NHS GRAMPIAN Clinical Strategy Board Meeting 02/06/2016 Open Session Item 9.1 1. Actions Recommended The Board is asked to: 1. Note the progress with the engagement process for the development of the clinical strategy and the key emerging themes; and 2. Endorse the development of a clinical strategy consultation draft based on these emerging local themes, taking into consideration feedback gathered during the engagement process, the National Clinical Strategy and the three strategic plans approved by the Integration Joint Boards. 2. Strategic Context The clinical strategy will build on the Healthfit 2020 strategy to provide renewed clarity of direction for the health system and for NHS Grampian s role in the north of Scotland. The strategy will be one of a suite of strategies that will guide future development and change including the Moray, Aberdeenshire and Aberdeen City strategic plans approved in March 2016, the National Clinical Strategy, and an emerging North of Scotland clinical strategy. NHS Grampian is an organisation in transition following the delegation of services to the Health and Social Care Partnerships (HSCPs) from April 2016.It is important, therefore, that the NHS Grampian strategy is focused on strategic issues that it is uniquely placed to develop i.e. the system of care in the north east of Scotland and the supporting actions that will bring the health and social care organisations together with a shared intent. Appendix 1 summarises the factors influencing the role of developing role of NHS Grampian. An important part of the strategic context is the changing profile and needs of the population i.e. Health is improving for everyone however whilst life expectancy rates are increasing overall, they are rising faster for the affluent than the most deprived so the gap is getting wider for men in Grampian this is almost ten years An ageing population requires the population in the future to be healthier than the population now to mitigate the health demands associated with old age. Like other parts of the country, Grampian has seen significant increases in the number of people with diabetes and other long-term conditions with increasing multi-morbidity. With an increasing population even reducing the rates of new diagnosis can result in increasing demand for services. 1
The National Clinical Strategy, published in February 2016, is also a significant influence on the Grampian strategy. The elements of the National Strategy include: Quality as the key focus all developments must ensure patient safety, clinical effectiveness and person-centred approach with equitable access to care Increased focus on primary and community care integration of health and social care, working in partnership with local communities Enhancing clinical roles and greater use of technology Networks of specialist services - planning and organisation of some specialist services will be done at a national or regional level, based on population size rather than geographical boundaries, working as part of a wider network The National Clinical Strategy also introduces the concept of realistic medicine which has received support from clinicians in Grampian. Key features of this approach include: Adopting least invasive or disruptive processes as a first step e.g. lifestyle interventions before drugs and operations Avoiding unwarranted variations of care or activity Avoiding wasteful interventions and treatments that do not add value for patients Recognising that patients can only be true partners in care if they are provided with comprehensive information about their illness and prognosis Understanding patient preferences and adapting treatment to their preferences It is likely that there will be further thinking by the Scottish Government regarding the implementation of the National Clinical Strategy and it will be important to take account of the next steps of this process to ensure consistency of approach. 3. Key Matters Relevant to Recommendation Engagement: There has been wide engagement with staff, partners and the public. The engagement has been continuous and has included discussions with the clinical advisory committees and the Area Partnership Forum at their routine meetings, together with the regular Board seminars which involve representatives of the advisory structure, Partnership Forum and senior clinicians/managers from across the system in the north east. A major strategy event was held in December 2015 and there was a period of wide engagement with staff, partners and the public during April and May 2016. In addition to 64 meetings with staff to discuss the emerging strategy the engagement information was viewed more than 21,000 times, the video on the strategy was viewed 1397 times and 400 surveys were returned by staff and the public. It is important to continue the conversation and this will be done through the development of a consultation draft strategy and discussions with the advisory 2
