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2006/7 LOCAL DELIVERY PLAN TEMPLATE

Health Board : Grampian

Introduction

The 2006/7 Local Delivery Plan is structured around the hierarchy of:

4 Key Ministerial objectives: Health, Efficiency, Access and Treatment 28 Key targets 32 Key performance measures and 20 Supporting measures.

The Local Delivery Plan template provides the basis for NHSScotland Boards to record planned performance with respect to the 2006/7 key performance measures which will be used to inform discussion about progress toward the 2006/7 key targets. A pragmatic approach has been taken to identifying the most appropriate regular and up-to-date ‘key performance’ measure relating to each ‘key’ target. In due course, as new data systems are introduced and embedded, we expect to increase the extent to which progress towards targets is measured by a ‘key performance measure’ which relates directly, or more directly to the relevant target.

Use of template

The LDP Template consists of a WORD document and an EXCEL file. The Word document presents the key targets within each of the 4 key objectives. It then provides details of each key performance measure, a link to the related key target and an opportunity to provide narrative describing the implications of meeting the related target – what it means locally; increases in life expectancy; how many more people will live a healthier life; any staffing implications; regional implications; risks associated with achieving delivery; relocation of services / out-sourcing & any other major issues affecting delivery. The EXCEL file includes a table for completion by the Board proposing planned trajectories for each of the 2006/7 key performance measures. For ease of reference Grampian has also included the trajectories in the main word document.

The Grampian Local Delivery Plan is made up of the following:-

Completed Word Template Completed Excel Template –Trajectories 5 Year Financial Strategy Financial Strategy Key Assumptions Financial Recovery Plan Board Development Plan

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NHS Scotland Objective 1:Health Improvement for the people of Scotland – improving life expectancy and healthy life expectancy.

Target No. Target

H.01TReduce health inequalities by increasing the rate of improvement for the most deprived communities by 15% across a range of indicators including; CHD, cancer, adult smoking, smoking during pregnancy, teenage pregnancy and suicides in young people: target date 2008.

H.02T To reduce adult (16+) smoking rates from 26.5% (2004) to 22.0% (2010).H.03T Reduce incidence of exceeding the weekly alcohol limit of 21 units to 29% for men,

and of 14 units to 11% of women: target date 2010.H.04T 50% of all adults (aged 16+) accumulating a minimum of 30 minutes per day of

physical activity on 5 or more days per week.H.05T 95% uptake target for all childhood vaccinations (ongoing).H.06T Reduce suicide rate between 2002 and 2013 by 20%.H.07T Reduce by 20% the pregnancy rate (per 1000 population) in 13-15 year olds from 8.5

in 1995 to 6.8 by 2010.

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Key Performance Measures

1.01.K Health Inequalities - CHD (linked to target H.01T) Crude mortality rate, per 100,000 population, (3 year average) for coronary heart disease in people aged less than 75 years living in the most deprived areas. Data are sourced from deaths registered with the General Registrars Office for Scotland.

Crude CHD Mortality Rate (<75 yrs)per 100,000 population

Grampian Vs Scotland: 1995-2004

0

50

100

150

200

1995-1997

1996-1998

1997-1999

1998-2000

1999-2001

2000-2002

2001-2003

2002-2004

Time Period

Mor

talit

y R

ate

Grampian Scotland

Planned Trajectory

2003-2005 2004-2006 2005-2007 2006-2008 2007-200998.4 92.4 86.7 81.4 76.5

Narrative

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As this measure relates solely to reductions in mortality for those in Deprivation Quintile 5 (most deprived), for NHS Grampian this involves very few people. This is only partially mitigated by the use of a 3 year rolling average. Concerns over the validity and sensitivity of this measure have been raised with Analytical Services Division.NHS Grampian is committed to reducing mortality and morbidity generally and closing the inequalities gap. It follows that the trajectory suggested by SEHD has been accepted. This requires the achievement of an absolute reduction of 5.5 deaths per 100,000 population per year in Grampian (a relative reduction of 22% over 4 years).We will aim to deliver this target through continued implementation of our health improvement policies and programmes. Implementation of the ‘public smoking ban’ will support our focus to reduce smoking among those living in our most deprived postcode areas, and is likely to have the largest impact on progress towards the CHD target. See narrative for 1.02K numbers smoking for more detail.

Risk: Moderate

1.02.K Numbers Smoking (linked to target H.02T) Number of Adult (16+) smokers as percentage of sample population (chart not currently available)

Planned Trajectory

2005 2006 2007 2008 2009 201024.4% 23.7% 22.9% 22.2% 21.5% 21.5%

Narrative

The Grampian Tobacco Control Strategy and Action Plan 2005 details our plans to reduce the harm caused by tobacco in Grampian, including achieving a reduction in smoking prevalence. Continued implementation of the strategy is expected to deliver the reduction in smoking as detailed in the trajectories. Priority areas within the strategy are areas of inequality, pregnant women, young people and people diagnosed with a mental illness. Work is outlined in three areas – protecting people from passive smoking, preventing tobacco use and smoking cessation.

NHS Grampian has an established Tobacco Control Team working towards the objectives of the strategy. A Tobacco Control Co-ordinator, oversees the Smoking Advice Service (SAS) and the Young Persons Tobacco Advisor. The SAS is run by a Service Co-ordinator and 2 Assistant Co-ordinators. The service has establishment for 8 smoking cessation advisors, who have responsibility for different geographical areas across the region and there is resource dedicated for providing support to secondary care, workplaces, schools and prisons. The Young Persons Tobacco Advisor provides tobacco workshops to Primary and Secondary schools across Grampian and provides tobacco training to professionals working with young people.

In addition NHS Grampian has recently appointed a Tobacco Information Officer to work on its largest site, initially for a 6 month pilot period. It is made clear in the strategy that its implementation relies on close working with partners across a number of sectors and partnership working will be key to achieving our objectives.

Protecting People from Passive SmokingWe are working to make sure that our smoking cessation service is ready to meet the increase in demand expected leading up to and following the introduction of legislation to prohibit smoking in public places on March 26th 2006. The introduction of this legislation will be key in helping NHS Grampian to meet targets for reduction in smoking prevalence. We are working to ensure that the legislation is well publicised across the region and that people know that they can access stop smoking support from the SAS.

Prevention

Stopping people starting is an important element of our Tobacco Control work. The Young Person’s Tobacco Advisor has this as a key objective of the workshops delivered to primary and secondary school children across Grampian. Preventing tobacco use is also achieved through regular media campaigns and a number of community based initiatives.

Smoking CessationNHS Grampian has used additional funding for smoking cessation to meet the following objectives. To increase the capacity of our smoking cessation services and to target our priority populations. To then communicate the availability of our services and ensure that we reach people in Grampian who want to stop smoking. This is vital in reducing smoking prevalence in Grampian. Our cessation services are designed to be accessible and we will continue to work to ensure that we are providing them in a way that people want. Our services are provided locally across the whole region. Group and one to one sessions are available with trained smoking cessation advisors. The Community Pharmacy Scheme allows people to access smoking cessation support through their local pharmacist and the network of participating pharmacies has increased very recently with additional funding used to finance this. We continue to support a number of projects designed to encourage and support pregnant women to stop smoking. Specialist training in smoking cessation support for pregnant women has recently been delivered to midwives across Grampian.

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NHS Grampian also continues to work to ensure that our smoking cessation services are delivered to a uniformly high standard. We ensure that our services are consistent with national guidance and work is ongoing to ensure PATH approval. It is our plan to use the new national smoking cessation database and ensure collection of the minimum dataset.

Collaborative Working with Community Health PartnershipsA proportion of the additional funding made available for tobacco control and smoking cessation was allocated to CHPs in order to address priority populations, within local areas. We have been working together to draw up proposals for projects which are designed to reduce smoking prevalence amongst pregnant women, young people and in areas of deprivation.

Risk : Moderate

1.05S Alcohol misuse Reduce incidence of exceeding the weekly alcohol limit of 21 units to 29% for men, and of 14 units to 11% of women: target date 2010. (chart not currently available)

Narrative

In Grampian, the strategy and management of alcohol-related issues is driven by the three Drug and Alcohol Action Teams which are constituted along local authority population boundaries of Aberdeen City, Aberdeenshire and Moray Councils.

