that can meet future demand To enhance service resilience through minimising variation and enabling cross border working To provide a sustainable, resilient, adaptable workforce linked to a credible workforce plan To provide improved and equitable outcomes for patients (2020Vision) by reconfiguring to support NHS transformation Deliver demonstrable value for money, reduce/avoid expenditure to enable appropriate investment in effectiveness Alongside the investment objectives a series of guiding principles for laboratory service improvement/transformation were developed and endorsed by stakeholders in workshop 2. These have also been subject to widespread circulation without objections received in response. The Page 15 of 65

16 Access Directorate of NHS Tayside has already adopted these as a point of reference to be considered in any imminent laboratory developments. The guiding principles that underpin the development of the DSM are listed in table 8. A table of how the investment objectives and guiding principles are mapped can be found in Appendix 6. Enables national planning of services while enabling a focus on local needs (right 1 testing, right place, and right time). Is aligned with the National Clinical Strategy, supporting health care improvement 2 with a Triple Aim focus. 3 Employs a Once for Scotland approach through an appropriate governance structure. 4 Enables national workforce planning. Allows the free flow of materials, information, data, knowledge and skills across 5 organisations. Enables optimised demand on services locally and nationally via appropriate 6 interfaces with users and planners. Supports local education and training of laboratory, other NHS personnel and 7 students to ensure optimal delivery and usage of laboratory resource. Ensures a sustainable Laboratory Service provision configured to deliver what is required locally to deliver equitable patient access and outcomes across 8 NHSScotland (right testing, right place, right time frame; support delivery of optimal patient flow and capacity). 9 Delivers services designed upon Lean principles. Enables appropriate standardisation of systems and processes, and sharing of 10 resources and best practice (simplify, standardise and share). Has an infrastructure that enables maximisation of return on investment in laboratory 11 services (e.g. optimal use of distributed capacity). Focussed on delivery of efficient, effective, resilient, and affordablelaboratory services 12 that address waste, harm and variation in terms of both service provision and clinical application of their outputs (deliver efficiencies and invest in effectiveness). Enables appropriate distribution of services to deliver economies of scale and to 13 enable investment in new or complex technologies. Is able to innovate and has developed mechanisms to enable rapid translation of best 14 practice/guidance and the benefits of new technologies uniformly into national approaches. 15 Supports delivery of POCT in primary and secondary care. Supports clinical research and other forms of research and development within 16 NHSScotland. Table 8: Guiding Principles A Future Service Model for the Delivery of laboratory services The proposal is that a future laboratories service model should enable equitable access to services to patients and meet the future needs of NHSScotland through a DSM complying with the guiding principles listed in table 8. The DSM would result in the development of a network of laboratories across Scotland configured to meet local and national requirements. The DSM will provide opportunities for the consolidation of colder, low volume and technologically challenging workloads, into a smaller number of centres. The goal is to deliver appropriate consolidation of workloads not centralisation. This is about delivering efficient, effective, equitable, resilient and affordable laboratory services. A visual representation of the DSM is presented in figure 3. This model will deliver the investment objectives which have been agreed with stakeholders and are presented in table 7, by enabling laboratory services to be configured to meet both national and local needs. This new configuration will meet the requirements of the service users and providers. Page 16 of 65

17 Figure 3: Distributed Service Model The DSM enables delivery of the right testing repertoire in the right place at the right time to enable optimal patient care locally and nationally. There is a notional workload of varying degrees of complexity and volume described as the national pie in the figure 3. The DSM will deliver laboratory services through a distributed network of laboratories of varying size and complexity. (pielets). They will be configured to deliver immediate local requirements with opportunities for the consolidation of colder, low volume and technologically challenging workloads, into a smaller number of centres. Each of these laboratories will have different compositions with each requiring a critical mass of resource to enable tailored delivery of local services. This will be delivered against the backdrop of a national standard with residual capacity within the critical mass of resource to deliver value added service to the network. Under the DSM specialist services need not be restricted to largest centres. The DSM delivers a focus on functional consolidation not centralisation: Form should follow function. Key Attributes of a Distributed Service Model Laboratories at different geographical locations will have differing configurations not necessarily include all disciplines. A critical mass of resource to enable tailored delivery of local services providing opportunities for local and national service development. Delivery of services against the backdrop of the national clinical strategy utilising residual local capacity to deliver a value added service with a national focus. Specialist services delivery not necessarily restricted to larger centres. Reduced intrinsic and extrinsic variation (demand optimisation). Reduced waste and improved patient safety. Right test, right place, right time. Efficiency, effectiveness, equitability, resilience and affordability. Table 9: Key Attributes of the DSM Page 17 of 65

