feedback report - nhs grampian - caring - … report page 2 of 16 board seminar on sustainability of...

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NHS GRAMPIAN

BOARD STAKEHOLDER SEMINAR

Sustainability of Secondary & Tertiary Services

05 November 2015

Hazlehead Park Café Conference Centre, Aberdeen

FEEDBACK REPORT

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Board Seminar on Sustainability of Secondary & Tertiary

Services

5th November 2015, Hazelhead Cafe, Hazelhead Park, Aberdeen

The next Board Seminar involving the ACF, GAPF, lead clinicians and senior managers will be held on

Thursday 5th November 2015 at 10am.

Tea and coffee available from 9.30am.

Agenda

10.00 Welcome and Purpose of the Seminar

10.10 Case for Change and the National Strategic Direction - is Grampian’s 2020 for

Secondary/Tertiary Services Still Relevant? – Nick Fluck

10.25 Question & Answer Session

10.35 Discussion in Groups

In the context of the 2020 and the gaps and challenges identified;

What examples are there from elsewhere where elements of the future 2020 system are described and delivered?

What might be the growth points in the future system?

What current practice do we need to keep or further build upon?

Coffee/Tea available

11.20 What Can We Do To Be More Efficient, Effective and Sustainable? – Malcolm Metcalfe

11.30 Discussion in Groups

In the context of sustainability;

What examples are there from elsewhere which support sustainable, efficient and responsive secondary/tertiary service delivery?

What current practice do we need to keep/build on and what do we need to stop?

12.20 Closing remarks

12.30 Lunch

Papers attached:

1. Healthfit 2020 2. Reconfiguration of Clinical Services - What’s the Evidence?

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3. Summary of the NHS Grampian Director of Public Health Annual Report – 2014/15

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GROUP DISCUSSIONS

TABLE NO: 1

FACILITATOR: Laura Kluzniak

EXECUTIVE LEAD: Nick Fluck

TABLE MEMBERS: Rhona Atkinson June Brown Arnab Rana Stuart Reary Steven Glass Steven Lindsay. (Stewart Cree – not present)

DISCUSSION 1

In the context of the 2020 and the gaps and challenges identified:




NARRATIVE: A good range of discussion focusing on a number of areas; challenging traditional ways of working, not removing service but making a shift to identify different ways of delivery i.e. patients doing their own follow up. Honesty – a number of points made to have open and honest conversations managing expectations that include the general population, the politicians and all professional groups. Conversations continue but no real change which is continuing to embed the ‘customer service’ approach we provide. We need to manage public demands in the future and keep up to speed with developments in technology and be aware of younger generations having different expectations. Has the NHS created this problem themselves due to political and public pressure? We operate a ‘Medicialised’ model providing a risk averse and ‘safe’ service and this needs to be challenged, but leadership has to come from the top to make this happen and address resistance at all levels. Look towards the Alaskan Health Board, a dynamic approach asking the population their expectations, or Spain whereby the family provide all the care for the patient. Look to include the extended family in the future. 3 KEY POINTS:

1. Services: Find new ways of delivering our services looking to other areas and addressing any resistance. For example – self follow-up but not necessarily with a consultant.

2. Honesty: inclusive of all parties, politicians, medics, professional

groups and the public have open honest communication and discussion about finding a solution focused approach to addressing the way forward for a robust and efficient health service in Grampian.

3. Expectations: how to manage the expectations of the general

population of the future and address the promises of the politicians. Look at embedding self management and investigate new ways of delivery.

DISCUSSION 2 NARRATIVE:

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In the context of the sustainability:


What current practice do we need to keep/ build on and what do we need to stop?