The H.03T target of reducing the incidence of exceeding the weekly alcohol limit of 21 units to 29% has been achieved for Grampian men and our incidence currently sits at 22%, well below the Scottish average of 27% (Scottish Health Survey 2003). Grampian women are faring worse than men as 15% of Grampian women currently exceed the weekly alcohol limit of 14 units compared to the target of 11% for 2010 and the trend from previous years' surveys has been upwards. Nor is the trend on alcohol consumption among children reassuring.

Through multi-agency partnership-working of the three Drug and Alcohol Action Teams, preventative and treatment issues are being addressed. Particular attention is being paid to the educational needs of schoolchildren, parents and staff in raising awareness of how alcohol can adversely affect people and on publicising sensible drinking levels. An assessment has been made of professional attitudes to broaching the subject of alcohol misuse among pregnant women and work is ongoing on how to best support professionals in this. Alcohol support services generally are being reviewed particularly in the context of providing access to the whole population within the challenges that a semi-rural location brings to provision of services.

Diseases related to alcohol misuse have significant implications in terms of life expectancy, work absences and health service costs. The short and long term sequelae of alcohol misuse and dependency include chronic liver disease (leading to cirrhosis and liver cancer), mental health (depression and anxiety), violence (domestic abuse and traumatic injury) and family challenges (unwanted pregnancies, family break-up), each of which carries a cost to society which is difficult to estimate.

The main challenges associated with achieving the targets are those of effective communication between agencies and with service users and implementation of evidence-based ways of doing things, issues which continue to be addressed in each of the Corporate Action Plans.

Risk: Moderate

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1.06S Exercise 50% of all adults (aged 16+) accumulating a minimum of 30 minutes per day of physical activity on 5 or more days per week. (chart not currently available)

Narrative

From a baseline figure of 37% in 2003 NHS Grampian is working towards the achievement of the exercise target performance measure of 50% of all adults (aged 16+) accumulating a minimum of 30 minutes per day of physical activity on 5 or more days per week. We are promoting physical activity by enhancing the strategic alignment between NHS Grampian and partner organisations, delivering direct and indirect services, bidding for project funds and promoting positive health messages.

Operating within the Health Improvement Team, NHS Grampian employs a Physical Activity Co-ordinator, two physical activity-based project staff and several sessional workers. Utilising the guidance incorporated with the National Physical Activity Strategy, NHS Grampian has set about addressing local needs through the development of its own physical activity strategy with an annual budget of £50K. The establishment of close working relationships with the three local authorities (LAs) within Grampian has led to health being given an enhanced profile within LA strategy documents, health-based physical activity measures being incorporated as performance indicators and policy being shaped to accommodate key health criteria e.g. Physical Education Curriculum Review. Furthermore, community planning fora provide a medium through which the health agenda can be disseminated to the private and voluntary sector.

NHS Grampian provides direct services that contribute towards the attainment of the Exercise measure. We promote walking as the prime physical activity medium through the ‘Walk to Health’ Programme (established in 1997), have developed a website where walking maps and advice can be obtained and, in conjunction with ‘Paths to Health’, will soon appoint two Regional Walk Co-ordinators. Considerable emphasis is placed on the establishment of healthy behaviours and active lifestyles through programmes such as ‘Kids in Condition ’ and the ‘Scotland’s Health at Work’. NHS Grampian also indirectly contributes to the promotion of physical activity by providing financial support and specialist training to partner organisations and through the co-ordination of bids to attract funding from sources such as the Big Lottery.

The challenges and risks associated with the attainment of the Exercise measure are substantial and cannot be underestimated. More sophisticated and extensive data gathering procedures will be required to enhance the validity and robustness of physical activity measures. It may sometimes be challenging to reconcile differing priorities e.g. the drive to reduce health inequalities through targeting of funds and expertise can detract from the goal of increasing physical activity at a population level. In addition to the traditional barriers and difficulties associated with behaviour change and effective partnership working, we also have to cope with issues such as organisational change within the public sector and the, often conflicting, demands that are placed on available resources. Finally, we are aware that in order to counter the continued development and use of labour-saving technology we must sustain our efforts to influence the development of an environment that is conducive to physical activity and one that restricts the dominance of the car. Risk : Moderate

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1.07S Teenage Pregnancies Reduce by 20% the pregnancy rate (per 1000 population) in 13-15 year olds from 8.5 in 1995 to 6.8 by 2010

Narrative

The target of reducing by 20% the pregnancy rate (per 1000 population) in 13-15 year olds from 8.5 in 1995 to 6.8 by 2010 has been echoed in the Grampian Health Plan. The rate among 13-15 years has declined by 30% from 8.9 per 1000 in 1993, to 6.3 per 1000 in 2002. However, these rates are based on a small number of pregnancies and are likely to fluctuate year on year.

In Grampian, sexual health education and prevention, screening and testing, and treatment are determined by Improving Sexual Health In Grampian - an inter-agency strategy.

Strategic Aims of the Strategy are to: Improve the sexual health and well-being of the population of Grampian. Reduce inequalities in sexual health

One of the strategic objectives is to reduce the rates of unintended pregnancy. To enable implementation of the objectives, a prioritised action plan has been derived and developed from an analysis of the key issues arising from a sexual health profile of Grampian, a review of best practice and evidence for intervention and informed by local knowledge/ experience. Planned and delivered in a coherent interagency manner, the aim of the strategy is to build on effective prevention measures as well as increase capacity of frontline services in order to meet growing demand.

In addition to strategic actions which should impact on teenage pregnancy such as health promoting school community activity, actions directly relating to this objective have been developed. As teenage parenthood rates are highest in areas of social deprivation there is a need to target initiatives to improve the health and social well-being of teenagers in these areas in partnership with local communities. The development of specific teenage programmes that build on the success of evaluated projects provide a valuable contact point for teenagers to obtain information, advice and referral to specific services.

NHS Grampian has nominated an Executive Director and Clinical Lead for sexual health in line with the national strategy in addition to maintaining the specialist health promotion capacity. Each local authority has also designated a strategic lead for sexual health. Community Health Partnerships will also be fundamental to delivery of this strategy to meet local needs. This grouping, together with voluntary sector (service and advocacy) partners will be charged with providing leadership to implementation of this strategy and action plan through the establishment of an inter-agency Strategy Implementation and Monitoring Group. The Group will develop intermediate indicators and will report through both the Health Plan and Community Planning structures. The strategy itself will be reviewed after three years.

Risk: Moderate

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1.03.K Immunisations - MMR (linked to target H.05T)MMR uptake rates (at 24 months old). Data sourced from Standard Immunisation & Recall System (SIRS) and Grampian Immunisation & Recall System (GIRS).

MMR Uptake Rates (at 24 months old)Grampian Vs Scotland

September 2003 - June 2005

60%

70%

80%

90%

100%

30-Sep-03 31-Dec-03 31-Mar-04 30-J un-04 30-Sep-04 31-Dec-04 31-Mar-05 30-J un-05

Time Period

% U

ptak

e

Grampian Scotland

Planned Trajectory

Sep 05 Dec 05 Mar 05 June 06 Sep 06 Dec 06 Mar 07 June 0787% 87% 87% 90% 90% 90% 91% 91%

Sep 07 Dec 07 Mar 08 June 08 Sep 08 Dec 08 Mar 0992% 92% 93% 93% 94% 94% 95%

Narrative

MMR immunisation uptake rates have suffered as a result of adverse publicity and public concerns. The importance of improving the uptake rate up to a level that confers herd immunity is fully understood. NHS Grampian's efforts are being directed towards ensuring that GPs and health visitors have access to up to date evidence and specialist support to assist them in informing parents fully and thereby facilitating decision making.

NHS Grampian is also in the process of implementing (SIRS) scheduling i.e. calling parents to bring their child for immunisation, a system used widely in other areas. This is expected to be implemented fully by end March 06 with consequent improvement in uptake and recording of uptake thereafter. We continue to have the challenge of a higher than average rate of migration to Grampian and the immunisation status of immigrant children is often incomplete or unknown.

Risk : Moderate

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1.04.K Suicide Rates (linked to target H.06T) Deaths from intentional self-harm and events of undetermined intent as a rate per 100,000 population. Data are sourced from deaths registered with the General Registrars Office for Scotland.

