NHS GRAMPIAN Grampian Clinical Strategy - Planned Care Board Meeting 03/08/17 Open Session Item 8 1. Actions Recommended In October 2016 the Grampian NHS Board approved the Grampian Clinical Strategy which set out the direction for change in the North East of Scotland. The strategy emphasised the need to enable staff and teams to change, and confirmed the focus required on four broad themes i.e. prevention, self management, planned care and unscheduled care. The strategy acknowledges the benefits of progressing all four themes across the system given the inter-relationship between them. The work being taken forward in relation to planned care, also described as elective care, covers the whole pathway from primary care to regional working with partners in the North of Scotland. This paper summarises the work being taken forward within the planned care theme of the clinical strategy. It is recommended that the Board: Notes the population and activity trends which have an impact on the need for planned care. Acknowledges the work underway with partners in the North of Scotland to ensure that there is a consistent regional approach. Endorses the work being taken to reshape the approach to planned care in Grampian. Notes the range of initiatives underway or planned which will improve efficiency and ensure that priority is given to those with the greatest clinical need. 2. Strategic planning context The NHS in Scotland, in common with other health systems across the world, is facing unprecedented challenges related to its ability to meet the increasing demand for treatment and care. In relation to planned or elective care i.e. non emergency treatment and care, the impact of the growing population, and the increasingly elderly population, have been considered by the Board at previous meetings and seminars. The planned care issues have been recognised nationally, regionally, and at Board level. A National Elective Care Strategy is being developed and a National Elective Care Programme Board is overseeing the development of the strategy and a range of elective care centres across Scotland as part of the response to increasing demand and workforce challenges. In the North of Scotland region an Elective Care Programme Board has been established with the aim of formulating a strategy for the north region which will include the harmonisation of pathways and processes, sharing of resources to manage waiting times as efficiently as possible, and coordination of capital funding available to improve the facilities available for elective care delivery.
Within NHS Grampian an elective care programme, linked to the regional work and the Grampian Clinical Strategy theme on planned care, is underway to develop a comprehensive transformation programme across 21 clinical services in partnership with acute and primary care clinicians, and public representatives. 3. Key matters relevant to recommendations a) Population and Activity Trends The changing demographic profile of Grampian is well publicised. Our population, like the rest of Scotland, is ageing and growing. These changes are gradual and have been occurring for some time. Since 2011, the Grampian population has risen by 3.3%, an increase of 15,590 people. Unsurprisingly this increase is biased towards middle age and older adults, where population groups between 65 and 74 and over 75 years of age have grown by 18% and 7% respectively. Clearly this has an impact on health care needs, particularly for conditions associated with ageing. In the past six years, specialties including ophthalmology and urology have seen considerable rises in demand for care, far in excess of the average population increase and in some specialties, and this increase will be magnified over the next decade. Whilst acknowledging the inevitable increased demand for elective care due to population factors, there are other reasons which have a major contribution on system pressures. In particular, these include; The pattern of supplementary funding and investment for elective care which is often uncertain and non-recurrent. The shortfall in supply of trained professional staff - as with all NHS Boards in Scotland, and indeed as seen across the UK as a whole, there is a significant and increasing gap in the supply of trained professional health care staff available to deal with the increasing growth in demand and expectations. The heavy reliance on agency and locum staff, with inherent vulnerabilities relating to stability, safety, affordability and sustainability. Waiting times reflect real experiences for patients: at March 2017 29% of people waited longer than 12 weeks for a new outpatient appointment, and 24% waited over 12 weeks for treatment. This has the inevitable effect on the overall number of people waiting for specialist care where projections indicate that this will continue to rise. This drives our need to deal with both capacity and demand in building sustainable models going forward. b) National Elective Care Strategy The development of a National Elective Care Strategy was prompted by the allocation of 200m of capital funding for the construction of elective care centres in Highland, Grampian, Tayside, Lothian and the Golden Jubilee National Hospital (GJNH). This funding allocation recognised the need to modernise the infrastructure and increase capacity to deal with anticipated demand for elective care over the next 10-20 years. Work to develop business cases for the elective care centres is underway and the Initial Agreement (IA) documents the first part of the capital 2
