NHS Forth Valley LDP Risk Narrative and Trajectories 2011/12

Transcription

1 NHS Forth Valley LDP Narrative and Trajectories 2011/12

2 Health Improvement for the People of Scotland Health Improvement Achieve agreed number of screenings using the setting-appropriate screening tool and appropriate alcohol brief intervention, in line with SIGN 74 guidelines during 2011/12. Achieve agreed number of inequalities targeted cardiovascular Health Checks during 2011/12. Reduce suicide rate between 2002 and 2013 by 20% Achieve agreed completion rates for child healthy weight intervention programme over the three years ending March NHSScotland to deliver universal smoking cessation services to achieve at least 80,000 successful quits (at one month post quit) including 48,000 in the 40% most-deprived within- Board SIMD areas over the three years ending March At least 60% of 3 and 4 year olds in each SIMD quintile to have fluoride varnishing twice a year by March 2014.

3 Achieve agreed number of screenings using the setting-appropriate screening tool and appropriate alcohol brief intervention, in line with SIGN 74 guidelines during 2011/12. NHS BOARD LEAD: Anne Maree Wallace, Director of Public Health Elaine Lawlor, FVADP Co-ordinator Suggested trajectory Apr-Jun 2011 Apr-Sep 2011 Apr-Dec / ,838 2,757 3,676 Delivery Insufficient development of screening and ABI in A&E and antenatal care. Not reaching target. IT system barriers, IT errors, paper based system compliance. Workforce Co-ordinator post not continued or becoming vacant. Insufficient engagement with Primary Care staff. Insufficient staff training on IT, EScRO system and data input, at practice level. Finance Ring-fenced funding for co-ordinator post not continued. Partnership working. Improvement Insufficiently joined up approach to health improvement and health behaviour change. Equalities Not being able to reach out to those groups Continued engagement with staff. Aim to maximise access to ABI call-back outpatient clinic in the acute setting. Encourage questions on alcohol as standard practice in all acute assessments. Continue the work to implement the Forth Valley Alcohol Strategy. Address other risk areas. Continue to develop information systems. Currently working toward the introduction of a single, integrated information management system. Include management of ABI including data collection / management within Health Promotion redesign plans. Continued engagement with Primary Care workforce in respect of delivery of ABI and appropriate follow-up. Develop training programme where possible. Share learning with other areas. Advocate continued funding. Create sustainable approach by mainstreaming ABI within all healthcare settings. Continue working in partnership with ADPs across Forth Valley to realise alcohol strategy objectives in line with needs assessment. Internal Audit to undertake work to identify weaknesses and good practice within NHSFV partnerships relating to alcohol and drugs. Link with Health Promoting Health Service, work on a generic approach to health behaviour change and develop the therapeutic encounter. Develop a holistic, recovery-based focus. Continued engagement with hard to reach, e.g. through

4 who are marginalised. Unable to reduce barriers to engagement as identified within EQIA work. Missing certain population groups, e.g. Latvian community, vulnerable people, staff Keep Well, within confines of efficiency. Identification of emerging themes collated from EQIAs completed; actions put in place to address any adverse effects. Continue to address these issues, working through existing groups etc. where possible, including ensuring HR policy on alcohol is employed appropriately. Workforce development opportunities within the community within Criminal Justice Social Work and Housing/homeless workforce.

5 Achieve agreed number of inequalities targeted cardiovascular Health Checks during 2011/12. NHS BOARD LEAD: Anne Maree Wallace, Director of Public Health Oliver Harding, Consultant in Public Health NHS Forth Valley takes a broad approach to inequalities targeted cardiovascular health checks through anticipatory care work considering risk for all disease, and any age group, whilst still targeting deprivation. Activity is well ahead of target. Work continues in partnership with Local Authority and Voluntary Sector colleagues in the delivery of the Health Improvement/Health Inequalities agenda. Joint work is agreed and developed across partners through the local joint health improvement groups i.e. Clackmannanshire Integrated Health Improvement Team, Falkirk Health Improvement and Health Inequalities Group, and Healthy Stirling Partnership. This work is supported by Community Planning Partnerships and Single Outcome Agreements with Annex 6 of the Local Delivery Plan highlighting the key priority areas of focus. Suggested trajectory Apr-Jun 2011 Apr-Sep 2011 Apr-Dec / Delivery Reduction in the number of health checks delivered Community pharmacy project not delivering expected activity Workforce Discontinuation of posts/ vacancies and changes is recruitment practices due to required global efficiency saving Loss or dip in activity due to movement of staff from redeployment register to cover vacancies - staff may not be as efficient or effective as desired due to settling in period and training time involved Finance Insufficient funding taking into account the global financial position Overall financial position Continue reach work Maintain and build on existing Keep Well projects Ensure learning associated with the successful targeting of hard to reach groups is maximised and disseminated appropriately across the programme Achievement of target not based on one aspect of delivery - community pharmacy still only delivered on a project basis which has yet to be evaluated Ensure close working with pharmacies providing support and assistance throughout the project and beyond Monitoring of progress through monthly monitoring reports Advocate the continuation of posts. Create sustainable approach by mainstreaming activities within all healthcare settings. Being reviewed through general workforce plan. Ensure, where possible, that redeployed staff have the basic skill set to assist in delivery Reinforce mainstreaming of activities to build on sustainability approach Promote anticipatory care as a priority in the current financial climate. Make the case for increased central allocation of Keep Well resource to Forth Valley. Develop an appropriate complement of mixed funding sources with partners. See financial plans

