NHS GRAMPIAN Local Delivery Plan - Section 2 Elective Care Board Meeting 01/12/2016 Open Session Item 7 1. Actions Recommended The NHS Board is asked to: Consider the context in which planning for future elective care requirements is being undertaken with reference to the National Clinical Strategy and the NHS Grampian Clinical Strategy. Review the progress against the actions agreed within the Local Delivery Plan in relation to elective (scheduled) care. These actions are in line with the workstreams within the elective care programme. 2. Strategic Context Elective care is broadly defined as including all non-emergency care and is also described as planned care or scheduled care. Elective care is identified as one of the main themes of the NHS Grampian Clinical Strategy alongside prevention, self management and unscheduled care. Elective care cannot, therefore, be seen in isolation as the high quality and efficient delivery of services depends on, and contributes to success in the other themes. For example, a focus on prevention and self management will reduce the need for elective care services, and an efficient and accessible elective care service will reduce the demand on unscheduled care services. Elective care is a significant part of the system of health and social care in Grampian. Because of the focus on waiting times, elective care is often associated with acute services delivered in hospitals. Elective care is, however, delivered by almost every part of the health services from primary care to the most specialist tertiary services; it is the day to day work of nurses, doctors, Allied Health Professionals, psychologists, health scientists and most other professions. Elective care is also provided on a local board, regional and national level and there is often debate about the tiering and location of elective services that have small volumes of activity. NHS Grampian will need to develop a strategic solution to the creation of additional capacity (for the Grampian, Orkney and Shetland population) to meet anticipated activity levels over the next 20-30 years, linked to changes in demography. For example, the total population of the Grampian area is expected to increase by 8% between 2014 and 2025, and by more than 16% in the period to 2037. For the over 60 age group, this increase will be markedly higher at 24% up to 2025 and 42% to 2037. Life expectancy is increasing and the over 80 population growth is calculated at 36% and 106% over the same time periods. This increase in the elderly population is amongst the highest in Scotland.
In general, elective care activity is increasing and is projected to increase significantly over the next 10-20 years, in areas such as hip and knee replacements, cataract operations and a wide range of other procedures and services to ensure that people can continue to lead healthy lives. In terms of strategic context, the NHS Scotland National Clinical Strategy set out a vision for planned elective care which took the following into consideration: Secondary and tertiary care services have seen a marked change over the last 10 years. There have been increases in elective admissions, a significant increase in the care provided as a day-case and a steady rise in out-patient referrals. Scotland has had success in managing increased demand, improving quality and safety, reducing wasteful variation and producing good clinical outcomes. In order to respond to, and effectively manage, increasing demand for secondary and tertiary care and ensure sustainability of provision, it was acknowledged within the strategy that Boards across NHS Scotland will need to make changes. The challenges that are prompting change include: the potential to significantly improve outcomes. new technology providing opportunities for the establishment of centres of excellence for more complex interventions (e.g. robotic assisted surgery). increasing demand for elective procedures such as cataracts and joint replacements. pressures in recruiting highly skilled staff, and financial considerations. This paper sets out how NHS Grampian is proposing to respond to the vision and challenges set out within the National Clinical Strategy, in the context of the NHS Grampian Clinical Strategy, the actions agreed within the Board s Local Delivery Plan, regional planning and our commitment to ongoing continuous improvement. 3. Key matters relevant to recommendation The NHS Grampian Clinical Strategy acknowledged that similar to the national NHS Scotland projections, we are anticipating increases in the requirement for elective care, including advice, diagnosis and treatment. Our ambition for elective care is to: Tailor specialist treatment based on the realistic needs and goals of each patient. Improve the efficiency and productivity of services whilst safeguarding quality of care and working conditions for staff. 2
Sustain planned care services locally as part of a North East and North of Scotland network. The need to extend service networks to manage elective care capacity pressures across the North of Scotland is well understood and NHS Grampian is an active partner to enable this to happen. In terms of implementing the ambitions of the clinical strategy we have established an overarching elective care programme. This incorporates the following, in line with the actions agreed in the Board s Local Delivery Plan: Elective Care Programme Demand and Capacity Planning Quality Improvement and Redesign Infrastructure Investment & Workforce Regional Networks We have secured funding to establish a dedicated team to work intensively on the review of elective care over the next 18 months, to develop the strategic vision and plan for elective care in partnership with the North Boards A Project Board will be established which will involve staff from across Grampian - primary care and acute care clinicians, acute services management, Health and Social care partnership representation, staff partnership and public representation. University of Aberdeen representation will also be sought to ensure that research opportunities are exploited as far as possible. A project team will be established by the end of December 2016 with external health planning support being procured to facilitate and support the clinical engagement process, the development of the regional strategic case and evaluation of options for the future delivery of elective care. A programme of intensive workshops involving all elective care clinical services will be organised to commence from January 2017. Demand and Capacity Planning Given that there will be an increasing need for a range of age-related surgical interventions as the population changes (e.g. hip replacement, knee replacement, cataract surgery) we have been undertaking detailed service by service demand and capacity analysis in order to understand the future shape of services and resources required to ensure that we can meet predicted levels of growth. 3