18 Benefits of a Distributed Service Model The clinical and financial benefits of the application of the DSM on a macro level Scotland wide are difficult to quantify specifically at this stage. Individual Health Boards have undertaken reorganisation that is consistent with this approach. Below in table 10 is an example of how this was achieved at Health Board level within NHS Tayside highlighting the benefits to one Board that has undertaken a review of services and delivered a distributed model with a Triple Aim focus. Efficiency Saving at NHS Tayside Innovative Solutions deliver efficiencies and enable investment What How Optimisation of laboratory services. An integrated management model for laboratory services was introduced which featured state of the art automation, data management and order communications software. The transformation delivered: An integrated management model for laboratory services; Merging of the Biochemical Medicine, Haematology and Immunology departments into the 1 st fully UKAS accredited integrated Blood Sciences Department in Scotland; Consolidation of 4 disciplines into a single automated track; Consolidation of GP workloads on to a single site; and, Transfer of medical microbiology from Perth Royal Infirmary (PRI) to Ninewells Hospital with introduction of paperless working. Benefit Enabled Ninewells Hospital to take on 73% of PRI workload avoiding a 5M lab rebuild cost in PRI; 97% of core blood sciences workload is now released in just over 2 hours, previously 4 hours; Consolidation to Ninewells Hospital has increased efficiency in Blood Sciences by 62%; Move to MSC transferred risk and generated 500k /annum revenue saving in year 1 with a projected financial saving of 4.59M over the course of the contract and 100K recurrent reduction in management costs. Novel application of advanced robotics combined with high functionality order communications is delivering a turnaround time to diagnosis of liver disease of 2.5 hours through the innovative ilft programme developed with support from the CSO; and, Redefinition of roles and role extension to enable more effective use of staff. Table 10: Efficiency savings at NHS Tayside Page 18 of 65

19 Whole system thinking and cross disciplinary working enables the delivery of significant service developments and benefits. It is difficult to extrapolate the potential benefits into a national arena without further investigation, but experience tell us that these are likely to be significant and will be considered as part of scoping benefits in the proposed business case. Options for the DSM In all three of the workshops held to date, the overwhelming consensus has been that laboratories in Scotland should adopt the DSM. Therefore this paper does not present a long list of options. The concept of the DSM could be delivered in a number of ways to address the guiding principles and deliver the business objectives. (Tables 7 and 8). A common requirement of any DSM would be national consistency which would include the following: Delivery and ownership of the national vision for the DSM; Ownership of a national strategy; Enabling alignment of service delivery to national priorities; Enabling assessment of adoption of new technology and facilitation of innovation; Specification and oversight of a national governance structure; Delivery on national standards; and Aspects of governance to ensure that the DSM is: o o o o o o Person centred; Safe; Effective; Efficient; Equitable; and Timely At this point there are two emerging options which would be appraised moving forward to a business case. These are: 1. National Governance; Regional Delivery (table 11) 2. National Governance; National Delivery (table 12) Option 1. National Governance; Regional Delivery Current laboratory services within Boards are distributed to best fit regional priorities and infrastructures effectively delivering 3 regionally distributed services. National services (supra-regional) identified through a national planning process would also be delivered through regional boards. A framework would be established to ensure that services are delivered within a shared vision for NHSScotland. Regional delivery is consistent with the guiding principles for the DSM to enable national consistency. Regional structures are developed to ensure and assure that services meet local needs, regional needs and support national approaches. Delivery of a regional infrastructure to ensure / assure compliance of the distributed service with all legal, statutory, regulatory and accreditation requirements. Structured to support delivery of the Triple Aim and support/enable the delivery of the National Clinical Strategy. Table 11: National Governance; Regional Delivery Page 19 of 65