6 Improvement Insufficient connection with other initiatives. Support the primary anticipatory care approach and therapeutic encounter approach to Long Term Conditions work and the Health Promoting Health Service. Where appropriate support wholesale public sector/ third sector redesign. Equalities Still not reaching the very hard to reach. Continue with engagement processes with specific client groups those experiencing homelessness for example, whilst recognising the constraints of feasibility and efficiency.

7 Reduce suicide rate between 2002 and 2013 by 20% NHS BOARD LEAD: Anne Maree Wallace, Director of Public Health Kathy O'Neill, Clacks CHP General Manager Work on the key mental health HEAT targets and commitments for Delivering Mental Health continue to be taken forward by the multi-agency Forth Valley Mental Health Delivery Plan Group. This work is integrated with local initiatives and includes the development of new Models of Care, and new ways of working in mental health. NHS Forth Valley continues to contribute to the Towards a Mentally Flourishing Scotland work, particularly via the multi-agency CHP Mental Health Planning Groups which are developing specific action plans. Work on anticipatory care also encompasses broader mental wellbeing. The Mental Health Collaborative has a lead role in supporting a range of initiatives relating to the mental health HEAT targets and improving the patients experience. A major Review of Adult and Old Age Community Mental Health Services (CMHS) is underway and will build on the new pathways developed for the Acute Mental Health Model. The CMHS Review first phase is ongoing and the development of new high level models which will be taken out for consultation with partners during early 2011 prior to implementation. The new Models will be required to respond to key initiatives including Integrated Care Pathways, the Psychological Therapies target and the need for improvements in efficiency and effectiveness. There are clear links with the ongoing work in respect of ABI, Access to Drug and Alcohol treatment, CAMHS and Psychological therapies targets. In addition, the transfer of A&E services to Forth Valley Royal in August, which are co-located with Mental Health Services, will support delivery of this agenda and the associated targets. There is a key focus on training within Forth Valley. No trajectory required Delivery Rates: Multifactorial nature of suicide rates out with NHS control Education. Insufficient capacity to deliver training Training is not coordinated across the 3 CHPs Partnership work ongoing with local multi-agency groups considering risk factors, with encouragement to include suicide in SOAs to ensure ongoing focus. Service Managers within Health and the 3 Local Authorities have been asked to ensure time is ringfenced for ASIST/safeTalk Trainers to deliver training. Existing lapsed trainers are encouraged to take up refresher training to increase the trainer pool. The need for additional trainers has been identified and will be discussed with NHS Service Managers and Local Authority Managers as well as senior representatives of other mental health agencies, including the 3 rd Sector. A program of training for 2011 has been developed to give plenty of notice for managers to allocate trainer time and maximise coordination. The Forth Valley Choose Life group (consisting of Service Managers from the 3 Local Authorities and from NHS Forth Valley) meets quarterly to plan and coordinate local initiatives. A Joint Priority Action Plan (developed in January 2010 by the local Choose Life Group) has been developed and approved by the Forth Valley Mental Health Delivery Plan Group (which includes Local Authority, NHS, 3 rd sector and other partners) to coordinate and target training to ensure the target is met by the end of the year. This provided a set of

8 training dates over 2010 each with dedicated trainers and set target attendance for each frontline staff group. The Forth Valley Priority Action Plan was used by the Mental Health Improvement Team as an exemplar for other Boards to follow. Administrative support to coordinate suicide prevention training across Forth Valley is being discussed with the 3 LAs. If this continues to be jointly funded, this post will support the trainers. A priority of this post is to ensure a consistent, schedule of training events is delivered in all 3 CHPs each year with a focus on key frontline staff. A program of training for 2011 has been developed to give plenty of notice for managers to allocate trainer time and maximise coordination. Workforce Key frontline staff cannot be released to attend training. The training is not viewed as a continuing priority. Finance The direct and indirect costs of delivering the training cannot be sustained. Improvement The target of 50% of frontline staff trained is not integrated with other National and local intitiatives. Senior Managers in Health and Local Authorities are being asked to consider this training as a continuing priority. ASIST and safetalk have been included as mandatory training in the draft Forth Valley Mental Health Nursing Training and Education Strategy. Provisional discussions have taken place (and more are planned) with CHP GP Clinical Leads regarding developing a shorter local training program for GPs that will have less impact on their time. Advice from the Mental Health Improvement team on how other Boards are addressing this issue has been helpful. The inclusion of ASIST and safetalk (and potentially STORM) training at induction for new staff is widely supported and continues to be pursued within NHS mental health services. ASIST training is also being considered for pre-diploma nursing students by the University of Stirling. Trainers have met with A&E managers to reinforce the need for this training. Service Managers in Mental Health and Acute Services are being asked to continue to prioritise this training. ASIST and safetalk have been included as mandatory training in the draft Forth Valley Mental Health Nursing Training and Education Strategy. Choose Life funding (held by Local Authorities) continues to fund direct costs including accommodation and training materials. The Choose Life leads in each agency will be approaching Service Managers to promote uptake of the training as a priority for the Board and Councils. Following guidance from the Mental Health Division, and completion of a Self-assessment template, a Priority Action Plan for H5 was approved in January The Action Plan was modified with support and advice