structure, the Area Partnership Forum and other groups to ensure that the feedback received is reflected in the strategy and supporting improvement plan. Purpose of the Strategy: The purpose of the strategy has developed over the past six months and has been influenced by the discussions with staff and partners during engagement meetings and events. The purpose of the strategy is therefore to provide high level direction in relation to the healthcare system and those issues and actions that will enable staff to implement change across all services. The strategy will not, therefore, focus on specific clinical services. These specific service strategies are already being formulated, or will be developed in response to local or national initiatives. For example Beating Cancer, the national cancer strategy, was published in April 2016 and will be developed into a local cancer strategy in the coming months by the Grampian Cancer Strategy Group. The local development of specific services strategies will, however, be influenced and supported by the Grampian clinical strategy. Shared Strategic Intent: It is clear from the engagement that there is a role for the strategy to express a shared strategic intent across the north of Scotland in relation to public health and the delivery of acute services, and HSCPs. Whilst all organisations have core responsibilities it is the collaboration on issues that will affect the whole of the population that will maximise the improvement of health and social care. The strategic priorities of prevention, self management, planned care and unscheduled care have the potential to represent a shared strategic intent. This was considered by the North East Partnership Steering Group, which brings together representatives of NHS Grampian and the Integration Joint Boards of Moray, Aberdeenshire and Aberdeen City, at its meeting in March 2016 when it was agreed that the sharing and alignment of strategies was a key aim of the Steering Group. This aim will be developed in the further period of engagement. Shaping the Strategy: The engagement on the strategy has identified the key strategic themes which will be developed across the area to ensure that the system within which clinical services are delivered meets the needs of the population. In addition to identifying the strategic themes a range of enabling actions have been agreed to support staff to work individually and in teams to improve and innovate to move towards the strategic direction. The key elements of the strategy are outlined below. a) Strategic Themes A focus on the following strategic themes to ensure that the health contribution to the health and social care system is focused and organised effectively: 3
Prevention: The NHS has a major contribution to make to the promotion of health and the prevention of disease across populations. Primary prevention activities aim to stop people becoming ill in the first place. They include promotion of healthy eating, immunisation programmes such as flu and childhood vaccinations and tobacco control policies to create smoke-free environments. Secondary prevention interventions aim to identify disease at the earliest stage to begin prompt treatment and minimise future health problems. This can include activities such as screening programmes (for example breast and cervical) and exercise programmes to prevent further heart attacks. Tertiary prevention aims to help those with an on-going illness to maximise their quality of life through for example support groups or vocational rehabilitation programmes. Self Management: The role of individual patients and families in the management of their own conditions is becoming increasingly important and valuable in the delivery of clinical care. There are many good examples of high quality self management of long term conditions. The further development of this approach will require clinical staff to develop as facilitators and educators as well as the direct providers of clinical care. Planned Care: Most people will require planned or routine care at some time in their lives. By definition planned care is organised in advance of treatment and with input from patients in relation to the time and location of treatment. Many planned care treatments can be undertaken urgently and very often good access to urgent treatment and diagnosis can avoid the need for emergency or unscheduled care where immediate attention is required. Planned care includes a wide range of treatment and procedures from hip replacements to cataract operations, and also treatment required for cancer and other complex conditions. It is projected that the need for planned care will increase as need is linked to the growing and ageing population. Unscheduled Care: Clinical care which is required immediately and is not planned is described as unscheduled care. It includes the care provided in emergency departments, at home, in primary care facilities, community hospitals, in hours and out of hours. Unscheduled care also includes the very specialist care required for patients who have suffered major trauma which involves a wide range of clinicians from different specialties. The high level ambition and actions related to these key strategic themes will be developed in further detail within the clinical strategy. The engagement process also identified the need to take forward a balanced approach to change across all of the priorities. Prevention, self management, planned care and unscheduled care are often seen as separate and distinct. They are, in fact, highly connected and progress in one will significantly influence the others. Self Management Planned Care Prevention Unscheduled Care 4
