Healthcare Science National Delivery Plan for Healthcare Science Professionals in Scotland 2014-2017

2. LEADERSHIP FOR CHANGE

Transformational change requires transformational leadership. HCS leads' influence is already high in a number of NHS boards, but not all are sufficiently well positioned to affect local decision-making or influence planning decisions. Where HCS leads exist, their professional role is not uniformly recognised as legitimate. Their visibility and accountability for delivery of organisational priorities needs to be strengthened through a new and innovative approach to leadership that supports them to exert influence across boards, applying their resources and abilities to help meet local priorities and performance targets and the ambitions of the Quality Strategy.

Many of the proposed recommendations outlined below rely heavily on HCSs leading improvements. It is essential that leadership development opportunities for HCSs continue to expand, building capacity across NHSScotland.

2.1 Leadership in service design

HCS staff work across a wide range of services that are often loosely described as 'demand-led'. The implication is that the primary drivers for their services are external, and their role is to respond to and support developments elsewhere.

A more efficient approach is to include HCS delivery at the heart of service design centred on the patient. This has traditionally been a difficult process, as clinical services often rely on diverse HCS input from physical, physiological and life sciences that are commonly situated in different parts of the management structure and which contribute to different stages of the patient pathway. Central, strategic, professional leadership should ensure that comprehensive HCS expertise is offered at an early stage in service design/redesign.

NHS boards are charged with providing health services for their geographical area. There has long been a recognition that some HCS services are better served by supra-regional or national network/consortia arrangements that offer the potential for economies of scale and ensuring equality of provision across the country. HCSs have been instrumental in building on existing informal professional networks to establish robust national networks that drive service improvement.

The national consortia for cervical cytology screening provide an example of what can be achieved through this collaborative approach (Box 1).

Box 1. Service redesign: cervical cytology

Cervical cytology has been going through structural change. Recognition that the NHS board-based model for ensuring a HPV (Human Papilloma Virus)-vaccinated population and greater influence of high-throughput molecular testing methodologies for HPV may be difficult to sustain prompted a review and the development of a new model.

Two consortia, East and West of Scotland, were established. New hub-andspoke mechanisms for automated imaging have been developed in the consortia and a multiple health board managed service contract that standardises technology across Scotland has delivered savings to all contracted boards by standardising price, realising VAT benefits and producing increased productivity through the introduction of imaging technology.

The model has been supported by a pan-Scotland IT system, the Scottish Cervical Cytology Results System (SCCRS), for call, recall, electronic laboratory requesting and reporting. This has facilitated a standardised methodology across Scotland and enabled the seamless transfer of regional work from boards facing capacity pressures to fellow boards in other regions.

A changing staff skill-set requirement and reduced numbers of staff will be necessary as these testing and technology changes take effect, which will probably render some board laboratories difficult to sustain in the longer term. The new consortia model will help departments to support safe and sustainable services through a period of significant change.

Molecular genetics and cytogenetics is another area in which services have come together to offer a comprehensive unified service across Scotland. While laboratories in Grampian, Tayside, Lothian and Greater Glasgow and Clyde are managed by their local NHS boards, they collaborate over shared training resources and have adopted an approach to maximise efficiency across the country. The more recent development of the Molecular Pathology Network has built on the strengths of the Scottish Pathology Network (Span) and the Genetics Consortium to develop an integrated approach to the delivery of molecular pathology testing that is the first of its kind in the UK.

Integrated physiology services

Physiology services are often spread across several departments, hindering the development of integrated care pathways. NHS Ayrshire & Arran houses a joint clinical physiology service in one department. It offers cardiology, vascular, respiratory and neurophysiology services, allowing greater freedom to cross-refer and reducing inefficiencies and unnecessary patient journeys.

Physiology services in smaller boards are supported by regional centres in spoke-and-hub arrangements, such as specialist advice and tests in neurophysiology and sleep physiology being available in Glasgow Southern General Hospital or the Royal Infirmary of Edinburgh (sleep physiology) and the Western General Hospital, Edinburgh (neurophysiology). Electronic traces in neurophysiology are checked, approved and reported or further opinion sought. This allows smaller boards to maintain a local service, with the benefit of professional-to-professional specialist opinion just a phone call or email away. Agreements are such that smaller boards have access to on-call systems in larger boards for 24-hour support.

Clinical perfusion scientists based in the Golden Jubilee National Hospital, Royal Infirmary of Edinburgh and Aberdeen Royal Infirmary provide cardiac bypass services, specialist procedures such as patent foramen ovale and atrial-septal defect closures and new services such as extracorporeal membrane oxygenation and transcatheter aortic valve implantation. They also provide national transplantation, organ-retrieval and vascular services, allowing groups of specialist staff to be in the right place at the right time.

Physical sciences such as rehabilitation engineering services operate in regional consortia to deliver wheelchair and bioengineering services and work to national quality ambitions. There are also national training schemes for medical physics and engineering in which supernumerary trainees are placed in various centres for service-based learning.

2.2 Leadership in quality

HCSs have much to offer health boards through their long-established use of quality-assurance approaches. Laboratory services have a wealth of experience in detailed benchmarking and external accreditation of laboratory services through Clinical Pathology Accreditation (UK) (CPA), United Kingdom Accreditation Service (UKAS) and the Medicines and Healthcare Products Regulatory Agency (MHRA), which have been powerful drivers of quality improvement in laboratories over the last 20 years. Accreditation is now available for physiology services and is under development for physical sciences. While the cost/benefit of accreditation services will have to be further evaluated, they provide a framework of standards by which services can be delivered to improve patient care.