9 from the Mental Health Improvement Team, including conference calls which involved discussion on how other Boards were approaching and resolving key issues such as low uptake from GPs. The Forth Valley Lead Trainer in suicide assessment and prevention attended related national events including Choose Life conferences to discuss new and innovative approaches to recruiting attendance at and delivering training. The relevance of the training to other mental health initiatives, including Closing the Gaps, A Fuller Life, See Me, Breathing Space and Towards a Mentally Flourishing Scotland, has been reinforced at NHS Board and local planning levels to ensure an integrated and supportive approach to delivery. At a local level, the association of the principles of the training has been fed into service improvement initiatives such as promoting Recovery, the development of Integrated Care Pathways (depression in particular) and in the development of Joint Health Improvement Plans with Local Authority partners in each of the 3 CHPs.. GPs do not view this training as a priority. Consideration is being given to making the training more accessible to GPs by potentially providing shorter locally developed evidence-based training. This will be discussed further with training coordinators for Primary Care in each CHP. GPS who have attended the training have provided positive feedback. Clinical practice does not improve following training. GPs now are more appreciative of what we are trying to achieve but maintain that training has to be more focused and accessible for them. Individual practitioners, and their Managers, are being advised to include this training in PDPs and in Clinical Supervision. The training has been linked to the implementation of a new Model of Care for Acute In-patient Services, including the electronic FACE care planning program, across adult and old age psychiatry services to promote good practice in risk assessment and management processes. Equalities GPs and other community-based staff do not uptake the training resulting in poorer quality suicide assessment and prevention for equalities groups. Consideration is being given to making the training more accessible to GPs by potentially providing shorter locally developed evidence-based training. This will be discussed further with training coordinators for Primary Care in each CHP. Community Psychiatric Nurses and Social Workers are being targeted to attend ASIST training. A large number of staff from a wide range of community based agencies, for example, youth workers, family support workers, and voluntary organisation staff, have attended safetalk and ASIST training enabling the practice of these skills across the wider community. Equality and Diversity workbooks developed to support staff within Mental Health Services to raise staff s awareness of equalities/inequalities issues. Training focuses on case studies and best practise.

10 Achieve agreed completion rates for child healthy weight intervention programme over the three years ending March NHS BOARD LEAD: Anne Maree Wallace, Director of Public Health Graham Foster, Consultant in Public Health Suggested trajectory Apr-Jun 11 Apr-Sep 11 Apr-Dec 11 Apr 11-Mar 12 Apr 11-Jun 12 Apr 11-Sep Apr 11-Dec 12 Apr 11-Mar 13 Apr 11-Jun 13 Apr 11-Sep 13 Apr 11-Dec 13 Apr 11-Mar Delivery 18 hour school based intervention is innovative non-medical model which relies upon support from Schools facing financial and performance pressures. Revised intervention will increase cost and increase training and follow up required. Focus on quantity of interventions rather than quality may reduce actual benefit to each participant. Requirement to measure BMI before and after increases focus on weight which may undermine core philosophy, create stigma or cause parents to withdraw children. Direct involvement of programme managers is vital to successful delivery of programme. Workforce Programme relies upon a small cohort of trained staff. Programme uses contractual workers for dance and drama components. Funding is insufficient to employ sufficient staff for direct delivery of whole class interventions. Cost of formal BMI measurement reduces resources for delivery. Finance Withdrawal of core funding. Improvement Evidence base indicates strong family engagement essential. Intervention is largely NHS Funded and is designed to address components of curriculum for excellence. Positive evaluations and links to Curriculum for Excellence will be used to promote widespread adoption of intervention in local schools. Programme will be revised to try and deliver additional requirements alongside proven core programme. Each years programme will be delivered to sufficient schools to try and guarantee required numbers. Programme will be revised to try and divert attention away from BMI whilst still capturing participants data. Funding from core programme will be used to secure input from experienced programme managers Training has been extended to class teachers, school nurses and community support workers and will continue to be delivered within programme. Programme managers work to identify future contract workers and retain existing team. Absolute number of Max Weeks could been reviewed to maintain quality or skill mix of staff could be reviewed. Use funding to train existing school staff and volunteers. Reduced absolute numbers to ensure quality of employed staff and impact of each intervention can be maintained. Core funding will be protected for delivery of interventions. Evaluation resources to be identified separately. Training will engage family support workers and community services. Consider engaging supplementary services such as counterweight families programme.