Planned Trajectory

2005 2006 2007 2008 200915.2 14.9 14.6 14.3 14.0

Narrative

NarrativeNHS Grampian has recently approved a Mental Health Improvement Framework following extensive consultation. This strategy has a Vision to achieve a mentally healthy Grampian.The Framework aims to: Seek to promote the mental and emotional health of the people in Grampian in particular

focusing on those who are particularly at risk. Raise awareness of the determinants of mental health at public, professional and policy-making

level in Grampian. Ensure those who have a role to play in promoting mental health are knowledgeable, skilled

and aware of effective practice in particular ensuring mental health promotion is considered in planning.

The strategy will be implemented through influencing the Joint Health Improvement Planning within the three localities in Grampian and as part of the NHS Grampian programme of delivering on Health Improvement, The Challenge (2003). Mental Health is an NHS Grampian health improvement priority. To ensure focused activity to address suicide NHS Grampian is an active partner in the implementation of the Choose Life initiative with specific action plans having been developed by the Choose Life multi-agency groups in Aberdeen City, Aberdeenshire and Moray. Action plans are kept updated on the Choose Life website which should be accessed for more detailed info www.chooselife.net All three action plans have identified the key specific local areas for delivery in relation to suicide prevention and specific priority groups. In some areas local data has been used and continues to be provided by for example the Liaison Psychiatry Team and Grampian Police to provide more specific information to support planning. The following are action areas: Addressing deliberate self harm, building capacity (knowledge and skills) through awareness raising and training (including

ASSIST trainers and course delivery and Mental Health First Aid), multi agency working in particular with specialist voluntary agencies such as Council for

Voluntary Services, Samaritans, Cruise, Penumbra and The Foyer Ensuring integrated working within Mental Health Services and Substance Misuse are detailed

and reported through Choose Life action plan reporting processes Doing Well by People with DepressionThe above initiatives are indirect attempts to reduce suicide and can be achieved only through effective multi-agency approaches and accountability. The Board as a Public Health Organisation, along with its partners in local authority and other agencies, will strive to achieve the reduction in deaths from intentional self-harm and undetermined intent as shown in the above trajectory.

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http://www.chooselife.net/

NHS Scotland Objective 2: Efficiency and Governance Improvements – continually improve the efficiency and effectiveness of the NHS

Target No. Target

E.01T NHS boards to operate within their revenue resource limit; operate within their capital resource limit; meet their cash requirement.

E.02T Sickness Absence Rate: 4% by 31 March 2008.E.03T Productivity: increase in consultant productivity by 1% pa over the next 3 years.


2.01.K Forecast Revenue Expenditure (linked to target E.01T)Forecast Deficit / Surplus for ‘End Year’ against total revenue resource limit. Data are extracted from monthly financial monitoring returns.

Forecast Deficit/Surplus for End YearGrampian: June 2004 - August 2005

-15000-10000-5000

05000

1000015000

Jun-04

Jul-04

Aug-04

Sep-04

Oct-04

Nov-04

Dec-04

Jan-05

Feb-05

Mar-05

Apr-05

May-05

Jun-05

Jul-05

Aug-05

Time Period

£ 00

0s

Note - Data not submitted by NHS Boards for April and May 2005

Planned Trajectory

Sep 05 Oct 05 Nov 05 Dec 05 Jan 06 Feb 06 March 06 June 06-8123000 -8123000 -8123000 -8123000 -8123000 -8123000 -8123000 0

July 06 Aug 06 Sept 06 Oct 06 Nov 06 Dec 06 Jan 07 Feb 070 0 0 0 0 0 0 0

March 07 June 07 July 07 Aug 07 Sept 07 Oct 07 Nov 07 Dec 070 0 0 0 0 0 0 0

Jan 08 Feb 08 March 08 June 08 July 08 Aug 08 Sept 08 Oct 080 0 0 0 0 0 0 0

Nov 08 Dec 08 Jan 09 Feb 09 March 090 0 0 0 0

Narrative

The NHS Grampian Delivery Plan is supported by the 5 Year Financial Plan 2006/07 to 2010/11 and its supplementary Financial Recovery Plan 2006/07 to 2008/09. These documents, which accompany the Delivery Plan, should be referred to in parallel.

NHS Grampian will spend more than £700 million of revenue funding in 2006/07 on health service delivery with above inflation rises in the four years beyond that. That investment is instrumental in achieving all of the targets set out in the Delivery Plan and has been allocated to services in 2006/07 to allow them to work together to make most effective use of available resources.

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Assuming that NHS Grampian end 2005/06 with a planned accumulated deficit of £8.1 million, that debt will be repaid in 2006/07 through non-recurring receipts including gains on sale of excess to requirement assets. Achieving break even will take until the end of the 2006/07 financial year as very challenging efficiency programmes will produce required cost reductions later on in the year while expenditure will arise on more of an even curve. This will lead to planned month end deficits reducing to break even by the end of the year.

Opportunities will arise during the year to invest further in delivering services as funding is released from programmes although it is expected that there will be an attempt by programme managers to release funds at the start of the year or at least earlier in the year than has been the case previously.

Key risks to operating within the revenue resource limit are meeting efficiency savings targets on a recurring basis while maintaining acceptable service levels.

NHS Grampian has consistently met its capital resource limit year on year and will do so again in 2006/07. The detailed capital allocation programme is presently being finalised to allow project managers maximum time to implement their plans which have been in place in outline for some months.

Risk : Substantial

2.02.K Absences (linked to target E.02T)

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Hours lost due to sickness absence expressed as a percentage of total hours available. This measure is based on all NHS employed staff working in NHS Scotland excluding private contractors (e.g. GPs and dentists) and their staff. Data are sourced from ISD(M) 39 – Occupational Health & Safety Minimum Dataset.

Hours lost due to sickness absence expressedas a percentage of total hours available

Grampian Vs Scotland: 2004-2005

0.0%

2.0%

4.0%

6.0%

2004 2005

Time Period

% H

ours

lost

Grampian Scotland

Planned Trajectory

2006 2007 2008 20095% 4.5% 4% 4%

Narrative

2.03.K Productivity – Total (linked to target E.03T)

NHS Grampian is committed to minimising staff absence rates and already experiences a low rate of absence when compared to elsewhere, although an increase has been experienced during 2005/06. A number of initiatives are planned or in place and further information can be found in our Staff Governance Audit report:

Proactive Support for Sickness Absence Project (PSSA) within Facilities Directorate will be reviewed with a view to gradual roll-out across NHS Grampian

Managing Attendance at Work Policy will be further developed and implemented Continued development of work/life balance policies.

Delivery of the suggested trajectories may be affected adversely by:

A flu pandemic or other major illness affecting staff’s ability to attend work the impact of calculating sickness absence in hours with effect from 10 April 2006.

Risk : Moderate

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Average Inpatient / Day Case case-mix adjusted activity per whole time equivalent (medical and nursing staff). Data are sourced from: SMR01, HRGs, The Medical and Dental Workforce Census and The Consultant Contract Uptake Census.

* Insufficient data to produce a graph of recent performance in relation to this measure.

Narrative

2.04.K Productivity – Consultants (linked to target E.03T)Average Inpatient / Day Case case-mix adjusted activity per whole time equivalent (clinical programmed activities). Data are sourced from: SMR01, HRGs, The Medical and Dental Workforce Census and The Consultant Contract Uptake Census.


Narrative

NHS Scotland Objective 3: Access to Services – recognising patients need for quicker and easier use of NHS services.

Whilst committed to increasing productivity a technical analysis of the LDP measure in association with ISD suggests that the current method of computing is flawed. We also have difficulty in that implementation of our strategy which involves shifting the balance of care, improving day case rates etc results in a reduction in efficiency according to the current measure.

See 2.03

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Target No. Target

A.01T Ensure that anyone contacting their GP surgery has guaranteed access to a GP, nurse or other health care professional within 48 hours from April 2004.

A.02T 60% of 5 year old children (primary 1) will have no signs of dental disease by 2010

A.03TNo patient with a guarantee should wait longer than 6 months for inpatient or day case treatment from 31 December 2005, reducing to 18 weeks from 31 December 2007.

A.04T By the end of 2005, no patient will wait longer than 6 months from GP referral to an out-patient appointment , reducing to 18 weeks from 31 December 2007.

