Meeting: IPG Date: 20 th November 2013 Item: 54/13 NHS LOTHIAN National Chief Executives Group December 2013 Alex McMahon Director of Strategic Planning, Performance Reporting & Information Catriona Renfrew Director Corporate Planning and Policy NHS Greater Glasgow and Clyde SCOTTISH DRIVING ASSESSMENT SERVICE: DRAFT FOR DOP COMMENT 1 Purpose of the Report 1.1 The purpose of this report is to inform the National Chief Executives Group of the proposed future provision of the Scottish Driving Assessment Service. 2 Background 2.1 The Scottish Driving Assessment Service is currently managed by the SMART Centre at the Astley Ainslie Hospital in Edinburgh. The service is delivered by a combination of appointments at the SMART Centre and through a Mobile Unit which rotates around Aberdeen, Dumfries, Dundee, Inverness, Irvine and Paisley. The service is currently characterised by long waiting times (circa 40+ weeks for the Mobile Unit and circa 30+ weeks for SMART). The inherent inefficiencies of a small team of mostly part-time staff providing assessments on multiple sites involving staff travel and downtime is a significant feature of the service. 2.2 Over the last 10 years service demand has outstripped capacity by a significant amount (see Para 4.5). Allied to this, certain naturally recurring human resource issues such as maternity leaves and long-term sickness have led to the current waiting times. 2.3 The funding of the service has been complex over the years with a mixture of contributions from NHS Boards and Scottish Government Departments (Transport Scotland and more recently Health). The Scottish Government has indicated that no further funding of a recurring nature will be available from 1 st April 2014 onwards. In light of this NHS Lothian and SMART Management have formulated a business case with several service redesign options. 2.4 A report containing these options for models of service delivery was circulated to all NHS Boards in August 2012 along with an internal options appraisal which recommended discontinuing the Mobile Unit and establishing a second static base in the West of Scotland. Following due process via the Directors of Planning Group this option appraisal and service model was challenged and modified as a result. In August 2013 a workshop was held with invitations to each NHS territorial board
where a single centralised national site model was identified as the most viable and economical option. This was further discussed at the Directors of Planning meeting in September 2013. At this meeting approval was given to a Waiting List Initiative to tackle this historical backlog. This commenced on 1 st November 2013 and will continue over the next 6 months. 2.5 SMART Management has calculated the relative efficiency of delivering the service via a Mobile Unit or from a static base. This takes into account the lost clinical time due to travelling to and from mobile locations and the frequency with which the Mobile Unit visits the various satellite centres. If the static base is considered to be 100% efficient then the various centres have different efficiencies in proportion to their distance from Edinburgh; for example Inverness is 63% efficient in comparison and Dykebar, Paisley is the most efficient mobile location at 80% efficiency. Overall the Mobile Unit is on average 69% efficient compared to a static base model. These factors lead to disparities in waiting times which have ranged typically from 17 weeks to 27 weeks for different Health Board areas. 2.6 At the same meeting of the Directors of Planning agreement was reached by a majority of Boards that from April 2014 the National Service would be provided from the Astley Ainslie Hospital in Edinburgh with no Mobile Unit (See Section 4). All Boards (with the exception of Lothian) agreed to consider funding travel costs for patients. This would apply to all new patients. 2.7 The table below shows a historical breakdown of referrals by Health Board area. Table 1 Referrals Received by Health Board Area 2008-2013 Health Board 2008/09 2009/10 2010/11 2011/12 2012/13 Average % of Total Ayrshire & Arran 72 67 83 60 72 71 5.9% Borders 31 39 49 39 31 38 3.1% Dumfries & Galloway 33 35 41 32 23 33 2.7% Fife 97 114 106 114 102 107 8.8% Forth Valley 81 87 77 68 61 75 6.2% Grampian 122 107 116 121 113 116 9.6% Greater Glasgow & Clyde 201 214 179 172 190 191 15.8% Highland 69 70 64 69 65 67 5.6% Lanarkshire 101 102 99 91 95 98 8.1% Lothian 405 365 328 288 319 341 28.2% Orkney 4 3 2 2 6 3 0.3% Shetland 1 3 4 2 3 3 0.2% Tayside 55 74 63 65 69 65 5.4% Western Isles 2 5 1 0 4 2 0.2% Total 1274 1285 1212 1123 1153 1209 2
3 Recommendations The Chief Executives Group is recommended to: 3.1 Note the outcome from the Directors of Planning meeting held on 26 th September 2013 (see Para 2.4 & 2.6). 3.2 Support the Directors of Planning proposed single site option based at the SMART Centre, Astley Ainslie Hospital in Edinburgh from 1 st April 2014 and the funding required to support the service at the current level of demand (see Section 4). 3.3 Note that for future proofing the service there requires to be a mechanism to increase capacity should demand rise to allow the service to maintain 18 weeks RTT. This would be taken forward as a second phase once the service has completed the Waiting List Initiative and identified any increase associated with future demographic trends. 4 Future Service Provision - National Service sited at SMART Centre NHS Lothian 4.1 The Service options were discussed in detail at the Directors of Planning event held on 30 th August 2013. The single site option of a National Service based at the SMART Centre with no Mobile Unit took into account the following issues as outlined in paragraphs 4.2-4.3. 4.2 The Directors of Planning acknowledged that the Mobile Unit delivers assessments closer to the patients home and that under the current model patients are offered a choice of assessment locations, however; delivery of a service on several sites throughout Scotland with a part-time team of staff and the consequent loss of travel time from the clinical capacity makes the Mobile Unit heavily inefficient (69% effective compared to the static unit). 4.3 Additional negative points regarding the Mobile Unit emerged from the meeting, see below: 3