11 Evaluation is a novel approach. Initial impact may not be sustained long term. Equalities Project may have greater impact on pupils from more affluent background. Project may exclude those for whom English is not a first language. Parents may choose to withdraw pupils during Max Week. Project may overly focus on a particular client group. Use of short loop learning to improve intervention with each cycle. Greater outreach and follow on to take place following the work of each Max Week thus maintaining the general positive focus and increasing the overall health improvement impact. Continual development of training to include follow-up events, projects and reminders for schools. Intervention is inclusive whole class approach. Intervention is targeted at schools with poorest performers and in areas of greatest social need. Intervention does not require financial commitment from participants. NHS FV has systems in place in respect of translation/adaptation of information into alternative formats on needs led basis. Project uses methodology that excels at including and involving all children. Project is carefully managed to limit focus on obesity and ensure positive engagement with schools and parents. Over 3000 pupils have been involved and no pupils have been withdrawn with reports of improved attendance during Max weeks. Project is a whole class approach with strong and positive prevention messages. Max is clearly aimed at all children in the class.

12 NHSScotland to deliver universal smoking cessation services to achieve at least 80,000 successful quits (at one month post quit) including 48,000 in the 40% most-deprived within-board SIMD areas over the three years ending March NHS BOARD LEAD: Anne Maree Wallace, Director of Public Health Oliver Harding, Consultant in Public Health Suggested trajectory Apr-Jun 11 Apr-Sep 11 Apr-Dec 11 Apr 11-Mar 12 Apr 11-Jun 12 Apr 11-Sep Apr 11-Dec 12 Apr 11-Mar 13 Apr 11-Jun 13 Apr 11-Sep 13 Apr 11-Dec 13 Apr 11-Mar Delivery Decrease in smokers wanting to quit fewer referral target not achieved Loss of expertise Workforce Posts not continued or vacant due to retirement and loss of fixed term contracts Discontinuation of posts/ vacancies and changes is recruitment practices due to required global efficiency saving Loss or dip in activity due to movement of staff from redeployment register to cover vacancies - staff may not be as efficient or effective as desired due to settling in period and training time involved Finance Insufficient funding taking into account the global financial position Overall financial position Increased prescribing costs Maximise data capture through pharmacy and primary care Monitor data recording within the pharmacy and primary care setting with support from CHPs to ensure timeliness and accuracy Focus on action to improve access to local smoking cessation services with on-going marketing taking every available opportunity to drip feed the message e.g. through the anticipatory care programme, GP practices, pharmacies etc - achievement of target not based on one aspect of delivery Ensure learning associated with successful targeting of hard to reach groups is maximised and disseminated appropriately across the overall programme See workforce section Promote the continuation of smoking cessation related posts Develop and promote CHP orientation for smoking cessation work Create sustainable approach by mainstreaming activities within all healthcare settings Being reviewed through general workforce plan Ensure, where possible, that redeployed staff have the basic skill set to assist in delivery Reinforce mainstreaming of activities to build on sustainability approach Promote anticipatory care as a priority in the current financial climate. See financial plans Work with Pharmacy Director ensuring that local

13 prescribing policy adhered to Improvement Unable to move towards generic health behaviour change as the preferred approach Equalities Unable to demonstrate an adequate proportion from deprived populations. Continue to develop links to Health Promoting Health Service, and primary anticipatory care and the therapeutic encounter Develop CHP orientation for smoking cessation work Continuation towards smoke free services across all sectors of health care within Forth Valley e.g. psychiatric inpatients smoke free by end calendar year Enable further linkage to Keep Well and its outreach. Ensure accurate data capture. EQIAs completed on a variety of smoking cessation initiatives within NHS Forth Valley. Actions in place if adverse impact in accessing same is identified. Several examples of best practice identified

14 At least 60% of 3 and 4 year olds in each SIMD quintile to have fluoride varnishing twice a year by March NHS BOARD LEAD: Anne Maree Wallace, Director of Public Health Derek Richards, Consultant in Dental Public Health Suggested trajectory Jun-11 Sep-11 Dec-11 Mar-12 Jun-12 Sep-12 5% 10% 15% 20% 25% 30% Dec-12 Mar-13 Jun-13 Sep-13 Dec-13 Mar-14 35% 40% 45% 50% 55% 60% Delivery Childsmile programmes in place which currently target those in worst SIMD quintile. Achievement of targets in other quintiles will require the co-operation of local independent dental contractors. Workforce Recruitment of additional support staff required to extend existing Childsmile programmes and support independent dental contractors. Finance Currently ring-fenced funding for Childsmile programmes potential risk should this funding be removed. Improvement Failure to meet targets in better off SIMD quintiles due to lack of co-operation from local independent contractors. Those in poorer SIMD quintiles will be included in school-based schemes provided through salaried service however those in better off quintiles may not be seen as at risk by independent dental contractors. Equalities Successfully reaching the target across each of the quintiles may result in the existing gradient across the quintiles being perpetuated. The use of educational events, and national and local guidelines. A new item of service fee for independent contractors practitioners has been proposed which is anticipated to have a positive impact. Clarify on-going budget and agree recruitment plans with CHPs along with actively engaging independent contractors. Clarify on-going budget and recruitment plans with CHPs and finance. The use of educational events and national and local guidelines. A new item of service fee for independent contractor practitioners is planned which will have a positive impact. The more targeted school based approach for those in the poorer quintiles should achieve greater uptake and has the potential to achieve greater reductions.

