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NHS Highland Board 3 February 2015

Item 5.3 (2)

NHS HIGHLANDS 10 YEAR OPERATIONAL IMPLEMENTATION PLAN

Report by Deborah Jones, Chief Operating Officer  

The Board is asked to: Comment on and note the high level draft 10 year operational implementation plan with a particular focus on 2015/16

1. Purpose

The purpose of this document is to provide the board with a high level briefing on the direction of travel taken in the development of the 10 year operational implementation plan. The aim of this document is to:

provide the board with a further opportunity to comment on the direction of travel provide the basis for future shaping and development of operational unit delivery

plans through discussion and debate provide a focus on some of the key work for 2015/16

It is anticipated that future board development sessions will enable the active participation of board members in the ongoing development of the plans to support the delivery of health and social care across Highland.

2. Introduction

The Highland Care Strategy outlines NHS Highland’s vision for the future delivery of health and social care services for the people of Highland for the next 10 years. Specifically the 10 year plan starts to describe the approach and shared focus for all the work to realise implementation of the strategy. This is supported by this plan which is underpinned by other supporting corporate strategies.

A longer term plan has been designed to retain our focus on improving quality and to make measureable progress to deliver the Highland Care Strategy. At a high level it, describes the priority areas for action. It recognises that the financial, demographic and political climate will change, and in doing so the demands for health and social care will change. There will be a clear need for care and services to be delivered in a radically different way, to ensure that NHS Highland secures the best possible outcomes for our population.

Our current approach recognises the complex planning arrangements that are in place for health and social care at local, regional and national level and provides a basis to govern the operational implementation across NHS Highland.

Key elements of the plan will require further significant work and this will be an ongoing process, such as with out of hours, proposed major service change, challenges with Rural General Hospitals, wider remote and rural issues.

 

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 2.1 Historical Context and Planning for the 21st Century

Decreased infant mortality and longer life spans are enormous successes of improvement in living standards, and in health care delivery (Figure 1). Better maternity care, immunisation and antibiotics have produced benefits that, in Scotland, we take for granted.

Clinical medicine has excelled at producing improvements in the health and life expectancy of people with specific conditions. Cancer survival has increased markedly. Heart disease death rates have decreased. Maternal and infant mortality has now become thankfully rare. This is due to a combination of public health changes, such as reduced smoking and better treatment of risk factors, and improved clinical treatment of catastrophic events such as heart attacks.

These improvements have been delivered by a combination of good generalist primary care availability, and specialist services. There has been increased specialisation, and improved standards of care driven by research, which in turn leads to evidence-based treatment guidelines. Specialist services are generally good at delivering care that is in line with current evidence.

This improved specialist care for individual conditions have come at a time, however, when the presence of multiple conditions has become the norm. General Hospitals are organised along specialist service lines – in order to deliver the highest quality care, general medicine and surgery have developed many sub-specialties over the last half century, which have in turn developed special sub-expertise. This has been associated with a marked increase in the quality of care for individual conditions, but does not always fit well with the existence of multi-morbidity.

Co-morbidity – the idea that people could have two or more diseases simultaneously – seems to have been first coined as a term as late as 19701. The term multimorbidity first appears in an academic paper in 1996 (Akker et al 19962, Almirall and Fortin, 20133). The importance of the idea is now clear. The term ‘multimorbidity’ is used here to mean that a person has two or more illnesses simultaneously, including mental health disorders.

There is very good information on multimorbidity in Scotland, from research work (see, for example, Barnett 20104). In a study of people registered with 314 medical practices in Scotland in 2007:

42% of patients had one or more morbidities. 23.2% had multimorbidity.

                                                            1 Feinstein AR (1970) The pre‐therapeutic classification of comorbidity in chronic disease. Journal of Chronic Diseases 23:455‐468. 2 van den Akker M, Buntinx F, Knottnerus JA. (1996) Comorbidity or multimorbidity: what’s in a name? A review of literature. European Journal of General Practice 2:65–70. 3 Almirall J, Fortin M. (2013) The coexistence of terms to describe the presence of multiple concurrent diseases. Journal of Comorbidity 3; 4: 4 – 9.  4 Barnett K, Mercer SW, Norbury M, Watt G, Wyke S, Guthrie B. (2012) Epidemiology of multimorbidity and implications for health care, research and medical education: a cross‐sectional study. Lancet 380; 9836: 37 – 43.  

 

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The rate of multimorbidity increased markedly with age, and most people age 65200 years and older had multimorbidity.

The greatest number of people who had multimorbidity were aged under 65 years of age. This is because, although there were lower rates in younger age groups, there are more younger people.

Onset of multimorbidity occurred 10 – 15 years earlier for people in the most deprived areas compared to the most affluent.

The presence of a mental health disorder increased as the number of physical morbidities increased, and people with five or more physical morbidities were almost seven times more likely to have a mental health disorder than people with no physical morbidities.

The chance of having a mental health disorder was more than doubled in more deprived people compared to less deprived.

