Steve McCormick Lead Antimicrobial Pharmacist NHS Lanarkshire
Achieving Excellence - NHS Lanarkshire Excellence NHS Lanarkshire A plan for person-centred,...
Transcript of Achieving Excellence - NHS Lanarkshire Excellence NHS Lanarkshire A plan for person-centred,...
Achieving ExcellenceA plan for person-centred, innovative healthcare to help Lanarkshire flourish
NH
S Lanarkshire
Ach
ieving
Excellence
March 20
17
MARCH 2017
1Contents
Contents
Foreword 2
1 THECASEFORCHANGEANDLANARKSHIREQUALITY APPROACH 3
2 THECHANGINGHEALTHANDSOCIALCARENEEDSOF THEPEOPLEOFLANARKSHIRE 9
3 THEROLEOFHEALTHANDSOCIALCAREPARTNERSHIPS 17
4 WORKSTREAMSUMMARIES 23
Introduction 24 PrimaryCare 24 LongTermConditions 32 OlderPeople’sServices 35 MentalHealthandLearningDisability 38 AlcoholandDrugs 42 Maternity,EarlyYears,ChildrenandYoungPeople 45 PlannedandUnscheduledAcuteCare 49 OrthopaedicServices 55 CancerServices 64 StrokeServices 68 PalliativeCare 72
5 CROSSCUTTINGSERVICES 75
Pharmacy 76 Property 80 eHealthandDigitalTechnologies 84 Transport 88
6 THEWORKFORCEOFTHEFUTURE 92
7 PLANSFORSERVICECHANGE 99
8 FINANCIALRESOURCES 104
9 LISTENINGTOYOURVIEWS 107
GlossaryofAbbreviations 111
2 Achieving Excellence: Healthcare Strategy
Foreword
ItisfiveyearssinceNHSLanarkshirepublished“AHealthierFuture–AFrameworkforStrategicHealthPlanning”whichsetoutaroutemaptoimprovethequalityoftheservicesweprovide,whilealsosettingoutourplansformeetingthefuturehealthneedsoftheLanarkshirepopulation.
Inthattime,wehaveseenimportantchangesinthewayinwhichhealthandsocialcareisplannedanddelivered.Theneedsofthepopulation,andthewayinwhichclinicalservicesareprovided,havealsomovedon.So,in2016NHSLanarkshirerevisedandrefreshedtheHealthcareStrategy,lookingtothefuturehealthcareneedsofthepopulation.Ourvisionistoensuretheseservicesaresafe,effective,person-centredandsustainable.
OuraiminLanarkshireistodevelopahealthcaresystemthatsupportsthedevelopmentofanintegratedhealthandsocialcaresystemwhichhasafocusonprevention,anticipationandsupportedself-management.Withtheappropriateuseofhealthandcareservices,wecanensurethatpatientsareabletostayhealthyathome,orinacommunitysetting,aslongaspossible,withhospitaladmissiononlyoccurringwhereappropriate.
During2015and2016,LanarkshireNHSBoardcollaboratedwithpatients,carers,staffanditspartnerstorefreshthevisionastohowservicesshouldandcouldchangeoverthenexttenyears.Werecogniseandacknowledgethevaluableroleplayedbycarersandthisisreflectedinourambitionsforthefuture.
Wecarriedoutathree-monthconsultationonthecontentofthedraftHealthcareStrategy.Thereweresomestrongthemeswhichcamefromtheconsultation,forexamplewithrespecttosupportingcarersandimprovingtransportlinks,andtheseledtochangestothestrategy.Asummaryofthatconsultationanditsconclusionsisdescribedinsection9,andisreflectedinsignificantrevisionstothestrategydocumentitself.
“AchievingExcellence”summarisesourfutureplans,whichwillplayanimportantroleinimprovinghealthandsocialcarealongside-andintegratedwith-thetwoStrategicCommissioningPlansforHealthandSocialCareNorthLanarkshireandSouthLanarkshireHealthandSocialCarePartnership.OtherkeyinfluencesonthisworkarebothTheNationalClinicalStrategyforScotland,andtheHealthandSocialCareDeliveryPlan,bothpublishedbytheScottishGovernmentin2016.Thekeystagestoimplementingtheseplansaredescribedinsection7.
OurforemostambitionistoensurewearesuccessfulinturningthisstrategyintopositivechangesforthecommunitiesofLanarkshire.
Finallywewouldliketothankthosewhohavehelpedshapethestrategy,thepeoplewhorespondedtotheconsultation,andthemanystaffinvolvedindevelopingtheworkstreams.
Mrs Neena Mahal, Chair of Lanarkshire NHS Board
Councillor Harry McGuigan, Chair of North Lanarkshire Joint Integration Board
Councillor Jackie Burns, Chair of South Lanarkshire Integration Joint Board
4 Achieving Excellence: Healthcare Strategy
THECASEFORCHANGE
IntroductionInScotland,justasintherestofthedevelopedworld,healthandsocialcareservicesarefacingarisingtideofdemandwhichisdrivenbydemographicchanges,advancingmedicalscienceandnewtechnologies,atatimeofconstrainedresources.Aspeoplelivelonger,healthylifeexpectancyisnotadvancingatthesamepace.Thismeansthatwewillhavemorepeople,manyofwhomareolder,livingwithmultiplelong-termconditionsandoftencomplexneeds,whowillbereliantonsupportandinterventionfromhealthandsocialcareservices.Ifwedonotchangeourapproachbyshiftingthebalanceofcareawayfromacutehospital-focusedcaretoonewherethereisagreateremphasisonpreventionandcommunity-basedintervention,thenNHSLanarkshirewouldneedanadditional500acutehospitalbedsby2025–equivalenttoafourthdistrictgeneralhospitalinthecounty.Thisisnotachievable,affordableordesirablegiventhatthepeopleofLanarkshirehaveclearlystatedthat1,whereitissafetodoso,theywouldliketoreceivetheircareathome.
Thesecircumstancesmeanthatallpublicsectorservicesneedtoadaptandinnovateinordertoensurethatthehigheststandardsoftreatmentandcarecontinuetobedelivered.ScottishGovernmenthascommissionedanumberofstrategicreviews,includingtheChristieCommission2;theHealthcareQualityStrategyforScotland3;EveryoneMatters:2020WorkforceVision4,theNationalClinicalStrategyforScotland(2016)5;theHealthandSocialCareDeliveryPlan6andtheCarers(Scotland)Acttoprovidearoadmaptosupportfuturepublicservicereformsthatensuresafe,effective,person-centredandsustainableservicesaredeliveredthroughaworkforcethathastherightskillsandcompetenciesandisabletoachievethebestpossibleoutcomesforourpatients.
AimOuraiminLanarkshireistodevelopahealthcarestrategythatsupportsthedevelopmentofanintegratedhealthandsocialcaresystemwhichhasafocusonprevention, anticipation and supported self-management. With the appropriate use of health and care services we can ensure that patients are able to stay healthy at home, or in a community setting, as long as possible, with hospital admission only occurring where appropriate.
Thishealthcarestrategyisonepartofatrilogyofplans,withessentialco-dependenciesbetweenthisandtheJointStrategicCommissioningPlansproducedbytheNorthandSouthLanarkshireHealthandSocialCarePartnerships(HSCPs).TheChiefOfficersoftheHSCPsandNHSLanarkshireareco-authorsofthisstrategy(seesection3formoreinformation).
Theplansarebasedontheassessedneedsofourcommunitiesandaredesignedtoensurethattherightmixandvolumeofservicesaredeliveredtobestmeetthechangingneedsofourpopulation.Atthesametimeasfocusingonlocalpriorities,theLanarkshirehealthcarestrategywilltakefullaccountoftheNationalClinicalStrategyandtheHealthandSocialCareDeliveryplanwhichsetouttheprinciplesthatwillunderpinclinicalservicechangesacrossScotland.Futureservices,locallyandnationally,willhave:
1
5The Case for Change
• system-widedriveforimprovementacrossdiseaseprevention,earlyprofessionalintervention,supportedself-careandimprovedrehabilitation
• primarycarewithamoreprominentrole,treatingmorepeoplewithouttheneedtorefertohospital
• secondarycareorganisedin‘centresofexcellence’andnetworksofhospitalsprovidingspecificclinicalservices(asopposedtoallclinicalservicesasatpresent)thusmakingbestuseofskilledstaffandspecialisedfacilitiesandequipmenttoproduceexcellentoutcomes
• anewclinicalparadigmwhichwillensurethatpatientvalueisenhancedbyproceedingwithminimallydisruptive,realisticmedicine.
LanarkshireQualityApproachNHSLanarkshireiscommittedtodeliveringworld-leading,high-quality,innovativehealthandsocialcarethatisperson-centred.Ourambitionistobeaquality-drivenorganisationthatcaresaboutpeople(patients,theirrelativesandcarers,andourstaff)andisfocusedonachievingahealthierlifeforall.ThroughourcommitmenttoacultureofqualityweaimtodeliverthehighestqualityhealthandcareservicesforthepeopleofLanarkshire.
Ourfocusonqualityisnotnew,butsometimesithasmeantdifferentthingstodifferentpeople.WehavethereforedevelopedaStrategicFrameworkcalledtheLanarkshireQualityApproach.Itwillunderpinalloftheworkthattheorganisationdoes.Itwillensurethatthedecisionstheorganisationtakes,theservicesweprovideandthewayinwhichinwhichwedoso,alignwiththevaluesatitscore.Thismeansthatwhenweplanandredesignourservices,theorganisation’skeyprincipleswillinformanychangeswemake.ItprovidesthestructureandvaluestodrivehealthcareimprovementssuchasthosedescribedinthisStrategy.
PeopleattheHeartofourApproachTheLanarkshireQualityApproachsetsoutcorevaluesandprinciplesandwillensurethesereflectouraimtoprovideassurancetothepublic,theBoardandMinistersthatasaqualityorganisationwedemonstrate:
• Acaringandperson-centredethosthatembedshighquality,safeandeffectivecare
• Thatwecontinuallystrivetodothebestindividuallyandcollectively• Thatweacceptindividualaccountabilityfordeliveringaservicetothebest
ofourability• Thatweareresponsivetochangingculture,expectationsandneeds
QualityDrivenAimsWehaveidentifiedfourstrategicaimstoachieveourvision,whichhaveaspre-requisitecriteriatheNHSScotlandQualityStrategyambitionsofbeingperson-centred,safeandeffectivealongwiththerequirementtoimproveefficiencyandtoachievefinancialsustainabilitybydoingtherightthing,ontimeandwithinbudget.Thesestrategicaimsare:
• toreducehealthinequalitiesandimprovehealthandhealthylifeexpectancy• tosupportpeopletoliveindependentlyathomethroughintegratedhealth
andsocialcareworking
6 Achieving Excellence: Healthcare Strategy
• forhospitaldaycasetreatmenttobethenorm,avoidingadmissionswherepossible
• toimprovepalliativecareandsupportendoflifeservices
Ourunderpinningqualityambitionsaretodeliverperson-centred,safeandeffectivecare.Forusthismeans:
• person-centred–mutuallybeneficialpartnershipsbetweenpatients,theirfamilies,carersandthosedeliveringhealthcareserviceswhichrespectindividualneedsandvaluesandwhichdemonstratecompassion,continuity,clearcommunicationandshareddecisionmaking;
• safe–therewillbenoavoidableinjuryorharmtopeoplefromthehealthcaretheyreceiveandanappropriatecleanandsafeenvironmentwillbeprovidedforthedeliveryofhealthcareservicesatalltimes;
• effective–themostappropriatetreatments,interventions,supportandserviceswillbeprovidedattherighttimetoeveryonewhowillbenefitandwastefulorharmfulvariationswillbeeradicated
Webelievethatoursharedpursuitofthesethreequalityambitionswillmakesignificantandpositiveimpactsonefficiencyandproductivityandthroughthiswewillsecurebothimprovedoutcomesforthepeopleweserveandfinancialsustainabilityfortheorganisation.
