NHS Tayside Assurance and Advisory Group: staging report of findings and recommendations

6. Strategic and Service Planning

In this section, we look at the planning framework that has been put in place to underpin the programme of service transformation which NHS Tayside has identified as a crucial and integral part of its Five Year Plan.

6.1 Key Points

• The overall framework for strategic and medium term service planning is not yet well-developed with a lack of clarity around how strategic priorities will translate into an integrated and coherent programme of change. The strategic priorities also require to be set within a realistic assessment of the ambition and level of service that can be delivered within the resources available to NHS Tayside.

• The plans require to demonstrate that the changes to current service models can be delivered in a financially sustainable manner and address those areas where the operating cost model has been historically at variance with comparative benchmarks.

• Existing Operational Plans supporting the Transformation Programme are in progress but are not yet supported by specific cost improvement plans or detailed action plans. They require further work to ensure effective delivery against financial efficiencies targets as set out in the six work streams. We are therefore unable to provide assurance on their capacity to drive delivery of the savings plans over the five year period of the financial plan.

• There is limited evidence within the Operational Plans that workstream leads can be held accountable against financial and efficiency opportunities due to the lack of detailed financial information relating to these elements of the programme of work. NHS Tayside and the Transformation Board recognise that improvements need to be made to enable more data driven strategic planning to underpin transformation across services, at the pace required.

6.2 Strategic Planning in Tayside

In June 2015, NHS Tayside approved a draft clinical services strategy entitled 'Reshaping Clinical Services for the Future', which set out, at a high level the strategic context and some of the key drivers for change in the shape and delivery of board services over the coming years. These include demographic change and an aging population; the increasing emphasis on prevention and the expectation of a shift in the balance of care from acute towards primary care, with potential implications for the nature of the patients seeking treatment in the acute sector.

However, the case for change set out in the document requires further development to highlight the scale of the current and future challenges, set in the context of the key factors and pressures which have led to NHS Tayside current financial position.

While the strategy recognises the need to change the way services are delivered, this would be strengthened by the inclusion of additional evidence such as the benchmarking information out in the previous sections of this report, to underscore the scale of the challenge and the transformational approach required to meet it .

The NHS Tayside Board has subsequently approved a number of service-specific strategies relating to Older People's Services, Primary Care, Mental Health, Surgical Services, Maternity Services, Paediatric Services and Cancer. However, these now require to be situated firmly within a single shared vision and accompanied by a robust monitoring and benefits realisation framework to drive and demonstrate real-time progress.

This imperative is recognised by NHS Tayside and proposals are under development to produce a comprehensive Integrated Clinical Strategy by the end of December 2017 for consideration by NHS Tayside's board and its partner HSCPs.

6.3 Transformation Programme

NHS Tayside's first Five Year Transformation Programme was initiated in 2015 to address the need to transform services in order to maintain quality of care delivery and performance while returning to sustainable recurring financial balance. A Transformation Board, headed up by the Board Chairman, was set up in October 2015 to provide oversight and governance for the management of the Programme.

The work associated with the Transformation Programme is assigned to six separate workstreams, encompassing:

1. Realistic Medicine;
2. Repatriation;
3. Workforce and Care Assurance;
4. Facilities and Estates;
5. Property; and
6. Better Buying and Procurement.

Alongside these workstreams the Transformation Programme includes a programme of work to deliver service redesign across a number of the areas outlined in the previous section: primary care, shaping surgical services, children and young people, mental health and learning disabilities, care for older people and maternity services. Presently, these redesign initiatives are at differing levels of development and it is difficult to identify clear line of sight between the existing draft Clinical Strategy or the above workstreams which underpin the projected savings programme for the current year, 2017/18.

A review of the governance arrangements in respect of the Transformation Programme Board was undertaken by NHS Tayside's internal auditors who reported their findings in December 2016. Whilst categorising the overall governance arrangements as 'Good', the Chief Internal Auditor highlighted that there were risks relating to workstreams failing to deliver anticipated targets within the required timescales.

6.4 Operational Delivery Service Plans

The one year plan for 2017/18 includes a number of service-level operational delivery plans. Ernst and Young carried out a review of these plans in order to provide a realistic and independent appraisal of the level of delivery risk present in NHS Tayside's savings plans for 2017/18.