planning process have been completed for NHS Highland and the GJNH. Initial Agreements for the other centres will be progressed over the next 6-9 months. In addition to supporting the elective care centres, the national work is developing a national picture of need and capacity, planning national activity flows, linking to the National Clinical Strategy and providing support for the regional planning work. c) Regional Elective Care Planning Consistent with the national approach, a North of Scotland Elective Care Programme is being taken forward as part of the elective care portfolio led by Malcolm Wright, Chief Executive, NHS Grampian on behalf of all North Boards. The initial work in the North region has focused on the formulation of a strategic case to be part of the business cases which are being prepared for the elective care centres in Highland, Grampian and Tayside. This will be developed into a comprehensive strategy which will guide change at a regional level, maximise the use of all resources in the region and retain the majority of elective care activity in the North. Further work in the short term is aimed at harmonising access policies and pathways to move towards the standardisation of processes in all Board areas, and determining how resources can be shared to contribute to minimising waiting times for each of the Boards. d) Grampian Elective Care Programme The Elective Care Programme in Grampian was originally stimulated by the Scottish Government s elective care centres programme. In Grampian it was agreed that a broader approach should be taken to the transformation of elective care as a whole to ensure that the available capital funding could be applied in the most efficient way. This broader, system wide, approach aims to ensure that individual elective care services and the wider elective care system are as efficient as possible by applying best practice and innovation. Key elements of the Grampian programme include: Comprehensive awareness raising effort has been undertaken to include professional advisory committees, Grampian Area Partnership Forum, Health and Social Care Partnerships, Acute Services, individual clinical services and the public. Intensive engagement process with 21 services involving a broad range of acute and primary care staff this commenced in March 2017 and will be complete in September. Cross system workstreams to identify the service specific redesign initiatives and the common themes that need to be progressed across patient pathways. The output of this process will be a comprehensive redesign programme and a specification for the use for the capital funding available for elective care centre development over the next five years. e) Workforce challenges and responses As indicated above all NHS Boards in Scotland, and in the UK as a whole, are experiencing significant and increasing gaps in the supply of trained professional 3
health care staff. This has a clear impact on the ability of Boards to deliver services at the required level. There is continuing exploration of new workforce models and new roles such as Advanced Nurse Practitioners, Clinical Development Fellows, Physicians Associates and Assistant Perioperative Practitioners. New roles create a broader pool of the population to recruit from and this is particularly important for NHS Grampian in addressing the historical challenges relating to workforce supply. For these roles to be attractive, whole life career pathways (incorporating accredited education) will require to be further developed and offer real opportunities which will place NHS Grampian at the centre of ground breaking initiatives for the rest of NHS Scotland. The development of these new roles will go some way to reducing the impact of unfilled vacancies, but these roles take some time to establish and train.. A Supply, Recruitment and Retention Task and Finish Group has been established to identify key opportunities and strategies to build on the existing work in relation to creating a resilient and sustainable workforce. Collaborative working with the local Higher Educational Institute s, North of Scotland Boards, Scottish Government Directorates and NHS Education Scotland continues to be strengthened to address the workforce supply challenges in the North The strategic approach being taken to address workforce supply, recruitment and retention in NHS Grampian recognises the importance of organisational context and culture to deliver an empowered and engaged workforce who are skilled, competent and enabled to deliver high quality care is fundamental to the sustainability of services f) Optimisation & Transformation Redesign and optimisation initiatives are a key feature of the overall strategy that will result from (a) the Elective Care Programme, and (b) the various improvement strands progressing within the Acute Sector. A wide range of redesign opportunities are in the process of being implemented and many others are emerging from the Elective Care Programme clinical engagement. Examples include: Institute for Healthcare Optimisation (IHO) Option 1 The right-sizing of emergency theatres based on demand, reducing variation through standardised emergency surgical urgency classification and booking processes. NHS Grampian is part of the wave 2 cohort and despite joining more than 1 year later than other Boards has been first to go live (20 th March) with testing the classification system Establishment of a Day of Surgery Admissions (DOSA) unit This project is underway to establish a DOSA unit adjacent to the main theatre suite in ARI in order to improve experience, and optimise available time and resource for patients prior to surgery. This will reduce cancellations, delays and reliance on ward based staff capacity to prepare patients 6-4-2 booking process Significant progress has been made in implementing more robust theatre booking processes, coordinating leave planning and substantive staff availability to ensure published theatre lists are planned at least 4