The authors comments (Barnett 2012):

‘Our findings challenge the single-disease framework by which most health care, medical research, and medical education is configured. A complementary strategy is needed, supporting generalist clinicians to provide personalised, comprehensive continuity of care, especially in socioeconomically deprived areas.’

The test of delivering high quality care to people with more than one morbidity has been well described by Mangin 20125. They comment,

‘Although evidence based models of single diseases in isolation work well for patients with one disease, they can lead to “siloing” of care for people with multiple conditions and this can result in chaotic care. One study found that applying individual disease guidelines to a patient with five chronic conditions would result in the prescription of 19 doses of 12 different drugs, taken at five time points during the day, and carrying the risk of 10 attendant interactions or adverse events. Care that is “measurably better” may be meaningfully worse and a nightmare for the patient.’

This is a central challenge for the delivery of health care. National guidelines tend to be disease specific, and many measures relate to performance for a single condition, rather than any person-centred view of care. Capacity in primary and community care to integrate care, and to deliver timely and comprehensive care focused on the needs of an individual is essential, but this has to be balanced against the need to deliver truly excellent disease specific care when required, as for example with a heart attack, cancer diagnosis or onset of diabetes – but again, taking in to account individual circumstances and preferences.

Individual preference is at the centre of this. The Royal College of General Practitioners and Primary Care Respiratory Society examined the care of people with Chronic Obstructive Pulmonary Disease (COPD) with multimorbidity (Royal college of General Practitioners 20136). They concluded that existing systems do not lend themselves to ‘the move away from a disease-centric model of care towards a patient-centred multimorbid system’.

                                                            5 Mangin D, Heath I, Jamoulle M. (2012) Beyond diagnosis: the multimorbidity challenge. BMJ 344: e3526. 6 Royal College of General Practitioners. Managing multi‐morbidity in practice...what lessons can be learnt from the care of people with COPD and co‐morbidities?  

 

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Incorporating physical health care, mental health care and social care into a seamless model is a trial of the value of integrated care. As described above, mental health disorders are more common in a significantly increasing proportion of people with multimorbidity, and delivering effective treatment, in combination with physical care, is very important in increasing quality of life (Langan 20137). To deal with the expected changes will require the same focus and expansion of provision in primary care to mirror the focus and expansion that has lead to such marked improvements in specialist care of individual conditions in secondary care.

A great advance in healthcare over the last decade is how much patients have become partners in their care with a better understanding of the conditions they have leading to more involvement and individual tailoring of their care to suit individual priorities and lives. This needs to extend with the aim being a population who feel in control of their conditions and treatments and are active partners rather than passive recipients.

Recent moves in health care have been in the direction to remove artificial barriers between what is counted a ‘social’ and what is a ‘health’ need. NHS Highland has lead the way in the tricky process of integrating health and social care. Over time this will make it more likely that adults will receive what they need when they need it be that a need for care support as a bridge to independence or a complex medical intervention.

Summary:

Increased life expectancy and the capacity for people to live longer with long term conditions is a major societal success

The need to deliver excellent disease specific care is still present, and this care is often very effective

The care of people with multiple conditions has become very important and much more common

Most older people have several conditions, and the rate of people with multimorbidities increases markedly with age

The largest number of people with multimorbidities, however, are aged under 65 years

Co-existing mental health disorders are very common The onset of multiple conditions happens much earlier on average in deprived

areas, and mental health disorders are particularly likely to accompany physical illnesses in deprived people

This does not readily lend itself to traditional treatment models, and integrated, person-centred care led by adequately resourced primary and community care services is essential

                                                            7 Langan J, Mercer SW, Smith DJ. (2013) Multimorbidity and mental health: can psychiatry rise to the challenge? British Journal of Psychiatry 202: 391 – 393. 

 

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NHS Highland needs to be prepared for the revolutionary health care advancements and social care requirements that will come during the 21st Century together with the increasing and possibly changing expectations of the population.

Figure 1 – Graphical Representation of Health Care Development

Public Health Measures – sanitation, hygienelater, immunisation, screening, 

risk factor treatment

Improved Medical Care ‐ Anaesthesia, Antibiotics, Obstetrics, Insulin

Better Acute Care  ‐ e.g. heart disease,  schizophrenia, Improved prevention – hypertension, ulcers

Long‐Term Condition Management, People living longer with multiple conditions

‘New Medicine’ – genetic engineering, tailored drugs, cloned organs

19th Century 21st Century

Phases of Care

2. Highland Quality Approach The triple aim of better health, better care, and better value has been adopted and developed in Highland for a number of years. It has led to the development of a Strategic Framework for Highland, which in turn has led on to the Highland Quality Approach (Figure 2). A clinical strategy was always envisaged as part of the HQA development; now referred to as a care strategy to reflect integration of health and social care.