An improved approach to prevention and the promotion of healthy lifestyles will reduce the requirement for clinical care overall. The more that people are supported to manage their own long term conditions the less likely they are to need planned care and unscheduled care. Planned care services which are more accessible and available on an urgent basis will result in fewer patients requiring unscheduled or emergency care. Within unscheduled care there is an aim to convert unscheduled care to planned care so that the resources available can be dedicated to those who are genuinely in need of emergency care. An example of this connection relates to inequalities, prevention and emergency admissions to hospital. Inequalities account for a significant element of the increasing demand on the health service in Grampian emergency hospital admission rates from the most deprived areas are more than twice that of the least deprived giving the potential to reduce emergency admissions by 12,400 per year (see Appendix 2). There is a need to implement actions to tackle health inequalities throughout the health and social care system across all our themes, and provide a broader public health contribution from all health practitioners, social care professionals and third sector staff support by the specialist public health workforce. b) Enablers The support for these themes is an indication of the high level of consensus on the way forward as they are consistent with the direction set in the Healthfit 2020 vision and national and local initiatives. Perhaps of more importance, therefore, are actions that will enable staff, NHS Grampian as an organisation, and its partners to change and improve across all of the themes as indicated in the diagram below: Prevention Self Management Planned Care Unscheduled Care Promoting Staff Health and Wellbeing Developing Our Workforce Information Sharing Across the System Continuous Improvement Collaborative Working and Networking 5
The enabling actions are related to: Developing the workforce to meet the future health, treatment and care needs of the population and supporting staff health and wellbeing Sharing information about treatment and care appropriately across the system Supporting staff to continuously improve, innovate and research Working collaboratively in care networks, across acute services and HSCPs and with north of Scotland partners Improving the clinical infrastructure to provide a better environment for the delivery of clinical services and a better experience of care for patients Working in Partnership with Staff: The value of involving staff in the preparation of the strategy has been demonstrated by the level of support for the themes and enabling actions. As indicated above there will be a further round of conversations with staff to ensure that the feedback is properly reflected in the strategy. A range of discussions have been held with the Area Partnership Forum and this culminated in a focused discussion on 24 May which was attended by more than 60 representatives of partnership forums from across the system. Key issues included: Support for all staff to lead the change that is necessary to improve outcomes for the population The empowerment of staff to make changes in their own areas that improve their experience and that of the population The need to ensure that a question or challenge should always be accompanied by a proposed solution The need to provide more support to prevention given the proven benefits to the population and its role in reducing the need for clinical care The importance of information sharing to support coordinated patient care; and mobile digital technology to support staff to deliver care efficiently and effectively Valuing and facilitating staff involvement in change given their vast knowledge how systems work and could be improved Continuing to promote a culture of dignity and respect at work and to tackle those who do not demonstrate this culture quickly and effectively Key issues identified by the Area Clinical Forum and its constituent committees included: Valuing and developing professionalism in the delivery of care 6
The need to continue to support clinicians where there is significant pressure arising from increases in activity and recruitment/retention challenges e.g. in general practice and interventional radiology The support for the development of innovative approaches to team working across the system, openness to new ways of working and the creation of new roles The need to bring together hospital based and primary care clinicians to ensure that health services are as integrated as possible Ensuring the sustainability of primary, secondary and tertiary services to improve the access to services for the population in the north east and north of Scotland Strengthening relationships with the universities and raising the profile of research and development on a collaborative basis Support Structure for Change: The views and ideas obtained during the engagement process have stimulated a renewed approach to the way that change is supported by coordinating quality improvement, innovation and research. A Quality Hub has been established to support, facilitate and contribute to improving the health and social care system for the population of the North East of Scotland by: Working directly with individuals, teams and service areas to improve the quality of care and service delivered on objectives and priorities included in the clinical strategy Establishing and managing a Quality Improvement Network across the North East of Scotland to share learning and promote collaborative working, empowering staff and teams to make improvements Promoting Quality Improvement (QI) methodology and