Mutual Aid between North Of Scotland Health Boards

Meeting: NoSPG Date: 16 th March 2016 Item: 13/16 NORTH OF SCOTLAND PLANNING GROUP Mutual Aid between North Of Scotland Health Boards NoSPG is asked to: To review and reflect on the content of the enclosed SBAR and discussion on Mutual Aid. To consider how the traditional role of Mutual Aid might be extended to increase support between Health Boards and improve the overall resilience of clinical services within the north of Scotland. To describe the barriers to the wider implementation of this model of support and to consider what actions might be required by Health Boards or by the Regional Planning Group to overcome these difficulties. Synopsis of Paper: All health and social care organisations in Scotland are under significant pressure due to financial and workforce constraints. Extending collaboration between Health Boards offers a way to enhance the planning and delivery of services. By sharing resources it should be possible to both improve and help sustain high quality patient care across the north of Scotland. While this approach has been used for many years with specialist services it is suggested that all services might benefit from this model of support. This paper suggests that the Regional Planning Groups have a significant role in supporting this process. Previous initiatives from The Scottish Government such as the Framework for Obligate Networks (March 2009), have suggested a similar model of collaborative service planning and delivery, but have not been implemented in the north despite being written with remote and rural healthcare as a primary consideration. Clearly barriers exist that need to be overcome. This paper has already been discussed by the Medical Directors and Chief Executives Group and now needs wider consideration. Dr Michael Bisset Regional Medical Director, NoSPG Board Representation: NHS Grampian Name Role NHS Highland NHS Orkney NHS Shetland NHS Tayside NHS Western Isles 1

Mutual Aid SBAR S B A R SITUATION: At the October Chief Executives Group Meeting, following discussion around the challenges and solutions for medical workforce shortages, the Scottish Association of Medical Directors were asked to explore the topic of mutual aid as a possible solution for addressing some of the short term workforce shortages being experienced. There was an interest in providing further clarity around its meaning and identifying whether it could be adopted on a regional or national basis to improve the resilience of essential services. BACKGROUND: Mutual aid agreements are currently in place between health boards to provide a framework for the sharing of workforce between health boards in the event of a major incident. With the rising number of medical vacancies across the country there is a risk workforce shortages could pose a risk to the sustainability of essential services. Further work on the regionalisation of services is being developed by the National Clinical Strategy which will involve a comprehensive review of the current distribution of services across Scotland; however, it is likely to be a number of years before these can be fully implemented. There is an opportunity to consider how mutual aid could be used in the short term to enable the sharing of skills and workforce across health boards in the event of a possible disruption to the provision of essential services. ASSESSMENT: The attached document was informed mainly through discussion by medical directors, with a focus on clarifying what mutual aid involves, along with potential advantages and barriers to its implementation. RECOMMENDATIONS The attached paper contains initial considerations on mutual aid. The Chief Executives Group are asked to: - Note and comment on the identified advantages of extending mutual aid which could form the basis of agreement on principles - Note and comment on the identified barriers and initial consideration of how these could be addressed - Consider how they wish this to be progressed. It is proposed that regional planning groups are best placed to develop this further. SAMD will continue to provide Medical Director input and leadership as required. Date: 27/11/15 Dr Roberta Lindemann, Scottish Clinical Leadership Fellow Professor Marion Bain, Co-Chair, Scottish Association of Medical Directors 1 Scottish Executive Health Department (2001). Rebuilding our National Health Service. 2

Mutual Aid: Increasing Resilience across NHS Scotland 1- Background Care across NHS Scotland is currently provided by 14 territorial health boards with the responsibility to improve and protect the health of local people and to focus clearly on health outcomes and people s experience of their local NHS system. 1 Across Scotland, health boards are experiencing a significant pressure on resources and the medical workforce supply is no exception to this. Consultant vacancies have risen year on year to over 8% in June 2015 2. NHS Scotland s expenditure on medical locum s has increased by over 400% in the last 7 years 3 and yet around 30% of locum agency requests remain unfilled 4. 17% of GP practices have at least 1 vacancy and three-quarters of these practices have struggled to secure locums 5. Healthcare teams across Scotland are experiencing workforce shortages and there is a concern this could pose a risk to the sustainability of essential services. 2- Emergencies and the traditional role of mutual aid NHS Scotland Resilience Team has issued guidance for health boards on the management of emergencies defined as any occurrence that presents serious threat to the health of community, disruption to the service or causes (or is likely to cause) such numbers or types of casualties as to require special arrangement to be implemented by one or more territorial and/or special health boards simultaneously or in support of each other. 6 The Civil Contingencies Act 2004 outlines the responsibility of health boards to be prepared for major incidents and to act in partnership to offer effective responses. Mutual Aid agreements are in place between health boards to support the management of major incidents. Mutual aid can be defined as the sharing of skills and workforce between health boards to support the sustainability of an essential service. At the heart of mutual aid is the idea that in circumstances where the immediate demand for an essential health service overwhelms a limited supply, that health boards will work collaboratively to provide safe and timely care to the affected population. It recognises that although NHS Scotland is divided into 14 territorial health boards, that there is a common responsibility to provide quality care to people across Scotland. 1 Scottish Executive Health Department (2001). Rebuilding our National Health Service. 2 NHS National Services Scotland, Information Services Division (2015) NHS Scotland Workforce Information: Publication Date: 1 st September 2015 3 NHS National Services Scotland (2015). Temporary Medical Staffing Project 4 Audit Scotland (2010). Using locum doctors in Scotland 5 March 2015 BMA Scotland survey with a 61% response rate 6 Scottish Government (2013) NHS Scotland Resilience: Preparing for Emergences Guidance to Health Boards. 3