 

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4. Context for Health and Social Care Planning in NHS Highland 4.1 Population and Maps 4.1.1 The Population National Records of Scotland (NRS) estimate that, in 2012, 319,800 people lived in the area served by NHS Highland. NRS project an increase to almost 323,000 people by 2027, before a gradual decrease to around 319,000 in 2037 (National Records of Scotland 2014). These totals conceal marked projected differences between the Argyll and Bute and Highland Council areas. The NRS main projection anticipates in Argyll and Bute from 86,900 in 2012 to 80,700 in 2027, a 7.1% decrease. In the same fifteen year time period, Highland Council resident numbers are anticipated to change from 232,900 to 242,100, a 3.9% increase. 4.1.2 Changes by Age Group Within these totals, large differences are expected by age group. In the NHS Highland area as a whole, the working age population (16 – 64 years) is expected to decrease from 199,600 in 2012 to 181.400 in 2027. The population of people aged 65 years and over is expected to increase from 65,200 to 89,700. Looking at it another way, people of working age are expected to decrease from 62.4% of the population in 2012, to 56.2% in 2027. People aged 65 years or over are expected to increase from 20.4% of the population to 27.8% in the same time period. Figure 3: Projected changes to NHS Highland Population by Age Group

  Source: NRS Population Projections 2012 Based by area, the number of people aged 65 years or over is expected to increase by 19,600 in the Highland Council area between 2012 and 2027 to 26.7% of the total population, and by 5,100 in the Argyll and Bute Council area (31.2% of the total population of the area). 4.1.3 Population Distribution The population of Highland is distributed in a relatively small number of settlements of 500 people or over (Figure 4) and a large number of more distributed settlements and houses.

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4.2 Competing pressures to transform services

NHS Highland operates in an environment of pressures that increase costs at a disproportionate rate to the measures that are put in to reduce the costs of providing health and social care to the population. The figure below provides a pictorial representation of some of these main competing pressures, with the size of the arrow representative of the relative impact on the costs for NHS Highland. Increasing Cost

Reducing Cost

Focus on quality, safety and targets

Reduce demand

Increased burden of work

Eliminate waste

Increasing population and older people

Reconfigure services

Increasing legislation

Changing operating environment

Increasing expectation

Negotiating changes in legislation

Technology and drug therapy Involving patients / public in decision making

Delivery in remote and rural settings

Maintaining focus on quality & safety

Providing care in the most appropriate setting

5. Impact of Planned Change to Current Care Model This section outlines the planned high level changes that are being taken forward in NHS Highland over the next 10 years, and these have been assessed against the principles of provision of health and social care. A driver diagram and action plan with designated owners is being developed for each of these planned changes, and the resource implications will be identified from these. In cases where there is major service change this will be taken through the required process to develop options and consult. Each Operational Unit is developing a High Level action Plan which summarises the main initiatives that will be delivered within the Operational Unit, taking account of the Planned Actions outlined in this section of the 10 year plan. This will set out in detail their annual plans. The importance of the overarching plan is to make sure change does not happen in isolation and the benefits of whole system working is understood and maximised. 5.1 Planned Actions

5.1.1 Regional Planning (North and West of Scotland)

NHS Highland is part of the North of Scotland planning consortium which, over the next few years, will play a more important role in planning and reconfiguration of services. Work is underway to define which core services must be delivered locally, which can be more cost effectively or safely delivered on a regional basis, and which will ultimately be delivered in a small number of specialised sites for the whole of Scotland.

 

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The next 12 months will see work undertaken on the development of a formalised Cancer Network across the North of Scotland, collaboration between Boards on Paediatrics and Head, Neck and Max-Fax services, as well as exploration of opportunities to reduce the number of sites providing out of hours on call to a single Board area. These and other areas of collaboration are listed below:

A96 Corridor – child health, paediatrics and eye care CAMHS Cancer Services Cardiac Services Out of Hours Microbiology Out of Hours Radiology Public Health On-call for the North of Scotland Link Caithness and Orkney Gynaecology Service Neo-natal services Major Trauma Centre including development of pre-hospital care and retrieval

services Seven Day Services Child Health Oral and Dental Health Vascular Services Paediatric Head, Neck and Maxillofacial surgery Out of Hours Primary Care

More generally the board will need to play in with wider discussions with other boards as opportunities arise or challenges emerge. 5.1.2 Argyll and Bute Integration

2015 will see the change in legislation to support the establishment of the Joint Integration Board for Argyll and Bute under the body corporate model. In addition the 1st April 2015 will result in the dissolution of the current Argyll and Bute CHP with a need for the Board to establish interim governance arrangements. The delegation of resources to the new body will be dependent upon the development of a strategic plan, which, it is anticipated, will encompass many of the issues and actions identified within this document from and Argyll and Bute perspective.

5.1.3 Social Care Provision in North Highland

Within North Highland the integration of Adult Health and Social Care will continue to develop. The role and function of integrated teams, single point of access and the ongoing development of new services to meet client needs through strategic commissioning will continue. The additional focus of self directed support and how this might be used to support complex care requirements in innovative ways will underpin much of the work planned.