create and deliver a range of QI learning and development opportunities for all levels of staff Developing links with neighbouring Health Boards and Health and Social Care Partnerships in the North of Scotland and wider to share and learn An Innovation hub has also been established to support and develop innovations which will support the strategic priorities and the development of an innovation culture across all health and social care organisations in the north east of Scotland. The Innovation Hub will also work with the universities and the business community to create an innovation network aimed at creating wider support for innovation in health and connecting to the Scottish Government s health, wealth and innovation initiative. Work has also been done to review NHS Grampian s approach to research and development and a joint research group involving the University of Aberdeen and Robert Gordon University has been established. This group will focus initially on coordinating research activity, promoting the profile of research in the area, and working towards focusing research effort on the identified strategic priorities. 7
Consulting on the draft Clinical Strategy: As indicated above, a draft clinical strategy, based on the feedback from the engagement process, is being prepared. This will be shared with the advisory structure, management structure and area partnership forum over the next two months to ensure that it properly reflects the advice received and to ensure that there is wide support for implementation. The final draft will be submitted to the Board seminar in September prior to formal submission to the Board in October 2016. In addition to the preparation of a consultation draft an improvement plan outlining the key actions for implementation is being formulated by the Senior Leadership Team. This plan will not only include strategy implementation actions but a range of other significant actions to provide an integrated improvement programme. 4. Risk Mitigation This paper relates to corporate risk 851 related to the need to develop strategies to meet the future health needs of the population. The development of a clinical strategy which has the ownership of staff and the public, and is aligned to the strategies of partner organisations will mitigate this risk and ensure that there is clarity on the way forward for NHS Grampian and the services that it delivers. 5. Responsible Executive Directors If you require any further information please contact: Responsible Executive Directors Nick Fluck, Medical Director nfluck@nhs.net Lead manager Lorraine Scott, Programme Manager lscott@nhs.net Amanda Croft, Director of Nursing, Midwifery and AHPs amanda.croft@nhs.net Susan Webb, Interim Director of Public Health susane.webb@nhs.net Graeme Smith, Director of Modernisation graemesmith@nhs.net Date: 26 May, 2016 8
Appendix 1: Changing role of NHS Grampian The Healthcare Quality Strategy for NHS Scotland, set out an ambitious approach to ensure that the National Health Service in Scotland could become one of the best health services in the world, with a world leading approach to patient safety, and more recently, a determined approach to deliver person centred care. In setting out a Clinical Strategy for NHS Grampian it is important to be innovative and ambitious, and be clear about the developing role of the organisation. The purpose of the Board has been considered at Board stakeholder seminars the influences that need to be taken into account, and the role of NHS Grampian, are summarised below. Health and Social Care Integration NHS Grampian has a budget for public health and the delivery of services of more than 1 billion every year. From April 2016 approximately 40% of this budget has been delegated to the Health and Social Care Partnerships in Moray, Aberdeenshire and Aberdeen City to plan and deliver a wide range of services for adults including primary care, community services, mental health services, and six major acute services which focus mainly of unscheduled care (i.e. Emergency Department, General Medicine, Geriatric Medicine, Respiratory Medicine, Rehabilitation Medicine and Palliative Care). The strategic plans developed by the Health and Social Care Partnerships map out the journey of integration in line with local priorities and the nine national integration outcomes. This positive action to integrate health and social care has, by definition, changed the role and purpose of NHS Grampian towards focusing more on the facilitation of partnership in the north east of Scotland; working to make the health system in the north east of Scotland effective; and to support the HSCPs in the achievement of the nine national integration outcomes. It is important therefore, that the integration of NHS Grampian staff with social care staff to create integrated teams is supported and encouraged. Planning and Delivery of Acute Services The change associated with health and social care integration is significant but NHS Grampian will continue to be a major provider of acute/tertiary services. NHS Grampian is one of four major acute and tertiary centres in Scotland and it essential that these services are developed and maintained to ensure good access to services for the people of the north of Scotland. In relation to HSCPs and acute services the aim is to encourage and support more autonomous working consistent with the Board developing more as a facilitator of partnership working and working to support the health system as a whole in the north east of Scotland. North of Scotland Regional Working For NHS Grampian to continue as a major acute and tertiary centre there is a need for the Board to be an active partner and leader in the north. The improvement of 9