OurValuesItisnotonlywhatwedothatisimportant;thewaywedothingsalsomattersenormously.TheNHSLanarkshirevaluesofFairness,Respect,WorkingTogetherandQualityunderpinourpurpose,providinglocalfocusandcontextfortheimprovementofourservicesandguidingourindividualandteambehaviours.Forusthismeans:
• Fairness:Ensuringclearandconsideratedecisionmakingatalllevels• Respect:Valuingeveryindividualandtheircontribution• Quality:Settingandmaintainingstandardsineverythingwedo• Working Together:Thinking,growing,deliveringasateam
Howwillwegetthere?Wearecommittedtoestablishingaconnectedinfrastructurethatsupportstheorganisationtodeliveronitsambitionofputtingqualityattheheartoftheorganisation.Thecomponentsofthisinfrastructureinclude:
• Leadership and Behaviours–Tobringtheculturetolifethequalityambitionsmustbedemonstratedindaytodaybehaviours“fromboardroomtothepatient”.Wewillensurethatleadersatalllevelsintheorganisationareempoweredtoworkinthisway
• Improvement and innovation–Wewilluseaconsistentapproachtoimprovementthroughouttheorganisationthatreflectallstagesoftheimprovementjourneyandapplytocontinuousdailyimprovementaswellaslarge-scaletransformationalchange
• Communications and Engagement–Tosupportourapproachwewillimplementacomprehensivecommunicationandengagementplaninordertopromoteourorganisationalpurposeandqualityambitionsanddevelopevenfurtherourpartnershipwithpatients,thepublic,staff,professional
7The Case for Change
advisorycommittees,localauthorities,generalpractitioners,generaldentalpractitioners,thirdandindependentsector,carerorganisationsandelectedrepresentatives
• Information–Wecollectarangeofdataontheservicesweprovide.ThisinformationcansupportustomeasurehowtheStrategicFrameworkisbeingappliedtogivetheBoardconfidencethattheorganisationisplanninganddeliveringwithintheaspirationsoftheFramework
• Knowledge and skills–Wewantourstafftobethemostcaring,knowledgeableandskilledworkforceinScotland.Wearecommittedtoensuringstaffareprovidedwiththeappropriateknowledge,skillsandconfidencetodeliverhighqualityservicesonadaytodaybasisandatthesametimecontinuouslyimprovethoseservices.
Thesethemesareintendedtoillustrateareasofactionthatwillenableustoachievetheculturalchangesneededtosustaintheorganisationwithqualityatitsheart.
Insummary,theLanarkshireQualityApproachprovidesaclearoutlineofthevision,mission,valuesandobjectivesofourorganisation.Itisimportantthatweareclearwithourselvesandothersaboutourvisionandthekeyvaluesandobjectiveswebelievewillenableustodelivergoodquality,person-centredcare.InordertoprovidethisclaritywehavedevelopedavisualisationoftheLanarkshireQualityApproachasshownbelow.
TheLanarkshireStrategicFramework
8 Achieving Excellence: Healthcare Strategy
References1 NHSLanarkshireOnlinesurvey,20162 CommissionontheFutureDeliveryofPublicServices.Edinburgh:Scottish
Government,2011.3 TheHealthcareQualityStrategyforScotland.Edinburgh:Scottish
Government,2010.4 EveryoneMatters:2020WorkforceVision.Edinburgh:ScottishGovernment,
2013.5 ANationalClinicalStrategyforScotland.Edinburgh:ScottishGovernment,
20166 HealthandSocialCareDeliveryPlan.Edinburgh:ScottishGovernment,
2016
9The Changing Health & Social Care Needs of the People of Lanarkshire
TheChangingHealth&SocialCareNeedsofthePeopleofLanarkshire
2
10 Achieving Excellence: Healthcare Strategy
THECHANGINGHEALTH&SOCIALCARENEEDSOFTHEPEOPLEOFLANARKSHIRE
PopulationProfile
ThepopulationofLanarkshireis654,490with338,260peoplelivinginNorthLanarkshireand316,230inSouthLanarkshire.
Figure1outlinesthepopulationbyagegroupandbyhealth&socialcarepartnershiparea.Therearemorepeopleagedlessthan65yearslivinginNorthLanarkshirewhencomparedtoSouthLanarkshire,whereasmorepeopleaged65yearsandoverliveinSouthLanarkshirewhencomparedtoNorthLanarkshire.
Figure 1:PopulationofNHSLbyagegroupandhealthandsocialcarepartnershipareas
Thetotalpopulationisexpectedtoincreasebyonly1%by2025.
Using2014dataasabaseline,figure2overleafillustratesthattherewillbefallingnumbersofpeopleagedunder65yearsandmorepeopleaged65andoverinfutureyears.
2.1
2
5599,,332222
113300,,114411
9933,,669955
3311,,554433 2233,,224499
5511,,227755
111144,,332244 9922,,115533
3322,,009999 2255,,550099 0
50,000
100,000
150,000
200,000
250,000
300,000
0 to 14 15 to 44 45 to 64 65 to 74 over 75
More North
More North
More North
More South More South
North H&SCP Population = 337,950South H&SCP Population = 315,360
Total Population = 653,310
11The Changing Health & Social Care Needs of the People of Lanarkshire
Figure 2:Predictedcumulativepopulationchangefrom2014to2020and2025byagegroup
BirthandDeathRatesandLifeExpectancyinLanarkshire
BirthsTherewere6,901babiesborninLanarkshirein2015.Thisnumberwillfalloverthecomingdecade.TheoverallbirthrateinLanarkshirewas56.5birthsper1,000womencomparedtotheScottishbirthrateof53.9.
DeathsTherewere7,121deathsrecordedinNHSLanarkshireresidentsin2015.ThereisconsiderablevariationindeathratesacrossthedifferentlocalitiesinLanarkshire,whichlargelyreflectsdifferencesindeprivationlevels.
Deathsratesfromtheso-called‘bigkiller’diseasesofcancer,coronaryheartdisease(CHD)andstrokecontinuetofallbutstillcausedalmosthalfofalldeathsin2015.
Individually,cancer,CHDandstrokewereresponsiblefor29%,12%and7%respectivelyofalldeathsinLanarkshire.Respiratorydiseasewasalsoasignificantcauseofdeathin2015,beingresponsiblefor14%ofalldeaths.
Whilethereissomeevidenceofimprovementindeathratesforcancer,CHDandstroke,thedeathratesforrespiratorydiseaseinLanarkshireremainssignificantlyhigherthanthatforScotland.Itisestimatedthattherewillbeanincreaseintheincidenceofallcancersby33.5%by2027,mainlyasaresultofthepopulationgrowingolder.
2.2
574
-12,598
3,064 6,349 8,165
5,554
-1,498
-15,179
-4,399
11,009
18,646
8,579
-20,000
-15,000
-10,000
-5,000
0
5,000
10,000
15,000
20,000
25,000
0 to 14 15 to 44 45 to 64 65 to 74 over 75 Total
2020 change 2025 change
Cumulative Change from a 2014 Baseline
REDUCING
INCREASING
12 Achieving Excellence: Healthcare Strategy
2.3
LifeexpectancyAsisthecaseacrossScotland,lifeexpectancycontinuestoincreaseinLanarkshire.AmaleinfantborninLanarkshirein2012couldexpecttoliveto75.8yearsofage,whileafemaleinfantcouldreasonablybeexpectedtolivetobe80.0yearsold.Thisrepresentsanincreaseacrossa10-yearperiodof2.9yearsformalesand2.1yearsforfemalesinLanarkshire.However,lifeexpectancyisstillbelownationallevels;bothmalesandfemalesinLanarkshireliveonaverageayearlessthanothersinScotland.
Therearesignificantinequalitiesinlifeexpectancyforthoselivinginsomeofourmostdeprivedareaswhencomparedtoourleastdeprivedareas.Forexample,lifeexpectancyforamanlivinginoneofourmostdeprivedcommunitiesis68.2yearscomparedwithalifeexpectancyof81.1yearsformenlivinginoneofourmostaffluentcommunities.
Key Points
• TheNHSLanarkshiretotalpopulationisexpectedtoincreasebyonly1%by2025
• Therewillbefewerchildreninthefuturepopulation• Therewillbefewerpeopleofworkingageinthefuture• Theelderlypopulationwillbegrowingatthefastestrateinthefuture–
whilegreatlywelcomed,thispopulationwillproportionatelyneedmosthealthcareresources
• Theover75spopulationisexpectedtogrowby11%by2020and29%by2025
• ThegrowthratefortheelderlypopulationishigherinLanarkshirewhencomparedtoScotlandasawhole
• LifeexpectancyisincreasinginLanarkshire• ThelifeexpectancygapbetweenLanarkshireandScotlandisnotclosing• Therearestarkdifferencesinthelifeexpectancyofthoselivinginourmost
deprivedareascomparedwiththeleastdeprived
InequalitiesandSocialIssues
TheLanarkshirepopulationprofileispoorerthanthenationalaverageformanyindicators.Forexample,NHSLanarkshireissignificantlyworsethantheaveragefor:
• smokingattributabledeaths• deathsfromalcoholconditions• childrenlivinginpoverty
Thereareexceptions,however,suchasthenumberofpeoplewithhighlevelsofneedbeingcaredforathome,childdentalhealthinprimaryschoolandimmunisationuptakefor‘5in1’vaccinationat24monthsinwhichNHSLanarkshireisbetterthanthenationalaverage.
Thelinkbetweeninequalitiesandpovertytopoorhealthhasbeenfirmlyestablished.Inequalitiesleadtopoorerhealthandincreaseddemandsuponclinicalservices.
13The Changing Health & Social Care Needs of the People of Lanarkshire
Lanarkshirehasmanychallengestoface.Forexample,20%ofpeopleinLanarkshireliveinoneofScotland’smostdepriveddatazones;thereare1,440looked-afterchildreninLanarkshire.
Inequalitiesgobeyondsocio-economicdeprivationissues.Thereare,forexample,particulargroupsinourcommunitiessuchashomelessandtravellingpeoplewhoexperiencepoorerhealthoutcomes.
TheworkoftheHealthandSocialCarePartnerships(HSCPs),theCommunityPlanningPartnershipsandofpeopleintheircommunitiesisvitalinaddressinginequalitiesandisinextricablylinkedtothesuccessofthisstrategy.DetailedanalysisofthisworkcanbefoundinbothNorthandSouthLanarkshireHSCPs’respectiveStrategicCommissioningPlans.
Key Points
• ThehealthconsequencesofpovertyarewelldocumentedandNHSLanarkshirefacesmajorchallengestodeliverhealthcareduetolevelsofpovertyandinequalitieswithinitscommunities
• NHSLanarkshireanditspartnerswillstrivetodeliverservicesthatareresponsivetoneedsandthatcontributetothereductionininequalitiesinhealth.
TheAgeingPopulation
Asdescribed,wewillseemorepeoplesurvivingintooldage,oftencontinuingtocontributetoourcommunitiesascarers.Itwillbetheroleofourhealthandsocialcareservicestosupportpeopleastheygrowoldertohelppeopletomaintainanactiveandenjoyableoldage.However,thiswillmeanwewillhavetoadapttheseservices.Diseasessuchasdementia,hipfractures,Parkinson’s,strokeandfrailtygenerallyhaveastrongagecorrelation.Inaddition,multi-morbidities(thepossessionofmorethanonechronicdisease)areincreasinglycommonamongstolderadultsleadingtoincreasedvulnerabilitytoacuteillnessaswellasariskofdependenceordisability.
Forthecaresector,impairedhealthresultingindisabilitycanleadtoincreaseddemandsoncareathomeoradmissionstolongtermcare.
Sustainingservicestopromotehealthyageing,activesocialinvolvement,managementofacuteillness,rehabilitationandultimatelypalliationmustbedonewiththepatientandcareratthecentreandwiththeaimofmaximisingahealthy,engagedandindependentoldage.
Figure3providesanindicationofthedistributionofthoseadultslivingwithlongtermconditions(LTC)byagegroup.
2.4
14 Achieving Excellence: Healthcare Strategy
2.5
Figure 3:Relationshipbetweenaperson’sageandnumberoflong-termconditions
Key Points • ThepeopleofLanarkshirewilllivelonger,buttheburdenofdiseasein
laterlifewillincreasetheproportionofpeoplewithlong-termhealthconditions.
• Theageingofthepopulationpresentspotentiallythesinglebiggestchallengetothehealthandcaresectorinthefirsthalfofthe21stCentury.
SignificantRiskFactorsandIssues
Therisktoindividualsofdevelopingthemajorlife-threateningillnesses(cancer,coronaryheartdiseaseandrespiratoryillness)canbereducedbynotsmoking;beingahealthyweight;beingphysicallyactive;drinkingwithinrecommendedlevelsofalcohol;andmaintainingahealthydietandgoodmentalhealth.
TobaccoTobaccosmokingremainsthemostsignificantpreventablecauseofillhealthinLanarkshire,accountableforapproximatelyonequarterofalldeaths.
SmokingprevalenceinLanarkshireis21.3%comparedtothenationalaverageof20.2%withmalesandallagegroupsnotsignificantlydifferentfromtheirrespectiveScottishaverages.
ObesityApproximately65%ofadultsinLanarkshireareoverweight(includingobese).Theproportionofadultswhowillbeoverweight(includingobese)willbe87.5%by2050.
Distribution of LTCs in Lanarkshire by age band in 2013/14
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
0–4
5+ LTCs
4 LTCs
3 LTCs
2 LTCs
1 LTC
0 LTCs
85+75–8465–7445–6425–4415–245–14
15The Changing Health & Social Care Needs of the People of Lanarkshire
ThepercentageoftotalNHSspendingonobesityrelatedconditionssuchasType2diabetes,heartdiseaseandstrokewas9%in2015andisexpectedtoriseto12%by2050.
Significanteffortsarerequiredtocreateenvironmentsthatsupportgoodhealthbypromotinghealthiereatingandincreasinglevelsofphysicalactivitytoreducenumbersofoverweightandobesepeople.