 

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Co-ordinate Care and Teams in Localities Consolidation of the current work in Social Care will continue in 2015/16 in order to

further integrate care across all areas of North Highland, and across the interface between hospital and community.

Review the criteria and provision of housing support and accommodation maximising the legislation to ensure equity of provision and charging

Consider increasing the number of clustered care packages Continue the review of commissioning services with the independent sector Review the 3rd and Voluntary Sector Agreements against the NHS Highland

principles and VFM Establishment of further integrated teams across Highland building on experience

from pilot area 5.2 Co-ordinate Care For Older People

Greater coordination of care to meet the specific needs of frail older people and those with complex conditions will be a major focus for NHS Highland over the next 12 months. Preventing unnecessary and potentially debilitating admission to hospital remains a key objective, as well as timely and person-centred assessment and delivery of care. NHS Highland has identified the opportunity to enhance the existing support provided to general practitioners out of hospital by augmenting and reconfiguring the existing care of the elderly medical team, supported by additional support in local community services. The current use of NHS Highland run Care Homes will be under review in 2015 with a view to more closely integrate these facilities into the local communities.

Appoint an additional three Geriatricians and introduce Zone Working Join up Geriatricians and Old Age Mental Health teams working collaboratively Ensure SEPS funding is co-ordinated Continued use of ACPAs (Anticipatory Care Plan Alerts) and polypharmacy reviews Increasing care at home provision through new models working with communities

and the independent sector Planning the provision of wider use of Care Homes Increase the age that people are admitted to Care Homes by provding alternative

support Review provision of day care services e.g. Adult Social Care, Day Care Units and

day hospitals 5.3 Review and refocus resources to voluntary organisations and 3rd Sector

NHS Highland plans to work closely with both 3rd sector and voluntary organisations to develop the capacity and communities to provide appropriate levels of care in collaboration with other partners.

1st responders in small population areas Local buy out of care homes Support voluntary and 3rd sector – local support Local solutions for care at home

 

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Home from Hospital and good neighbour schemes

5.4 Extend End of Life Care

Supporting death with dignity, at a location of choice, will be a major focus of work in 2015. Providing support for both individuals and families, to maximise the quality of life when time is finite, will be an explicit aim to ensure that services deliver what matters to them. Closer working with specialist hospice and 3rd sector organisations with expert knowledge will be as important as developing skills within existing teams to have different conversations about the end of life.

Facilitate the choice to enable less people dying in hospital Better infrastructure to enable people to stay in their own home Anticipatory care plans prepared and available with place of death identified Increased support for palliation Closer working with hospice service providers

5.5 Out of Hours New Models

There has been significant work undertaken over the last few years to attempt to consolidate models of out of hours care across NHS Highland. Currently there is a significant disparity of costs and payments to individuals due to an extensive use of locum doctors and premium payments due to last minute call off from shifts. Providing out of hours care has not been attractive to new GPs in remote and rural area and the responsibility then reverts to the Board to provide cover. In the future, it is suggested that out of hours must be more integrated to in hours and anticipatory care and better coordinated across Highland. There will be a networked multi professional team approach with fewer doctors and fewer manned sites. The service will make use of technological solutions backed up with a robust clinical decision support mechanism. It is important that primary care out of hours service is not confused with emergency response for which an ambulance is required and we will continue to work closely with Scottish Ambulance Service on developing and strengthening community resilience.

These new models will be based on multi-professional teams, using technology to support clinical decisions, with fewer manned sites. There will be increased co-ordination through the Hub, strong functional relationships across Primary Care Emergency Centres (PCECs) and improved transport links. Community resilience will be required together with improved anticipatory care.

Small Isles Pilot Pilot Pre / out of hospital care Argyll and Bute Pilot Use of Advanced Nurse Practitioners in small population areas A&E support Trauma out of Hospital care Review location of primary care emergency centres in Northern Highland

 

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5.6 Reduce use of Acute Beds for non-acute care

Increasingly patients are delayed in acute hospital beds whilst alternative arrangements are made for their discharge. This vital flow work will continue next year and will provide different models of care. There will need to be wider collaboration across all of our acute settings in order to maximise operating capacity and to secure beds ring fenced to service high pressure services. Whilst the acuity of patients in acute beds has increased we will need to continue to work to ensure that individuals are discharged as quickly as possible, with alternatives for some tests and treatments. Flow work including delayed discharge

Fewer specialised services Elective separation for Orthopaedics / Eyes Technology Hubs, Bloods, X-ray, Tests Locally Relocation of Dermatology

5.7 Highland Wide Services

Many support services are delivered across the whole of Highland and consideration must be given to ensuring best value and economies of scale. The roll out of specific initiatives and the replication of successful pathways may allow higher quality at reduced costs, with easier and timelier access to services for patients.