Our work over the past two years has focused on new outpatient, inpatients and day case activity. We aim to extend this modelling incrementally over the next two years to include theatres, beds and return outpatients as part of planning for the future investment in diagnostic and treatment capacity. This demand and capacity planning will inform our comprehensive redesign programme to maximise opportunities for service delivery in primary/community care, and streamline specialist acute. This will build on the quality improvement and redesign work that has already been progressed. Quality Improvement and Redesign In order to support the quality improvement and redesign work, we have been building capacity including clinical leadership to drive forward the changes required to make care ultimately more patient centred, as well as making better use of existing resources. We are taking forward a number of initiatives aimed at transforming the way we organise our services and improving patient quality and outcomes. Examples of the quality improvement and redesign work being progressed include: Outpatients Many outpatient appointments can be dealt with by letter, email or telephone advice to the patient s GP. Other appointments and advice can be given to the patient directly without the need for them to attend in person at a physical clinic. In terms of reshaping outpatient services, we are engaged in the NHS Scotland Delivering Outpatient Integration Together (DOIT) which is focused on three key areas: Gastroenterology and Dermatology for all Boards and, in Grampian, we have elected to progress work within the Respiratory specialty. In terms of redesign arising from the DOIT programme we are progressing the following: Change Adopt advice only, clinical dialogue and referral feedback response Standardise triage using electronic triage Reduce Did Not Attends (DNAs) through use of patient reminder services Adopt direct access to imaging (MRI) knee through Orthopaedics, Radiology and GP/Allied Health Profession (AHP) redesign Current Situation The majority of specialties have this embedded as normal practice, although there is still more potential. Currently in place for the majority of specialties and a rolling programme continues, facilitated by e-health. Patient Reminder Services in operation for all of Grampian using a letter based system. Currently trialling phone based system for musculoskeletal services. Orthopaedic / musculoskeletal pathways have been updated in consultation with Radiology and GPs, currently being worked through on a modality basis. 4
Change Transforming Community AHP musculoskeletal (MSK) services pathway Current Situation A Referral Centre has been established and processes are in place and embedded. Work is ongoing to refine pathways such as Foot and Ankle Pathway. Information Technology and Clinical Guidance Intranet There are significant advantages that can be obtained by having electronic clinical notes, electronic clinical decision support, and electronic prescribing and administration systems. Such systems can improve safety, reduce wasted patient and clinician time, reduce the costs of medical records departments, and, with appropriate safeguards in place, allow for treatment across hospitals, professions and regions. Building on the implementation of the Patient Management System, NHS Grampian is committed to progressing the development of an Electronic Patient Record in Grampian to meet key aims of the Grampian Clinical Strategy and Scottish Government National Clinical Strategy. Electronic Patient Record (EPR) is a term used to describe a series of software applications which bring together key clinical and administrative data in one place. It enables a way of viewing a patient's medical record using technology. There are a number of benefits from implementing an EPR, not least the ability for clinicians to view a patient's medical record when and where they need it, without having to wait for the paper record to be brought or found. It also gives greater legibility of key clinical information and increased accuracy of data. The proposed design of the EPR in Grampian is to deliver access to a comprehensive clinical and social care information system for the population of the North East of Scotland. In addition to the above, we are progressing with a further phase of the development of the NHS Grampian clinical guidance intranet (CGI), through collaborative working between our primary and secondary care clinicians. The CGI is populated with information on health and health related services and organisations available in Grampian. It also holds information to support good referral practice helping to ensure patients are referred to the right person in the right place every time. Quality Improvement Delivery of care through reliable, safe services has been shown to promote both quality and cost-effectiveness. It can be a way of driving out waste and variation in services, producing better services more effectively and efficiently. Quality improvement work is focused on improving quality for patients, reducing bed usage where possible by finding alternatives to admission, and by aiding early discharge to make sure care is more effective for patients. Across clinical specialties there is a continuous programme of quality improvement. 5