AlcoholandSubstanceMisuseLevelsofalcoholconsumptioninLanarkshire,asintherestofScotland,arefalling.Fewerpeopleareexceedingweeklydrinkingguidelinesandtheaveragenumberofmeanunitsconsumedisfalling,bothformenandwomen.Whilethisisawelcometrend,itdoesmaskagreatertendencyinLanarkshirethanintherestofScotlandtoexceeddailydrinkingguidelines.
Therateofdeathsdirectlyattributabletoalcohol-relatedcausessuchasliverdiseasecontinuestobehigherinLanarkshirethaninScotlandoverall,andisofparticularconcerninNorthLanarkshire.Theoutcomesforhealthissuesrelatedtoalcoholanddrugusearealsoworseindeprivedareas.Similarly,themajorityofdrug-relateddeathsoccurinareaswiththegreatestlevelsofmultipledeprivation.
MentalHealthandLearningDisabilitiesThereisnohealthwithoutmentalhealth:everypartofthehealthandsocialcaresystemisrequiredtoplayamoreactivepartinimprovingthementalhealthandwell-beingofthepeopleofLanarkshire.
Oneinfiveadultswillhavementalhealthcareneedsatsomepointintheirlife.Itisestimatedthatthereare10,000peoplewithdementialivinginLanarkshireandthatapproximately17,000peoplemayhavealearningdisability.Thenumberofpeoplewithlearningdisabilitiesislikelytogrowby14%by2021:advancesinmedicalscienceandcaremeanthatmanymorepeoplewithlearningdisabilitiesarelivinglonger,morefulfilledlivesthanhaseverbeenthecasebefore.
ImprovementsarebeingmadeinLanarkshirewithfewerpeopleself-reportingcommonmentalhealthproblemsandmoreself-reportingimprovedlevelsofwellbeingandlifesatisfaction.Themodernisationprogrammeinmentalhealth,whichinvestedacrossthevarioustiersofserviceprovision,hasresultedinthedeliveryofmorepreventionandearlyinterventionprogrammes,improvedaccesstoself-help,socialprescribing,groupbasedandtelephonesupportandenhancedaccesstocommunitybasedmentalhealthandpsychologicaltherapyservice.
16 Achieving Excellence: Healthcare Strategy
Key Points • Smokingisreducing,butremainsamajorcauseoflife-threateningillness• Increasingobesitywillimpactonbothhealthandsocialcare• Alcoholandsubstancemisusepresentsmajorchallengesforthedeliveryof
healthcare• Significanteffortisrequiredtopromotegoodmentalhealthandwell-
beingandprovidesupportstopeoplewithmentalillhealthoralearningdisability
WhatWillSuccessLookLike?
LifeexpectancyformenandwomentobesimilartothatoftheScottishpopulation,withthegreatestimprovementamongthoselivinginourmostdeprivedareas
SmokingprevalencetocontinuetoreduceandachievethesamelevelastherestofScotland
ToworkwithCommunityPlanningPartnerstoreducethenumberofchildrenlivinginpovertyto,atleast,theScottishaverage,withspecificfocusonthosewhoaremostdeprived
ToachievetheScottishaveragefortheprescriptionofdrugsforanxiety,depressionandpsychosis
ToimprovethemeanmentalwellbeingscoreasmeasuredbytheScottishHealthSurveytothatofthenationalaverage
ToworkwithScottishGovernmentandCommunityPlanningPartnerstoreducethepredictedrateofincreaseinthepopulationwhoareeitherobeseoroverweight
Toenablethosewithlongtermconditionstomanagetheirconditionsinthecommunityandreducetheirrelianceonacuteservices.
18 Achieving Excellence: Healthcare Strategy
3 THEROLEOFHEALTHANDSOCIALCAREPARTNERSHIPS
IntegrationofhealthandsocialcareistheScottishGovernment’sprogrammeofreformtoimproveservicesforpeoplewhouseadulthealthandsocialcareservices.ThePublicBodies(JointWorking)(Scotland)Actwasgrantedroyalassenton1April2014.Thatmeanschangestothelawwhichrequirehealthboardsandlocalauthoritiestointegratetheseservices.TheActisalandmarkadulthealthandsocialcarereformforScotlandandisthemostsubstantialreformtothecountry’snationalhealthservicesandsocialcareservicesinageneration.
OneofthemainaspectsofthePublicBodies(JointWorking)(Scotland)ActistocreatestatutoryIntegratedJointBoardsineachlocalauthorityareareplacingCommunityHealthPartnerships(CHPs).1April2015markedtheconclusionofahighlysuccessfulerainthedeliveryofcommunityhealthservicesinLanarkshire.Astheintegrationofhealthandsocialcarecameintoeffect,therespectiveNorthandSouthLanarkshireIntegratedJointBoardssupersededLanarkshire’sNorthandSouthCommunityHealthPartnerships(CHPs).
Thereareninenationaloutcomesthatprovideaframeworkformeasuringtheimpactofintegratedhealthandsocialcareonthehealthandwellbeingofindividuals:
1 Peopleareabletolookafterandimprovetheirownhealthandwellbeingandliveingoodhealthforlonger
2 People,includingthosewithdisabilitiesorlongtermconditionsorwhoarefrail,areabletolive,asfarasreasonablypracticable,independentlyandathomeorinahomelysettingintheircommunity
3 Peoplewhousehealthandsocialcareserviceshavepositiveexperiencesofthoseservices,andhavetheirdignityrespected
4 Healthandsocialcareservicesarecentredonhelpingtomaintainorimprovethequalityoflifeofpeoplewhousethoseservices
5 Healthandsocialcareservicescontributetoreducinghealthinequalities6 Peoplewhoprovideunpaidcarearesupportedtolookaftertheirown
healthandwellbeing,includingtoreduceanynegativeimpactoftheircaringroleontheirownhealthandwellbeing
7 Peoplewhousehealthandsocialcareservicesaresafefromharm
TheScottishGovernmentVisionforHealthandSocialCareIntegration:‘Ensuring better care and support for people where users of health and social care services can expect to be listened to, to be involved in deciding upon the care they receive and to be an active participant in how it is delivered. This will result in better outcomes for people, enabling them to enjoy better health and wellbeing within their homes and communities.’
19TThe Role of Health and Social Care Partnerships
8 Peoplewhoworkinhealthandsocialcareservicesfeelengagedwiththeworktheydoandaresupportedtocontinuouslyimprovetheinformation,support,careandtreatmenttheyprovide
9 Resourcesareusedeffectivelyandefficientlyintheprovisionofhealthandsocialcareservices
TheIntegratedJointBoardsarethebodiesthatareresponsibleforplanningandhaveoperationaloversightofintegratedcare.Theywilldecidewhichintegratedserviceswillbeprovided,howtheywillbefundedandwhattheyshouldlooklikeandwilldirecttheNHSBoardandlocalauthoritytodeliverthoseservices.Theywillreportannuallyagainstprogresstowardstheninenationaloutcomes.
ThetablebelowdescribeswhichLanarkshireserviceswillbedeliveredorcommissionedbytheHSCPs.
Figure 4:ResponsibilitiesofthetwoHSCPsinLanarkshire
Communitybasedhealthservices
Hospitalbasedhealthservices
Communitybasedsocialworkservices
•AlliedHealthProfessionals(inanoutpatientdepartment,clinicoroutwithahospital)
•CareHomeLiaisonservice•CommunityAddictionservices•CommunitybasedGeriatricMedicine•CommunitybasedPaediatrics•CommunitybasedPalliativecare•CommunityChildren’sHealthservices•CommunityLearningDisability
services•Continenceservice•Diabetesservice•Dietetics•DistrictNursing•GPoutofhours•HealthandHomelessness•HealthVisiting•MentalHealthandLearningDisability•Ophthalmicservices•Pharmaceuticalservices•PrimaryCareAdministration•PrimaryCareoutofhours•PrimaryMedicalservices•PrisonerHealthcare•Psychology•PublicHealth–HealthImprovement•Public,GeneralandCommunity
Dentalservices•Sexual&ReproductiveHealthand
BloodBorneViruses•TraumaticBrainInjury
•Accident&Emergency(A&E)
•GeneralMedicine•GPInpatientservices•Hospitalbased
Addiction/Dependenceservices
•HospitalbasedGeriatricMedicine
•HospitalbasedMentalHealthservices(includinglowsecureforensics)
•HospitalbasedPaediatrics
•HospitalbasedPalliativeCare
•OccupationalHealth•Physiotherapy•Podiatry•Psychiatryof
LearningDisability•Rehabilitation
Medicine•RespiratoryMedicine•Speechand
LanguageTherapy
•Addictionservices•AdultProtection•AdultswithDisability
andLongTermConditions
•CareHome•CarersService•CommunityCare
AssessmentandPlanning
•ContractedSupportservices
•Dayopportunitiesanddayservices
•EquipmentsandAdaptations,Technology,EquipmentandTelecare
•HealthandWellbeingimprovement
•Homecareservices•Housingsupport
(someaspects)•IntermediateCare
service•MentalHealth
services•Occupational
Therapy
20 Achieving Excellence: Healthcare Strategy
Coretotheethosofintegrationisamovetowardslocality-basedplanning,providinglocalitieswiththeautonomytoidentifyprioritiesandshiftresourceswithinacoherentstrategiccontextandwithdueregardtoclinicalandprofessionalgovernance.LocalityprofileshavebeendevelopedaspartoftheJointStrategicNeedsAssessment,providinganassessmentofactivity,demandandresourcewithineachofthetenrecognisedlocalities,sixinNorth(Airdrie,Bellshill,Coatbridge,Motherwell,North-Cumbernauld,KilsythandtheNorthernCorridor-andWishaw),fourinSouth(Clydesdale,HamiltonEastKilbrideandCambuslang/Rutherglen),supportingtheidentificationofkeyactionstoenablethedeliveryofbetteroutcomesforthepeopleofLanarkshire.
ThevisioninLanarkshireistodevelopanintegratedmodelthatwillputthepersonatthecentreofdecisionsabouttheirtreatmentandcare,withgreaterunderstandingandconfidencetomanagetheirowncondition,takingcontroloftheirlifeandhavingtheirvoiceheard.Thiswillbesupportedbyeducationandgroupprogrammes,harnessingtherangeofthirdsectorandcommunityassets,anticipatorycareplanningandgreateruseoftechnology,preventingordelayingtheneedtousemoreintensiveservices.Wewillpromotetheuseofanticipatorycareplanswhichenableindividualstodeveloparecordofwhattheywouldlikecareproviderstodofollowingaclinicaldeteriorationintheirconditionoracrisisintheircareorsupport.Thisproactiveapproachaimstopreventtheneedforformalservicesarising,buildingresilienceinbothindividualsandcommunities.
Whereformalservicesarerequired,thesewillbeintegratedinlocalities,removinghand-offsandservicebarriers.Theintegratedmodelwillsupportpeopletomaintaintheirhealthandwellbeinginthecommunityortheirownhome,withhospitalservicesonlyrequiredforrealaccidentsandemergenciesandsomeelementsofspecialistcare.Componentsofacutecarewillalsobedeliveredinthecommunity,co-designedandembeddedwithintheintegratedcommunityinfrastructure.
TheobjectivesandprioritiessetoutinthisHealthcareStrategyareonepartoftheoverallprogrammetoimprovethehealthandsocialcareforthepeopleofLanarkshire.TheStrategicCommissioningPlans(SCP)developedbytheHealthandSocialCarepartnerships(workingwiththewidercommunityplanningpartners)formthetwootherkeycomponentsofthisworkanddescribetheactionsthatthePartnershipswillundertakewithinthenearfuturetoimprovehealthandtacklehealthinequalitiestoformtheStrategicCommissioningPlans.
TheSouthLanarkshireIntegrationJointBoard,hasagreedavisionwhichcommitsthepartnershipto“working together to improve health and wellbeing in the community – with the community”.
ThroughthestrategicdirectionoftheIntegrationJointBoard(IJB)therewillbeaconsciousmovetowardscommissioningbasedupontheachievementofbetterpatientandclientoutcomes.
21TThe Role of Health and Social Care Partnerships
TenemergingprioritiesarereflectedintheSouthLanarkshireSCP:1 Statutoryandcorework2 Earlyintervention,preventionandhealthimprovement3 Carerssupport4 Modelsofself-careandself-managementincludingtelehealthandtelecare5 Sevendayservices6 Intermediatecaretoreducerelianceonhospitalandresidentialcare7 Suitableandsustainablehousing8 Singlepointsofcontact9 Mentalhealthandwell-being
10 Enablerstosupportbetterintegratedworking
Theimplementationplanwillensureallcommissioningintentionsarelinkedtothe9nationaloutcomesandthe10HSCPpriorities.