Laboratory Services across NHS Highland Radiology Services across NHS Highland Management of Chronic Conditions Management of Low Volume Activity MSK Pathway redesign

5.8 Improved Use of Technology

By 2020 Scotland will be recognised internationally as a leader in digitally enabled care with efficient services in place to support people to live longer, healthier lives at home or in a community setting. NHS Highland has a detailed e-Health Delivery Plan which provides further detail on the steps that are planned for the next 10 years but these can be broadly summarized as follows:

Continued closer working with eHealth and the Councils to achieve the delivery of truly integrated services to each of the client/patient groups including care homes, the care at home service and telecare

finalisation of the Trak Patient Management System (PMS) implementation programme continuing a safer medicines reconciliation process utilising the extension of the

Emergency Care Summary (ECS) into scheduled care and collaboratively participating in HEPMA evaluation;

improving patient information flows between primary and secondary care with the continuing roll-out and support of the Key Information Summary (eKIS) and the Palliative Care Summary (ePCS);

develop local data and use this as the basis of reporting nationally, corporately and operationally to include dashboard style reporting.

 

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continue to roll out electronic document transmission (EDT) between secondary and primary care sectors;

progress work around the Clinical Portal in respect of NHS and Social Care. strengthen ties, partnership and liaison between the North of Scotland NHS Boards, continue to strive to replace and develop infrastructure and networking components

to ensure that there is a robust and resilient underlying eHealth infrastructure; implement privacy breach detection software (Fairwarning) and develop single sign-

on capability; continue to implement the Eyecare Integration Project allowing direct referral from

Optometrists to secondary care Ophthalmology plan the “Acute Hospitals” – Patient Flows activity to Outline Business Case status to

allow further discussion to take place (Scottish Government funding has been received); continue to participate and advise on the DALLAS/Living it Up (LiU) National

Programmes; ensure that Northern NHS Highland and the Argyll & Bute CHP operate strategically

and in an integrated way and that the Head of eHealth asserts his corporate accountability in this regard;

Clinical document scanning – the scanning of clinical documentation to facilitate space and retrieval issues;

Order Communications for Primary care. Initially scoping and defining the requirement to allow the remote ordering and tracking/audit of diagnostic test requests from general practice.

Introduce the Electronic Patient Record and Patient Portal Understand the technology links with NHS Greater Glasgow and Clyde for Argyll and

Bute patient pathways

5.9 Technology to deliver redesigned services

NHS Highland has been successful in the implementation of state of the art clinical equipment but has failed to provide connectivity to the complex systems which have resulted in a disjointed patient pathway. Investment and coordination will be a significant focus of effort in the next 12 months and will require a clear strategy to ensure that we can plan to have systems that will best support the future clinical practice. Further work is required to ensure that the e-heallth strategy and plans align both national and local requirement. It has already been identified that this section of the plan requires further development and will be particuraly important to ensure ongoing review to keep with emerging technologies and innovation. .

30% clinics delievered by vc Automate laboratories in Rural General Hospitals Connect primary and secondary care clinicians to support easier access to advice Less face to face patient contact to optimise more people accessing timely specialist

advice Develop electronic patient record Develop clinical Portal Develop auto booking of Appointments

 

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More mobile working for Office based activities to reduce office requirement Extend Patient Reminder Services Extend E-communications with patients Maximising PMS to include Order Communications, Real Time Bed Management

and E-vetting and e-outcoming Extend Telecare Services Scheduling technology to support delivery of Care at Home

5.10 Community Hospitals as part of Community Services

The exciting opportunity to re-provide a new model of care in new build hub on Skye and Badenoch and Strathspey are hoped to be supported by the Cabinet Secretary in the next few months. This will be a major redesign of services including capital investment. It form a key part of our strategy to develop integrated services , and disinvest in facilities which are no longer fit for delivering 21st century health and care. Maximising the whole of the community services including care homes and hospital capacity will be important to ensure flow and the best opportunities for rehabilitation. Over the next few years this will see:

Re-design of services across Skye, Lochalsh and Wester Ross & Badenoch and Strathspey

Ongoing re-design in all districts Virtual wards extended and supported Review models of medical cover Review space utilisation and service provision

Example: Skye, Lochalsh and South West Ross Service redesign:

Following extensive consultation the redesign has led to the following recommendations:-

The future model of care in the District will have a strong focus on community and primary care, maximising the potential of a fully integrated adult health and social care system. The clear aim is to support people to live at home or in a homely environment for as long as possible and so community and care at home service will be augmented. This will include Voluntary and independent organisations, through strategic commissioning arrangements and a strong partnership approach. The primary and community services will be supported by a new modern Community Resource Centre and Hospital in Broadford, which will have state of the art facilities for day case, outpatient and diagnostic services as well as an emergency centre, primary care centre and inpatient beds. A facility in Portree will also be developed to provide a range of day and outpatient services and a primary care/minor injury/ailment centre. Both facilities will also be a base for the local health and care teams.

To further support the model of community based care and treatment, investment will be made in care at home, community nursing and in anticipatory care and more support for self care and self management. Negotiation with local care homes will take place to increase the flexibility of use of those beds with a view to augmenting step up/ step down options and end of life care in a homely environment where death at home is not possible or desirable for the individual.