3- Mutual aid and the opportunity for forward planning While emergencies are generally thought of as periods of extraordinary demands on a service, service disruption can also occur during a period of workforce shortage creating inadequate supply. As healthcare teams across Scotland experience difficulties in recruiting permanent and temporary staff it is becoming increasingly common for teams to be working close to capacity and therefore increasingly likely that loss of a member of staff or a moderate increase in demand could destabilise a service. The three regional planning groups have been successful in developing collaborative service models that are able to improve the quality, access, resilience and efficiency of services while the National Services Division of NHS National Services Scotland has offered similar advantages to specialist services and screening programmes at a national level. To date regional planning groups have had a particular focus on re-designing specialist services. As workforce pressures threaten to destabilise local essential services it is considered whether there is a broader range of services that could benefit from the stability of regional working. At a strategic level, the shared services agenda and the National Clinical Strategy are considering the establishment of new models for the re-organisation of services across Scotland in order to make best use of current resources and improve the quality of care offered. Successful collaborative working links have the potential to guide strategic thinking around service re-design at a regional and national level. Whilst mutual aid could continue to be used in the context of a major incident there is an opportunity for health boards to work together to develop new regional or national models of workforce deployment that would be capable of improving resilience and sustainability of essential services. 4- What could be some of the advantages of extending mutual aid? Considering a regional, or in some instances a national approach to workforce resilience could have a number of benefits. Essential benefits are the main drivers for consideration of mutual aid and identify factors that in the absence of collaborative working would severely compromise the quality of services offered to patients. 1. Patient safety: allowing for the regional prioritisation of services that are essential for safe patient care preventing avoidable harm to patients; 2. Equity: ensuring patients have access to safe services irrespective of where in the country they live; 3. Effective: ensuring patients can access appropriate care when they need it; 4. Resilience: reducing the risk of workforce shortages causing unacceptable service disruption; Desirable benefits suggest outcomes that may be drivers for the consideration of mutual aid between health boards. 5. Timely re-organisation: preventing an acute crisis resulting in unplanned redistribution of services; 6. Supporting pressured teams: reducing burnout in local teams who may be working excessive hours to keep up with service demands; 4

7. Person-centred care: when possible supporting the provision of care close to patient s homes avoiding unnecessary transfers across the country; 8. Efficiency: networks may reduce demand for avoidable locum spend and reduce the need for costly last minute re-organisation of services as well as ensuring the workforce across a region are valued and optimally utilised; Additional benefits identify secondary gains that could be derived from participating in mutual aid. 9. Multi-disciplinary approach: consideration how mutual aid may support new multidisciplinary teams across a region; 10. Making best use of technology: in some instances it may be possible to identify opportunities for technological solutions to support service sustainability by, for example, installing a videoconference link to support local staff with decision making; 11. Strengthening regional links: investing in regional networks may provide an opportunity for clinicians to make regional contacts, learn from other teams and improve referral patterns; 12. Regional disinvestment: an opportunity for a regional approach to disinvestment of services of low clinical value or rationalisation of service delivery. 5- What could be some of the barriers for progressing with mutual aid? Despite the potential benefits for considering a regional approach to the delivery of a number of services there are significant barriers to be overcome including: 1. Local accountability: health boards are currently held accountable to deliver on local performance targets which does not recognise contributions to regional service stability; Mutual aid would require a regional commitment between health boards to prioritise the sustainability of essential services in the best interest of patients. 2. Funding: there are no established mechanisms to guide the re-imbursement of services offered to different boards in the setting of mutual aid; Regional or national agreements would need to be developed to set out a fair mechanism of payment for the sharing of workforce between health boards. 3. Recovering efficiency savings: while the provision of services at a regional level may have the potential to provide financial efficiency savings it may be difficult to recover these resources due to the interdependency of local services; Tapping into the experience of regional planning groups when considered services suitable for regional delivery, developing a good understanding of local services before instigating change and considering re-design of services that are not regionalised may help release resources and inform the planning process. 5

4. Potential disruption to elective services: in some instances re-organisation of staff to ensure adequate emergency cover across a region could potentially disrupt the provision of elective services; 5. Patient expectation and political pressure: New models of care proposed by regional groups may be challenged by political groups. Raising public awareness of the principles of mutual aid and facilitating early public engagement may help gather public support. 6. Human resources: allowing doctors to work across a number of boards would likely involve modifications to their current contracts; Human resources input would be required to ensure contractual barriers are overcome to facilitate the movement of staff across the country. 7. Clinician support: it may be challenging to persuade clinicians to agree to work with different teams or across different sites; 8. Shifting pressures: there is a potential for a service that is apparently stable to be put under pressure by the additional work generated by supporting another service; 9. Adaptation: there is a potential for service disruption during any period of reorganisation of services; Clinical leadership is likely to be crucial to the success of regional networks. Clinicians and managers will need an environment where they can work together on the design and implementation of mutual aid. 6- How could mutual aid be taken forward? The practical implementation of mutual aid would firstly require a national or regional agreement around the principles of mutual aid. This could be followed by the design of a process for planning regional support networks and an agreement of when these would be instigated. Senior managers would require a forum where they could come together to openly discuss services that could benefit from a regional approach. Regional planning groups are experience in designing services across health boards and would be well placed to support mutual aid. Human resources and directors of finance could be employed to find ways to facilitate mutual aid agreements, and public and staff engagement would be crucial during both the design and implementation of mutual aid. Expansion of mutual aid and regional planning models would require health boards to work collaboratively to achieve the common goal of sustainable services across their regions. At a time when NHS Scotland is experiencing financial pressures it can be seen as a significant ask for health boards to think out with their geographical boundaries, however, collaborative 6

working may provide the best approach to support the safe delivery of care across NHS Scotland at a time of limited resources. 7