NHS Tayside Assurance and Advisory Group: staging report of findings and recommendations
Report prepared by Ernst and Young for the NHS Tayside Assurance and Advisory Group, reviewing the deliverability of NHS Tayside's five-year transformation programme.
10. Appendix 2: Transformation Progress
Significant work has already been undertaken by NHS Tayside in partnership, to progress transformational change, recognising the extent of the challenges involved. In particular changes in the following are underway or planned:
Mental Health Services: A formal three month public consultation is due to commence in July 2017. The proposal involves a move from three sites to one for general adult psychiatry services and from two sites to one for learning disability services.
The preferred option for mental health and learning disability adult inpatient services will help provide a safe and sustainable service for the future, with safe inpatient staffing levels ensuring a sufficient medical, nursing, allied health professional ( AHP) and psychology workforce which can share learning and experiences across specialities. The option also makes the most efficient use of workforce and would maximise the number of posts available for transfer to local community services.
The proposed model will allow remodelling and reinvestment in community workforce to provide services to the majority of the population and prevent unnecessary admissions for both General Adult Psychiatry and Learning Disability services. By shifting the balance of care and providing centralised specialist services, reduction in variation can be helped.
The preferred option would provide a reduction in supplementary staffing costs, as well as potential income and recurring savings from the disposal of surplus property with significant running and backlog maintenance costs.
Shaping Surgical Services: A formal three month public consultation is due to commence in July 2017. The model proposed supports a move from two emergency surgical receiving sites to one, at Ninewells Hospital, Dundee and the transfer of planned (elective) major surgery to Perth Royal Infirmary.
Maintaining and improving safe, sustainable and high quality unscheduled care is the primary goal driving the Shaping Surgical Services work and the proposed reconfiguration of hospital services.
The proposal, which would strengthen the surgical model for the delivery of unscheduled and elective care across NHS Tayside, would deliver an opportunity to increase consultant numbers and theatre availability by relocating unscheduled surgery on a single site, resulting in improved standards and speed of care, a reduction in cancellation of planned operations for patients, and an expansion of unscheduled care at Ninewells Hospital.
This proposal will result in ceased used of mobile theatres, and is estimated to significantly reduced independent sector and agency staff costs.
Older People's Services: The introduction of an enhanced community service model across Tayside for older people has demonstrated a reduction in the number of older people being admitted to hospital or experiencing delayed discharge from hospital. The model is fully established in Dundee and Angus and is now being implemented in Perth and Kinross. On-going deployment of this model has resulted in a reduction in the requirement for inpatient beds on a number of sites. Front-line clinical leadership with administrative support has been a prominent and essential feature of this model.
Maternity Services: The new model of maternity care introduced in quarter 3 of 2016 in Angus, offers women a choice to give birth locally in the Arbroath Community Midwifery Unit or at home. This has led to an increased number of home births and positive feedback from the women and their partners. Further work is progressing with the Angus Health and Social Care partnership to move from two Community Maternity Units to one.
Prescribing: Given the key overspend in primary care spending, NHS Tayside has undertaken considerable efforts to address this issue. This was set out in a paper considered at the Board meeting on 1 December 2016:
"The financial environment within Tayside's prescribing budgets remains a challenging one; however it is important that we do not lose sight of the clinical excellence delivered to our local populations. NHS Tayside has embarked on a clinically based, clinically focussed programme based on examining variation; polypharmacy; waste, safety and harm; and formulary compliance. This has been supported by central clinical guidance, a practice visiting programme and local Medicine Management Group ( MMG) led initiatives within practices supported by local, Tayside and national prescribing information. Despite a limited degree of success in these programmes the prescribing budget remains significantly overspent.
Five key priorities have been identified to further address the efficiency opportunities within the FHS prescribing budget. These are: quality prescribing visits (initially targeting practices at greatest variance to prescribing spend); projects aimed at specific drugs, rosuvastatin, lidocaine plaster, pregabalin; reviewing the formulary.
In addition we recognise the importance to inform our local communities regarding their role and responsibility in the prevention of medicines waste and how we can manage expectations round ensuring adequate stocks of medicines during holiday periods. To deliver on this agenda weekly meetings will be held, to monitor progress and risk. However, without a joint approach from all members of the multidisciplinary team, where all members contribute to the same aim of delivering the best possible healthcare, at the lowest possible cost, delivering the best experience for our patients - we will fail to maximise opportunities. Teams must be aware of the need to comply with clinical pathways that have been developed within Tayside.
It is critical to accept that our costs in many areas are higher compared to other boards because we treat more patients, our clinical workforce are proactive and strive to deliver the best possible care for our communities. This is supported by NSS data [data provided by Information Services Division, National Services Scotland, ISD NSS] that describes our cost per treated patient.
However it is also recognised that there are a number of areas of unexplained or unwanted variation which this accelerated programme will seek to address."
The full Board paper 133/2016 is available on the NHS Tayside website:
NHS Tayside has recently sought and received three external reviews on optimal primary care prescribing practice. A new Drug Prescribing Formulary was introduced throughout NHS Tayside in April 2017. As yet, it is too early to assess the impact of this new formulary on prescribing activities and outcomes.
Realistic Medicine Framework
NHS Tayside is progressing a Realistic Medicine Framework linked to clinical and medical leadership plans. This builds on care pathway work already underway in chest pain, paediatric eczema, upper GI endoscopy and ophthalmology.
Review of NHS Tayside Board's Committees and Executive Groups
Restructuring of standing committees and executive groups are presently in train. This restructuring seeks to provide greater clarity on strategic and operational business, performance management, decision-making and to develop a framework for public performance reporting.
Tailored Programme Support - NHS National Services Scotland ( NSS)
During 2015/16 NHS Tayside established the Transformation Programme with the aims of ensuring financial balance, improving patient outcomes and cost- effective service delivery. NHS Tayside recognised the requirement for robust programme leadership, governance and accountability. As a result, a request was made to NSS for external Programme Director leadership and subject expertise to support the development and adoption of the transformation plan. The purpose of this approach was to enhance transformation governance and leadership, to create an external 'critical friend' approach and to establish an independent feedback mechanism to the Transformation Programme Board. NSS support activity commenced in February 2016, initially focusing on leadership around the programme approach and structure, with specific requests relating to health data and analytics.
NHS Tayside already had in place an established Project Management Office ( PMO) which follows a tailored (P3M3) based methodology recognising the requirement for Portfolio, Programme and Project management.
NSS support has included a maturity assessment of the local PMO model within NHS Tayside and focused on wider support including data analysis and insight, advice and support in areas such as business planning, enhanced programme management, realistic medicine, pharmacy and prescribing. The support was facilitated by having NSS staff embedded onsite within NHS Tayside as well as utilising the wider resource on a remote basis. NHS Tayside has valued the tailored programme support from NSS, which is on-going.
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