20 Option 2. National Governance; National Delivery Single laboratory service provided as the DSM to NHSScotland. A national delivery of the DSM consistent with the guiding principles that also enables delivery of the right test, right time, right place to the population of NHSScotland. Delivery of a national infrastructure to ensure / assure compliance of the distributed service with all legal, statutory, regulatory and accreditation requirements. Delivery of a nationally consistent service within a unified distributed service. Delivery of a national DSM assuring nationally consistency. Structured to support delivery of the Triple Aim and support/enable the delivery of the National Clinical Strategy. Table 12: National Governance - National Delivery Laboratory services are highly complex. The optimal design for the DSM will deliver many challenges as the process progresses to define the optimum delivery model. The next steps would be to progress a detailed design process with options appraisal. An objective would be to deliver a development route map for implementation of the preferred model that enables incremental change and benefit. Development of the options and business case will require continuation of existing enabler projects and may deliver requirements for additional projects. Enablers The development of the DSM is underpinned by a number of enablers which were identified by stakeholder at the Visioning Workshop on the 15 September These are detailed in the table 13 below. Enabler A robust management and governance structure Why it is important for this proposal Ensures that local needs are effectively served but with the efficiencies of a nationally coordinated distributed service. Joined up IT systems / Robust interoperability A move towards a consistent and joined up IT strategy in laboratory services throughout Scotland, is an essential prerequisite to the move towards the DSM. Robust and consistent benchmarking data This will enable service planning, improvement and standardisation of information across Scotland. Innovation in practice Technological, scientific and clinical innovation provides opportunities for increasing the impact of investment in diagnostics. Innovation delivers opportunities of new ways of working that challenge existing models of service delivery impacting on effectiveness and resilience. A resilient workforce This is important to enable delivery of service sustainability and value. A highly trained and flexible workforce is needed to deliver complex clinical, scientific and technologically driven service. Technology will deliver new opportunities for transformation of laboratory services to meet the need of NHSScotland, but this cannot be achieved without an appropriately configured and trained sustainable workforce. Cross discipline, cross border working will facilitate the DSM, and gives us the potential to Page 20 of 65

21 manage workloads evolving in workload and range of repertoire. Delivery of an effective 24/7/365 service requires a critical mass of trained staff. Standardisation of systems, processes and approaches This is a fundamental requirement to enable convergence of services, sharing of outputs, to enable service optimisation enabling cross border working, facilitating best practice adoption of best practice, easing the burden of accreditation. Enables future specification and procurement of diagnostic and IT systems. Logistics An appropriate logistics approach will enable timely and safe transport of samples between centres supported by lab to lab communications to enable associated and required data flows. Table 13: Enablers Main Benefits Criteria The main benefits for the DSM are identified in the following table. These are not exhaustive and further benefits will be identified as the models are developed and appraised by stakeholders. Outputs Outcomes Benefits Lean systems for delivery of service locally and nationally Better use of existing infrastructure Just in Time philosophy NHSScotland focus to ensure maximum benefit from targeted investment to the whole system Better value for money Improved flow and capacity Better use of existing analytical capacity Reduction of excess capacity Full exploitation of capacity 24/7 Shared Infrastructure Efficiency, economies of scale, better use of capacity including facilities, knowledge and skills. Shared Quality Systems Shared HR/Finance/H&S/Procurement Reduction of risk Reduction of variation Equitability Affordability. Scotland wide focus on delivery of accreditation with flexible scope delivery of accreditation across larger and more diverse functional units. National focus for investment of existing and in new resource. Innovation Centre/s to enable co-working with commercial partners Support of national international clinical trials Provision of services for Once for Scotland approaches enabling/facilitating rapid adoption of emerging technologies. Income generation Page 21 of 65