15 Efficiency and Governance Efficiency and Governance NHS Boards to operate within their agreed revenue resource limit; operate within their capital resource limit; meet their cash requirement. NHS Boards to deliver a 3% efficiency saving to reinvest in frontline services NHSScotland to reduce energy-based carbon emissions and to continue a reduction in energy consumption to contribute to the greenhouse gas emissions reduction targets set in the Climate Change (Scotland) Act 2009.

16 NHS Boards to operate within their agreed revenue resource limit; operate within their capital resource limit; meet their cash requirement. NHS BOARD LEAD: Fiona Ramsay, Director of Finance Delivery Workforce Finance Improvement Equalities SEE FINANCE PLAN AND CAPITAL PLAN

17 NHS Boards to deliver a 3% efficiency saving to reinvest in frontline services NHS BOARD LEAD: Fiona Ramsay, Director of Finance Delivery Workforce Finance Improvement Equalities SEE FINANCE PLAN AND CAPITAL PLAN

18 NHSScotland to reduce energy-based carbon emissions and to continue a reduction in energy consumption to contribute to the greenhouse gas emissions reduction targets set in the Climate Change (Scotland) Act NHS BOARD LEAD: David McPherson, General Manager, Forth Valley Facilities Suggested trajectory - reduction in carbon emissions 2009/ / / / /15 8,205 7,720 7,488 7,264 7,046 Suggested trajectory - reduction in energy consumption 2009/ / / / /15 217, , , , ,672 Delivery The CO2 emissions reduction target has been set for a five year period. Significant changes to the estate will take place or are planned for implementation during this period. Although the new sites should be more efficient there will be prolonged periods of double running. Energy consumption in the period immediately after opening a new building can be high as systems are tuned to give their optimum performance. The National Environment Report 2009/10 highlights that NHS Scotland has reduced its CO 2 emissions by 41.42%. Many of the obvious measures to improve efficiency have been implemented. In the short term there are a few projects that can be implemented without major capital expenditure, but in the longer term performance improvements will become increasingly difficult to achieve. Workforce The commencement of the Carbon Reduction Commitment Energy Efficiency Scheme in April 2010 will impose an additional administrative workload with a complex reporting and emissions trading system to be established. This new task along with other initiatives to monitor performance will be time consuming and reduce the time available to the implementation of energy abatement projects. Hospital staff transferred or about to transfer to the new Forth Valley Royal Hospital will be focused on the standard of service delivered to patients during the transitional period and perhaps less likely Health Facilities Scotland has devised a methodology which makes allowance for changes to the floor area in use across the estate. This does not however modify absolute consumption figures which will rise during the first half of the 5 year period. Arrangements are in place to monitor energy consumption and review performance with the PFI contractors. An awareness of current best practise and developing technologies must be maintained in order to fully exploit opportunities for improved performance. As far as possible information gathered for one scheme will be used for the others. Some prioritisation of workload and reduction of time spent on lower priority tasks may be necessary. Energy Efficiency Groups have been established at the new PFI hospitals to provide a focus on maintaining staff awareness.

19 to give their full attention to Energy Efficiency. Finance NHS Forth Valley has made little use of renewable energy as an emission reduction tool. There is increasing pressure through building regulations to make renewables a feature of new build projects and major refurbishment. Notwithstanding grants and other incentives these technologies have long payback periods, usually much longer than 5 years. The Government decision to scrap recycling payments from the CRC and take the money into the Exchequer imposes a significant additional financial burden at a time when capital funding is less readily available. Securing funding for Energy Efficiency Schemes will be more difficult. Improvement The major reorganisation of service delivery across NHS Forth Valley should ultimately result in more energy efficient buildings but it will make the delivery of a sustained year on year improvement during the transition difficult. The collection of accurate and verifiable data, provided in a timely fashion by the PFI contractors is untested but the experience of others suggests this may present a risk. Equalities The improvement of energy efficiency should not present a risk to any of the six equalities groups, and/or for people living in socio-economic disadvantage Renewable energy projects need to be considered against different criteria to other investment in plant and machinery. The decision needs to be based on whole life costs rather than the front end capital cost. Innovative funding routes will be exploited when possible. Grant funding and ESCO arrangements are under investigation. Overall performance across the estate will be monitored as facilities open and close. Metrics other than absolute energy consumption will be used that demonstrate improvement despite changes to the building portfolio. Assistance/guidance from Health Facilities Scotland will be sought as necessary. The performance of the PFI contractors will be monitored closely and early action taken to establish a sound working relationship between the various parties involved.

20 Access to Services Access to Services From the quarter ending December 2011, 95 per cent of all patients diagnosed with cancer to begin treatment within 31 days of decision to treat, and 95 per cent of those referred urgently with a suspicion of cancer to begin treatment within 62 days of receipt of referral. Deliver 18 weeks referral to treatment from 31 December By March 2013, 90% of clients will wait no longer than 3 weeks from referral received to appropriate drug or alcohol treatment that supports their recovery. Deliver faster access to mental health services by delivering 26 weeks referral to treatment for specialist Child and Adolescent Mental Health Services (CAMHS) services from March 2013; and 18 weeks referral to treatment for Psychological Therapies from December 2014.