A.05T By end 2007 no patient will wait more than 4 hours from arrival to discharge or transfer for accident and emergency treatment.

A.06T By end of 2007 the maximum wait for cataract surgery will be 18 weeks from referral to completion of treatment.

A.07T By end of 2007, the maximum wait for admission to a specialist unit for hip surgery following fracture will be 24 hours.

A.08T Women who have breast cancer and need urgent treatment will get it within one month where appropriate.

A.09T By 31 December 2005 no patient urgently referred for cancer treatment should wait more than 2 months.

A.10T From June 30 2004 the maximum wait from angiography to surgery or angioplasty will be 18 weeks.

A.11T By end 2007, the maximum wait for cardiac intervention will be 16 weeks from GP referral through rapid access chest pain clinic or equivalent.

A.12T Bt the end of 2007 patients will wait no more than nine weeks for any MRI or CT scans and other key diagnostic tests

A.13TFrom the end of 2007, no patient will wait more than 16 weeks for treatment after they have been seen as an outpatient by a heart specialist and the specialist has recommended treatment.

A.14T By end 2007, 75% of 999 emergency calls responded to within 8 minutes.


3.01.K Primary Care Team Access (linked to target A.01T)Percentage coverage of Health Board population, using list sizes for GP practices, taking part in Primary Care Collaborative.


April 05 April 06 April 07 April 08 April 0937.4% 37.4% 37.4% 37.4% 37.4%

Narrative

3.02.K Dental Registrations (linked to target A.02T)

Access to General Medical Services (GMS) is a vital component of health service delivery. Through the GMS Quality and Outcomes Framework review process, we have been assured that all practices are currently meeting this target. Participation in the Primary Care Collaborative is therefore not a robust measure for this target. We do not envisage further uptake in the collaborative in Grampian although learning from this and other improving access initiatives is being shared.We are working with the Community Health Partnerships to ensure that practices not only achieve this target, but also that the quality of the experience for patients trying to access GP services is positive.

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Percentage of children aged 0-17 years registered with an NHS dentist. Data are sourced from the Management Information & Dental Accounting System (MIDAS).

Dental Registrations aged 0-17 yearsGrampian Vs Scotland

31st March 2000 - 31st March 2004

50%

60%

70%

80%

2000 2001 2002 2003 2004

Time period

% R

egis

trat

ions

Grampian Scotland

Planned Trajectory

March 05 March 06 March 07 March 08 March 0959 59.3 61.8 64.5 66.1

Narrative

NHS Grampian is committed to improving dental health services for its population. Access to dental services is beginning to improve and we are on target to open 6 new premises across Grampian within the next 12 months, each with 1-4 surgeries. This includes the Centre for Excellence Training Centre and the Homeless Surgery. The waiting list for allocation to an NHS dentist is expected to reduce significantly as a consequence. The Community Dental service continues to deliver a significant part of dental care in Grampian and around a fifth of all Scottish community dental activity is undertaken here but does not show in registration data. We have recently appointed a Clinical Dental Director to oversee primary care dentistry throughout Grampian.

This measure looks at the dental registration rate for children only. The number of children in Grampian was extrapolated from the ISD figure on child registration as at 31 Mar 2005. This was used as the benchmark for the calculations. A trajectory showing improvement has been provided but is based on a number of assumptions:-

A growth rate of 1% per annum in the number of children No further reduction in GDP child registrations New Job Descriptions will include a target of a minimum of 1000 new patients registered within

2 years, a minimum of 400 being children. New Salaried GDP practices opened as predicted Registration policy is successful in relation to new jobs All new posts are based on new whole time dental practitioners. Recruitment is successful in line with opening dates. Parents are prepared to accept the transfer of children from the Community Dental Service to

the new salaried service

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The Salaried and Community Dental Services are planning to merge under a new title, The Public Dental Services. This may take place as early as March 2007. The current Regulations surrounding General Dental Practice and Community Dental Services will need to change to accommodate this merger. Should this merger take place and the Community Dental Service be integrated with Salaried General Dental Practice then the number of registered children under MIDAS would rise significantly.

We are aware that the Clinical Dental Directors Group for Scotland have a sub group looking at objectives and measurements for salaried dentists across Scotland. The findings of this group and recommendations may impact upon NHS Grampian’s planned increases.

Risk: Substantial

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3.03.K Inpatient / Day Case Waiting Times over 6 months (31 December 2005) (linked to target A.03T)For all acute specialties, number of inpatient / day cases waiting over 6 months excluding ASCs. Data are sourced from Monthly Management Information.

Number of inpatients/day caseswaiting over 6 months - Grampian

January 2004 - July 2005

0100200300400500600700800

Jan-0

4

Feb-0

4

Mar-04

Apr-04

May-04

Jun-0

4Ju

l-04

Aug-0

4

Sep-0

4

Oct-04

Nov-04

Dec-04

Jan-0

5

Feb-0

5

Mar-05

Apr-05

May-05

Jun-0

5Ju

l-05

Time period

Num

ber w

aitin

g ov

er

6 m

onth

s

Planned Trajectory

Aug 05 Sept 05 Oct 05 Nov 05 Dec 05 Jan 06 Feb 06 March 06

April 06

146 102 79 44 0 0 0 0 0May 06 June 06 July 06 Aug 06 Sept 06 Oct 06 Nov 06 Dec 06 Jan 07

0 0 0 0 0 0 0 0 0Feb 07 March

07April 07 May 07 June 07 July 07 Aug 07 Sept 07 Oct 07

0 0 0 0 0 0 0 0 0Nov 07 Dec 07 Jan 08 Feb 08 March

08April 08 May 08 June 08 July 08

0 0 0 0 0 0 0 0 0Aug 08 Sept 08 Oct 08 Nov 08 Dec 08 Jan 09 Feb 09 March

09April 09

0 0 0 0 0 0 0 0 0

Narrative

At the end of December 2005, NHS Grampian delivered the 26 week target for all inpatient /daycases on its waiting list. In 2006/7 this performance will be sustained while moving towards delivery of the 18 week target, which is currently forecast for December 2006 (see 3.04K).

Risk : Acceptable

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3.04.K Inpatient / Day Case Waiting Times over 18 weeks (31 December 2007) (linked to target A.03T)For all acute specialties, number of inpatient / day cases waiting over 18 weeks excluding ASCs. Data are sourced from Monthly Management Information.

Number of inpatients/day caseswaiting over 18 weeks - Grampian

April - September 2005

0

200

400

600

800

1000

1200

Apr-05 May-05 Jun-05 Jul-05 Aug-05 Sep-05

Time period

Num

ber w

aitin

g ov

er

18 w

eeks

Planned trajectory

Jan 06 Feb 06 March 06

April 06

611 571 530 470May 06 June 06 July 06 Aug 06 Sept 06 Oct 06 Nov 06 Dec 06 Jan 07

410 350 291 231 171 114 57 0 0Feb 07 March





09April 09

0 0 0 0 0 0 0 0 0

Narrative

NHS Grampian agreed its trajectory for the delivery of this very challenging target with the National waiting Times Unit (NWTU) in 2005. This was contingent on access to a number of facilities, particularly the new unit at Stracathro, which was then scheduled to be operational in January 2006. The scheduled start date for the facility is now July 2006 at the earliest, and it is unlikely that major orthopaedic joint work will be undertaken there in 2006. There is therefore significant risk around delivery of the 18 week target for orthopaedics in 2006. It is certain that some further contingency will be required to deliver targets – possibly further use of mobile theatre solutions, but such options will require resource to be made available, for which bids are to be made to the NWTU. (The Stracathro facility was worth £2m per annum to NHS Grampian, and would have been deployed fully).There is also risk in a number of key specialties where there are local capacity problems. Traditionally these have been resolved through spot purchasing of private capacity. Opportunities

18

for this are more constrained because of the heavy demand on the local private sector caused by orthopaedic see and treat contracts. This is already reducing flexibility for short term capacity, and putting delivery of targets at risk.

A significant element of Grampian’s plan to meet targets requires redesign of services to ensure that management of the waiting list is aligned to the clinical prioritisation process. Implementation of revised arrangements will contribute to improvements in waiting times for all patients. The risk associated with this is around management capacity to take forward.

