NHS Tayside Assurance and Advisory Group: third progress report

Annex A: Recommendations from AAG Staging Report, June 2017

Actions for the NHS Tayside Senior Executive Team

1. We recommend that NHS Tayside should take urgent and robust action in order to maximise the likelihood of achieving the planned in-year savings and delivery of NHS Tayside's projected financial outturn for 2017/18.

Detailed action plans must have support from key stakeholders and include anticipated financial impact, identified timetables and milestones. There should be clear trigger points for escalation to ensure swift action when delivery is found to be at risk.

2. Over the next three months, NHS Tayside should subject its financial planning framework to rigorous and comprehensive review. This should help to ensure that projections and targets for future years are based on a thorough service by service understanding of cost drivers, risks and opportunities.

3. Over the next six months, NHS Tayside should continue to work with its partners to agree the content and a realistic timeline for completion of the Integrated Clinical Strategy, already in progress. We would expect that the completed Integrated Clinical Strategy would set out a comprehensive and evidence-based case for transformational change. This would build upon the HSCPs' strategic plans for social care, primary healthcare and unscheduled hospital care, taking account of public health imperatives. It should provide a clear strategic direction for acute and community healthcare in Tayside, including the development of Regional Plans.

The Integrated Clinical Strategy should take full account of present and future challenges, including those set out in the National Clinical Strategy, Realistic Medicine and the Health and Social Care Delivery Plan. It should provide concrete and detailed options for long term strategic positioning of NHS Tayside's role within a local and regional setting. We would encourage NHS Tayside to accelerate its work together with HSCPs, Local Authorities, the Third Sector, Universities and other partners.

4. NHS Tayside should undertake an early and comprehensive review of staffing levels across all services and sites, including those delegated to or utilised by HSCPs. This review should aim to clarify key drivers of NHS Tayside's workforce levels compared to peer Boards and to identify safe options for bringing redesigned services and sites within available resources.

5. In relation to service development, the clear focus on optimal drug prescribing and wastage minimisation should continue unabated.

6. Further and appropriate delegation of decision-making to managers and staff at operational level is required in order to ensure that executive director level capacity is released for strategic development and transformation of services. Actions for the NHS Tayside Board

7. In order to continue to ensure safe and effective services for the people of Tayside in a challenging and changing environment, the Board must ensure early, meaningful and sustained engagement in partnership with its staff, its stakeholders and moreover the public and political representatives.

8. The Board should build on current restructuring of the senior executive team and recruitment of non-executive members, addressing skill-mix gaps, particularly for effective strategic planning and oversight. It should maximise opportunities for induction and development of non-executive members to ensure robust and effective governance and scrutiny of the executive function of the Board.

9. The Board should ensure that the actions [Actions 1-6] recommended for the senior executive team are rigorously scrutinised and governed to ensure effective and timely delivery. Restructuring of its financial framework control systems must ensure that budgetary control is assured for all its functions (see Action 2 above). In particular, leadership and continuous scrutiny of a very high order will be required for all aspects of strategic planning to deliver sustainable transformation over the next five years.

10. The Board must continue to foster and enable leadership development at all levels. As NHS Tayside moves forward, strong clinical leadership will be essential to realise the ambitions of the Chief Medical Officer's Report on Realistic Medicine and the National Clinical Strategy.

Actions for Scottish Government

11. The Scottish Government should ensure that necessary skills, expertise and support are swiftly made available for NHS Tayside in order to address its significant and longstanding challenges. While assisting the delivery of planned short term in-year savings and projected financial outturn for 2017/18, this support should primarily focus on delivering effective transformational change, including an in-depth comprehensive review of existing plans to return NHS Tayside to sustainable financial balance.

12. Implementation of the recommendations in this report should be closely monitored, in order to realise timely and sustainable transformational change in Tayside.

13. In light of our findings, the Scottish Government should consider the potential impact on NHS Tayside of being required to repay the £33.2m of accumulated financial support which is still outstanding and note the potential need to provide further financial support in future years.

14. Learning opportunities arising from the experience of NHS Tayside should be assimilated for the wider benefit of NHS Scotland. This includes the role and contribution of national services support, on the basis of a 'Once for Scotland' approach - as outlined in the recent Health and Social Care Delivery Plan.

AAG Supplementary Recommendations - January 2018 Report

NHS Tayside:

In addition to continuing to implement our ten Staging Report Key Recommendations for NHS Tayside, we offer the following summary observations and ancillary recommendations for consideration:

• NHS Tayside has continued to make progress over the period September to December 2017.
• We suggest that there is much significant work still to be done. Several key projects are now at a crucial point and it is vital that NHS Tayside does not lose the momentum which it has built up over past six months.
• NHS Tayside must ensure it achieves the right balance and equilibrium between programmes of work to produce short and longer-term outcomes. In its pursuit of financial stability, maintaining patient safety and service quality must continue to be a priority.
• Robust governance and leadership will be key to success. NHS Tayside must continue to secure/develop all relevant skills and capabilities required to realise effective transformation.
• NHS Tayside should maximise the benefit from, and continue to secure the on-going contribution of the North Regional Finance Lead.
• NHS Tayside must continue to build and strengthen relationships with partners including IJBs, Local Authorities and other territorial and national health boards. This must be pursued to fully exploit the benefits of effective collaboration on new models of service delivery and best use of resources.
• Forward financial projections for NHS Tayside - both within year and on a five-year basis - should clearly demonstrate service and savings deliverables, underpinned by the Integrated Clinical Strategy and its associated infrastructure and workforce plan.
• The Integrated Clinical Strategy should have clearly understood and agreed objectives and implementation milestones in concert with all partners - with shared and robust governance mechanisms.
• The Integrated Clinical Strategy should maximise the potential of regional planning, working and sharing of resources across the North of Scotland - to ensure best use of assets and optimal provision of primary, secondary and tertiary services.

Scottish Government:

• Scottish Government should continue to hold NHS Tayside to account on a regular and systematic basis, to ensure that the pace of progress is maintained.
• Scottish Government should consider a further and formal independent review of progress of NHS Tayside at some point during the 2018/19 financial year.
• In keeping with recommendation 14 of our Staging Report, the Scottish Government should ensure that the learning points from the work with NHS Tayside inform the development of the new Performance Improvement and Value Framework for NHS Scotland. This should take into account developing an adaptable range of tools and techniques to provide effective and integrated support for improvement across NHS Scotland.