The plans were assessed against seven key areas ^[30] . A summary of the risk assessment, categorised as Red, Amber or Green ( RAG status), is provided below:

Criteria	RAG status	Comments
Project Brief	Amber	The majority of the plans do include a high level plan with broad financial outcomes, but lack more specific and tangible detail such as clearly defined financial and operational outcomes. Cancer and Primary Care do not currently include any financial outcome data.
Lead Responsibility	Amber	The majority of the operational delivery plans identify an appropriate lead individual, However, there is not consistent evidence that all the necessary individuals are involved in supporting the delivery of the plan. Particular areas such as Primary Care, Medicines Management and Unscheduled Care will require the involvement and co-operation of key stakeholders such as GPs, patients and the wider public, and there is insufficient evidence of appropriate engagement plans to support and enable this to happen.
Plans and Milestones	Red	It appears, at present, that none of the operational delivery plans reviewed contain the appropriate degree of project planning (project brief, milestones with timescales, actions with identified owners, quality impact assessments, etc.)
Financial and activity calculation	Red	Whilst the majority of the operational delivery plans reviewed include some level of financial outcome, none of them provide evidence that all elements of the savings have been adequately identified and incorporated into the calculation, eg, Planned Care identifies £11m of savings opportunities but does not break these down by the 30 underpinning components.
Financial phasing	Red	Two of the plans do not include any financial savings information as referenced earlier. None of the remaining eight plans provide sufficient information on the financial savings, phased according to timing of plans and milestones.
Risk and mitigation	Red	Many of the operational delivery plans do identify specific risks, eg, Planned Care cites challenges with recruitment and retention of consultants. However, it appears that to date, none of the plans contain evidence that a comprehensive risk assessment has been conducted and appropriate mitigating plans have been identified.
Alignment to the financial plan	Red	There is insufficient clarity of the alignment between each of the detailed components within the operational delivery plans and the cost reductions initiative file which contains the complete breakdown of the £45.8m savings plan for 2017/18.

Ernst and Young concluded that the operational delivery plans do not currently provide a sufficient level of detail to provide assurance of their ability to deliver the savings plans for 2017/18. Within their report, Ernst and Young set out the steps that would be required to address each of the key areas for improvement highlighted above. A summary is set out in the following table:

Criteria	Recommended next steps
Project Brief	Operational plans would benefit from clear plans with detailed financial and operational outcomes and metrics
Lead Responsibility	Deliverability will be enhanced by structured and resourced delivery teams Broader engagement across services and with internal and external stakeholders, with evidence of sign-off of plans for some of the more cross-cutting plan areas will be essential
Plans and Milestones	Evidence based project plans, to include Project Initiation Documentation, milestones, timescales and management of risk, quality impact assessments are rapidly needed to increase confidence in delivery
Financial and activity calculation	Robust and adequately detailed financial savings need to be developed for each area within the plans. These need to be measured and tracked using a cohesive benefits realisation framework
Financial phasing	The financial savings need to be phased against the milestones within the plans as the plans are developed to the next level of detail
Risk and mitigation	The risks associated with delivery should be proactively assessed and a robust process for monitoring and mitigating the identified risks should be introduced where this does not exist already
Alignment to the financial plan	Operational delivery plans, and the detailed components and savings plans within them should align to the overall NHS Tayside's savings plan, providing the operational delivery vehicle for the savings.

In addition to requiring NHS Tayside to work in close partnership with the HSCPs who have delegated powers in many of these areas, effective implementation of these will also be dependent upon the engagement, cooperation and involvement of key stakeholders including GPs and other clinicians, the broader health and social care workforce, as well as the people of Tayside. At this stage, the draft plans do not set out the processes and timescales for taking forward and supporting this critical programme of engagement.

6.5 Business Intelligence

Another aspect of the service planning framework examined by Ernst and Young was the extent to which the plans make best use of the available comparator datasets or benchmarking information to support the identification of opportunities for delivery of savings.

The review identified a range of national and local benchmarking and performance databases which are readily available to NHS Tayside In addition, NHS Tayside has been in receipt of support from NHS National Services Scotland ( NSS) since February 2016 which has included support around benchmarking and future use of financial benchmarking. The benchmarks provide some useful information and areas for further exploration, with tools such as NSS Discovery able to provide data in support of financial opportunities. This is an area being developed by the Transformation Board of NHS Tayside.

The Ernst and Young review, commissioned by the Scottish Government, concluded good use is being made of some of the more mature benchmarking mechanisms, but there are a number of gaps and areas for further development.