22 Table 14: Main Benefits Criteria other UK Health care systems Provision of consultancy work to 3 rd parties Provision of education and training The benefit criteria for each of the enablers can be found in Appendix 6. Risks Broadly the risks to delivery of the investment objectives relate to reduction of variation and stakeholder engagement. The highest scoring risks for the programme are summarised in the table 15 below. These risks were identified by the programme team and stakeholders. Risk description Impact Risk score Mitigation Health Boards continue with capital plans/ service development for laboratory services Reduced benefit and minimal impact on service improvement. 16 high Recommend that Health Boards use the guiding principles as a standard for procurement / service design. Clinical engagement We are unable to define a robust service model as part of the business case. 16 high Engage with professional groups and networks e.g. SPAN, SMVN, SCBMN and Haematology SLWG. Health Boards do not support proposals if they are not seen as positive for their Board Reduced benefit and minimal impact on service improvement. 12 medium Establish a technical working group which involves stakeholders from all Health Boards. We will not be able to source the baseline data we need to support the development of the business case Inaccurate data collated and therefore unable to baseline appropriately medium Establish a data working group which involves stakeholders from all disciplines, Health Boards and Networks. Engage with the DSG. Table 15: Risks Page 22 of 65

23 Constraints Initial assessment identified the following constraints. These are not exhaustive and further benefits will be identified as the DSM is developed and appraised by stakeholders: 1. The design of the DSM will need to be compliant with guidelines from the professional bodies associated with all of the laboratory disciplines, and compliant with all applicable legal, statutory and regulatory frameworks. 2. The development of the DSM needs to continue to support existing academic partnerships to include teaching, clinical research and research and development priorities both within the NHS Boards and nationally. 3. The DSM will need to be designed to ensure that the required support of all relevant public and private sector users continues. Services which are obtained out with Scotland may still need to be supported in the new model. Dependencies Laboratory Services are highly complex and variable in form, delivering outputs from as many as 19 disciplines across the Boards. Design and eventual establishment of the DSM to enable optimal delivery of high impact laboratory outputs will have multiple dependencies. These will be further characterised as the design process progresses. Design of the DSM and delivery of a business case will be dependent upon: 1. Delivery of a focused and co-ordinated multidisciplinary approach to the design of the DSM for NHSScotland with continued committed engagement of multiple stakeholders. 2. Continuing investment within the Laboratories Programme to support the delivery of the next steps and existing enabler projects. 3. Successful delivery of the desired outputs of the current enabler projects with coordination with the diagnostic networks to avoid duplication. 4. A clear mandate to progress the design and business case development, with commitment from the Boards to ensure local staff are prioritising the initiative. Redesign/transformation of laboratory services is already occurring to greater or lesser extent within Health Boards. In addition there is a now also a superimposed regional perspective emerging on service delivery/development as a consequence of the Health and Social Care Delivery Plan. Dependencies arise as a consequence of these to collate and understand Health Board/Regional developments in order assess their potential impact upon future design and delivery of the DSM. New localised or regional initiatives in underpinning infrastructure such as IT, communications, or commitment to long term contracts for new analytical technology, may deliver impediments to standardisation and lock in variation across the wider system with impact on the DSM business case. Page 23 of 65

24 3. Economic Case Introduction Stakeholders have agreed that the current model of laboratory services in NHSScotland is not sustainable and improvements could be made in service delivery to support future service demands in the form of a DSM. The investment objectives in table 7 outlines what is needed to be achieved to overcome the problems with the existing arrangements to move towards the DSM. This is about delivering efficient, effective, equitable, resilient and affordable laboratory services for NHSScotland. Financial Costs The estimated annual cost of running laboratory services across NHSScotland in 2015/16 was estimated at 251.6million per annum. This is made up of: 178.9m staffing costs; and 72.7m non staffing costs. Table 16 below is a breakdown of the total spends per discipline per Board. Board Name Direct Costs for Labs by speciality Clinical Chemistry Clinical genetics Haematology m m m Microbiology m Other m Pathology m Total m NHS Ayrshire & Arran NHS Borders NHS Dumfries & Galloway NHS Fife NHS Forth Valley NHS Grampian NHS Greater Glasgow & Clyde NHS Highland NHS Lanarkshire NHS Lothian NHS Orkney NHS Shetland NHS Tayside Total Table 16: Direct costs of labs For breakdown between pay and non-pay, see Appendix 5, table A7: NHSScotland capital expenditure in laboratories services This is the most reliable financial data available to date, however it is acknowledged that the quality of the information within the Cost Book is not fit for purpose moving forward. It is important that any financial data is accurate to enable the design of the DSM, therefore a coordinated approach to data gathering and analysis is integral to the future planning. Page 24 of 65