Delivery is also dependent on implementation of a new theatre timetable (scheduled for April 2006), which implies additional anaesthetic input.

The additional resource required to deliver this target is estimated at around £6.3m, to which the Stracathro capacity in essence added some £2m. There remains a gap between this cost and available funding, although it is anticipated that this will reduce in year. The gap reflects assumptions regarding funding availability from the NWTU and from within NHS Grampian. The income stream will reflect contributions from other health systems to meet the target for their patients.

Risk : Substantial

19

3.05.K Inpatient / Day Case ASCs (linked to target A.03T)For all acute specialties, number of inpatient / day cases waiting with an ASC. Data are sourced from Monthly Management Information.

Number of inpatients/day caseswaiting with an ASC - Grampian


0500

1000150020002500300035004000

Jan-0

4

Feb-0

4

Mar-04

Apr-04

May-04

Jun-0

4Ju

l-04

Aug-0

4

Sep-0

4

Oct-04

Nov-04

Dec-04

Jan-0

5

Feb-0

5

Mar-05

Apr-05

May-05

Jun-0

5Ju

l-05

Time period

Num

ber w

aitin

g w

ith

an A

SC

Planned Trajectory


April 06

3279 3791 3611 3048 2800 2859 2917 2976 2905May 06 June 06 July 06 Aug 06 Sept 06 Oct 06 Nov 06 Dec 06 Jan 072835 2764 2693 2623 2552 2481 2411 2340 2268

Feb 07 March 07

April 07 May 07 June 07 July 07 Aug 07 Sept 07 Oct 07



1545 1475 - - - - - - -Aug 08 Sept 08 Oct 08 Nov 08 Dec 08 Jan 09 Feb 09 March

09April 09

- - - - - - - - -

Narrative

The trajectory sets out the agreed milestones for elimination of ASCs agreed with the Executive. Delivery of these milestones is entirely dependent on successful implementation of national system amendments (yet to be introduced) to patient administration systems, to accommodate the new rules on measuring and monitoring waiting times. In parallel with the systems issues, NHS Grampian has well developed internal systems to ensure that ASCs are monitored and managed.

Risk: Moderate

20

3.06.K Outpatient Waiting Times over 6 months (31 December 2005) (linked to target A.04T)For all acute specialties, number of new outpatients (GP/GDP referrals) waiting over 26 weeks excluding ASCs. Data are sourced from Monthly Management Information.

Number of outpatientswaiting over 6 months - Grampian


02000400060008000

1000012000

Jan-0

4

Feb-0

4

Mar-04

Apr-04

May-04

Jun-0

4Ju

l-04

Aug-0

4

Sep-0

4

Oct-04

Nov-04

Dec-04

Jan-0

5

Feb-0

5

Mar-05

Apr-05

May-05

Jun-0

5Ju

l-05

Time period

Num

ber w

aitin

g ov

er

6 m

onth

s

Planned Trajectory


April 06


0 0 0 0 0 0 0 0 0Feb 07 March





09April 09

0 0 0 0 0 0 0 0 0

Narrative

This target was delivered in December 2005, and will be sustained. See 3.07K

Risk : Acceptable

21

3.07.K Outpatient Waiting Times over 18 weeks (31 December 2007) (linked to target A.04T)For all acute specialties, number of new outpatients (GP/GDP referrals) waiting over 18 weeks excluding ASCs. Data are sourced from Monthly Management Information.

Number of outpatientswaiting over 18 weeks - Grampian

April - September 2005

0500

1000150020002500300035004000


Time period

Num

ber w

aitin

g ov

er

18 w

eeks

Planned Trajectory

Jan 06 Feb 06 March 06

April 06

1307 1336 1365 1300May 06 June 06 July 06 Aug 06 Sept 06 Oct 06 Nov 06 Dec 06 Jan 071235 1170 1106 1042 978 913 849 784 722

Feb 07 March 07

April 07 May 07 June 07 July 07 Aug 07 Sept 07 Oct 07




09April 09

0 0 0 0 0 0 0 0 0

Narrative

Delivery of a maximum 18 week wait for outpatients is at least as challenging as the inpatient target. Delivery is dependent on a range of measures, including in particular successful implementation of major redesign initiatives in key specialties. These involve a range of interventions in the patient pathway and include, for example, the development of an intermediate tier (GPs and extended role clinicians), use of telemedicine solutions, the provision of referral support and advice through clinical eMail etc. Perhaps most significant of all is the implementation of effective referral managementsystems in primary care, currently being piloted in a small number of practices. This focuses on demand rather than capacity, and if rolled out has the potential to transform the pattern of delivery.

As regards capacity expansion, national initiatives, including Stracathro, will also play a part, but are unlikely to have any impact in 2006 (because the focus will be on inpatient waiting lists in the

22

early stages of the contract). More traditional means of delivery include short term capacity expansion – and provision of additional clinics, either within the NHS or within the private sector for a very few services.

There are several risks associated with delivery. The implementation of referral management requires significant investment in GP systems, and this has yet to be programmed. In addition, the speed with which the redesign process can be rolled out depends on both management capacity and funding (to allow for double running in theshort term). At a strategic level, the ability to negotiate remuneration arrangements (in the absence of any national guidance on this matter) for extended role practitioners represents a threat, and may impact on schemes which are already demonstrating success. More positively however, it is clear that there is widespread support within Grampian, and particularly in the CHPs to effect these changes, which are being led through system wide redesign programmes.

There are major workforce issues arising from the redesign programme and these affect clinicians throughout the system as new roles are developed and new ways of working implemented. The success of the new arrangements are wholly dependent on clinician involvement and support. All redesign initiatives are clinician led with whole system involvement.

The estimated cost of delivery of the outpatient plan stands at around £700k, excluding the various capital initiatives (referral management systems etc) identified above. In addition to these costs, the recurring costs of successful Centre for Change and Innovation projects must be met. This will affect orthopaedics, dermatology and neurology, in particular. Evaluation of these projects is underway and decisions about continued funding will be made as part of the formal budget setting process.

Risk: Substantial

23

3.08.K A&E Waits less than 4 hours (linked to target A.05T)The percentage of patients spending less than 4 hours in Accident & Emergency Department. Historical data are sourced from SMR30C (A&E Survey).

% of patients spending less than 4 hours inAccident & Emergency Department

Grampian Vs Scotland

80%

85%

90%

95%

100%

2000 2001 2002 2003 2004 2005

Time Period

% o

f pat

ient

s

Grampian Scotland

Planned Trajectory

April 06 Dec 06 April 07 Dec 07 April 08 Dec 08 April 0992% 95% 96% 98% 98% 98% 98%

Narrative

Achievement of this measure is a key outcome of the work of the local Unscheduled Care Collaborative. We are confident that the 98% (not 100 due to clinical exceptions) is achievable as we are approaching delivery on a system wide basis, thereby avoiding the perception of this being purely an acute/ Accident and Emergency issue.

Current work to support this improvement has focussed around

* Sourcing real time admission and discharge information * the development of a discharge lounge * clear discharge plans* developing ‘Plan Do Study Act’s around Estimated Date of Discharge

Full Achievement will be difficult but the overall redesign of services within the health campus development, including intermediate care beds within Aberdeen will support this alongside staff commitment to high quality patient care.

Risk : Moderate

24

3.09.K Cataract Waiting Times over 3 months (linked to target A.06T)Number of Inpatient / Day cases waiting over 3 months for a cataract operation. Data are sourced from SMR3 records. Measurement of this will be improved when total journey information becomes available.