The focus on quality of services has been renewed following the Francis Inquiry report. HCS expertise in quality management needs to be shared not only among the HCS community, but also with wider healthcare provision. There is nevertheless tremendous variation in the quality support measures in place subject to where the patient links in to the healthcare system. Quality initiatives should cover the whole patient pathway and deliver a coherent, seamless and high-quality experience. HCSs are well placed to develop and lead a risk-based, proportionate and reliable system of clinical governance focusing on measurement and testing in healthcare services. They should be encouraged to identify, support and, where appropriate, lead implementation of activities to improve service quality, including sustainable and robust mechanisms for sharing good practice and learning.

With this robust platform to build on, HCS now need to develop additional skills and leadership within the discipline of improvement science to fully exploit their potential in delivering safe, effective and multi-professional clinical care.

Our questions are:

How can HCSs best influence the improvement of patient care, utilising the quality tools at their disposal?

Are the right systems in place across HCS delivery?

If not, what can be done to improve the adoption of quality systems and reduce variation in their use throughout the patient pathway continuum?

2.3 Leadership in research and innovation

Innovation is at the core of scientific training and experience. The drive towards automation of laboratory testing in biochemistry and haematology and the development of strategies for personalised medicine (based on underlying genetic variation) are clear examples. This continues at pace: developments in microbiology are not simply automating existing tests, but moving far more towards molecular-typing strategies.

The Scottish Life Sciences Strategy (2020 Vision) observed:

Our vision is of a Scotland where:

• our National Health Service (NHS) moves centre stage as a key customer for Scottish Life Sciences businesses and a pivotal stimulator of innovative products and services
• there is a more positive appreciation of the opportunities to participate in trials of the most advanced healthcare products, and the associated economic, employment and investment benefits of Scotland’s participation
• our people increasingly benefit from the early adoption of innovations in diagnosis and treatment, contributing to a better quality of life and longer life expectancy.

Innovation around physics and physiology

QuickSIN (speech-in-noise) testing is not routine but is regularly being used in audiology to provide extra insights into what might be the most personally appropriate amplification strategy and influence better hearing-aid decisions for clinicians, improving early uptake of hearing aid use.

Physical sciences and engineering are involved in innovation in areas such as upper limb prosthetics, medical optics and scanning for retinopathy. The iLimb hand serves as an example of leadership in healthcare science from technological and business perspectives. The iLimb prosthetic hand is an innovative and world-leading product developed in Edinburgh by an NHS spin-off rehabilitation engineering company founded in 2003. The prosthesis has been available in NHSScotland as of 1 April 2014 as part of the 'State of the Art' prosthetics development programme, the creation of which was led by a HCS, demonstrating HCSs' strong commitment to delivering innovation.

HCSs have a significant leadership role to play in delivering innovation. Their expertise in innovation can bring a fresh perspective to the Scottish life science agenda. They need to be working alongside medical and academic colleagues as equal partners, influencing and bringing new thinking and solutions to the challenges of demographic change, sustainability and affordability of services and to the delivery of more innovative solutions.

Our question is - how might we strengthen HCS leadership at strategic and operational levels to support innovation and promote the added value that HCSs can bring to current challenges and priorities?

Our proposals are set out below. Are these the right actions? What else could we do?

2.4 Proposals

• Each NHS board shall appoint a HCS professional lead and establish a reporting structure to an executive board member, who should encourage HCS leads to adopt corporate leadership roles in clinical engagement, inter-professional working and local planning processes.
• Each NHS board should seek to strengthen and support the ongoing work of local HCS forums. These will work with the HCS lead to improve service visibility and cohesion, ensure inclusion in board-level decision-making and develop HCS services to meet local users' needs.
• HCS leads will consider how to strengthen HCS leadership within and across agencies, identifying HCS line managers' development, training and support needs and promoting the values and behaviours expected in relation to the Staff Governance Standard and quality ambitions.
• National leads for each of the three strands of HCS will work with service managers, HCS leads in each board and existing diagnostic networks to identify and drive improvement, publicise areas of best practice and encourage greater use of supra-regional/national networks.
• HCS leads in physiological and physical sciences will work with networks and Healthcare Improvement Scotland (HIS) to establish working groups to agree and drive service standards and mechanisms against which services can be audited.
• Each NHS board will ensure that HCS quality managers' expertise is utilised in driving wider safety and quality improvement activities across the organisation.
• The national lead HCSs in each stream of HCS will lead work on influencing the research and innovation agenda, establishing clear links with the National research and development strategy and supporting the HCS workforce in developing partnerships for innovation.
• HCS leads in NHS boards will drive improvement locally, identifying improvement champions and strengthening data collection to demonstrate outcomes and service impacts.
• The CHPO will work with NES and HIS to establish and train a cadre of improvement leads across HCS.
• HCS leads (and the national lead) will work collaboratively with senior management to develop integrated models of service provision in physical sciences and engineering, covering areas such as medical equipment management. The full potential of the clinical technology workforce will be scoped and utilised to improve the quality and coherence of services.
• HCS leads will work collaboratively with other clinical leaders and managers to explore a more integrated approach to service leadership and delivery of routine physiological measurements in physiological sciences, creating more sustainable and coherent services for the future.