25 In order to gather accurate and specific financial data for the laboratories in NHSScotland it is intended that the programme: Identify the gaps and inaccuracies in the current cost book data; Define what additional data is required to support service design; Format a questionnaire to capture these gaps and inaccuracies; and Approach the individual Directors of Finance in each health board to gather the data. Willingness and ability to contribute will have a significant effect on the quality of the data gathered. Once a national financial picture is developed, it will be easier to identify variation that may lead to inefficiency and waste. Staffing There are approximately 3,759 full time equivalent (FTE) staff currently in laboratory services in NHSScotland with a combined direct cost of 178.9m per annum. See table 17 for a breakdown by Board. WTE for NHS Scotland Laboratory Departments Board 2011/ / / / /16 NHS Ayrshire & Arran NHS Borders NHS Dumfries & Galloway NHS Fife NHS Forth Valley NHS Grampian* NHS Greater Glasgow & Clyde 656 1,267 1,278 1,181 1,288 NHS Highland** NHS Lanarkshire NHS Lothian NHS Orkney NHS Shetland NHS Tayside 1, NHS Western Isles Total 3,912 3,727 3,855 3,701 3,759 Table 17 Laboratories WTE * NHS Grampian WTE in 2015/16 has been manually adjusted as the value returned in the Cost Book was 1186 WTE due an increase in 835 WTE for Support Service staff. ** NHS Highland attributed too many Administrative Services staff to labs in 2014/15 & 2015/16. The 2015/16 value was updated in the Cost Book and the updated value is presented above. The 2014/15 value has been manually adjusted here by taking the average of the previous & subsequent years WTE. The unadjusted 2014/15 WTE was 1108 WTE. Zero WTE indicates lack of return for that year. Table 17 shows that despite factors which would increase workload (e.g. ageing population, long term conditions, 7 day working), the actual WTE has remained the same over the last five years, which indicates that the workforce has overall become more productive, and has met the challenges presented. As a programme, these success stories within laboratories need to be identified; to present an opportunity to learn from past situations. Page 25 of 65

26 The SWOT analysis, Appendix 1, however highlights that we have a workforce demographic who are nearing retirement age. If nothing is done to address this, the current workforce framework could very soon become unsustainable. Investment in Diagnostics There will be many individual case studies across Scotland that demonstrates improvements in efficiency and effectiveness through transformation. This has resulted in pockets of best practice that may deliver greater benefits to NHSScotland through a Once for Scotland approach. Work on the Laboratories Program has identified several examples where investment in new investigations could significantly alter care pathways with benefits to patient experience and efficiencies which can be realised as savings or capacity (performance) gains. The following are examples of this. At this stage it difficult to estimate these gains on a national level, however moving forward to a business case these will be evaluated. Triple Aim win The impact of diagnostics is whole system however it is frequently viewed as a cost to the service rather than an investment. Design and investment in service consistent with delivery of the Triple Aim identified by the Institute for Healthcare Improvement and adopted by NHSScotland would enable the value of diagnostics to be realised and recognised. A good example of this is the development of the use of Quantitative Faecal Immune Testing (qfit) for detection of bleeding in the faeces of patients with symptoms consistent with bowel cancer. This is a low cost test that can rule out the need for gastrointestinal referral reducing the demand for colonoscopy. Therefore, a comparatively small investment in laboratories is delivering a significant reduction in demand for pressurised expensive downstream services. The results are better quality of care, cost of care and experience of care. Other Health Boards are now are now seeking to develop a relationship with NHS Tayside with the intention of delivering a distributed service in this area: table 19 refers. Investment in Diagnostics at NHS Tayside Investment in diagnostics delivers Triple Aim win What Optimise the pathway for investigation in patients in primary care with symptoms consistent with bowel cancer. How New stool test (qfit) which measures blood in faeces and predicts likelihood of serious bowel disease was used at the point of assessment in the GP Practice Benefit Negative qfit result rules out the need for a colonoscopy; Table 18: qfit Testing 70% of patients did the test at the point of assessment (GP); 14% reduction in referrals to outpatients; and Reduced demand of services in secondary care. Page 26 of 65