Number of cataract patients waiting over 3 months

Grampian

0

10

20

30

40

50

31-Mar-04 30-Jun-04 30-Sep-04 31-Dec-04 31-Mar-05 30-Jun-05 30-Sep-05

Time Period

No

of p

atie

nts

Planned Trajectory

Dec 05 Mar 06 June 06 Sep 06 Dec 06 Mar 07 June 0756 50 40 34 26 18 12

Sep 07 Dec 07 Mar 08 June 08 Sep 08 Dec 08 Mar 096 0 0 0 0 0 0

Narrative

Within NHS Grampian the vast majority of cataract operations are undertaken as outpatient procedures and do not feature in the assessment of current performance shown by this measure. Waiting times for outpatient cataracts is currently around 13 weeks and is expected to fall further. The inpatient/day case cataracts are the more complex cases and waiting times for these are also expected to fall as shown in the trajectories. Initiatives underway and being put in place will impact on both outpatient and inpatient/day case waits.The one stop cataract clinics started in 2003 and have proved to be successful in ensuring the journey of care for patients is streamlined. Patients attend this clinic where diagnosis of cataract is confirmed and patient's placed on a list for surgery. The clinic is predominantly nurse led and pre admission assessment including all eye and other investigations is carried out. Recently the role of the in house optometrist has been extended to undertake an additional one stop cataract clinic. This allows approximately 54 patients extra to be seen per week.Additional theatre lists have been allocated and this increases the capacity for additional operating time.Postoperative clinics have been discontinued except in the case of Specialist Registrars operating, patients attend their optometrist at 6 week post operatively and are referred back if there are any significant problems.Patients are referred directly from their optometrist and bypass the GP except for a medical history, which is requested.From March 06 the ophthalmology department will be taking part in the NWTU/CCI funded initiative The Eye Redesign and Cataract Delivery Programme. Through redesign this will release capacity to improve the throughput of cataracts. The national Cataract Delivery Team, of which the current service manager is a member, will over see this and be on hand to provide appropriate support in the event of any barriers to the changes as prescribed in the programme.

25

3.10.K Hip Surgery Waiting Times over 48 hours (linked to target A.07T)Percentage of hip fracture operations performed within 48 hours of admission to orthopaedic speciality. Data are extracted from the August 2005 version of the linked SMR01 catalogue of Inpatient and Day case admissions.

% of Hip fracture operations performed within 48 hours of admission to orthopaedic speciality - Grampian Vs Scotland

March 2002 - December 2004

0%

20%

40%

60%

80%

100%

Mar-02

May-02

Jul-0

2

Sep-0

2

Nov-02

Jan-0

3

Mar-03

May-03

Jul-0

3

Sep-0

3

Nov-03

Jan-0

4

Mar-04

May-04

Jul-0

4

Sep-0

4

Nov-04

Time period

% o

f pat

ient

s

Grampian Scotland

Planned Trajectory

March 05 June 05 Sept 05 Dec 05 Mar 05 June 06 Sep 0680% 80% 80% 80% 80% 80% 80%

Dec 06 Mar 07 June 07 Sep 07 Dec 07 Mar 08 June 0880% 80% 80% 80% 80% 80% 80%

Sep 08 Dec 08 Mar 0980% 80% 80%

Narrative

The measure relates to access to hip surgery within 48 hours of admission to a specialist unit, a target against which we believe we are already compliant at c80%. This position will be maintained. The overall target is hip surgery within 24 hours, and this is not routinely collected by information systems. A 2005 audit showed current performance against the 24 hours to be 71.23% at ARI and 70.53% at Dr Gray's. We would expect that implementation of a range of initiatives in orthopaedics, including improved access to theatres and improved post-operative rehabilitation flows would lead to improvements in the 24 hour position with 80% achieved by Dec 07.

Risk: Moderate

26

3.11.K Breast Cancer Waiting Times over 31 days (linked to target A.08T)Percentage of patients diagnosed with breast cancer treated within 31 days. Data are sourced from Regional Cancer Networks.

Breast Cancer% of patients from diagnosis to treatment within 31 days

Grampian Vs Scotland

0%

20%

40%

60%

80%

100%

30-Jun-03 30-Sep-03 31-Dec-03 31-Mar-04 30-Jun-04 30-Sep-04 31-Dec-04

Time period

% o

f pat

ient

s

Grampian Scotland

Planned Trajectory

March 05 June 05 Sept 05 Dec 05 March 06 June 0646% 46% 46% 48% 50% 52%

Sept 06 Dec 06 March 07 June 07 Sept 07 Dec 0755% 58% 60% 62% 65% 68%

March 08 June 08 Sept 08 Dec 08 March 0970% 71% 72% 73% 75%

Narrative

Actions to deliver improvements in performance are detailed in 3.12K and will impact on this target also.

Risk: Substantial

27

3.12.K Cancer Waiting Times over 2 months (linked to target A.09T)Percentage of patients urgently referred for lung, colorectal and breast cancer treatment seen within 2 months. This will be extended to cover an increasingly wider range of cancers as information becomes available. Data are sourced from Regional Cancer Networks.

Percentage of patients urgently referred for lung, colorectal and breast cancer treatment seen within 2

months - Grampian

0%

20%

40%

60%

80%

100%

Sep-04 Dec-04 Mar-05 Jun-05

Time Period

% o

f Pat

ient

s

Breast Colorectal Lung

Planned Trajectory

Cancer June 05 Sept 05 Dec 05 Mar 06 June 06 Sept 06 Dec 06 Mar 07Breast 42% 50% 73% 75% 95% 95% 95% 98%Colorectal

40% 47% 63% 75% 95% 95% 95% 98%

Lung 90% 90% 90% 90% 95% 95% 95% 98%Cancer June 07 Sept 07 Dec 07 Mar 08 June 08 Sept 08 Dec 08 Mar 09Breast 98% 98% 98% 98% 98% 98% 98% 98%Colorectal

98% 98% 98% 98% 98% 98% 98% 98%

Lung 98% 98% 98% 98% 98% 98% 98% 98%

NarrativeThe 62 day target is a challenge, both in terms of meeting this waiting time and also in terms of data recording and reporting against the whole patient journey. A wide range of initiatives have and are being implemented to optimise achievements of the target time. These include:

Protocols for all urgent referrals, including the use of a new electronic referral system and desktop symptoms alarm system for GPs. This will help improve the appropriateness of urgency of referrals and will allow focus and directed resource on those cases of the highest clinical priority.

Electronic patient tracking: now in place throughout NHSG to minimise delays and support service management teams and clinicians identify referrals at risk of breaching target.

Various initiatives to ensure rapid assessment and diagnosis, including dedicated fast track clinics, reduced number of entry points, increased capacity, mobile diagnostic facilities and nurse led clinics.

Multi-disciplinary team approach in all cancers Each cancer has a Focus Group responsible for leading service improvements and identifying

the areas of highest priority for service development/improvement. Delivery of the suggested trajectories is not without challenge and risk although it is believed that appropriate controls are in place to optimise achievement. Capacity issues such as theatres have

28

generally been addressed. Colorectal cancer poses the most significant challenge currently and delivery of improvements is dependent on redesign of the patient pathway to minimise access points, development of common services and referral in line with regionally and nationally agreed guidelines. This is in hand but will take time to impact fully. The most significant risk to delivery is the continued availability of key staffing groups particularly radiologists, surgeons and pathology. Delivery is also dependent upon continuation of funding and as Grampian provides a service to the north of Scotland this includes appropriate funding by other Boards in the network. Whilst this delivery plan measure relates solely to urgent referrals, the initiatives being progressed are aimed at improving waiting times for all cancer patients. NWTU have asked that the target be achieved as soon as possible, specifically achievement of 95% for breast and colorectal by June 06. We will strive to deliver on this.

Risk : Substantial

29

3.13.K Angiography Waiting Times over 8 weeks (associated with target A.10T)Angiography patients waiting longer than 8 weeks excluding ASCs. Data are sourced from Monthly Management Information.

Angiography Patients waiting > 8 weeksGrampian: April 2004 - July 2005

05

101520253035

Apr-04

May-04

Jun-0

4Ju

l-04

Aug-0

4

Sep-0

4

Oct-04

Nov-04

Dec-04

Jan-0

5

Feb-0

5

Mar-05

Apr-05

May-05

Jun-0

5Ju

l-05

Time Period

Num

ber o

f Pat

ient

s


April 06


0 0 0 0 0 0 0 0 0Feb 07 March





09April 09

0 0 0 0 0 0 0 0 0

Narrative

The 8 week target is being met in full and this position will be sustained. Current arrangements include the use of a private modular cath lab 3 days per week. The main risk to delivery concerns equipment failure.

Risk : Moderate

30

3.14.K Revascularisation Waiting Times over 18 weeks (linked to target A.10T)Revascularisation patients waiting longer than 18 weeks excluding ASCs (includes angioplasties and CABGs). Data are sourced from Monthly Management Information.