acute and tertiary services requires the successful partnerships with the NHS Boards in Tayside, Highland, Orkney, Shetland and the Western Isles. The potential for further public service reform and the creation of larger, regional NHS Boards also requires an increased focus on regional working and the development of solutions to service challenges which fit the specific geography and population distribution of the north. Training, Education and Development of People With more than 14,000 staff NHS Grampian is a people organisation we will require an appropriately skilled workforce to deliver services. A core function of NHS Grampian must therefore be to train, educate and develop staff and carers (formal and informal) in partnership with the University of Aberdeen, Robert Gordon University, North of Scotland College, University of the Highlands and Islands, NHS Education Scotland and other education providers. Community Wellbeing and Partnership NHS Grampian is a major influence in the community given the annual expenditure on health and healthcare in the area and its workforce of more than 14,000. The Board therefore has a duty to use its influence to improve the overall wellbeing and public health of the north east of Scotland and work in partnership with other public sector organisations, the third sector, the business community and with communities across the area to further this aim. NHS Grampian will therefore develop its role as a partner in: community planning and the empowerment of communities to develop their own solutions the development of an innovation network with educational institutions and the business community the improvement of the built environment through the construction of new and improved healthcare buildings benefitting the communities in the north east of Scotland as far as possible through the use of all of its resources research and development with the University of Aberdeen, Robert Gordon University and the University of the Highlands and Islands 10
Appendix 2: Prevention and Unscheduled Care Inequalities account for a significant element of the increasing demand on the health service in Grampian emergency hospital admission rates in the most deprived quintile are more than twice that of the least deprived. A greater focus on prevention provides the potential to reduce emergency admissions by more than 12,000 per year. One way to determine social position of the population is through an area-based measure such as the Scottish Index of Multiple Deprivation (SIMD). By measuring a range of variables neighbourhoods can be ranked by their level of relative deprivation. 1 It can be seen that most of Grampian s population live in some of the least deprived neighbourhoods in Scotland (Figure 1). Figure 1 There are around 50,000 emergency hospital admissions in Grampian each year. In absolute terms the largest number of admissions arises from the least deprived quintiles (Figure 2). This is perhaps unsurprising given this is where the majority of the population live. Figure 2 1 www.gov.scot/topics/statistics/simd 11
However, the number of admissions is not proportionate to population size. Dividing the number of emergency admissions per quintile by the population in each quintile gives an emergency admission rate, and it can be seen that the rate of admissions increases incrementally across the quintiles. As population deprivation increases so does the emergency admission rate (Figure 3). Figure 3 Dividing the rate in each quintile by the lowest rate shows that the relative risk of emergency admission increases with each quintile of deprivation, and in the most deprived quintile is more than twice that of the least deprived (Figure 4). Figure 4 12
The rate in the least deprived quintile demonstrates what is possible in the local population if circumstances are at their most favourable. (This is not the same as saying that the rate in the least deprived quintile is as favourable as it could be. Compared internationally, the health of the least deprived in Aberdeenshire might still be poorer than could potentially be the case.) Applying this rate to the other quintiles gives a measure of the excess admissions in each. This can be interpreted as an indication of potentially preventable admissions that would occur if there were improvements in overall risk exposures (Figure 5). Figure 5 The absolute number of excess admissions based on 2012 data was 12,400; this represents one quarter (25%) of all admissions that year. Achieving a reduction in the rate of emergency admissions across the quintiles would require preventive efforts across the whole social gradient. Because the causes of ill-health increasingly cluster with rising deprivation, it is likely that efforts required would rise in proportion to social position: to prevent one admission in SIMD1 would likely require more resource than the prevention of one admission in SIMD4. These same patterns can be seen for other parts of the healthcare system (e.g. primary care) and also more narrowly for specific health conditions. The need to allocate resources proportionate to need is expected to hold true across these different settings. 13