 

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Given that over 90% of contacts that people have with the health service are in primary and community care through their GP, dentist, community nurse, therapist or pharmacist, there will be a strong focus on further developing those services. There has been a large investment in recent years in dental services with new facilities in Portree and Kyle and an upgraded facility in Dunvegan. GP Practices are located throughout the District and there is potential through stronger links between some of those Practices, to offer an enhanced range of service at local level.

5.11 Maximise use of Rural General Hospitals

NHS Highland is currently responsible for the delivery of care in the three Rural General Hospitals based in Wick, Fort William and Oban. The building are of varying age and standard and there are some staffing challenges. These hospitals currently provide a range of services including A&E and some elective surgery. They support a local hub for diagnostics and visiting services, as well as training opportunities in remote and rural medicine and care. Based in geographically important areas, they will need to connect as part as clinical networks to ensure that the capacity is maximised, skills can be maintained and the model fits with modern practice.

Redesign in Caithness General Hospital, Belford Hospital and Lorn and the Islands Hospital including surgical pathways

Develop centres of excellence for specific conditions Maximise the use of each hospital Develop Clinical Network Arrangements in NHS Highland and with other boards such

as NHS Lothian and NHS Greater Glasgow and Clyde Review models for local minor surgery Consider potential for relocation of Ophthalmology services

5.12 De-medicalise care

It will be important to ensure that we are able to encourage and support individuals in their honest discussions with family members about how they wish to have care provided at critical points in their life. Over years the health service has built a dependency, and it is now time to reconsider this position and empower and support individuals to make decisions that will change the way that they interact with services and receive care.

Midwife led deliveries Further develop “what matters to you?” conversations

5.13 Health Improvement The NHS Highland has already moved to more preventative work, supporting individuals to take care of themselves, and to support long term conditions with minimal intervention. This will be an important area of continuing work over the next 10 years and will build year on year.

 

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Increase self care Anticipatory care plans for at risk younger adults and older people Identification of specific long term conditions that can be self managed in the

community Earlier intervention (screening, lifestyle, co-production) Community well-being Maximising adaptive technologies including telecare and Living It Up

5.14 Shift work from Doctors

It is likely that we will see a reduced number of medical staff in some specialties and general practice due to the feminisation of the workforce and a reduced number of younger people in training. This means that it will be vital for us to maximise the use of medical talents and other talents as well as greater use of technology to ensure that safe care can continue to be provided. This will include:

AHP support to MSK services to reduce work on orthopaedic surgeons Sports Exercise Medicine Consultant to reduce work on consultant specialists Reducing time in Job Plans for work in Out Patient Work Advanced nurse practitioners for example nurses to inject eyes instead of

Ophthalmologists Unscheduled Care Practitioner developed to reduce dependency on doctors

5.15 Changing Primary Care

There are 4 pillars of professionals within Primary Care: Dentists Optometrists General Medical Practitioners Pharmacist Primary care currently caters for 90% of all patient contact with the NHS and therefore provides the backbone of the health and care service, providing direct support to individuals and long term relationships with their families. There is no doubt that the model of care in the community in the future will need to be significantly different from the one that has served us well for many years.

NHS Highland recognise that to deal with the expansion of long term conditions and co-morbidities will require an expansion of provision in primary care services. In addition, new ways of working together across the professional groupings will require to be developed further, similar to the changes of relationships in localities as in Rural General Hospitals and Out of Hours.

Providing support to make decisions easily will be a key piece of work for the next year including:

Move towards no single handed practitioners Configuration of primary care teams to deal with multi-morbidity

 

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Review the balance between the Public Dental Service and General Dental Practice Standardisation of pharmacy input to service departments Consistent prescribing practice across Primary and Secondary Care Breaking down the traditional boundaries of care between the various professional

groups and sectors

5.16 Increase Community Support to Care Homes

NHS Highland has a unique opportunity to provide homes with care which are part of the local community infrastructure. There is more exciting work to be done in this area to build on the current enthusiasm of staff to provide homely and high quality care. Greater focus will be placed upon enabling individuals to manage the risks associated with living their lives to ensure that they can get the most out of life. To support this we will explore how we can enrich the lives of people living in care homes settings through

Getting young people and schools more involved Considering the ‘wellbeing ‘ benefits of in house pets and poultry Development of gardens etc Development of ‘My Home Life’

5.17 Increased Care at Home

Wherever possible and desired, NHS Highland will continue to provide support to individuals to stay in their homes. It will be important to continue to work with families and providers to ensure that needs are met with encouragement for independence, and care is personalised. The emphasis on developing our strategic commissioning approach will need to be teased out here to ensure that there is clarity over the critically important relationship is between third and independent sector partners

Zoned care at home Inverness Introduction of a tariff based approach to paying for care services Maximise opportunities to create an asset based approach to local service delivering Maximise the potential of Self Directed Support and community led options – Development of rural health care support workers on a retained basis

5.18 Continue to implement Lean Ways of Working

NHS Highland is committed to the HQA model and implementation of Lean Methodology and the Scottish Patient Safety Programme and this will underpin the way forward in the delivery of health and social care. Building on experience so far, NHS Highland remains keen to maintain the roll out

and rigour of the lean approach to service redesign encouraging the development of skills in the wider workforce.