Revascularisation Patients waiting > than 18 weeksGrampian: April 2004 - July 2005

02468

101214

Apr-04

May-04

Jun-0

4Ju

l-04

Aug-0

4

Sep-0

4

Oct-04

Nov-04

Dec-04

Jan-0

5

Feb-0

5

Mar-05

Apr-05

May-05

Jun-0

5Ju

l-05

Time Period

Num

ber o

f Pat

ient

s

Planned Trajectory


April 06


0 0 0 0 0 0 0 0 0Feb 07 March





09April 09

0 0 0 0 0 0 0 0 0

Narrative

The 18 week target is being met in full and this position will be sustained. Current arrangements include the use of a private modular cath lab 3 days per week. The main risk to delivery concerns equipment failure.

Risks for CABG patients relate to closure of ITU due to lack of beds. Plans for a ward move linked to upgrade of facilities could have an impact on patient throughput for a short period.

Risk : Moderate

32

3.15.K Maximum Radiology Waiting Times: CT Scan (linked to target A.12T)Longest wait for CT Scan. Data are sourced from Monthly Management Information.

Maximum Radiology Waiting Times: CT ScanGrampian Vs Scotland

0

5

10

15

20

25

30


Time Period

Long

est W

aits

(Wee

ks)

Grampian Scotland


April 06


6 6 6 6 6 6 6 6 6Feb 07 March





09April 09

6 6 6 6 6 6 6 6 6

Narrative

Currently NHS Grampian waiting times for CT vary between 4-6 weeks. This position is not expected to change significantly over the next 2-3 years. Should demand increase significantly then the waiting time may drift to 6-7 weeks but efforts will be made to reduce this and sustain the position within target in the period to 2009. The main challenge is ensuring diagnostics deliver within the overall timeframe that does not compromise the maximum 18 weeks from GP referral to out patient appointment and 18 weeks from the decision to undertake treatment to commencing treatment.

Risk: Moderate

34

3.16.K Maximum Radiology Waiting Times: MRI Scan (linked to target A.12T)Longest wait for MRI. Data are sourced from Monthly Management Information.

Maximum Radiology Waiting Times MRI ScanGrampian Vs Scotland

0

20

40

60

80


Time Period

Long

est W

ait

(Wee

ks)

Grampian Scotland

Planned Trajectory


April 06


20 20 18 18 16 16 14 12 11Feb 07 March





09April 09

9 9 9 9 9 9 9 9 9

Narrative

Achieving the 9 week target for MRI will be extremely challenging. Substantial improvements from 42 weeks to 19 weeks have already been delivered. Additional sessions have been introduced and patients have been given the opportunity to be seen at Golden Jubilee Hospital. We are in further negotiations with GJH about future access for Grampian patients.

To reduce the waiting time to the required 9 weeks will require significant investment. Discussions are underway with Highland about a shared consultant radiologist post and the use of either a mobile MRI Scanner or a dedicated extremity MRI scanner using a lower magnetic field strength. The latter would release sessions on the MRI high field strength scanners for chest, abdominal/pelvic and central nervous system imaging.Over the next two years we will work towards the achievement of a reduction in waiting times to ensure delivery of 9 week maximum waiting time for 95% of referrals by the end of 2007 and sustain this through to 2009.

Potential risks to delivery include:- funding and the ability to recruit the appropriate radiographers and radiologists timescale for Stracathro MRI facilities being made available for Grampian patients access to GJH which is less than required to assist in meeting waiting time targets permanent failure of the current ageing MRI scanner at ARI in advance of commissioning a

36

replacement system (Risk Control Plan in preparation)

Risk: Substantial

37

3.17.K Maximum Endoscopy Waiting Times: Upper GI endoscopy (linked to target A.12T)Longest wait for upper GI endoscopy. Data sourced from Monthly Management Information.

Maximum Endoscopy Waiting Times: Upper GIGrampian Vs Scotland

0

10

20

30

40

50


Time Period

Long

est w

ait

(wee

ks)

Grampian Scotland

Planned Trajectory


April 06


20 19 19 18 17 16 15 15 14Feb 07 March





09April 09

9 9 9 9 9 9 9 9 9

Narrative

Proposals to improve endoscopy waiting times are being taken forward through the Endoscopy Group. There are 2 elements to these proposals – the first is straightforward expansion of capacity – and this involves investment in local facilities, funded through diagnostic monies made available through the Executive. It is envisaged that this will increase the number of fully equipped rooms available. We are also making use of capacity through the Stracathro Independent Treatment Centre contract. Our second wave bid for diagnostic resource will enable consultant gastroenterologist input to be expanded by releasing the team from responsibilities for receiving. This will enable somewhere between 600 and 1000 additional scopes to be undertaken, per annum, in addition to expanding outpatient capacity. We have plans to expand nurse endoscopist input and to use nurse input to improve utilisation of endoscopy facilities.

The redesign element of the service includes development of a common waiting list.

The risk around this target arises from any short term disruption impacting on capacity as a result of the proposed expansion although it is hoped that temporary mobile capacity could be made available for this purpose.

38

Risk : Moderate

39

3.18.K Maximum Endoscopy Waiting Times: Lower GI endoscopy and colonoscopy (linked to target A.12T)Longest wait for lower endoscopy or colonoscopy. Data sourced from Monthly Management Information.

Maximum Endoscopy Waiting Times: Lower GIGrampian Vs Scotland

020

4060

80100


Time Period

Long

est w

ait

(wee

ks)

Grampian Scotland

Planned Trajectory


April 06


20 19 19 18 17 16 15 15 14Feb 07 March





09April 09

9 9 9 9 9 9 9 9 9

Narrative

The plans to expand capacity and to redesign services are the same as those identified for upper GI endoscopy – a combination of investment in additional facilities, use of Stracathro, expansion of consultant and nurse time coupled with implementation of a common waiting list. In addition diagnostic protocols which stream patients into particular diagnostic pathways are being implemented.

Risk: moderate

40

3.19.K Outpatient Appointment To Cardiac Procedure (linked to target A.11T & A.13T)In the absence of total journey information, the numbers waiting over 10 weeks from date added to waiting list for a revascularisation procedure is used. Data are sourced from SMR3 records.

Outpatient Appointment To Cardiac Procedure(Revascularisation Patients waiting > than 10 weeks)

Grampian: March 2003 - September 2005

0

10

20

30

40

50

Mar-03 Jun-03 Sep-03 Dec-03 Mar-04 Jun-04 Sep-04 Dec-04 Mar-05 Jun-05 Sep-05

Time period

Num

ber o

f pat

ient

s

Planned Trajectory

Dec 05 Mar 06 June 06 Sep 06 Dec 06 Mar 07 June 0713 12 11 10 9 8 6

Sep 07 Dec 07 Mar 08 June 08 Sep 08 Dec 08 Mar 093 0 0 0 0 0 0

Narrative

Very small numbers of patients currently wait longer than 10 weeks and it is expected that this will reduce to zero by December 2007. Fair to All, Personal to Each sets out whole pathway targets for GP referral through rapid access chest pain clinic to intevention (16 weeks max) and for all other patients from specialist decision to treatment (16 weeks max). We are currently modelling how these targets can be achieved. It should be noted that for some patients the pathway may be ‘interrupted’ when medical management of their condition is the most appropriate clinical option.

A range of initiatives, including increased capacity, is being implemented through the Grampian and North of Scotland Clinical Networks. There are a number of risks associated with delivering targets. These include unforeseen closure of ITU due to lack of beds (CABG) and unexpected equipment failure (angioplasty). As a regional service, delivery is also dependent on appropriate regional funding arrangements being in place. It should also be noted that improvements in the early stages of the pathway will compress times at the end of the pathway, especially for cardiac surgery. It follows that whole system redesign must take place in parallel with the introduction of the new targets.

Risk : Moderate

3.20.K Ambulance Response Times (linked to target A.14T)Percentage of 999 emergency calls responded to within 8 minutes. National measure sourced from Scottish Ambulance Service – no Board level measures for 2006/7.

42

NHS Scotland Objective 4: Treatment Appropriate to Individuals: ensure patients receive high quality services that meet their needs.

Target No. Target

T.01TWe will reduce the number of people waiting to be discharged from hospital into a more appropriate care setting by 20% year on year between 2005 and the end of 2008, cutting to a minimum the number of people waiting more than 6 weeks to be discharged.