21 From the quarter ending December 2011, 95 per cent of all patients diagnosed with cancer to begin treatment within 31 days of decision to treat, and 95 per cent of those referred urgently with a suspicion of cancer to begin treatment within 62 days of receipt of referral. NHS BOARD LEAD: Jonathon Procter, Director of Capacity and Access Mary Orzel, Cancer Services Manager Suggested trajectory - suspicion referrals - 62 days Apr-Jun 2011 Jul-Sep 2011 Oct-Dec % 94.0% 95.0% Suggested trajectory - treatment - 31 days Apr-Jun 2011 Jul-Sep 2011 Oct-Dec % 94.0% 95.0% Delivery The Cancer Targets are one of the many initiatives which are required to be delivered. These increase the risk of conflicting prioritises and objectives. The demand for certain Diagnostic Investigations is challenging as they are only supplied at Regional or National level e.g. PET, EUS. of not meeting the 62 day target. The demand on surgical sessions to enable all patients to be treated within the 31 day target is challenging. The management of access to tertiary services is improving however access to radiotherapy and breast reconstruction within the waiting time target remains a challenge, with the risk of not meeting the targets New Hospital Arrangements Systems and processes in respect of the storing, pulling and transfer of case notes could have an impact on the target as case notes are required for OPDs and MDTs. Timescales for planned move to the new hospital site will be concurrent with achievement of the 62 and 31 Day Target. Management of Pathways and MDTs Inability to track suspicion of cancer under redefined target. of not capturing all patients eligible for the 31day Target. Pressure on resources as cancers are added to the targets. Regular internal meetings to update on on-going issues. The development of a local cancer plan. Work is being taken forward at National and Regional Groups. The 3 PET centres are working together to manage the demand. A 2 nd PET scanner will open in the West of Scotland early in 2011/12. On going review of theatre utilisation. Close working with the Beatson Oncology Centre/ NHS Greater Glasgow & Clyde and NHS Lothian to manage this continues. Glasgow has compiled an inter-hospital transferral policy to assist with the process. Work is being taken forward at National and Regional groups. Procedures and processes regarding the management and tracking of case notes with particular reference to the move from one hospital site to another being developed and monitored. Keep milestones realistic Ensure good communication links with clinical teams Detailed transition planning Systems have been in place to do this for sometime in NHS Forth Valley. The pathology system generates a list of patients who have a positive histological/cytological diagnosis of cancer on a weekly basis. MDT lists received on a weekly basis. Reviewing alternative ways of tracking and reporting of the targets. Part of the agenda for National and Regional groups in particular with regard to funding etc.

22 A&E Referrals of not capturing all the A&E referrals which turn out to be cancer. Bowel Screening Programme The national pathway for bowel screening does not fit easily into the 62 day target and is in danger of not meeting the target. Pressures within theatre and endoscopy. Breast Screening Programme Communication delays from screening centre to local health boards Cervical Screening Programme Pathway bottlenecks may prevent meeting the 62 Day Target. Colorectal Cancer The level of demand presents a risk to achieving the cancer target particularly in relation to: Less than 10% of patients referred to the colorectal service are diagnosed with cancer however they still require investigation. There is a marked increase in levels of urgent referrals and despite increasing clinic capacity there are still challenges. Pressures within endoscopy. Pressures within theatre. Waits of up to 5 weeks for Radical Radiotherapy in tertiary centres being reported. in not meeting the targets. Breast Cancer Breast service continues to experience a high number of referrals to the service. The Breast one stop clinic has limited radiology capacity for these patients to be investigated and reported. Head & Neck Cancer The Head and Neck Cancer service is a single consultant service. This limited capacity is causing some variation in the performance and is therefore highlighted as a compliance risk for H&N services. Possibility of delays at the beginning of the patient journey with a positive diagnosis more likely to occur in patients experiencing neck-lump problems. in not meeting the 62 Day Target. Head & Neck Patients who require chemoradiotherapy/radiotherapy are at risk of not meeting the targets. Melanoma The pathology system generates a list of patients who have a positive histological/cytological diagnosis of cancer on a weekly basis. System has been set up at the front door where the staff contact a dedicated number to give details of potential cancer patients/newly diagnosed patients. Bowel This is being discussed at National, Regional and local groups. Monitor demand for surgery. Review theatre sessions availability daily. Endoscopy group meets up every two weeks to monitor demand and discuss issues. Breast On going work with the screening centres to ensure good communication systems are in place and that information is transferred appropriately between sites. Cervical Meetings are being held nationally, regionally and locally to discuss the cervical screening pathway. Bottlenecks to be identified to streamline the pathways. Colorectal Pathway monitored on a daily/weekly basis The colorectal referral proforma includes mandatory fields which allow patients to be effectively triaged. Patient waiting times reviewed weekly and escalation policy invoked when required. Work ongoing to shorten the outpatient and endoscopy stages of the pathway. Demand for surgery monitored - theatre session availability reviewed daily. Additional pathway stages make expediency difficult - pathways under constant review. Close working with the Beatson WOS Cancer Centre to manage this continues. Glasgow has compiled an interhospital transferral policy to assist with the process. This is being reviewed at National and Regional groups. The introduction of nurse-led Breast clinic has freed up some clinic slots for consultants to see more new patients however there is still an ongoing pressure. Radiology capacity under review. Review of ENT consultant staff with view to managing elective pressures. There will also be an opportunity to review the current skill mix and consider the introduction of nurse-led services. OMFS H&N surgery is undertaken by the Forth Valley OMFS surgeon at the Southern General Hospital and no issues are reported. The introduction of a neck-lump clinic has enabled faster review and diagnosis. It also supports the lymphoma pathway as patients with neck-lumps may have lymphoma. This clinic will expedite their journey. The Beatson WOS Cancer centre is reviewing the pretreatment planning process as well as capacity. This is being reviewed at National and Regional groups. The Skin Cancer service runs photo-triage as part of the