There was a broad range of discussion on the future and how we deliver the same outcomes with fewer resources. The procurement process and productivity were examples used. The Review of Operational Productivity in NHS Providers Interim Report, June 2015 by Lord Carter of Coles, DOH was cited and suggested we could generate ideas from it. A national approach could be taken for many non-clinical services but to be wary it does not stifle innovation and change and reduce patient choice. If a ‘lock down’ was enforced, for example instead of Grampian providing 2 types of hip, Highland and Tayside providing another 2 types of hip, we all provide the same, would this be beneficial to the service, the population and financially. It was noted there is 1 national contract for toilet roll – national approach at this level would be welcomed. Boards should be empowered and supported to create effective and efficient services on their own, where appropriate, but to encourage a regional approach for other services although political interference can disrupt this. It was felt the workforce follow a medical model but need to move towards a more psycho-social model. This requires a strategic change in thinking and approach. Primary care are starting to ‘let go’ of the simple things (signing prescriptions) but this is dependent on a new GP contract. Patients are to take more responsibility towards their care and promote choice, for example can a patient refuse further care, within certain pathways. 3 KEY POINTS:

1. Local/Regional/National services - if services can be identified to deliver the same outcomes but at a reduced cost then this work needs to progress at all levels. Addressing variations across the systems could be a quick win.

2. Workforce – clinicians and professionals should be delivering a realistic health care service. Within the present training programme specialists are rewarded, encouraging reward and the ability to do private practice the balance needs to shift.

3. Person Centred Approach - let patient make choices and offer a variety of pathways and a variety of access points encouraging responsibility but have the technology (tele-health) and infrastructure in place to allow this to happen.

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TABLE NO: 2

FACILITATOR: Mark McEwan

EXECUTIVE LEAD: Malcolm Wright

TABLE MEMBERS: Raymond Bisset Jonathan Passmore Caroline Howarth Amanda Croft Niall Craig Malcolm Metcalfe Mike Adams Mark McEwan

DISCUSSION 1: In the context of the 2020 and the gaps and challenges identified

What examples are

there from elsewhere where elements of the future 2020 system are described and delivered?



NARRATIVE: The group had a wide ranging discussion that focussed on IT, data sharing and coding. These were seen as essential areas of improvement to create the ‘new world’. Current barriers were both technological and cultural. The technology is often available but not adopted or consistently applied. Tayside was highlighted as an area of good practice in relation to harmonising systems. This should be investigated as a matter of priority to see if lessons can be applied in Grampian. On deeper discussion it was agreed that many of the issues are more cultural and within the control of management to positively influence. Key among the approaches required is to increase empowerment of staff to take responsibility / make decisions consistent with the top of their licence. 3 KEY POINTS: 1. IT – the future system is almost predicated on the systems between

sectors and services being compatible and shareable, or ideally being a unified system. The ideal would be single patient record. The challenge facing NHS Grampian is addressing historical, organic, uncoordinated development..

2. DATA Sharing – organisationally we have control over the culture and

risk appetite around date sharing. Scan on demand programme stopped. This is potentially causing misuse of space that could be used for clinical consultation as well as staff time required to retrieve.

3. Coding systems – coding in Scotland is poor. In other health systems were there is a commissioning dynamic and payment is dependent on accurate coding – the information gathered is of higher quality, providing intelligence that facilitates performance management and planning.

DISCUSSION 2


NARRATIVE: Initial discussion explored the concept of realistic medicine. It was agreed that this term is short hand for patients taking more responsibility for their

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health and creating more appropriate access to service that manages increasingly unrealistic expectation. This needs to be applied at all levels in the service from national policy to local service delivery. This will have a positive impact on managing expectations. Managing of expectations, use of available technology, expanding community health and care options to stem flow of activity to secondary care formed the remainder of the discussion. In most cases there was a consensus that we have it within our own control to make changes, cultural, behavioural messages that will increase empowerment of staff were again key. The view that EHealth is a means of supporting service change and should not be a constraining factor was expressed.

3 KEY POINTS:

1. Board level communication strategy required to provide a touchstone for management of external relations. Focus on what we can influence at a local level and be sure to use local staff to convey agreed corporate position. Fewer and ‘smaller’ ( more easily understood) messages to be conveyed.