T.02TBy 2008-09, we will reduce the proportion of older people (aged 65+) who are admitted as an emergency inpatient 2 or more times in a single year by 20% compared with 2004/05.

T.03T Cervical screening target 80%, ongoingT.04T QIS clinical governance and risk management standards improving


4.01.K Delayed Discharges over 6 weeks (linked to target T.01T)Patients experiencing a delay in discharge where the delay was 6 weeks or more. Data are sourced from the Delayed Discharge Census.

Delayed Discharges(Where the delay was 6 weeks or more)

Grampian: January 2004 - April 2005

020406080

100120140160

Jan-04 Apr-04 Jul-04 Oct-04 Jan-05 Apr-05

Time Period

Num

ber o

f pat

ient

s

Planned Trajectory : The following trajectory reflects the revised targets relating to those delayed over 6 weeks issued on 23rd February 2006:-

For 2006-07, to reduce all delays over 6 weeks by 50%; For 2006-07, to free up 50% of all beds occupied by delayed patients in short-stay beds; For 2007-08, to reduce to zero patients delayed over 6 weeks; and For 2007-08, to reduce to zero those delayed in short-stay beds.

July 05 Oct 05 Jan 06 April 06 July 06 Oct 0699 128 164 100 75 60

Jan 07 April 07 July 07 Oct 07 Jan 08 April 0850 38 35 25 20 0

July 08 Oct 08 Jan 09 April 090 0 0 0

43

Narrative

Total delayed discharges in Grampian have reduced considerably over a number of years from 365 in 2002 to 194 in April 2005. This has been achieved by effective joint working between the health service, the local authorities and private and voluntary organisations and in spite of ongoing redesign also putting heavy pressure on the system. The Grampian Integrated Care Group meets on a monthly basis to monitor the delayed discharge process, agree funding of projects and take any necessary action to further reduce delayed discharges on a joint basis.

Our Grampian Joint Winter Plan for 2005/2006 contains information on all the projects which are funded from our winter planning budget. In addition some recent actions have been taken to support and encourage further reductions :-

Continuing to work with hospital staff to make them aware of the delayed discharge issues and being pro-active in preventing this happening.

The Discharge Planning Team is screening for any available vacancies on a daily basis More discussion on admission to hospital with patients and their carers about going home as

quickly as possible. More negotiation with relatives and the patient regarding discharge. Some patients have

agreed to move to a home out of area. The developed Choice booklet has been helpful in this regard. However, this is not suitable for many elderly patients in rural areas because of lack of transport and long distances of travel

More patients going home with an extensive care package instead of waiting for a care home place which are in short supply.

The development of step down/intermediate care beds in community hospitals, care homes and sheltered housing

Dialogue with the private sector for an expansion of nursing home beds. Weekly meetings to look at all delayed discharge patients and sorting out any problems to

enable timely discharge. The appointment of a Grampian-wide falls co-ordinator Extra funding provided to the Ambulance Service for the provision of a dedicated discharge

service during out of hours The Joint Equipment Project is developing shared procurement and management of equipment.

This is often an issue in delayed discharges. The Project Manager post is funded from the winter planning budget.

The total delayed discharge target for April 2006 is 142 (75 over 6 weeks) and we have advised SEHD that whilst doing all we can, we do not expect to meet this. We have also sought ratification of an agreed local protocol on definitions.

The delivery plan measure and trajectory currently relates to delayed discharges waiting more than 6 weeks, however new targets were issued on 23rd February 2006 (see above).

There are a number of reasons why achieving the submitted trajectory will be extremely challenging. Identified areas of risk are as follows:

Lack of vacancies in care homes. This is especially acute in Aberdeen City. In the rural areas vacancies are often in the wrong place. Sending patients to a nursing home far away from their own locality makes it impossible for close relatives/spouses to visit as transport is problematic. This is not in the best interest of elderly people.

Places in Care Homes have reduced through redesign of a number of homes to comply with Care Commission standards.

A new Care Home to be build on the former Tor-na-Dee site (60 places) will not be ready until after April 2008.

All three local authorities have major budget problems and have not increased funding for care home places and/or high cost care packages.

Recruitment of appropriate staff (home carers, nurses, AHPs) is difficult in this area of full employment

There will be a large increase in the number of people over 65 and especially in people over 85

Major redesign projects are underway in Aberdeen City and Aberdeenshire as well as within ARI. It will take time to have the planned new provision in place and this is unlikely to be ready before 2008.

Risk: Substantial

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4.02.K Emergency Re-admissions (aged 65+) (linked to target T.02T)Rate of emergency re-admissions per 100,000 pop (aged 65+). Data are sourced from SMR01 records.

Emergency Re-admissions(aged 65+ per 100,000 population)

Grampian Vs Scotland: 1999 - 2003

0

500

1000

1500

2000

1999 2000 2001 2002 2003

Time Period

Re-

adm

issi

on

Rat

e

Grampian Scotland

Planned Trajectory

March 04 March 05 March 06 March 07 March 08 March 094340.0 4245 4033 3821 3608 3396

Narrative

Delivery of this challenging target will require a systematic approach to unscheduled and chronic care. NHS Grampian is already performing well against the Scottish average but will aim to reduce the admissions further over the period to 2009. Delivery is dependent on cross system actions to maximise care at home, ensure effective escalation of care where required and minimise hospital admissions. Key to the success in the achievement of this target is the engagement of Community Heath Partnerships and the possibility of further enhanced service arrangements. Delivery of these initiatives is an integral component of NHS Grampian's change and innovation programme.

Risk: Substantial

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4.03.K Cervical Screening (linked to target T.03T)Percentage of women in the 20-60 year old age group attending a screening. Data are sourced from ISD (D)4.

Cervical Screening: Percentage of women in the 20-60 year old age group

Grampian Vs Scotland: 1998 - 2004

50%60%70%80%90%

100%

1998 1999 2000 2001 2002 2003 2004

Time Period

Perc

enta

ge

Scre

ened

Grampian Scotland

Planned Trajectory

March 05 March 06 March 07 March 08 March 0985% 85% 86% 87% 88%

Narrative

The rationale for performing cervical smear testing as a means of identifying those at risk of developing cervical cancer is well documented. NHS Grampian has consistently performed well in this area, exceeding the Scottish average and the national target of 80% for many years.No particular problems are anticipated, although a move to the national call/recall system will require quite considerable input in terms of training and support to practices. However, we expect to continue to perform well in this area.

Risk : Acceptable

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4.04K QIS Standards Improving (linked to target T.04T)Measurement for this proxy indicator is based on the sum of the scores for the 3 standards within the QIS Clinical Governance and Risk Management assessment.


Planned Trajectory

2005/06 2006/07 2007/08 2008/098 9 10 11

Narrative

There has been substantial development in single system Clinical Governance arrangements in NHS Grampian with an overarching NHSG Clinical Governance strategy (Statement of Intent) shortly to be confirmed and the development of an Assurance Framework and associated work plan for the single system NHSG Clinical Governance committee. This identifies key areas of weakness/risk within Clinical Governance systems and processes with associated actions and a timetable to address. The Clinical Governance committee will be responsible for ensuring actions agreed are progressed and any areas of enduring concern are notified to the NHSG Board. With the establishment of Clinical Governance structures within the sectors (Acute and 3CHPs) taking place this allows for the delegation of responsibility to sector level as detailed in the Clinical Governance Statement of Intent. Through attendance of the sector Clinical Governance leads at the NHSG Clinical Governance Committee this allows for the development of processes for co-operation, implementation and feedback. These processes include reporting frameworks against agreed work-plans, the latter reflecting both organisational issues as well as local concerns/lessons to be shared and provides the opportunity for developing a co-ordinated approach to addressing clinical governance issues and ongoing monitoring and evaluation of organisational Clinical Governance arrangements

To provide NHS Grampian with information on the success or otherwise of its internal Clinical Governance Arrangements an Internal Audit conducted by PriceWaterhouseCoopers (internal auditors) was commissioned in December 2005 and is due to report at the end of February 2006.External Review of both Clinical Governance and Risk Management arrangements will be conducted by NHSQIS in July 2006 when we expect to improve on the preliminary score of 6

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2006/7 local delivery plan template - nhs grampian · web viewthe 2006/7 local delivery plan is...

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