Patient facilities not ideal Difficulty in re-scheduling cancelled appointments Potential time delay in allocating review appointments Lack of staff cover for short notice illness or other absence Significant amount of staff travel time to and from mobile sites (Average efficiency over 1 year typically 69%) Need to predict assessment vehicles required for each clinic (risk that appropriate vehicle / modifications may not be available) Risk of Mobile Unit mechanical breakdown Lack of replacement assessment vehicles in case of breakdown Vulnerable to adverse weather conditions Reliant on availability of space at hosting site Risks associated with lone working for staff 4.4 Following this discussion, it was considered that by locating the service at the SMART Centre only and providing the facilities for two static driving assessment rigs, the service would eliminate the inefficiencies associated with the Mobile Unit and maximise clinical capacity. Conversely through centralising the service it was acknowledged that there would be a loss of local service delivery and the requirement for patients to travel to Edinburgh. It was further considered that part of the loss of local access to the service would be mitigated by reimbursing patient travel expenses. 4.5 A single site can offer a total of 978 appointments per annum with current resources (see Para 4.6). This would therefore leave a demand/capacity gap of 232 assessments per year with current establishment and rates of referral (see Section 5). 4.6 A summary of the current operational costs and funding streams are detailed below. The Service operates within an annual budget of 250,000. The staffing establishment and costs for the current service delivery is as follows: Consultant in Rehab Medicine 0.2 wte = 22,735 Specialist Therapist (Band 6) 3.04 wte = 128,066 Manager / Administrator (Band 5) 1.0 wte = 34,365 Medical Secretary (Band 4) 0.48 wte = 11,344 The total staffing cost for the service is: 196,510 The remainder of the budget (circa: 53k) includes vehicle running costs, admin, travel and subsistence, training and other costs associated with the Mobile Unit i.e. transportation, maintenance, fuel. The funding stream per annum to support the operating costs is as follows: Scottish Government - 103,000 Revenue from DVLA - 16,900 Contributions from all Boards circa 130,100* *It should be noted that the recharge for individual boards is based on activity. 4
As indicated above, the service has received 103,000 per annum from the Scottish Government. NHS Lothian has been advised that this funding will cease with effect from 1 st April 2014. Chief Executives may wish to agree to follow up this point with Scottish Government. In addition the funding for the lease of the Mobile Unit ( 7k per annum) will no longer be provided. 4.7 With a service model change to a single static base and no Mobile Unit the service operational costs reduce by approximately 23,000 per annum which are made up of: Transferring Mobile Unit between sites - 6,000 per annum Fuel costs for Mobile Unit and Assessment Vehicles - 3,400 per annum Overnight accommodation for staff - 6,600 per annum Lease of Mobile Unit - 7,000 per annum The annual cost for the service with existing staff would equate to 227,000 per annum. 5 Resource Implications 5.1 Demand versus capacity calculations indicate that additional 0.56wte Therapy staff are required to meet current demand. This equates to an additional cost of 23,600. 5.2 The loss of Scottish Government funding effects 1.4wte Therapy staff and 1.0wte Manager at a cost of 93,350. For future service delivery, Boards would be required to make up this funding. 5.3 The existing fleet of assessment vehicles range from 10-13 years of age and will require replacement within the very near future. It is therefore estimated that annualised fleet replacement costs along with a non-recurrent capital investment to refresh the fleet (purchase/lease) should be built into the new service model. An initial cost of 28,500 would be required for priority upgrading followed by a recurrent sum of 11,000 per annum. 5.4 NHS Lothian has indicated a willingness to convert funding within the SMART Centre for the Therapist resource to meet the current demand. Recruitment for this is now underway and has been done mainly to address the lead time for training (6 months) and the future proofing of the service to ensure that following the Waiting List Initiative, the service is 18 week compliant. It is expected that the long-term funding for this post would be met from contributions by NHS Boards. 5.5 In summary, the additional resources required from all NHS Boards equates to 127,950 per annum plus a one-off payment for fleet renewal of 28,500. 5.6 The Waiting List Initiative has been costed at 80,000 and would be met from this years Scottish Government funding. 6 Impact on Inequality, Including Health Inequalities 5
6.1 With the current model of service delivery, there are variations in relation to waiting times and access to the service across the country. There may be a perceived impact on inequality due to the centralisation of the service at the Astley Ainslie Hospital. However in our view that geographic access impact is fully mitigated by the fact this change enables patients to access the service much more quickly and in equitable time across the country. Where Boards wish to discuss local options to ensure that any inequity of access is reduced the NHS Lothian SMART team have offered to convene local discussions to see how this may be managed in the context of a national service. 7 Next steps 7.1 For most Board areas this change affects less then 100 patients each year. The assessment is carried out (mainly) in a single visit. Each Board needs to engage with referrers to ensure that the format of the new service is clear and that new patients should not expect to access a service locally but there will be major efficiencies and reduced waiting times in the future. 6