2. Embrace modern communication for engaging with patients and the

public – currently IT security concerns present barriers to this. Use existing widely available technologies – Skype, facebook, text etc. As with previous discussion much of this is cultural and within the scope of system leaders to change or influence. We use telemedicine when we have to ( e.g. Follow up clinics to Island Boards) but we don’t drive this approach system-wide as much as we should.

3. Develop wider options at community level that reduce the flow of

activity in to secondary care.

4. Use evidence to stop low or no value activity – historically we are poor at this – some good example provided by Orthopaedics in relation to reduction of back surgery procedures.

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TABLE NO: 3

FACILITATOR: Jenny Ingram

EXECUTIVE LEAD: Laura Gray

TABLE MEMBERS: Steve Logan Sharon Duncan Alison Hawkins Alistair Palin David Pfleger Jackie Berry Judith McLenan





NARRATIVE: Discussion focussed on the Healthfit 2020 and if the vision was still current or required revision. It was felt that there should be an evaluation now of what had been achieved in order to plan the key next steps. There was agreement that this needed to be done with a sense of urgency and certainly within the next six months given the discussion re financial position, demographic change, workforce etc. Within this it was felt we needed to be bold and explicit on what we would provide. Discussion centred on elements of services we continue to provide that either other Boards have redesigned or eliminated (e.g. Tayside and Lothian). NHS Grampian should actively seek dialogue now with other Boards who have successfully completed redesign of services and how this was achieved with staff and public engagement. Further discussion centred on decision making and service delivery and the priority around systems/infrastructure to support this. There was a strong feeling that technology and systems communicating seamlessly with each other should be the main focus to support integration. However, it was acknowledged that this is often then given much less of a priority in terms of business case approval, which builds in delays and duplication. THREE KEY POINTS:

1. Systems/Infrastructure. There needs to be agreement on and investment in technology and compatible/unified systems to enable and support care provision. The group felt that any redesign or clinical developments must include and have support for this from the outset otherwise the outcomes identified from implementing the change may not be realised.

2. Clinical Outcomes. There needs to be a focus on clinical outcomes and engagement with services and the public on what NHS Grampian can and cannot provide. To support this there is a need to work with the IJBs to localise the community profile and optimise opportunities to support care delivery that does not necessitate the need for acute secondary care.

3. Out Patient Services. Recognition that we can learn not only from external

sources but how internal service redesign has added value for patients and the service (e.g. Diabetes). There was agreement that there were potentially major gains to be made in a systematic and supported review of out-patient services to reduce unnecessary variation. This would require agreed infrastructure to complete.

DISCUSSION 2

In the context of the

NARRATIVE: Discussion centred on the future and there was agreement that as the IJBs

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sustainability:



evolve it will not be necessary or sustainable to retain 14 Territorial Boards. The group explored the existing discussions that are ongoing with Tayside and Highland and the Islands as well as the North of Scotland Regional Planning work. There is merit in rationalising not only non-clinical services such as payroll but clinical services on a regional basis, which may include closure of sites. There was strong support for continuing to progress this now at pace and not just relying on decisions made centrally. This was seen as key to setting the future direction for the North of Scotland and both setting and managing expectations for patients and the public. Further discussion followed on the expansion of the IJBs and how the lead advocate for patients should sit within this setting. There was agreement that the clinician who cares for the patient most of the time for most of the conditions is the GP and hence developing a system that maintains that Lead advocate/consultant role is key. This will require strong support and leadership across the Board to support this and to address potential professional/cultural/behavioural boundaries that exist, in places between primary and secondary care. We have examples within Grampian already that adopt a “virtual ward” approach when a patient is in secondary care. The lead consultant role remains in primary care and this supports person-centred care by facilitating a “pull” rather than “push” system for the patient. THREE KEY POINTS: 1. Regional Working. This was seen as both urgent and important to progress

in order to provide sustainability of services, stabilise recruitment and retention and maintain quality of service delivery for the patients of the North of Scotland.

2. Solution Focussed. This was seen at two different levels;

Local Service Redesign: Linked to the previous discussion on focus on outcomes it was agreed that data should be utilised to compare practice locally between clinicians as well as with services across Scotland and beyond. The Board should lead and support work with those services where the data shows the biggest gains are to be made from redesign.