6 weeks ahead. The booking of cases is monitored at key points thereafter, with automated reports generated to support the process Theatre dashboard metrics Development of a performance dashboard for all theatres with key metrics and key performance indicators (KPIs) against e.g.: utilisation, cancellations, booking performance, etc. Managing demand - For some specialties, conversion rates post new outpatient appointment is as low as 50% of patients requiring any further input from that specialty. A range of actions require to be taken to improve the appropriateness of referrals and the efficiency of referral pathways through the revised Clinical Guidance Intranet (CGI), and with systems in place that facilitate prompt and easy decision support Outpatient Referral Triage NHS Grampian is in the lead in relation to the transformation of the way that outpatient referrals are managed. A process is being developed which will support clinicians to review referrals and provide a range of options to patients as an alternative to attendance at an outpatient clinic Cross NHS Board Working - NHS Grampian is actively engaged with its North of Scotland partner Boards in the establishing of new ways of working to achieve equitable access for patients. In addition, there are specific opportunities at speciality level being driven by colleagues within partner Acute Sectors Preoperative Assessment (POA) being undertaken in the community or online instead of on acute hospital sites Shared treatment areas - in the acute hospital for administering modern biologic medicine treatments Importance of IT systems further extending the Electronic Patent Record cross acute services to improve the ability to share clinical information appropriately Separation of Elective and Unscheduled Care working towards a greater separation to avoid planned activity being interrupted by unscheduled admissions and treatment Organisational Development working to improve team working and relationships between clinicians across primary and acute services g) Risk Mitigation Elective Surgery Categorisation In order to mitigate the clinical risk associated with the recurring demand and capacity gap, a clinical elective surgery categorisation system has been developed and deployed to ensure that those patients who require surgical intervention within a clinically defined time period receive it. This process introduces prioritisation across three categories, with priorities assessed by clinicians on the basis of clinical need. 5
A detailed risk-based surgical activity plan has been collated in conjunction with services. This plan includes baseline and current assessments of risk against the following domains: Service sustainability challenges Morbidity and mortality risk Impact on quality of life/patient experience Number of patients impacted upon/waiting In addition, a process of clinical escalation has been developed and implemented. This process allows clinicians to escalate specific patients where compliance with the revised classification is challenging. This then allows resolution at three levels (a) within the speciality, (b) across surgical specialities, and (c) at sector / external capacity level. To date, all escalations have been resolved at individual speciality level. From a research perspective we will robustly evaluate the impacts across the healthcare system and patient experience. This is being taken forwards with Public Health colleagues in terms of scope and commission. h) Non-Recurring Investment The Acute Sector Management Team is in discussion with the Scottish Government Access Support team as to new ways of jointly working to distribute further in-year non-recurring funding in ways that lead to a sustainable benefit, rather than shortterm or one-off increases in capacity. For example, priority will be given where equipment, technology, new ways of working etc would have lasting positive impact on increased appropriateness of referrals, efficiency and productivity. i) Governance A Surgical Transformation Programme Board (STPB) has been established and performs a governance role, reporting both to the Acute Sector Leadership Team and the Board level Performance Governance Committee. As this transformation programme evolves, risks will be identified and escalated appropriately to the STPB. The current major workstreams are shown below: 6
j) Engagement There has been a high level of public engagement in the processes related to the improvement of planned care. The Elective Care Programme has dedicated support to ensure the highest possible quality of engagement with public representatives. Each of the service engagement processes has involved public representatives and this will continue through cross system check events. The Elective Care Programme also include staff partnership and the elective care issues have been considered with the Grampian Area Partnership Forum in the context of the Clinical Strategy The Elective Surgery Categorisation process has been shaped by the clinical staff in the services and this will continue in the ongoing governance of the process Support will also be provided to the other North of Scotland Boards which have expressed an interest in implementing the categorisation process. A unified approach to Communication and Engagement has been agreed through the formation of a single operational group which will drive the required engagement work on behalf of the Surgical Transformation Programme Board, the Elective Care Programme Board and the Intermediate Unscheduled Care Integrated Planning Board. This group will drive and report progress to each of those committees. 4. Conclusions This paper has confirmed the context for the delivery of planned care in relation to demographic change and the consequent need for services in the short and long term. A summary of the comprehensive range of actions across the planned care agenda has also been included in the paper to provide an assurance that the approach being taken in Grampian is ambitious, coordinated across the whole system of care, and consistent with the national and regional workstreams. In Grampian, innovative approaches are being taken to the redesign of pathways and to ensure that resources are prioritised according to clinical need. The work to improve the approach to planned care will be developed to ensure that actions are targeted at current challenges whilst moving towards a future model which maximises efficiency, quality and patient experience. However, concerns remain that the workforce supply and resource challenges will persist and will continue to impact on the ability of services to meet the required waiting times standards. 5. Responsible Executive Director and contact for further information If you require any further information please contact: Responsible Executive Director Gary Mortimer Director of Acute Services gary.mortimer@nhs.net Contact for further information Neil Strachan General Manager - Elective Care Programme neil.strachan@nhs.net July 2017 7