23 This service experiences a very high number of referrals, few of which are subsequently diagnosed with melanoma. Upper GI Cancer Pressure on Endoscopy Capacity - risk of not meeting cancer targets with particular respect to: Some OG surgical patients being referred to Glasgow for Surgery. If OG patients are treated locally two consultants are required for the operation. Management plans, treatment decisions and some treatment for HPB cancer patients carried out in Edinburgh. Lung Cancer Regional capacity issues and restraints are putting pressure on the achievement of cancer targets in particular in respect of lung patients who require CHART Urological Cancer Challenges in respect of achieving targets due to pressures on theatre Capacity, Brachytherapy and Oncology Ovarian Cancer Patients who require surgery as treatment for ovarian cancer are at risk of not meeting the 31 day and 62 day target due to regional capacity issues. Workforce The impact of MMC on the delivery of the cancer target in the long term requires to be monitored closely. Unexpected loss of key staff will impact on capacity to meet targets. The reporting and management of additional cancers and pathways against the 62 and 31 day targets requires to be monitored closely as risk of not meeting these targets. Finance Working within financial constraints. See Workforce above referral procedure. Review individual patient waiting times weekly and invoke escalation policy when required. Work on-going in respect of shortening the outpatient and endoscopy stages of the pathway. Discussions in progress with regard to centralising all complex OG resection surgery in Glasgow. Management of capacity being discussed at National and Regional groups. Aim to expedite the start of the journey to ensure more time at the end of the pathway to arrange surgery - this is being pursued on a National and Regional level. Meetings have been held between Edinburgh and Forth Valley to discuss HPB surgery, and access to be reviewed by WOSCAN. Close working with the Golden Jubilee National Hospital to manage access for thoracic surgery and with the Beatson WOS Cancer Centre regarding demand for CHART. The demand for treatments is being discussed at National and Regional Groups. Monitor demand for surgery. Review theatre session availability daily. The demand is being discussed at National and Regional Groups. Close working with the Beatson Oncology Centre continues Inter-hospital transferral policy produced by Glasgow to assist processes. Close working with Glasgow to manage this continues and NHS Greater Glasgow & Clyde have to complete implementation of the WOS regional model for ovarian cancer surgery. The demand is being discussed at National and Regional Groups. Human Resources Review underway to inform workforce plan. Ensure processes are in place for cross cover This is being examined as part of the Workforce review. Involve staff in pathway redesign and ensure they are kept informed of changes. Note: Part of the overall Financial Plan.

24 Improvement Sustaining management of the suspected cancer patient pathways is dependant on the Access Database used to keep track of individual s pathway. Some improvements are required to enable this. Communication system delays Equalities Capacity limitations at tertiary centres Impact on accessibility with the pending move of acute services to a Single Site Acute Hospital Currently holding discussions with e-health surrounding the developments required. Locally systems are being put in place to ensure stronger communication linkages between clinicians and cancer general and specialist teams (e.g. section on MDT form enabling transfer of information between clinicians, for early notification of treatment provided in tertiary centres and for patients attending A&E) to streamline pathways and improve communication. Discussions are ongoing in respect of the appointment systems, capacity at tertiary centre and priorities given to cross border referrals. Transitional Plan being progressed EQIA to be completed on same.