HealthandSocialCareNorthLanarkshirehasidentifiedthecoreaimofenabling“safer, healthier, independent lives”throughlocality-basedengagementaseriesofcommissioningprioritieswhichwillformthebasisoftheNorthLanarkshireStrategy:
1 Developmentofintegratedlocalityteams;2 Strengtheningrehabilitationwithinthecommunity;3 ReconfiguringSupportatHome;4 BedModeling;5 SelfDirectedSupport;6 UniversalHealthVisitingPathway;7 FamilyNursePartnership;8 Campaignsandmessagingforthepublic;9 Organisationaldevelopmentforstaff;
10 Technicalsolutionsanddatasharingmechanismstoimprovecaredelivery;11 ImplementationoftheCarers(Scotland)Act2016.12 Communitytransport;13 Telehealthandtelecareservicesandsolutionsforpeoplerequiringsupport;14 Communitycapacitybuildingandcarersupport;15 SupportingtheredevelopmentofMonklands.
YoucanfindoutmoreabouttheseplansforNorthLanarkshireathttps://mars.northlanarkshire.gov.uk/egenda/images/att85465.pdf
22 Achieving Excellence: Healthcare Strategy
WhatWillSuccessLookLike?
Preventavoidableadmissionstohospital
Improvetimelydischargefromhospital
Supportmorepeopletoremainathome
Shiftresourcesfromahospitaltoacommunitysetting
24 Achieving Excellence: Healthcare Strategy
WORKSTREAMSUMMARIES
Introduction
During2015and2016,LanarkshireNHSBoardaskedserviceleaderstoengagewiththeirpatients,carers,staffandpartnerstosetoutarefreshedvisionofhowtheirservicesshouldandcouldchangeoverthenexttenyears.
ThissectionoftheHealthcareStrategysummarisesthatwork.ThereisparticularemphasisonwhatourprioritiesforimprovementaretoensureweimprovehealthcareoutcomesforthepeopleofLanarkshire.ThisprogrammeforimprovementhasbeendevelopedalongsidetheplanssetoutintheStrategicCommissioningPlansforNorthandSouthLanarkshireHealth&SocialCarePartnerships(HSCPs).
PrimaryCare:ATransformationProgramme
VisionThe future model of primary care in Lanarkshire will help all clinicians to spend more time with their patients, less time on unwarranted bureaucracy and have each professional individually and collectively working to their full potential. It will promote the aims at the core of Scotland’s Quality Strategy. Safe, effective and person-centred care will be delivered within a more collaborative health and social care system, and increasingly shaped at a community level.
Stronger primary care services are essential to: managing future demand; ensuring the success of community-based integrated working; and reducing the healthcare system’s reliance on hospital beds. Multidisciplinary teams in health and social care will work together to meet the assessed needs of patients and it is this multidisciplinary team work which will deliver improved care for the future.
However,thefuturevisionwillonlymeettheneedsofthepopulationandtheserviceifcontinuinginvestmentismadeincommunitybasedservicesandtheentirehealthandcaresystemisbettercoordinated.Wealsowanttopreventillhealthandreducetheburdenofexistingillhealth.Thisrequiresamajorchangeinthesizeandskillsofourworkforce,aswellasmajorchangesinthewaythatpeopleaccessprimarycareservices.
TheimplementationofthisvisionwillbestrengthenedbythecommitmentofScottishGovernmenttospendanadditional£500monprimarycareservicesby20213.
CurrentServicesPrimaryhealthcareprovidesthefirstpointofcontactinthehealthcaresystem.Thismaybewithageneralpracticedoctor(GP),nurse,communitypharmacist,optometrist,generaldentalpractitioner,podiatrist,healthvisitororotherallied
4.1
4.2
4
25Workstream Summaries
healthprofessional.Assuch,primarycareisthelargestpartofthehealthcaresystem.
Theaimistoprovideaneasilyaccessibleroutetocare,whateverthepatient’sneeds.Primaryhealthcareisbasedoncaringforpeopleratherthanspecificdiseases.Thismeansthatmanyprofessionalsworkinginprimarycarearegeneralists,dealingwithabroadrangeofphysical,psychologicalandsocialproblems,ratherthanspecialistsinanyparticulardiseasearea.However,therearemanyspecificservicesprovidedinprimarycaresuchasoptometryorcontinenceservices.TheGPisoftenseenastheultimatelyresponsibleprofessional.
AnimportantroleoftheGPisactingasthepatient’sadvocateandco-ordinatingthecareofthemanypeoplewhohavemultiplehealthproblems.Sinceprimarycarepractitionersoftencareforpeopleoverextendedperiodsoftime,therelationshipbetweenpatientandpractitionerisparticularlyimportant.Primaryhealthcareinvolvesprovidingtreatmentforcommonillnesses,themanagementoflongtermillnessessuchasdiabetesandheartdiseaseandthepreventionoffutureill-healththroughadvice,immunisationandscreeningprogrammes.Throughthevarietyofdisciplines,italsoprovidesinputtorareillnessesandcomplexinterventionstopatients,carersorotherhealthprofessionals.
Primarycarealsoactsasaconduittotheopportunitiesforcareprovidedbyspecialisthospital-basedservices,anditistheseinterconnectionswhicharefundamentaltotheeffectivenessoftheentirehealthsystem.TheGPisoftenseenastheroutetomorespecialisedcare.
TheNeedforChangeDemandsongeneralpracticeandprimarycarehaveneverbeengreaterwithprimarycareprofessionalsseeingmorepatientsthaneverwithcomplexhealthissues.Risingpatientexpectationsandpersistenthealthinequalitiesillustratethechallengesfacingprimarycare.Descriptionsofthechallengesatapopulationlevelhavebeenprovidedintheearlysectionsofthestrategy,andwithoutchangethesechallengescannotbeaddressed.Thereiscurrentlyasignificantandincreasingdifficultywithworkforceandresourcecapacitywithintheprimarycaresectorandwithoutchangethecurrentarrangementswillnotdeliverontherequirementsofthepopulationorthesystem.Thisishappeningnowandisevidencedbyshortagesofcliniciansinanumberofareasandadeterioratingperformanceonaccesstoprimarycare.
Atpresent,generalpracticeandinparticulartheGPisexpectedtoprovideservicestoallthosewhoareorbelievethemselvestobeunwell.Thisisunsustainable.
Thechallengesdescribedwithin‘RealisticMedicine’1needtobeaddressed.ThisreportresonateswiththeNationalClinicalStrategywhichcallsforanewclinicalparadigmthatadoptstheleastinvasiveordisruptiveprocessesasafirststep.Thisisbothachangeofmind-setandachangeofserviceprovision.Thiswilloftenmoreappropriatelyincludelifestyleinterventionsbeforedrugsandoperations
26 Achieving Excellence: Healthcare Strategy
aswellasabetterunderstandingofthelimitationsofanyintervention.Wewantpatientstoremainincontroloftheirownillnesses.
Weneedtoavoidunwarrantedvariationinstandardsofcareandavoidwastefulinvestigationsandtreatmentsthatdonotaddvalueforpatients.Qualityimprovementisoneofthekeystounlocktheproductivityofprimarycare.
TheScottishGovernmenthassetoutanambitiousvisionforhealthandsocialcaretoenableeveryonetolivelonger,healthierlivesathomeorinahomelysettingby2020.Primarycareisattheheartofthisvisionandismostpeople’sexperienceoftheNHSmostofthetime.Tomeetthisambitionatatimeofincreasingdemand,weneedtochangethewaythatprimarycareoperatesbycreatingteamsofhealthandcareprofessionalsworkinginpartnership.
Whilstlifeexpectancyisrising,healthylifeexpectancyisnotrisingsorapidlyandsotheneedforillhealthcareincreases.Sustainabilityforthesystemcanonlybedeliveredwhenthehealthylifeexpectancyincreasesandwhenthepopulationareempoweredtotakeamuchmoreactivepartintheirowncarewhentheydobecomeunwell.Thisrequiresresourcemuchearlierinthehealth/illhealthcontinuum.
WhatWillChangeThepresumptionthattheGPaloneisresponsibleforallhealthcareoutsidehospitalwillchange.Thewaythiswillchangeislikelytobemadeclearerinthe2018andthe2020GPcontractreviews.ThesechangeswillbemanagedbytheHealthandSocialCarePartnerships(HSCPs)inNorthandSouthLanarkshire.
Self-managementwillincreasinglybeseenasasensibleoption.Thisistrueforlongtermconditionsandshorterdurationillness.Self-managementshouldnotbeconsideredaninferioroption:itisadesirablehighqualityinterventionwithanevidence.Itdoesrequireadequateresourcing,andisacost-savingoption.
Also,theassumptionthatallcomplexcarehastobedeliveredinahospitalwillcontinuetochange:therewillbeincreasedintheclinicalskillsacrossawidevarietyofhealthcareprofessionalsinprimaryandcommunitycare.Thisideaismentionedalotin“AchievingExcellence”,butisdeliveredinprimarycare.Thestrategicdirectionsoutlinedacrossotherpartsofthisdocumentare
27Workstream Summaries
fundamentallydependentonthechangesinprimarycarebeingeffective.
Hospitalcareremainsasanimportantelementoftotalhealthcare.Thechangeaswemoveforwardisthatonlythosewhoneedtobeinhospitalwillbeinhospital.Theservicesprovidedinhospitalwillbebetterabletodeliverontheserequirements(seesection4.8).
Asaresultofthis,ourapproachtoprimarycarewillsupportGPsandotherhealthprofessionalstoworktogethertoenablethesustainabledeliveryofhighquality,safeandeffectivepatientcarethatisintegratedwherenecessarywithaccesstohospitalbasedserviceswhenrequired.Thiswillinevitablyincludeagreaterfocusonself-care,supportedself-managementandjoined-upcareforpeoplewithmultipleconditionsandcomplexneeds.ItalsorequirescontinueddevelopmentofITsystems,laboratoryandinvestigationaccess.Assuch,wearedependentonnationalaswellaslocalchanges.
Asresponsestothe2016consultationemphasised,peoplewanttobeathome;theyalsogetonbetterathome.Therefore,thereneedstobeamechanismbywhichtheproportionofhealthandsocialcarespendingonprimaryandcommunitycareisincreasedinrealterms.
Transportisanimportantconsideration.Transportationofpatientstoroutineappointmentsviathepatienttransportservicehastraditionallybeenonlytoplacesdesignatedashospitals.Formoreinformationonhowwewilldothisseesection5.4.
“AchievingExcellence”dealswiththehealthandsocialcarecontributiontothelivesofourpeople.Itwouldbewrongtoignorethevastcontributionmadebyunpaidcarers,thevoluntarysectorandthepaidcarerstohealthcare.Furtherdevelopmenttoallowtheseservicestocontributetoaneverincreasingextentandinapersoncentredwayisessentialtomakesenseoftherestofprimarycare.
Prescribinginprimarycarewillbedevelopedtoensuremaximumbenefitsforpatientoutcomes,whileavoidingwastage.Wastageincludesunused,unwanted,ineffectiveandunnecessarymedications(seemoreinsection5.1).
Localityteams,includingGPs,willbeconfiguredtoco-ordinateandmanagecomplexclinicalconditions;thiswillspeedupaccessandimproveoutcomes.
Threeadditionalthemeswillformpartofourchanges:healthimprovementmodelswillbeimplementedtodelivertheninenationalhealthandwellbeingoutcomes;therewillbegreateruseofdigitaltechnologiestoimprovesafety,efficiencyandeffectivenessofclinicaldecisionmaking;wewillsupportleadershipforchange,qualityandefficiency.
Recentimprovementsinthequalityofurgentout-of-hoursprimarycarewillbesustained,withclearlinkagesbetweentheseservicesandotheremergencycareservices(hospitalemergencydepartments,NHS24,ScottishAmbulanceService).TheHSCPswillcommissionUrgentCareServices(out-of-hours)thatdeliversafe,effectiveandsustainableservicesinaccordancewiththeIndependent
28 Achieving Excellence: Healthcare Strategy
ReviewofUrgentPrimaryCareServices2.Thenewmodelwillbedevelopedandimplementedtosignificantlyimproveaccesstoarangeofin-hoursservicesandtoprovideimprovedcollaborativeworkingtoprovideurgentcareinthecommunitythatrequiresaresponsebeforethenextroutinecareserviceisavailable.
There are multiple initiatives being employed to implement some of these changes, many of which are collected together as the Primary Care and Mental Health Transformation Programme. Some of these are described below.
HouseofCare(HoC)TheHouseofCareProgramme(HoC)describesaframeworktoenhancethequalityoflifeforpeoplewithlong-termconditions(LTCs),nomatterwhattheirconditions.ItisbeingintroducedcurrentlywithinLanarkshireacrossanumberofpracticesandteams.BylisteningtotheexperiencesandfeedbackfrompeoplecopingwithLTCs,itisevidentthattheindividualneedstobeatthecentreofhowcareisdesignedandimplemented.(Seesection4.3).
Personalisedcarewhichunderstandsandsupportstheindividualisvital.Thereisnomagicbulletwhichwillsupportthedeliveryofpersonalisedcarebutthereisevidencethatthinkingsystematicallyabouttheessentialcomponentsdoes.
TheapproachprovidesthebuildingblocksthatneedtobeinplacetoenablecareandsupportplanningtotakeplaceasthenewnormalcareforeveryonewithoneormoreLTCs.TheHoCprovidestheplanningtoolforbothacommunity-widesteeringgroupandforapracticebasedteamtouseastheyredesigntheirservicesandisalreadybeginningtotransformthinkingacrossthewholehealthsystem.Strategically,HouseofCareisoneexampleofanimportanttransformativewayofworkingandcanbeseenasamodelofchangeacrossmanypartsofthesystem.Itcoordinatesdeliveryofcare,concentratesonwhatisimportanttothepatient,encouragesself-careandmakeslinkstothewidernetworksofsupport.Itmaybecomeastrategicleaderinoursystem.Allofthisis
29Workstream Summaries
consistentwiththeotherpartsof“AchievingExcellence”andwiththeHealthandSocialCareDeliveryPlan3,whichcommittedanadditional£23mtosupportthesenewmodelsofcareacrossScotland.
PharmacistsinPracticesPharmacistsareexpertsinmedicationandintroducingpharmacistsintopracticesettingsshouldassistinqualityimprovementandreleasetimeforotherprofessionalstodeliverontheirspecialistareas.Pharmacistsbegantobeintroducedandtheirimpactassessedin2016.Thelearningfromtheearlyphaseswillbeusedtoextendthisin2017andbeyond.
MentalHealthTransformationScottishGovernmenthasfundedourmentalhealthtransformationplanwhichwilllinkupandsupportthecaredeliveryinmanywaysclosetopracticesandatanearlystageinthepatientjourney.Wewillmeetthementalhealthneedsofpeoplewithotherill-healthproblems.Fromapatient’spointofview,thiswillimproveboththedeliveryofcomplexmentalhealthinterventionsandtheabilitytoreducethedurationofimpactofproblemswithinamentalhealthfield.
WebGP/eConsultThisinitiativeusesinnovativeprocessesalreadyusedinEngland,andisbeingtriedinLanarkshiretoencouragepatientsaccessingtheirpracticetoaccessservicesofallkindsviaadigitalroute.Thiswillincludeemailbasedconsultations.Thishasthepotentialtobringpartsofprimarycareintotheheartofthedigitalage.Itwillbeimplementedfrom2016-2018whereappropriateforindividualpatientsandtheirmedicalcondition.
Therearealsoinitiativesinleadership,useofIThardwareandsoftware,recruitmentandretentionofGPs,andnewdeliveryofpsychologyserviceseachofwhichareofsignificantimpact,butwhenappliedtogetherhavethepotentialtocreatesignificantchange.
Takentogether,thesechangesarerequiredtoprovidebetteraccesstoappropriatecliniciansandothersandenablemanymorepeopletoself-manage(withgoodsupport).Thewholesystemimpactofthisapproachwillreducethepressureonhospitalswhilstexpandingtherangeofcareavailableincommunityandprimarycare.
WhenWillItChange?Asdescribed,somestrategicchangesarealreadyhappeningaspartofthetransformationprogramme.Additionally,thissectionwithintheHealthcareStrategyrepresentsasummaryofworkstartedin2015andcontinuedinto2016.Wewillcontinuetousethislargerbodyofworkfrommanystakeholderstodriveourimprovementsoverthecomingyears.Theprogrammeforimprovementtimescaleissupportedbychangesin2018tothecontractualarrangementsforgeneralpracticebeingledbytheScottishGovernmentandkeystakeholders,andontheworktobesetoutintheStrategicCommissioningPlansoftheHSCPs.
30 Achieving Excellence: Healthcare Strategy
Thelikelymilestoneswillbe:
Phase 1:2016–2018Testsofchangeinpreparationfor2017contract:EmbeddingthestructuresandopportunitiesfromintegrationofHealthandSocialCarePartnerships.Developmentofnewrolesforhealthandcareprofessionalstoenablethemtodeliverawiderrangeoftreatmentsandinterventions.
Phase 2:2018–2020/2021ImplementationofsubstantialchangesrequiredbynewGPcontract.Thisworkwillleadtowidespreaduseofnewroleswithmoreintegratedworking.Wewillimplementworkforceplanstoprovidestaffwhohavetherightskillsandcompetencestomeetchangingpatientandcarerneeds.
Phase 3:2020–2025Consolidationandcompletionofspreadofsuccessesof2018contractandnewservicemodelsusingtheevidencefromthetest-of-changetodemonstrateimprovedaccess,betteroutcomesandenhancedpatientandcarerexperience.
ThestrategicchangeswillcontinuetobeledbythestrategiccommissioningplansoftheHSCPs,theirimplementationplansandtheoutputsfromthetransformationprogramme.
ThetimetabledescribedhereisinrelationtochangesdrivenonaScotland-widebasis.Thereisalsoaneedtodeliverbefore2018substantialchangetoprimarycare.Thecontractualchangescannotlimittheimmediatelyrequiredchangesacrossthewholesectorwhicharealreadydevelopingatpace.
31Workstream Summaries
References1 ChiefMedicalOfficer’sAnnualReport2014–15;ScottishGovernment,2016.2 Pullingtogether:transformingurgentcareforthepeopleofScotland;
ScottishGovernment,20153 HealthandSocialCareDeliveryPlan;ScottishGovernment,2016
WhatWillSuccessLookLike?
Betterclinicaloutcomesforpatients
Speedieraccesstoacareprofessionalwiththerightskillstomeetthepatientneed
Designofcarebuiltaroundneedsandaspirationsofpatientsandcarers
Patientsgoingtohospitalonlywhenthatisthebestplacetomeettheirneedsasmorecarewillbedeliveredat(orcloserto)homewithbetterpatientandcarerexperienceofourservices
Improvedlinkagestostreamlinethepatientjourneyacrosscareboundaries,includingprogressonasingleelectronicpatientrecordtosupportclinicaldecisionmakingwhereverthepatientreceivestheirtreatment
AsustainablelongtermfutureforgeneralpracticebuiltaroundthenewGPcontract,withasmallerGPworkforceworkingaspartoflargermultidisciplinaryteams
Asustainablelong-termfutureforcommunitybasedservicesbuiltaroundavarietyofprofessionalsworkinginthemultidisciplinaryteamswithwiderskills
Greaterself-managementbasedonbetterinformationforpatientsandtheircarersenablingmorechoiceandoptionsforcare
Saferandmorecost-effectiveprescribinganduseofnewertechnologiestosupportallofthesesuccessmeasures.
Reducedneedtoaccesshealthcarebutwhenneededaccessinallitsformsincludingtransportsupportisimproved
32 Achieving Excellence: Healthcare Strategy
LongTermConditions
Vision We will provide integrated care – care that brings general practice and community services closer and crosses the boundaries between primary and community, hospital and social care. We will provide a full range of services for people with long-term conditions (LTCs) in the form of high quality, comprehensive community health care and, when necessary, hospital care. Active and early interventions to prevent the onset of worsening conditions, coupled with more effective management of people living with LTCs, will be pivotal to improving health and wellbeing outcomes for the population.
CurrentServicesServicesforpeoplewithlong-termconditionstendtofocusonasingleconditionmanagementapproachanddonotalwaysconsidertheperson’smultipleconditionsorthepersonasawhole.Existingservicesareprovidedacrossacuteandprimarycareservicesanddonotalwaysmeettheneedsofpeopletoallowthemtoliveasindependentalifeastheywouldwish.
TheNeedforChangeServicesinthefuturewillneedtochangebecauseof:
• AnincreaseinthenumberofpeoplelivingwithLTCs(someofwhichcanbedelayedorprevented)
• advancesinhealthtechniquesandtreatmentsmeanthatpeoplearelivinglongerliveswithlongtermconditions
• increasesinthenumberofpeoplelivingwithcomplexcareneeds(morethan3or4LTCs)
• thehealthneedsoftheLanarkshirepopulationisgreaterthanthenationalaverageformanyindicatorsofhealthinequalities
• patientshavingagreaterexpectationofhealthcare• challengesinavailableworkforcecreatingplanning,retentionand
recruitmentchallenges
WhatWillChange?Theproposedapproachhasbeendesignedasamodelofcarewhichtakesaccountoftheimportanceofmaintainingpeople’swellbeingandprovidingcare,supportandtreatmenttopreventanydeteriorationorexacerbationoftheircondition.Thisintegratedmodelofcarewillbesupportedbythedevelopmentofpathwaysofcarewhichcontainclearthresholdstoassistinstrengtheningawhole-personapproachtothemanagementofthecomplexcareneedsofpeoplewithseveralchronicandlong-termconditions.
• Peoplewillhaveaccesstoarangeofhighqualityservicestomeetphysicalandpsychologicalhealthneeds,aswellaswelfareservicestoprovideawellinformedandsupportiveadvice,support,careandtreatmentservicewithsign-postingtoalternativeorganisationstoensuresupportisavailable.
4.3
33Workstream Summaries
• ThefuturemodelwilldemonstratethatwehavelistenedtopatientswhouniversallysaythattheywishtobetreatedasawholepersonandfortheNHSandsocialcaretoactasoneteam,supportingpeopletoremainintheircommunitieswiththeappropriateinfrastructureofsupport.
• Futurecaremodelswillfurtherimproveservicesforthosepeoplewhohavemorethanonecondition,particularlyadultsandolderpeople,whomayhavepreviouslyfacedanincreasinglyfragmentedresponse.
• Theneedsofpeoplewithlong-termconditionsgobeyondtheorganisationalboundariesofsocialcare,GPs,primarycareandhospitalcare.Thefuturemodelofcarewillreplacethecurrentsystemwhichfeelsdisjointedforindividualpatients,islackingcontinuityandthatevidencesuggestsoftenleadstopooreroutcomesandincreasedhospitaladmission.
Key Point
Amodelforcommunitypractitionershasbeendevelopedtomeettheneedsofthefuturecommunityhealthservicesmodel.Thiswillrequirethecurrentnursesandalliedhealthprofessionalstoworkinnewwaysanddeveloparangeofskillstomeetthechangingneedsoftheirpatients,creatinganenhancedrangeofaccessibleserviceoptionsforpeopletoimprovetheopportunitiestodelivercarewithincommunities.Thefuturemodelwillbefacilitatedbyrobustinformationsystemstosupportthesenewmodelsofcaredelivery.
Wewillprovidesupportatarangeofpoints:1 Asolidfoundationofpopulation-wideprevention,healthpromotionand
targetedhealthimprovementactivity,throughactiontopreventdisease,raiseawarenessofriskstohealthandsupporthealthylifestylechoices.ThiswillinvolveeducationacrosstheagespectrumtobothpreventandreducetheimpactoflongtermconditionsonthepeopleofLanarkshire.Thisisessentialgiventhehighprevalenceoflongtermconditionswhicharepreventable,andthehealthinequalitiesassociatedwithlivingwithlong-termconditions;
2 Self-careandsupportedmanagement,wherepeoplewithlongtermconditionsaregiventheinformationandotherpracticalsupporttheyrequiretomanagetheirownconditionsinawaythathelpsthemusethisinformationtotheirownbenefitwithconfidenceintheirknowledgeoftheirconditionandwhatsupportisavailable;
3 Conditionmanagementinwhichagreaterlevelofprofessionalsupportisrequiredtohelpmanagetheircondition(s)andavoidcomplicationsorslowtheprogressionofdisease;and
4 Forthosewithparticularlycomplexcareneedswhorequiremorefrequentandanintensivelevelofcare,oftenreferredtoascaremanagement,aproactiveandco-ordinatedapproachtoimprovetheirhealthcircumstances,helppreventdeteriorationwherepossibleandmanageexacerbationsandcomplicationsoftheircondition(s).
Throughprovidingthissupport,thehealthandsocialcaresystemwillplaceanexplicitexpectationonusersofourservicestoincreaseself-managementand
34 Achieving Excellence: Healthcare Strategy
intimemakethisthenorm.Primary,communityandsecondarycareserviceswillbeprovidedwhennecessary,thatiswhereotheralternativesandself-managementoflongtermconditionshaveprovedinsufficient.Thiswillsupporthealthservicesbeingmoreaccessibletoallwhennecessary.
NextSteps2 Generalpractice,communityhealthandsocialcareserviceswillwork
togethertodesignanddeveloptherangeofcommunitybasedservicestosupportthepopulationtolivehealthierandhappierlives.
2 Aswemovetoimplementchangewewillmoderniseourworkforcetomeetfuturerequirementswiththecapacityandcapabilitytomeettheneedsofthepopulation.
2 Wewillbuildonareasofgoodpracticeinintegratedcommunityteamsandaddresstheservicepressurestodeliverthecurrentdemandinoutpatientsaswellasthenumberofpatientswhocurrentlyattendandareadmittedtoacuteservices.
WhatWillSuccessLookLike?