27 Whole System Benefits Under existing funding and organisational arrangements, it is extremely difficult to introduce new diagnostics across Scotland to translate proven benefit into practice. This is often because the investment required is new and the main beneficiaries are down steam services with non linked budgets. B-type natriuretic peptide (BNP) testing is one such example highlighted in the Chief Medical Officer s Annual Report. A letter from CEs has clearly identified the benefits of this investigation in terms of both impact on cardiology resources and drug spends, however there is still a requirement for 15 separate business cases to enable its introduction. The DSM could enable a more nimble approach to this type of scenario. Individual Health Boards have been attempting for 10 years or more to enable this. NHS GGC - Investment in Diagnostics in BNP Testing Investment in diagnostics delivers impact on waiting times, patient pathway and need for waiting time initiatives and also delivers prescribing cost avoidance What How Increased waiting time for echocardiography, delaying treatment for priority patients. Expensive drug prescribed routinely for heart failure is only effective in some patients BNP testing was used to triage patients to either eliminate heart failure as a diagnosis or to refer to a one stop clinic where management of the condition can be initiated. Benefit 10-20% reduction in use of echo cardiograms; Reduction in waiting times for an echo from 12 to 6 weeks; Reduction in waiting times for cardiology clinic from 19 to 6 weeks; Test enabled urgent cases to be expedited; Renfrewshire pilot over 10 months sees 12k savings; and Prioritises high risk patients. Business case put to the Chief Executives in March 2017 Table 19: BNP Testing Once for Scotland Approach Laboratories are often judged against sets of Key Performance Indicators (KPI) that focus on efficiency (cost per test, number of test performed per WTE, etc.) rather than clinical impact (impact on bed stays, impact on drug bills, antibiotic stewardship, etc.). The introduction of procalcitonin assays on NHS Tayside is an example of how the correct whole system focus can justify investment in diagnostic services with measurable outcomes that are of importance to users. Page 27 of 65

28 Improving Patient Management & Outcomes at NHS Tayside Improving patient management through effective antibiotic stewardship What Antibiotic stewardship in acute settings How Benefit Procalcitonin (PCT) analysis - biomarker used for the identification and management of sepsis - used to guide antibiotic treatment 30 day pilot in ICU yielded 753 saving in costs Reduction in antibiotic days by 38 days Reduction in staff time and cost of administering Reduction in bed days easing patient flow & capacity Reducing risk of antibiotic side effects Reducing risk of antibiotic resistant strains of bacteria Table 20: Antibiotic Stewardship This is now a routine test in ICU, MHDU and SHDU on Tayside These are all good examples of practice that are transportable, a Once for Scotland approach. The technologies involved are not new, but with an organised delivery structure (DSM) they are more effective. It would require appropriate infrastructure to enable translation. The above case studies demonstrate the potential economic benefits that could be achieved within the DSM. There will be many other examples to be drawn from other disciplines and Health Boards. The benefits of extending the type of thinking and practical examples illustrated above across an NHSScotland DSM will be substantial, but difficult to quantify at this point in time. Moving towards business case this will be developed. Page 28 of 65

29 4 Commercial Case A commercial case for establishing the DSM for laboratories has not yet been established. This will be developed as we move to business case. Where relevant, it will contain: Procurement viability; Procurement strategy; Service requirements; Charging mechanism; Risk transfer; Sources of budget funding; Key contractual arrangements; Personnel, i.e. Transfer of Undertakings (Protection of Employment) Regulations (TUPE) implications; Accountancy treatment; and Discussion of the affordability of the proposal. Page 29 of 65