25 Deliver 18 weeks referral to treatment from 31 December NHS BOARD LEAD: Jonathan Procter, Director of Capacity and Access Amanda Forbes, 18 week RTT Programme Manager In terms of overall risk to delivery of RTT, NHS Forth Valley will be in a transitional period this year as the Integrated Healthcare Strategy continues to be delivered. There is the risk of an impact on activity over the times of the physical moves and the inevitable downtime with work continuing in respect of trajectories. This work acknowledges both the financial position and the service changes that will be implemented over summer 2011 as the final phase of the move to Forth Valley Royal Hospital takes place. This has been sized as part of the overall capacity plan. Suggested trajectory Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 83% 84% 85% 85% 85% 86% 86% 88% 90% Delivery The 18 weeks RTT is one of many initiatives underway locally, which increases the risk of conflicting priorities and objectives. Operational sustainability an important factor for all work streams. The 2011 timescales for planned move to new hospital site is concurrent with achievement of 18 weeks RTT target. Resistance to change project success and progress compromised leading to delays in implementing changes and improvements resulting in a delayed schedule and inability to meet core objectives. Reduced momentum makes it difficult to regain ground. Acute and Primary Care resources insufficient to cope with demand of 18 weeks RTT work and shifting the balance of care. Assumptions made regarding efficiency gains around theatre and day case rates. Potential for programme to be seen as distorting clinical priorities to achieve target. Project team meet monthly, Project board meet 3 monthly, monthly in house Performance Management and monthly operational unit performance management with GMs. Reporting through Acute Access Delivery Group (AADG) and key strand of this group. Long term sustaining strategies developed through AADG as well as delivery of short term operational targets. Detailed transition planning. Ensure robust links with and reporting to Executive Management Team and NHS Board. Keep programme milestones realistic. Long term sustaining strategies developed through AADG as well as delivery of short term operational targets. 18 week RTT strategy developed with key milestones and plans has executive support. Keep up momentum through robust communications and good news stories. Key staff and clinical leads involved from start of process. NHS Board, Executive Leads and GMs kept up to date and proactive approach maintained with ownership - programme strategy and milestones agreed. Build culture change through overall NHS FV strategy of building capability and capacity within organisation to support change LEAN practitioner and awareness training. Supporting change with performance measures and timely information for operational teams on request. Robust demand and capacity analysis before pathway redesign. Robust planning linked to overall Capacity Plan with key performance indicators developed for all strands. Reporting measures in place and reviewed. Ensure clear understanding and robust communications plan for programme initiatives and pathway redesign.

26 E Referral Management delivery Work closely aligned with more efficient administration flow from referral. Most out patient clinics now on TOPAS There is a significant role in primary Care in Robust planning, involvement and good achieving the 18 week RTT target. communication are key components of the process of Establishing ownership of this target from acute care to a whole system challenge is a complex task. ensuring the target is achieved by NHS Forth Valley as a whole system. These risks are being actively managed e.g. Service Improvement Directory (S.I.D.) enables referral information to GP surgery right place, right time. Engagement through GP sub-group and CHP Professional Group. Link established with practise managers group and informal communication encouraged if particular issues to be tackled. Diagnostics MRI capacity remains challenging due to significant increase in demand. Additional MRI/CT and Ultrasound capacity booked with the Golden Jubilee. Position to be monitored. Sustainability paper has been produced. Need to develop a plan to support the sustaining of the 4 week target. Endoscopy inputs remain challenging Local endoscopy target being reviewed as well as a diagnostic capacity review and look at demand management capabilities Workforce Planning for and recruiting enough skilled clinical staff to undertake any additional activity required Impact of MMC and EWTD. Unexpected loss of key staff impact on project. Finance Working within financial constraints of the whole system - development versus managing existing services. Assumptions made regarding efficiency gains around theatre and day case rates. 18 week RTT success closely linked to success of the ehealth Strategy. Funded capacity is not available to meet the demand for MRI and General Ultrasound. Demand will continue to rise as efforts are made to meet the 18 week RTT and this will increase the pressure on the Radiology department to meet demand. MRI is a particular pressure area as current levels of demand already exceed funded capacity. Capacity plan developed to include risk qualifications. Clear understanding of workforce implications of pathway redesign. Training needs assessment. Operational Workforce Plans to include any action required in relation to 18 week RTT. Succession planning. Ensure processes and work plan up to date. Service teams have ownership and detailed understanding of project. Involve all staff in pathway redesign and keep informed of progress to ensure buy in. Monitoring of monthly budget position. Ensure robust capacity planning with gains assessed at speciality level. Exercise picking up Productive Opportunity and links with the National Benchmarking project and balanced scorecard essential. Financial risk assessment being completed as part of the financial planning process. ATOS Prioritisation work to look at Efficiency and Productivity Capacity plans drawn up in consultation with service Capacity management approach being implemented.

27 Improvement Sustainability for the long term not just moving acute work to primary care Ability to track and measure 18 week pathways. Reliance on External Suppliers to provide IT Systems change (to TOPAS and Helix) Reducing DNAs and avoidable cancellations through evidence based learning e.g. SBAR completed for avoidable cancellations in SRI and FVRH and acting on learning. E-health plan has been developed and has supported o Unique Care Pathway Number (UCPN) Implementation o Development of Patient Tracking List (PTL), fully automated and current o Clinical Outcome Codes robust education and support plan for clinical and non-clinical staff carried out with continuing support o Working on method of tracking tertiary centre referrals and consultant to consultant (internal) referrals Equalities Recognised need to ensure systems for appointing patients makes provision to ensure equitable access to services Review access needs of equality groups EQIA completed Patient Access Policy has undergone an EQIA and worked closely with the Disability Nurse Advisor and the Disability Equality Advisor to ensure equitable access to services 18 week specific EQIA to be carried out in next couple of months