Peoplewithlongtermconditions(LTC)willbesupportedtoliveasindependentlivesaspossible
Careacrosscommunityserviceswillbeintegratedtomeettheneedsofthelocalpopulations
WorseningofaLTCwillbeidentifiedearly,throughselfmonitoringorenhancedcommunitymonitoringandtreatedappropriately
oCommunitybasedstaffwillbeskilledandequippedtosupportmorecomplexillnessincaringforpeoplewithLTCthereforepromotingselfcareandbettermanagementofhealthconditions
Transitionsofcareacrossthesystemwillbeseamless,supportedbyrobustinformationsystemsaroundepisodesofcare,creatingcarecontinuums
TailoredcarepathwayswillbedevelopedforpeoplewithLTCstosupportchangesincareneedsandtheabilitytoreturntoahomeortoacommunitysettingasquicklyaspossible
Peoplewillbeinvolvedindevelopingtheircareconsideringalloftheircareneedsandnotdesignedwithasinglediseaseprocessapproach
PeoplewithLTCswillnotrequirehospitaladmissionunlessinthemostacutecircumstances
Asaresultofamoreintegratedcommunityhealthservicepeoplewilllivelongerinanindependentenvironment
35Workstream Summaries
OlderPeople’sServices
VisionWe will promote independent, active and engaged citizenship; ensure clear recognition of crises through shared information between agencies; support active early specialist management of acute illness; facilitate rapid recovery and independence at home or close to home and provide patient-centred, dignified, supportive care to those who require support at the end of life.
CurrentServicesAswedescribedinsection2,peopleinLanarkshirearelivinglonger,moreactivelivesandthistrendwillcontinueintotheforeseeablefuture.ThepartnerorganisationsinLanarkshirehavedevelopedastrongtrackrecordofdevelopingnewandinnovativeservicemodelswhichcanadapttothechanginghealthandsocialcareneedsofpatients,theircarersandtheirfamilies.
Thishasincluded:• testingofdifferentmodelstopreventpeoplebeingadmittedtohospital
andprovidingmoresupportathomeafterdischarge;• linkinghousingservicestosocialcarepackages;• listeningtowhatclients’andcarers’needsare;• movingtoward24hour/7dayperweekcareinthecommunityand
reducingtheneedtoadmitpeopletoolderpeople’shospitalbeds.
Peopleastheyagearelikelytohaveoneormorechronicdiseases.Inaddition,theprevalenceofimpairmentanddisabilityisalsodirectlylinkedwithage.Thepriorityoftreatmentistopreventdependence,declineandphysicalorcognitiveimpairmentwithamovetoearlierintervention,self-managementandenhancedrecovery.
Whatwillchange?Ouraimistoreducedependenceonacutehospitalorresidentialcarebybuildingadditionalcapacityandcapabilitywithinlocalcommunities.OnekeyelementofthisenhancedprovisionistheIntegratedLocalityTeamswhichbringtogetherdistrictnurses,AlliedHealthProfessionals,socialworkers,mentalhealthclinicians,homesupportworkersandgeneralpractitionerstoensurethatthereisaunifiedfocusonprevention,self-managementandsupportand,whereserviceisrequired,toprovideaseamlessapproachtodelivery.
Weneedtochangethewayinwhichhospitalbedsareusedforthecareofolderpeople,withmorefocusonrehabilitationfollowedbysupportathome:morehospitalbedswillbeusedas‘intermediatecare’whichisdefinedbyHealthcareImprovementScotland1as:
‘Intermediate care services provide a package of focused, intensive, time-limited interventions commonly provided in the home or a community setting.’
4.4
36 Achieving Excellence: Healthcare Strategy
Intermediatecarehospitalbedscanbeusedbothtoavoidadmissiontoacutehospitalservicesandalsoaspartofthedischargeandrehabilitationpathwayfollowingaspellinanacutehospital.
Bybuildingthiscapacityandcapabilityinthecommunity–includingearlyaccesstoservicestraditionallyonlyavailableviasecondarycare,wewilllessendependenceonresidentialcarehomesandhospital-basedcare.Thiswillenableanongoingreviewofhowtheseresourcesaredeployedinwayswhichbettermeettheneedsofpatients,carersandfamilies.
Toreducethelengthofstayinhospital,wewillidentifypatients’acute,rehabilitationandhomecareneedsearlierintherecoveryphase.Thiswillincludetheidentificationandallocationofcommunitysupportandinterventions,i.e.moreintensiveearliercare,theninitiationofcomprehensiveassessment.Thiswillreducetheneedforhospitaladmissionsandtimespentinhospitalforthosepeoplewhodoneedtobeadmitted.
Providingsafealternativestoadmittingfrailpeopletoahospitalwillbethemainobjectiveandwillleadtocarepackagesdeliveredbyajointhealthandsocialcareteam,leadingtoongoingrecoveryandrehabilitationinthecommunity.Jointworkingalsoresultsinbetterdischargeplanningandearlierreturntohomeorcommunitycare.
Themodelofservice,whichisclearlyarticulatedintheNationalClinicalStrategy2,willrecognisethattheacutehospitalisasmallpartofthesupportthatpeopleneedtomaintaintheirhealthandwellbeing;themajorityofadvice,supportandcare(includingsomeurgentandnon-urgentacutecare)canbeprovidedintheperson’shomeortheplaceofordinaryresidencesuchasresidentialornursinghome.
37Workstream Summaries
Alllocalitystaffandprimarycareprofessionalswillworkasanintegratedteamandhaveaccesstodiagnosticsandsupportfromacuteclinicaldecisionmakersallowingthemtoprovidesupporttopeopleacrossthespectrumfromprimarypreventionthroughtoacutecareathome.Thelocalityteamwillincludeallhealthandsocialcarestaffincludingconsultants,GPs,thethirdandindependentsectorsandwillbeabletoharnessarangeofthirdsectorandcommunityassetstosupportitswork.
Supportingindependence,givingchoiceandcontrolthroughsignpostingandgivingnonservicebasedoptionswillbeakeyfocusofplanningwithinlocalitiesaswillthefollowing:
WhatWillSuccessLookLike?
Carersandfamilywillbesupportedandenabledtoprovidecarethroughappropriateadviceandsupport
Communitycapacitywillbedevelopedandcommissionedonlocalityneed
Personaloutcomesareattheheartofdecisionmaking
Servicesareprovidedfromafullyintegratedhealthandcareservice.
Olderpeoplewillspendlesstimeinhospitalbeds
Delayeddischargeswillbeeffectivelytackledbyallcareproviders
Greaterleveloftreatmentandcarewillbeprovidedathome
Peoplewillbeenabledtolivelongerathomeorinahomelyenvironment
References1 HealthcareImprovementScotland.CareofOlderPeopleinHospital
Standards,Standard12.2 ANationalClinicalStrategyforScotland;pp65;ScottishGovernment,2016
38 Achieving Excellence: Healthcare Strategy
MentalHealthandLearningDisability
VisionThe Mental Health and Learning Disability (MH&LD) element of the strategy proposes further expansion of our focus on prevention; supporting people to look after their own mental health wherever possible; building stronger, more resilient, better informed communities; and providing consistent advice, information, support and care so that fewer people require specialist mental health services. Those who require mental health or learning disability services will receive the majority of these in their local area. We aim to provide person-centred, clinically effective, safe mental health and learning disability care, where required, which is of the highest quality.
Of paramount importance is the principle that there is no health without good mental health. Every part of the health and social care system is therefore required to play a more active part in improving the mental health and well-being of people with whom they work and by doing so contribute to the well-being of the population through collective action.
TheimplementationofthisvisionwillbegreatlyassistedbytheScottishGovernmenttoinvest£150minimprovingmentalhealthservices1.
CurrentServicesTheMH&LDserviceisaLanarkshire-wideservicehostedwithinHealthandSocialCareNorthLanarkshire.TheMH&LDServiceprovidesinpatientandcommunityservicesforpeoplelivinginLanarkshireaged16toendoflife.Thereareapproximately1,200MH&LDhealthstaffbasedacrosstheservice.
InpatientProvisionTheMH&LDservicecurrentlyprovidesinpatientcareforacuteadmission,rehabilitationandrecovery,forensiclowsecure,intensivepsychiatriccare,learningdisabilityassessmentandtreatmentandcontinuingcare.Thisisprovidedwithin17wardsbasedovereightsitesacrossLanarkshire.Inaddition,urgentassessmentandliaisonservicesareavailable24/7atthethreedistrictgeneralhospitalsbothinemergencydepartmentsprovidingadvice,assessmentandsupportandthroughoutthegeneralacutehospitalwards.Thereisacommitmenttosustainingaccesstospecialistassessmentandinitialtreatmentatallthreehospitalsites.
Hospitalcareremainsavitalaspectofthemodelofcarebutisincreasinglybeingusedfortheshortesttimerequiredforsafetyandclinicaleffectiveness.
CommunityProvisionThecommunityprovisioniscentredonmulti-disciplinarycommunitymentalhealthteamsforadults,olderpeople,andcommunity-basedpsychologicalserviceswithineachofthe10localities.Thesecommunityservicesprovide
4.5
39Workstream Summaries
arangeofinterventionsfromlowlevelinputsthroughtohighintensitysupportforpeoplewithcomplexneeds.Localityservicesaremulti-agencyandincludecolleaguesfromNorthandSouthLanarkshireCouncils,thethirdandindependentsectorsandserviceuserandcarerorganisations.AdditionallythereareLanarkshire-widespecialistcommunityserviceswhichincludelearningdisability.Thesecommunityservicesareanessentialpartoftherangeofservicesthatneedtobeavailableforpeoplewithlearningdisabilities.Theyhaveimportantrolestoplayintraining,facilitatingaccesstomainstreamservices,healthpromotion,healthscreeningandtheprovisionofspecialistassessment,interventionsandmonitoring.
NeedforChangeByshiftingthebalanceofcarefromhospitaltocommunitylocality-basedcareandincreasinglydeliveringcarethroughatieredmodel,LanarkshireMH&LDServicehasseenasignificantimprovementinsafe,efficient,person-centredcarewhileatthesametimeimprovingcapacitytomeetincreasingservicedemand.Thissignificantservicechangehasseenareductioninbedswithanincreaseinoccupancywhileatthesametimeareductioninlengthofstayandreadmissions.Theimplementationofthetieredmodelhasseenanincreaseincommunitycapacitywhichhassupportedimprovedaccesstolowertierinterventionsanduseoftechnologyenabledcareandadecreaseinwaitingtimes.
LanarkshireMH&LDservicehasconsistentlyperformedwellagainstnationaltargetsandstandards,beingoneofthebestperformingBoardsinScotland.However,therearestillsomeareaswherematchingcapacitytomeetdemandremainachallenge.Theseinclude:
• postdiagnosticsupportfordementia• clinicalhealthpsychologyincludingneuropsychology• developingasustainableseniorandtraineemedicalstaffingmodel• inpatientnursingstaffacrossmentalhealthandlearningdisabilitywards• servicesforadultswithautism• providingfit-forpurposeclinicalaccommodation• reviewingthebalancebetweenlevelsofsecureforensiccare
Theneedtomeetthesedemandscanbesupportedbycontinuingthemodernisationprocessthathasdeliveredatransformationinqualityofservicesoverthelastdecade.Furthermodernisationwillincludeprogresstowardsthegoalofbringingspecialistadmissionbedsformentalhealthontotwodistrictgeneralhospitalsites(withinNorthandSouthLanarkshire,respectively).Theprovisionofbedsontwositeswillbesupportedbyfurtherdevelopmentofassessmentandinitialtreatmentcapacityonallthreesites.Furtherdetailedstakeholderinvolvementwilltakeplaceaspartoftheprocessofmovingtowardsthisgoal.
In2016wesawtheintegrationoffunctionalassessmentbedsforolderpeople,inCoathillHospitalandAirblesRoadCentre,intomorefit-for-purposeaccommodationinWishawGeneralHospital.Furtherconsiderationwillalsobenowgivento‘bestfit’ofadultandolderpeople’swardsacrosstheestateandtopotentialsolutionsforolderadults’inpatientservicesinSouthLanarkshirethat
40 Achieving Excellence: Healthcare Strategy
willinduecoursemovetoHairmyresHospital.Thesemoveswillhelpensurethatmentalhealthinpatientfacilitiesbestmeetthehighestspecificationswithpatientsafety,dignityandcomfortasprincipleaims.
WhatWillChange?
Community• Afurthershifttowardsaperson-centredapproachthatencourages
selfmanagementandfamily,carerandpeersupport.Prevention,earlyidentificationandinterventionformentalhealthproblemsinprimarycaresettingswillbesupportedthroughincreasedmultiagencyworkingaspartoftheprimarycaretransformationprocess.
• oIntegratecommunitymentalhealthserviceswithwiderhealthandsocialcarefunctionsatlocalitylevelinbothNorthandSouthLanarkshire,usinglocalassetsandresourcestosupportimprovedmentalhealthforall.
• Improvethephysicalhealthofpeoplewithmentalhealthproblemsand/oralearningdisabilityandimprovethementalhealthofpeoplewithco-morbidphysicalillness.ToincludethedevelopmentofaclinicalhealthpsychologyserviceacrossLanarkshirefocusingonco-morbidphysicalhealthandmentalhealthconditions,andmedicallyunexplainedsymptoms.
• Furtherimprovecarepathwayswhichsupportaccesstoandintegrationofserviceswhichincludeprimarycare,acutecare,independentsectorandvoluntaryorganisations.