Radical: The growth and development of the IJBs offers opportunities to redesign services and therefore potentially close sites and rationalise services. Mental Health was given as an example where redesign and adoption of other models of care (e.g. Edinburgh City) could in theory allow for closure of RCH and a move onto the ARI site. It was agreed this type of approach may not be viable but at least should be discussed as options for a sustainable future.

3. Lead Advocate. NHS Grampian needs to support work in partnership with

the IJBs to explicitly develop a model where the community where the patient is part of and cared for has the lead role for the patient at all times.

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TABLE NO: 4

FACILITATOR: Anne Ross

EXECUTIVE LEAD: Annie Ingram

TABLE MEMBERS: Mike Greaves Eric Sinclair Jenny McNicol Rebecca Riddel Julie Fletcher Jillian Evans Alan Gray

DISCUSSION 1





NARRATIVE: The group had a wide ranging discussion which focused on utilising technology, the changing workforce and the need to build community resilience to keep people well at home. It was noted that there had been some progress with the electronic patient record in Scotland. Learning from the situation in England it was acknowledged that a national solution is not necessarily the only solution. We need to be better at using existing systems and devices differently. Potential for App development. We should be looking further afield to Canada and Australia with rural populations to see how they are making progress. There is evidence that Hospital at Home can help people stay at home. The individual is supported by a multidisciplinary team. The challenge is doing this at scale. Risk appetite needs to be challenged, particularly relating to discharge and staying at home in less than ideal circumstances. This requires to be addressed through clinical training but also with wider societal change. Workforce needs to be flexible and used appropriately. ‘Drs doing what only Drs can do’ but recognising need to ensure jobs remain varied and interesting otherwise recruitment and retention would worsen. What more can we do? Need to build community resilience to keep people healthy. Focus on the younger population for benefit as they get older. Need to manage unrealistic expectations (the L’Oreal I’m worth it ideal). Realistic medicine (term not liked) - over investigation and over treatment as risk averse. Staff must challenge the behaviours of others and ‘walk the talk’. 3 KEY POINTS: All underpinned by the need to have transparent reconsideration of risk appetite:

1. Build community resilience to keep well. Expose where expectations are too high. Opportunity to do more with staff – health promoting health service.

2. Develop workforce and ensure scarce skills utilised appropriately 3. Use technology better. Don’t wait for national solutions. See how it

is done elsewhere eg Canada, Australia

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DISCUSSION 2




NARRATIVE: Answer to first question is generally ‘dont know’. What can we build on and stop? There needs to be transparent and difficult conversation with the public about priorities. Recognising however that this may not give us the answer we would wish. Actually rationing/stopping provision of a service or drug requires a regional or national approach. A Board acting on its own unlikely to be successful. Examples included bariatric surgery, pharmacy towards end of life, slowing down elective activity. Need to boost life skills and parenting skills. Those with chaotic lifestyles consume a lot of resource – health, social work, police. Population based approach to lifestyle and need to start early. Good example of population approach to diet in Finland. Have to use legislation as evidence suggests this is what works eg seatbelts, smoking, plastic bags. Re-introduce food and nutrition classes in schools. Consider sugar tax. 3 KEY POINTS:

1. Undertake research/review as we don’t know answer to question 1 2. Use the law to support change 3. Population based approaches to lifestyle, starting early

TABLE NO: 5

FACILITATOR: Kate Livock (scribe)

EXECUTIVE LEAD: Susan Webb

TABLE MEMBERS: Christine Lester Terry Mackie Shona Strachan Rick Herriot Helen Moffat Fiona Mitchelhill Stephen Lynch