30 5 Financial Case A financial case for establishing the DSM will be developed as we move to business case. It is anticipated that establishing the DSM for laboratories will provide a platform for more cost effective utilisation of resources. This will be explored in parallel with the development of the DSM along with any additional costs and funding required in the next business case presented. It is likely this will involve working with Health Boards to provide more detailed financial information due to the limitations of working with currently published information such as the Cost Book. Page 30 of 65

31 6 Management Case The arrangements required to successfully manage and deliver the project will be defined when developing the business case. The areas covered will include: Project management strategy and methodology; The project framework; Project roles and responsibilities; The project plan, including the high level timeline for the project; and Project communication and reporting arrangements. Page 31 of 65

32 7 Readiness to Proceed Shared Services Laboratories is a programme of significant scale and complexity. It faces the challenge of delivering transformation change while maintaining current service provision and causing no disruption to patient care. In the interests of making things manageable, the approach adopted will have to be iterative and incremental, in a way that does not miss or preclude opportunities. Laboratories encompass a number of disciplines currently delivered as discrete entities. Each deliver a spectrum of activity ranging from less complex high volume activity to small volume but highly, and increasingly, specialist activity. At the less complex end of the spectrum new and anticipated technologies provide an opportunity to have a common generic core in relation to activity and necessary skills. In recent years this has already been seen in blood sciences across clinical biochemistry and haematology and could be explored further across multiple disciplines. This is important because, while there is an attraction in managing the challenge of scale by taking a discipline-by-discipline approach to redesign there is a significant risk that such an approach misses the opportunity for economies of scale and commonality across the disciplines. Health Boards are currently at various stages in taking forward initiatives in relation to laboratories whether (re)procurement of information systems, (re)procurement of analysers, local reconfiguration of laboratories or exploration of regional opportunities. It is important that the strategic direction set by Shared Services complements this activity while ensuring that it aligns and synchronises in a way that achieves consistency and convergence at a national level. In this way the gains from a Once for Scotland approach are optimised. This is in keeping with the principles agreed earlier in the process and will be a key consideration as the business case is developed. There are real opportunities for the Shared Services team to work with Health Boards to align and coordinate these established activities. This ensures the benefits of consistency and economies of scale whether they are multi-board, regional or national, are realised while enabling Health Boards to pursue local operational imperatives. Figure 4: Illustrates how a potential pilot could be run between boards going out to procurement of IT systems. This approach makes no assumptions about specific software solutions, but rather pilots a model of working which can be replicated out to the regions as appropriate. Figure 4: Potential Pilot Page 32 of 65

33 Through engagement with Health Boards, the intention is to acknowledge and address local priorities while pursuing and delivering whole system benefits. It is anticipated that this approach will establish a new way of working which will lead to continuing successful delivery of transformational change. To enable the ongoing process of a successful design, a programme delivery group will be established. This will include multidisciplinary representation from: 1. Territorial Health Boards; 2. Appropriate Special Health Boards; 3. Managed Diagnostic Networks; 4. Diagnostic Steering Group; and 5. Partnership Working. Conclusion There is the opportunity to improve efficiency, effectiveness, equity, resilience and affordability of the Laboratories Services in NHSScotland. Stakeholders overwhelmingly agreed that progression to a distributed services model for laboratories in Scotland is the most appropriate way to achieve this and to support the future development of NHSScotland. What we are asking of the CEs The CEs are asked to: a) Give authority for the laboratories programme to develop a business case(s) outlining options for a distributed service model with key components for Scotland in accordance with the guiding principles; and, b) Ensure support from the NHS Boards to assist with enabler projects / pilots; and, c) Ensure that any future capital investment and re-procurement plans considered necessary to sustain business as usual are aligned with the work of the Laboratories Programme and comply with the guiding principles for a distributed service model (as listed on page 17) d) Support the next steps of the Laboratories Programme. Page 33 of 65

34 Appendix 1 SWOT analysis SWOT

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39 Appendix 2 PESTLE analysis Page 39 of 65

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42 Appendix 3 Workshop Outputs Workshop 1 Flash report Page 42 of 65

43 Workshop 2 Flash Report Page 43 of 65

44 Workshop 3 Flash Report Page 44 of 65

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46 Appendix 4 Laboratory services in Scotland 2015 Page 46 of 65