• Addressspecifichealthinequalitiesofpeoplewithalearningdisabilitythroughhealthimprovement/healthpromotioninitiatives.
• Animprovedresponsetocrisisand/ordistresswillbeprovidedbyamulti-agencyapproachofferingimprovedaccesstobriefinterventions.
Hospital• Pursuestrategicintentforadultandolderpeople’smentalhealthacute
admissionstomovetoatwositemodelondistrictgeneralhospitalsites.• Completeolderpeople’smentalhealthinpatientmodernisationplanfor
acuteadmissions/hospitalbasedcomplexcare.• ReviewofLanarkshireservicemodelforforensicinpatientandcommunity
servicesandinformworkoftheNationalForensicNetworktoassessfutureneedsforhigh/medium/lowsecureprovision
• AllwardswillhaveaQualityImprovementGrouptoallowlocalfocusonsafeandclinicallyeffectivecare
• ReviewofLanarkshireservicemodelforrehabilitationandrecoveryinpatientandcommunityservices
• IncreasecapacityofmentalhealthliaisonserviceinallthreeDGHstoensuregoodmentalhealthserviceprovisionateachsite
41Workstream Summaries
We will also:• Strengthenpartnershipworkingbetweenhealth,thecouncils,thethird
sectorandotherkeypartners,buildingonexistingjointandintegratedworking
• Developaninformationsystemwhichworksacrosssectors,providingbothquantitativeandqualitativeinformation,andwhichprovidesabasisforinformationsharingacrossservicesinvolvedinsupportandcare.
• EnsuretheMH&LDinpatientandcommunityestateisfitforpurposetosupportthedeliveryofsafeandeffectivecareintherightsettingtomatchanindividual’slevelofneedatanypoint.
• Resolvemedicalstaffingissuesatseniorandtraineelevels• Provideagoodfitforfluctuatingdemandforthethreelevelsofsecurecare.
WhatWillSuccessLookLike?
Increasedfocusonpreventionandearlyintervention
Morepeopleabletolookaftertheirownmentalhealth
Betterinformed,moreresilientcommunities
Morepeopleabletolivewithmentalillhealthoralearningdisabilityunaffectedbystigma
Provisionofeasilyavailableandconsistentaccessibleinformation;advice;support;highquality,safe,locallybasedcarewhenrequired
Fewerpeoplerequiringspecialistcommunityorhospitalbasedserviceswitheaseofaccessandflowthroughforthosethatdo
Narrowingoftheinequalitiesgap
Provisionofservicesthatrecognisethediverse/complexhealthneedsofpeoplewithlearningdisabilities
References1 HealthandSocialCareDeliveryPlan;ScottishGovernment,2016
42 Achieving Excellence: Healthcare Strategy
AlcoholandDrugs
Vision We will continue to develop a recovery orientated system of care which has at its heart the needs of individuals, their children and other family members affected by alcohol and drug problems.
Thenationalalcoholstrategy,Changing Scotland’s Relationship with Alcohol: A Framework for Action1 2009,andthenationaldrugstrategy,The Road to Recovery: A New Approach to Tackling Scotland’s Drug Problem2 2008,willcontinuetoprovidetheframeworkfordeliveringalcoholanddrugprevention,treatmentandsupportservicesinLanarkshire.TheLanarkshireAlcoholandDrugPartnership(ADP)isresponsibleforimplementingthesenationalalcoholanddrugstrategieswithineachofourlocalauthorityareas.
CurrentServicesAllofouralcoholanddrugservicesrecognisethatrecoveryisnotsimplyabouttacklingthesymptomsandcausesofdependence,butaboutenablingpeopletosuccessfullyreintegratebackintotheirfamilyandlocalcommunities.Itisalsoaboutensuringthattheyhavesomewheretolive,somethingtodoandtheabilitytoformpositiverelationshipswithothers.ThisincludesensuringthatthereisafullrangeofserviceswithineverylocalityinLanarkshire.Theseservicesinclude:identifiablecommunityrehabilitationserviceswhichhavepeoplewithlivedexperiencewithintheirstaffingcomplements;accesstodetoxificationandresidentialrehabilitation;accesstoafullrangeofpsychologicalandpsychiatricservicesandproactiveengagementwithemployabilityandaccommodationproviders.
Gotowww.lanarkshireadp.orgforfurtherdetailsoftheservicesavailableacrossLanarkshire.OurDeliveryPlanalsoprovidesthisinformation.
TheNeedforChangeThelifecourseperspectivereferstoanapproachwhichrecognisesthestructural,social,andculturalcontextsinwhichweliveandwork.Indoingso,itreflectstheimportanceofourearlyyearsandhowthisimpactsonarangeofotherhealthandsocialindices.Additionallytherefore,wewillstrivetopromotehealthandwell-beingwithinourwidercommunitiesbytacklingtheunderlyingrootcausesofalcoholanddrugproblemsincludingtrauma,socio-economicdeprivation,familybreakdown,poverty,mentalill-healthandcrime.
Moreover,theissuesassociatedwithsocialexclusionandhealthinequalitiesforpatientsonlongtermopiatereplacementtherapy(ORT)aredeepening.ThedemographiccharacteristicsofthoseusingsubstancesthatmightbenefitfromORThavechangedinrecentyears.Theaverageageofthegrouphasmarkedlyincreasedsuggestingthatthedegreeofbothphysiologicalandpsychologicaldifficulty,alreadyhigh,islikelytoincreasefurther.Equally,ashealthinequalitiescontinuetoincreasesotheeffectsonthisalreadydeprivedandmarginalisedgroupwillbecomemoreextreme.Thesefactorsfurthercompoundedbythe
4.6
43Workstream Summaries
effectsofstigma,willproduceapictureofincreasinglycomplexsocialandmedicaldifficultywhichwillrequireamorecoordinatedapproachfromallprovidersofsocialandmedicalcarethaniscurrentlythecase.
IndevelopingtheLanarkshire Alcohol and Drug Partnership Strategy3,wehavethereforeincludedtheviewsofserviceusers,theirfamilymembers,carers,staffworkingwithinourtreatmentandcareservices,membersofourthirdsectorandcommunitygroupsaswellasotherkeycommunityplanningpartners(housing,mentalhealth,criminaljustice,education,socialworkandpolice).Wehavealsoreviewedanumberoflocalplansandnationalstrategiestoensurethatwearereflectingthekeyprioritiesofourcommunityplanningpartners.
ContinuinginvestmentbytheScottishGovernmentalsoprovidesanopportunityforourADPtomakeconsiderableprogresstowardsachievingthenationaloutcomesandministerialprioritiesassetoutinthenationalstrategies
WhatWillChange?ThecommunityplansandsingleoutcomeagreementsforbothNorthandSouthLanarkshireCouncilsoutlinetheprioritiesforLanarkshire’scitizensandcommunitiesinthefuture.Thesearetheoverarchingstrategydocumentswhichlinktothepriorityoutcomeswehopetoachieve.Wehavereflectedtheseprioritieswithinourstrategyandwillworkwithourcommunityplanningpartnersoverthenextthreeyearstoreportonourprogress.FurtherinformationonhowthiswillbeachievedisincludedinourdeliveryplansforNorthandSouthLanarkshire(2015–2018).
ThereisalsoasuiteofnationalrecoveryindicatorswhichformpartofthenationalDrugandAlcoholInformationSystem(DAISy)databasewhichwillbeusedfrom2016.Wewillthereforeworkinpartnershipwithourlocalstatutoryandthirdsectorproviderstoensurethattheseareincludedwithinourservicelevelandpartnershipagreementsinorderthatwecanmeasuretherecoveryoutcomesforallclientswithinourtreatmentandcareservices.
WhatWillSuccessLookLike?
Recoveryorientatedsystemofcarearedevelopedwithinourcommunities
Adults,includingparentsandolderpeoplewithalcoholand/ordrugrelatedproblemsaresupportedtoreceivetherightkindofservice,intherightplaceattherighttime
Theinterestsofchildren,youngpeopleandyoungcarersaffectedbysubstancemisusearesafeguardedandpromoted
Speedyaccesstowiderhealthcareservices(suchasprimarycare,sexualandreproductivehealth)
44 Achieving Excellence: Healthcare Strategy
References1 ChangingScotland’sRelationshipwithAlcohol:AFrameworkforAction.
Edinburgh:ScottishGovernment,20092 TheRoadtoRecovery:ANewApproachtoTacklingScotland’sDrug
Problem.Edinburgh:ScottishGovernment,20083 LanarkshireAlcoholandDrugPartnershipStrategy:
www.nhslanarkshire.org.uk/boards/2015-board-papers/Documents/August/15-ADP-Strategy-2015-18--August-2015-Board.pdf
45Workstream Summaries
Maternity(IncludingNeonatal),EarlyYears,ChildrenandYoungPeople
Vision All children and young people will have the best possible start in life and reach their full potential – regardless of their starting point. We will improve health and wellbeing outcomes by delivering targeted early intervention and prevention from services which are designed and delivered to reduce inequalities and best meet the changing needs of women, children and their families achieving generational changes by 2025.
CurrentServicesUniversal and Additional Service Provision: NHSLanarkshiretogetherwiththeirpartnersinNorth&SouthLanarkshireareintheprocessofadoptingtheUniversalPathwayforchildrenandyoungpeoplesetoutinGettingItRightForEveryChild(GIRFEC)1nationalguidancewhichspanstheearlyantenatalperioduntilthechild’s18thbirthday.InadditiontherearenationalandtargetedinitiativessuchasFamilyNursePartnership,EarlyYearsCollaborative2andFirstStepswhichprovideafocusofintensivesupportforparticularcohortsofthepopulationfromtheantenatalperiodintothepostnatalperiodandbeyond.
Maternity and Neonatal Services withinNHSLanarkshirearedeliveredfromawiderangeofcommunitysettingsincludingthewoman’sownhomeandWishawGeneralHospital.TheNeonatalIntensiveCareUnitiscapableofcaringforthesmallestandsickestofnew-bornbabiesdeliveredbothwithinWishawGeneralHospitalandthosetransferredinfromotherMaternityUnitsacrossScotland.
Community and Primary Care: Mostoftheactivityrelatedtochildreniscarriedoutinthecommunity.Generalpracticeactivityislargelyconcernedwithchildrenpresentingwithacuteillness.InadditiontothishoweversomechronicconditionswhichwerepreviouslymanagedinanacutesettingarenowalmostentirelymanagedinaGPsetting,e.g.asthma,teenageacneandchildhoodeczema.NursesandAlliedHealthProfessionalssupportGPpracticestoofferbothspecialisedclinicsandone-to-oneconsultations.
Hospital Care: forchildrenisconcentratedonasinglesiteatWishawGeneralHospital.GPsreferchildrentoWishawHospitalforemergencytreatmentorcanaccessspecialistpaediatricadvicefromthePaediatricUnit.OutpatientconsultantclinicsareheldonallthreeacutehospitalsitesandalsoinhealthcentresacrossLanarkshire.Clinicswhicharemorespecialistaregenerallyfocussedonthethreeacutesites.ThosechildrenwhocannotbetreatedlocallyarereferredtotheRoyalHospitalforChildreninGlasgow.
Thereareintotalapproximately30,000attendancesperannumatthethreeEmergencyDepartments(EDs)withinLanarkshireforpatientsagedunder16,ofwhicharound80%areclassedasminorinjuryandillness.
4.7
46 Achieving Excellence: Healthcare Strategy
TheNeedforChangeItisessentialthattheservicesweprovidetochildren,youngpeopleandtheirfamiliesaretimely,ofhighquality,efficientandcontinuallyimproving.WeneedtodemonstratethroughtheservicesweprovidethatweunderstandthehealthneedsofLanarkshire’schildrenandyoungpeopleandthatweareresponsivetothem.
• Mostoftheactivityrelatedtochildreniscarriedoutinthecommunity,notinhospitals,andsodevelopingcommunityteamsmustbeourpriority.
• Maternalobesitylevelsareexpectedtorisefromthecurrentlevelof20%toaconservativelyestimated30%by2030.Thiswillincreasethecaesareansectionrates,whicharecurrentlyathirdofalldeliveries.Therefore,hospitalmaternityserviceswillneedtoadapt.
• Thereisanissueofcotspacingwithintheneonatalunitwhichwillneedtoberesolved.
• WecanexpectthepopulationofchildreninLanarkshiretofall,andsoourpaediatricmodelsofcarewillhavetoadapt.
• Thereareapproximately30,000attendancesperannumatEmergencyDepartments(EDs)forpatientsagedunder16,ofwhicharound80%areclassedasminorinjuryandillness.Dataanalysissuggeststhatalargeproportionofthesechildrencouldbemanagedbetterinprimarycare,withspeedieraccessandbetteroutcomes.
• Generally,healthandlifeoutcomesforthosechildrenbornintopovertyarepoorerwhencomparedtochildrenwhoarebornintomoreaffluentlifecircumstances.LikewisethehealthandlifeoutcomesforLookedAfterChildrenaregenerallymuchpoorerthanthosewhoarenot.