DISCUSSION 1



NARRATIVE: The group’s discussion commenced by highlighting concerns that the existing 2020 vision should not be rebadged as the 2030 vision. The healthcare climate had changed so significantly this would be a grave mistake. Managing patient expectations was identified as a challenge and it was suggested that the board had a role in trying to influence the politicians to refrain from raising the public’s expectations of future healthcare. The discussion then focused on the key role of IT technology across many aspects of healthcare in NHS G, supporting integration, data sharing to improve patient journeys, reducing social isolation and supporting self care/self management by brining the benefits of psycho/social support to

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patients in this setting. Integration of services and teams was identified as the sustainable way forward with the Primary care Hub model at “New Dyce” quoted as a good example. Observed that this had arisen “out of a crisis” and that it was important to develop future integrated models of healthcare without the crisis. 3 KEY POINTS:

1. The use of technology to reduce social isolation and to increase self care/self management support is essential, taking the lead from existing services such as NHS 24 who utilise IT in such as way.

2. Managing the healthcare expectations of the patients and the public

in an open and transparent manner is vital to get engagement in self care and self management.

3. Integration/co-location of services is the model of the future and a

cultural shift amongst staff was essential for this to be successful.

DISCUSSION 2




NARRATIVE: Initial discussion in response to Malcolm Metcalf’s presentation considered that small changes over a wide range of services/settings could increase efficiency and make savings and should not be dismissed. The group identified a number of areas from which lessons could be learnt to support sustainable, efficient and responsive e.g Primary care’s management of patients without always conducting a face to face consultation could influence new to return ratio It was felt that sustainable and efficient services required a strong infrastructure. The group felt strongly that increased IT investment was required to support clinical services and that existing barriers in relation to the use of IT needed to be challenged e.g texting patients, data sharing. It was acknowledged that expenditure on IT might not be considered a high priority by the public and patients. The ongoing erosion of infrastructure services (IT, HR, Estates etc) was felt to hinder new developments and HR was cited as an example of when delays in processes create inefficiency e.g the recruitment process. 3 KEY POINTS: 1. The importance of streamlining the information journey within the NHS and across private healthcare providers. With the future model of integrated teams information sharing will be key to supporting patients. 2. Need to change our current NHS behaviours which engender dependant behaviours in our patients. The future voting population (15, 16 & 17 yr olds)

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are considered open to change and we should be having open and transparent conversation with them at this stage about the future availability of healthcare 3. We need to protect our infrastructure e.g estates/HR/IT. It is essential to supporting the efficiency of services.

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DISCUSSION 2: IN THE CONTEXT OF SUSTAINABILITY

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Summary

As can be seen from above, the Board Seminar events continue to attract enthusiastic participation and a true link between management and

clinical leaders in developing coordinated Board thinking and direction.

Discussion 1 focussed on the 2020 vision and identification of gaps and challenges. Strong themes to emerge across all discussion tables

related to use of technology, aspirations to harmonise systems in the quest for single patient record and improved coding practices to improve

the quality of health intelligence. Added to this was a desire for better data sharing protocols –a developing consensus that we could use

technology to improve service if we committed to these themes on a whole-system basis. This inward looking discussion was balanced with

some outward looking solutions around improved engagement better manage public expectations as well as streamline service, e.g. reduce

inappropriate follow up hospital appointments.

Discussion 2 developed some of the themes discussed above and usefully pointed to examples of good practice both home (Grampian,

Tayside, Lothian) and abroad (Canada, Australia).

A strong theme that emerged in this discussion session was around patient centred approaches and emerging concepts of realistic medicine.

Key to this is the management of expectations through improved community engagement. Key to this will be empowering staff to work at ‘top of

licence’ and developing of relationships at local levels through IJBs. This engagement process should at its heart promote population based

public health approached. Again technology and communications emerged in some tables and this was as much to do with existing widely held

technologies and creating governance that allows the safe and efficient use of smart phones, tablets a video conferencing as it is to do with

cutting edge medical technologies.

Next Steps

As the Board Seminar events continue it is interesting to note clear communication of priorities being expressed by system leaders from both

management and clinical colleagues. These provide a mandate that will inform future direction of travel.

feedback report - nhs grampian - caring - … report page 2 of 16 board seminar on sustainability of...

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