5.19 Maximisation of Workforce

All staff will need to change the way they work and practice, so it will be necessary to develop new skills, support and training across the workforce for the future. Leadership will be a key element to support progress. Key enabling activities will include:

 

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Establishment review HR Policies – e.g. Protection Apprenticeship Scheme for Health and Social Care Support Staff Improved working with NES and Colleges to support recruitment & retention Hub and spoke development and working across Borders Ensure workforce operate at the top end of practice

5.20 Facilities Review

There are opportunities for the sharing of services across organisations and these will need to be further explored in the next year (and beyond) to ensure best value. There is national work underway to ensure that any benefits can be realised locally.

Domestic services Catering services Portering services Laundry services Master Plan for Building review to reduce foot print across NHS Highland and ensure

that resources are maximised

6 Resource Implications

6.1 Technology

The technology infrastructure is complex and as new development come on line it will be important to disinvest in some things. This will require carefully planning and good governance

 

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squeeze on public sector resources likely to continue for the foreseeable future combined with rising demand and increased cost pressures. It is clear that “more of the same” will not be sufficient and significant redesign of services will be required. However, it is equally clear that there are opportunities for redesign that can deliver efficiencies at the same time as maintaining and in many cases significantly improving quality services and quality of care.

The assumptions are as follows:

Scottish Government Uplift as Basic 1.8% per annum THC Uplift as per agreement to 16/17 NRAC is based on known figures with no information available after 2016/17 Inflation is assumed at the same rate for each year Known cost pressures in 2016/17 and then assumed for the remaining years Savings brought forward every year assumed on a reducing basis.

 

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Figure 9 – NHS Highlands Financial Plan 2015 - 2025

SG Uplift 2.80% 1.91% 1.80% 1.80% 1.80% 1.80% 1.80% 1.80% 1.80% 1.80% THC Uplift 1.80% 1.80% 1.80% 1.80% 1.80% 1.80% 1.80% 1.80%

10 Year Plan - Summary 2015/16 2016/17 2017/18 2018/19 2019/20 2020/21 2021/22 2022/23 2023/24 2024/25 Cumulative Total

£000's £000's £000's £000's £000's £000's £000's £000's £000's £000's £m

Funding

SG government funding (654,927) (673,246) (686,125) (696,235) (706,528) (717,006) (727,579) (738,343) (749,301) (760,456)

Social Care funding (92,036) (91,836) (92,236) (93,896) (95,587) (97,307) (99,059) (100,842) (102,657) (104,505)

Net funding Budget (746,963) (765,082) (778,361) (790,132) (802,114) (814,313) (826,638) (839,185) (851,958) (864,960)

SG Uplift (9,453) (9,879) (10,110) (10,292) (10,478) (10,574) (10,764) (10,958) (11,155) (11,356) (105,018)

NRAC Additional Uplift (3,500) (3,500)

NRAC Parity uplift (5,000) (3,000) (8,000)

Innovation fund (1,015) (1,015)

Pressures (2,852) (2,852)

Delayed Dischage (1,845) (1,845)

THC Uplift 200 (400) (1,660) (1,690) (1,721) (1,752) (1,783) (1,815) (1,848) (1,881) (14,350)

(23,465) (13,279) (11,771) (11,983) (12,198) (12,325) (12,547) (12,773) (13,003) (13,237) (136,579)

Total Funding (770,427) (778,361) (790,132) (802,114) (814,313) (826,638) (839,185) (851,958) (864,960) (878,197)

Net Expenditure Budget 746,963 765,082 778,361 790,132 802,114 814,313 826,638 839,185 851,958 864,960 Add

 

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10 Year Plan - Summary 2015/16 2016/17 2017/18 2018/19 2019/20 2020/21 2021/22 2022/23 2023/24 2024/25 Cumulative Total

Inflation 14,584 15,847 16,328 16,833 17,362 17,818 18,295 18,796 19,322 19,875 175,059 Cost pressures 20,863 11,939 6,806 6,573 6,550 6,550 6,550 6,550 6,550 6,550 85,482 Benefits 0

35,447 27,786 23,134 23,406 23,912 24,368 24,845 25,346 25,872 26,425 260,540

Total Expenditure 782,410 792,868 801,495 813,538 826,026 838,680 851,483 864,531 877,830 891,385

GAP 11,982 14,507 11,363 11,423 11,714 12,043 12,298 12,573 12,869 13,188 123,961

B/fwd previous year unit savings not achieved 6,262 5,000 4,000 3,000 3,000 3,000 3,000 3,000 3,000 3,000 36,262 B/fwd previous year non recurrent target 1,500 1,500

Total Recurrent Savings Target 19,744 19,507 15,363 14,423 14,714 15,043 15,298 15,573 15,869 16,188 161,723

Non Recurrent 0 Raigmore recovery plan 3,000 3,000 6,000 Brokerage payment to SG 1,000 1,000 2,000

Total Non Recurrent Savings Target 4,000 4,000 0 0 0 0 0 0 0 0 8,000

Plan assumes reduction in underlying deficit by 50% by 31st March 2015

NHS Highland Board 3 February 2015

Item ?