For example, within the orthopaedic service the following has been implemented as part of a bundle of quality improvement measures: Enhanced recovery for patients with a joint replacement has been implemented to improve patient experience with faster recovery through reductions in the rates of nausea and vomiting, catheterisation, blood transfusion and early return to normal diet and early mobilisation. Implementation of the Hip Fracture Pathway to support patients' early recovery and optimise their ability to retain their independence. This set of interventions with a clinical evidence/best practice base is leading to improved patient care and reduced variation in clinical practice Theatre productivity We have established a theatre productivity project team which is working in collaboration with the Scottish Government and the Institute for Healthcare Optimization with the aim of improving theatre access for urgent/emergency cases and to smooth elective patient flow. The re-engineering of the Aberdeen Royal Infirmary and Woodend Theatres under this programme was launched on 25 November. Initiatives related to this initiative include the establishment of a surgical advisory group to facilitate peer review of theatres practices and implementation of a surgical urgency classification system to inform future theatre modelling proposals to best manage demand. Whilst this work is at an early stage, it is anticipated that this will bring significant benefits, including: Improved patient experience and outcomes Improved staff well being Improved performance and efficiency The first step toward designing optimal surgical services is to clearly characterise patient demand, not only in terms of diagnosis and procedure type, but also urgency. The theatre productivity project team is currently working with surgeons, anaesthetists and surgical teams to develop a Surgical Urgency Classification System. This is a system of quantifying the maximum clinically acceptable length of time that a patient can wait from the time of the decision-to-treat to start of the procedure ( anaesthesia start or patient-in-room time). The Surgical Urgency Classification System should be agreed by early 2017, when a 12 week period of prospective data collection will begin to determine the level of resources (rooms, staff, etc.) required to care for immediate/urgent patients. 6
Infrastructure Investment and workforce In recent years, the Board has invested significantly in additional elective care capacity, with funding enabling: The 10.8m investment in additional theatre capacity at Aberdeen Royal Infirmary and Woodend Hospitals and an associated investment in additional consultant and nursing capacity. Introduction of the first state-of-the-art Robotic Assisted Surgical System in Scotland for minimally invasive procedures for conditions including prostate cancer. The ambition to be the first centre is one example of a number of steps we are taking to make NHS Grampian a highly attractive place for clinical staff to develop their professional skills and career. Aberdeen Royal Infirmary is the first hospital in NHS Scotland to use an O-Arm scanner. This sophisticated machine generates high-resolution 3D images of patients' spine, bone and soft tissue structures, improves the speed and accuracy of operations, removes the need for repeated X-rays, reduces the extent of incisions, and improves recovery time. In February 2015 we opened the new 13.6 million Radiotherapy building at Aberdeen Royal Infirmary (ARI) bringing all aspects of radiotherapy delivery under one roof to deliver 1,700 courses of treatment a year to patients across NHS Grampian, Orkney and Shetland. During 2015/16 we welcomed the announcement by the Scottish Government of 200 million over the next five years to expand diagnostic and treatment capacity across a number of hospitals, including Aberdeen Royal Infirmary. These new facilities will be designed to adopt best practice in the clinical delivery of services with the latest technology and enhanced recovery techniques. We will wish to ensure that this investment in elective care leverages in benefits for the wider community with greater operational efficiency and with the promotion of smooth flow through the entire healthcare system. A key element of planning for the future will be to ensure that we also have a supporting workforce plan to enable us to identify the skills and capacity required to meet any changes in future demand and redesign of services. Regional networks The National Clinical Strategy sets out a future position where services will also be planned regionally in a way that sees the advantages of specialisation, and clinical networks of excellence. A North of Scotland Regional elective care planning group has been established involving the three mainland Boards which will be developing the new diagnostic and treatment centres - Grampian, Tayside and Highland, together with NHS Fife which has an interest in continuing to refer elective activity to Tayside. 7
The regional elective care portfolio will be led by the NHS Grampian Chief Executive, on behalf of the other North of Scotland Chief Executives as part of the development of a portfolio approach to service planning in the north of Scotland. This work should ensure that services, where applicable, are planned across large populations, locally, regionally or nationally with the mutual aims of: improved clinical outcomes through established clinical networks. effective use of highly skilled staff. more standardised care, through agreed clinical pathways, and optimal use of high technology equipment. services that are much less dependent on a small number of individuals, and establishing centres of excellence for teaching, research and development. 4. Risk Mitigation The risks and challenges that the elective care programme aims to address include: Increases in elective admissions, day-case procedures and out-patient referrals. Improving quality and safety, reducing wasteful variation and producing good clinical outcomes. Ensuring sustainability of service provision. 5. Responsible Executive Director and contact for further information If you require any further information in advance of the Board meeting please contact: Responsible Executive Directors Alan Gray Director of Finance alangray@nhs.net Graeme Smith Director of Modernisation graemesmith@nhs.net 22 November 2016 8