 

 

By way of example, NHS Highland have worked up 2 vignettes of the action plans outlined in section 5 to demonstrate the financial savings that can be released from providing new models of care over the next 10 years. The models are based on: a) Community Hospital Provision Subject to ministerial approval, NHS Highland are planning to disinvest in facilities at Ian Charles Hospital, St Vincent’s Hospital and Aviemore Health Centre which are no longer fit for delivering 21st century health and care, and to re-provide these facilities in a new fit for purpose Aviemore Hospital. This revised model is likely to achieve circa £787K in financial savings and reduce the workforce by 27 WTE, and deliver improved healthcare that achieves the principles outlined in the Care Strategy.  

 

  

Case Study 1 – Developing Community Hospitals

Badenoch and Strathspey

Current Service Clinical Redesign Future Budget Budget WTE Budget WTE Budget WTE

Service £'000 £'000 £'000

Ian Charles Hospital 830 20.88 -830 -20.88 0 0.00St Vincent's Hospital 1,298 34.30 -1,298 -34.30 0 0.00Aviemore HC (A&E) 37 -37 0 0.00New Aviemore Hospital 1,300 28.49 1,300 28.49

Hospital Services 2,165 55.18 -865 -26.69 1,300 28.49

Community Nursing 346 8.92 346 8.92Midwifery 108 2.20 108 2.20Community Mental Health 405 12.40 100 5.00 505 17.40Other Locality Services 73 73 0.00Community Transport 100 100 0.00

Community Services 932 23.52 200 5.00 1,132 28.52

Allied Health Professionals 341 8.53 -83 -1.71 258 6.82

AHP Services 341 8.53 -83 -1.71 258 6.82

General Medical Services 4,647 4,647 0.00Out of Hours 530 5.00 530 5.00

GMS and Out of Hours 5,177 5.00 0 0.00 5,177 5.00

ASC Care Homes (in house) 1,630 45.85 1,630 45.85ASC Day Services (in house) 270 6.72 270 6.72ASC Community Team 250 7.00 250 7.00ASC Independent Sector Care 2,678 2,678 0.00Care at Home (In house) 523 18.21 523 18.21Care at Home (ISC) 322 100 5.00 422 5.00

Adult Social Care 5,675 77.78 100 5.00 5,775 82.78

Utilites 314 -170 144 0.00Hotel Services 395 16.04 -232 -9.42 163 6.62Capital Charges 94 23 117 0.00Maintenance 15 60 75 0.00Unitary Charges 180 180 0.00

Asset Related Costs 817 16.04 -139 -9.42 678 6.62

Total Budget 15,107 186.05 -787 -27.82 14,320 158.23

 

  

b) Improved Use of Technology

Case Study – E-Communications

NHSScotland Acute and Primary Care Hospitals print pro-rata 16 million letters per year. The majority of outpatient appointment (4.2 million 2013) include accompanying literature, which has historically been difficult to maintain good version control and print quality.

NHS Highland have been working with ATOS and NHS Lothian to develop an e-communications solution that provides the safe, secure and timely delivery of patient information via a patient portal, that defaults to print when the e-communications has not been opened.

This provides an improved quality service at reduced costs to NHS Highland, with a full audit trail, and confidence of version control of accompanying literature. In addition the solution provides a contribution to the Carbon Dioxide Emission reduction target.

1. Assume NHSH population 320,000

2. Each patient receives 2.4 letters per annum = 768,000 letters per annum

3. Average cost of £1.43 per letter equals £1.1m per annum

4. £11m over 10 years on printing and posting letters

5. If NHS Highland implement a Patient eCommunciations Service NHSH potential savings would be in the region of £4.4m over 10 years.

c) Way Forward

Over the coming months, each of the actions in Section 5 will be worked up to the same level of detail to further inform the 10 year operational plan for NHS Highland. This will include:

Finance Workforce Buildings and Future Development Information Technology Clinical Evidence Partnership Working Communications and Engagement Planning for Fairness

 

  

8 References

Douglas I. (2014) Trends in inequalities in emergency hospital admissions for assaults in NHS Highland. Inverness, NHS Highland Health Intelligence and Knowledge Team.

Douglas I. (2015) Inverness Master Plan. Inverness, NHS Highland Health Intelligence and Knowledge Team.

Douglas I, Stark C. (2011) Evidencing the Gap: Measuring and comparing local health inequalities in NHS Highland. Inverness, NHS Highland Health Intelligence and Knowledge Team.

National Records of Scotland (2014) Population projections for Scottish areas (2012 based). Edinburgh, National Records of Scotland.

Deborah Jones Chief Operating Officer NHS Highland