• TheChildrenandYoungPeople(Scotland)Act2014requiresustostrengthenthefocusontherightsandwellbeingofindividualchildrentoenablethemtoachievetheirfullpotential.
WhatWillChange• Improvedhealthandwellbeingoutcomesforthisparticularpopulation
willonlybeachievedthroughdeliveringtargetedearlyinterventionandpreventionfromserviceswhicharedesignedanddeliveredtoreduceinequalitiesandbestmeetthechangingneedsofthewomenandchildrentoachievegenerationalchange.InlinewiththeChildrenandYoungPeople(Scotland)Act2014childrenandfamilieswillbenefitfromenhancedsupportfromuniversal(midwiferyandhealthvisiting)andAHPservicesenablingearlieridentificationofneedandsubsequentappropriateintervention.AllchildrenandyoungpeopleinLanarkshirewillhaveaNamedPersonwhowillberesponsibleforpromoting,supportingandsafeguardingtheirwellbeing.
• SupportwillbegiventotheCommunityPlanningeffortstoaddressthewiderissueofobesity.Specificfocuswillbeplacedonintensivesupporttowomenbefore,duringandafterpregnancy.Lengthofstayforobesepregnantwomenrequiringplannedcaesareansectionwillreduceasaresultofanenhancedrecoveryservice
• Wewillimplementtherecommendationsoftherecentlypublishedreport“TheBestStart:AFive-YearForwardPlanforMaternityandNeonatalCareinScotland”3
47Workstream Summaries
• Neonatalserviceswillberedesignedtoensureappropriatecapacityandimprovedcotspacing.
• AsopposedtoattendingA&Eunnecessarily,pathwayswillberedesignedtoensurethatchildrenandyoungpeoplearetreatedinthecommunitywhenclinicallyappropriate.
• WewillredesignourservicestosupportourmostvulnerablechildrenandyoungpeoplesuchasChildrenwithLearningDisabilities,thosewithComplexCareNeedsandLooked-AfterChildrentoimprovetheirhealth,wellbeingandlifechancesastheytransitionintoadultservices.
• Datasystemswillbereviewedtoensureidentificationofneedandrisksinvulnerablepopulations.
WhatWillSuccessLookLike?
Overall,wewillfocusonthedeliveryofthekeyoutcomessetoutintheChildrenandYoungPeople’sHealthPlantoensure:• Thehealthandwellbeingofchildrenandyoungpeopleisimproved
andthestretchaimsoftheEarlyYearsCollaborativeareachievedandexceeded
Deliveryoftargetedearlyinterventions• Reducingtherateofincreaseinmaternalobesitylevels• Reducingfoetalalcoholspectrumdisorderlevels• Enhancingsupportforperinatalmentalhealth• Enhancingthemultiprofessional/agencyinterface
Deliveryofincreasinglypersoncentredmaternityandneonatalservices• Enhancingearlypregnancyassessment• Enhancingthemodelofparenthoodeducation• Reducinginappropriateinterventions• ReducingneedtotransferbeyondLanarkshire
DeliveryoftheStretchAimsoftheEarlyYearsCollaborative• Womenexperiencepositivepregnanciesandtheratesofstillbirth
decreaseby15%• 85%ofallchildrenreachalltheirexpecteddevelopmentaloutcomesat
thetimeoftheir27–30monthchildhealthreview• 90%reachtheirexpecteddevelopmentaloutcomesatthetimethechild
startsprimaryschool• 90%ofchildrenachievetheirdevelopmentalandlearningoutcomesby
theendofprimary4
Deliveryofincreasinglypersoncentredpaediatric,childandadolescentmentalhealthservices(CAMHS)• Enhancingoutofhoursservicesforchildren• EnhancingaccesstoCAMHSupto18yrs• ReducingminorEDAttendances• Reducingno-showratesatcommunityandhospitalclinics• Childrenandyoungpeopleexperiencesmoothandefficienttransitions
References1 Gettingitrightforeverychild(GIRFEC);ScottishGovernment,20042 www.gov.scot/Topics/People/Young-People/early-years/early-years-
collaborative3 TheBestStart:AFive-YearForwardPlanforMaternityandNeonatalCarein
Scotland;ScottishGovernment,2017
48 Achieving Excellence: Healthcare Strategy
Deliveryofmorewithless• Buildingcommunitycapacitytoreduceinequalities• E-enablingtheworkforce• Remodellingclinicprovision• Strengtheningoutcomefocusedapproachtoinformcontinuous
improvement
49Workstream Summaries
PlannedandUnscheduledAcuteCare
Vision Our Health and Social Care Partnerships (HSCPs) will commission services that support people in the community and avoid hospital admission. Both Partnerships will aim to ensure that social work and community health support and services for people who are admitted to hospital are better aligned so that our discharge processes from hospital are as smooth as possible.
Acute hospital teams will work with our partner agencies and clinical teams in community and primary care settings to ensure the demand for planned and unscheduled services is delivered by the most appropriate healthcare professional, in the most appropriate location, through the development of clinical and service models designed to meet the assessed needs of the population.
CurrentServicesEachofourthreeacutehospitalsWishaw,HairmyresandMonklandshasthefollowingcoreservices:
• anemergencydepartment(ED),• acutemedicalandsurgicalservices• diagnosticsandimaging• operatingtheatresandcriticalcare• outpatientservices
Clinicalservicesoneachhospitalsitearerelevanttoeachhospital’sbedconfigurationsandservicemodelsarearrangedaroundour‘CentresofExcellence’2inLanarkshirewhereindividualspecialtyservicesdelivercareforthewholeoftheLanarkshirepopulationwithconsistentlyhighlevelsofclinicalqualityandpatientsatisfaction.Thesearearrangedasfollows:
MonklandsDGH HairmyresHospital WishawGeneralHospital• ENTsurgery• Haematology(cancer)• Histopathology• Infectiousdisease
medicine• LanarkshireBeatson
(radiotherapy)• Renalmedicine• Urologysurgery
• Interventionalradiology
• Ophthalmologysurgery
• Optimalcardiacreperfusion
• Vascularsurgery
• Bariatricsurgery• IntensivePsychiatric
Care• Maternity&neonatal• Paediatricservices• SpecialistLabservices
TheseservicesareunderpinnedbyclearpatientpathwayssupportedbytheScottishAmbulanceService,NHS24andPrimaryCareOutofHoursServices.
4.8
50 Achieving Excellence: Healthcare Strategy
TheNeedforChange
Key Points
• In2016Lanarkshireresidentsusedtheequivalentof1,750acutehospitalbeds;mostlyinLanarkshire,butalsointheGlasgowandLothianacutehospitals
• Ifwedonotchangeourmodelsofcare,thepopulationneedsassessmentshowsthatthiswillrisetoover2,200by2025:nearlya30%increasewhichwouldrequireover500morehospitalbeds,theequivalenttoanotherDistrictGeneralHospital
• Tostandstill,admissionsand/orhospitallengthsofstaymustreduceby25%inthenext10years.
• Theserviceredesignworkbothinhospitalsandinthecommunityoverthelast10yearshasalreadydelivereda29%reductioninlengthsofstayinhospital.
ChangestoSpecificClinicalSpecialties
a Gastroenterology and Upper Gastrointestinal (GI) CareDuringthelast15yearstherehasbeenasignificantchangeinthenumberofgastroenterologyandupperGItreatmentswhichcannowbedeliveredbykeyholesurgeryorusingendoscopes,whichmeansthatmanypatientshaveashorterlengthofstayinhospital.Thereiscurrentlyadifferentmodelofcareinplaceoneachsite.Animprovedclinicalmodel,asingleCentreofExcellencewithinLanarkshire,couldbecreatedtodealwithpatientswithseveregastricbleeding.Forpatients,thiswouldensurebetterclinicaloutcomesandabetterpatientexperience,basedonamulti-disciplinaryapproachformanagementbetweenendoscopictechniques,interventionalradiologyandsurgery.Wewillexplorethisideafurtherin2017andbeyond.
b TraumaHealthcareservicesmustconstantlyadapttotheevolvingneedsofthepopulation.TheAcademyofMedicalRoyalCollegesandFacultiesinScotlandevidencedtheneedtoreconfigureorthopaedicservicestoprovidetheconsolidatedclinicalteamswhoworktogethertoimprovethequalityofourservices,theclinicaloutcomesandexperienceofourpatientsandoptimisetheuseofourresources.
TheNHSLanarkshireBoardhasacceptedthatthefirstchangethatNHSLanarkshiremustmaketoacuteservicesisintheprovisionoforthopaedicsurgery.InkeepingwiththeNationalReportonTraumaServices,andtheNationalClinicalStrategy2,themosteffectiveandefficientwaytomeettheneedsofpeoplewithseveretraumaticinjuriesmustbeprovided.TheAcademyofMedicalRoyalCollegesandFacultieshasspecificallyaskedNHSLanarkshiretoconsidercreatingatraumaservicewithinpatient
51Workstream Summaries
servicesbasedatasinglehospitalsite.Thiswillbeamajorchangeintheconfigurationofseveralkeyacutespecialties(includingcriticalcare,generalsurgery,orthopaedicsandrehabilitation).Thisworkwillrequiretimetoplanandimplement.IntheinterimsteptowardsthisinNovember2016wereconfiguredorthopaedicinpatientservicestobesharedbetweenHairmyresandWishaw(seealsosection4.9).
WishawGeneralHospitalwillbeatraumaunitaspartoftheWestofScotlandTraumaNetworkcentredattheQueenElizabethUniversityHospital’snewMajorTraumaCentreinGlasgow.Thiswillseethedevelopmentofimprovedpatientpathwaysforthosewhosuffermajortraumaticinjury,andtheaugmentationofthehealthcareworkforcetodeliver24/7integratedcareacrossarangeofclinicalspecialtiesparticularlyemergencymedicine,criticalcare,generalandemergencysurgery,orthopaedics,paediatricsandimaging.Shoulditprovepossibletoresourceasingletraumasiteinfuturewithoutsubstantialdisruptiontootherkeyservices,thiswouldbelocatedatWishawGeneralHospital.
c Impact of Glasgow changes in hospital servicesThechangestoGlasgow’shospitalservicesin2015sawastep-changeincreaseintheunscheduledcareactivityatHairmyresHospitalandacorrespondingincreaseinthecapacityofthehospital’semergencycareteams.ThepatternofpatientflowsacrossEastRenfrewshire,SouthGlasgow,RutherglenandCambuslangwillcontinuetobecloselymonitoredbutincreasedregionalworkingislikelytobeagrowingfeatureofhealthcaredeliveryinthefuturewithlessemphasisonwhichNHSBoardpeoplelivein.ThisisexpectedtohaveasignificantimpactonthefuturedevelopmentofbothgeneralandspecialistregionalservicesatHairmyresHospital.
d Other areas of possible changeThecontinuedcapacityforophthalmologyprocedures,e.g.cataracts,tobeprovidedatHairmyresHospitalwillbereviewedin2017inconjunctionwithregionalplansforcapacityattheGoldenJubileeNationalHospital.
Theprovisionofvascularsurgeryandinterventionalradiologyserviceswillalsobereviewedinconjunctionwithregionalplansbasedonavailabilityofspecialistexpertiseacrossanumberofhealthboards.
Wewillseektogetthebestclinicaloutcomesthroughensuringspecialistsurgery(eitherinvolvingovernightstaysorasadaycase)isprovidedsafelyandeffectivelyaspartoftheCentresofExcellenceconcept.
TheScottishGovernmentwillcreateaseriesofdiagnosticandelectivetreatmentcentreswhichwillaffecthowplannedorthopaediccareisdelivered(seesection4.9).
52 Achieving Excellence: Healthcare Strategy
WhatWillChange?
a On all three hospital sites
Key Point
EachDGHwillcontinuetohavestaffingandinfrastructuretodeliveremergencycarethatincludes:• Anemergencydepartment(ED)• Acutemedicalandsurgicalservices• Diagnosticsandimaging• Operatingtheatresandcriticalcare• Outpatientclinics
Weplantocontinuetoprovideacomprehensiveprogrammeofplannedcareacrossthethreeacutehospitalsites,butreducetheproportionofcarewedeliverwhichisunscheduledinnatureandonlyuseemergencyinpatienthospitalservicesasalastresort.Thiswill,inturn,allowustoshiftresourcesanduseagreaterproportiontodelivermoreplannedcareinhospitalandinthecommunity.Thiswouldreducetheneedforinpatientstaysinhospital.
Inthemain,patientswouldhavetheirclinics,pre-admissionassessmentandrehabilitationlocallyattheirDGH,butwithspecialistsurgeryprovidedincentresofexcellencecoveringthewholeLanarkshirepopulation(asisthecaseatpresentformanytypesofsurgery–seetableabove).Thismayinvolvefurtherconcentrationofdaysurgeryprocedures,and/orshiftingsomeclinicalproceduresfromoperatingtheatrestooutpatientclinictreatmentrooms.
WeplantodeliverRealisticMedicine1eliminatingprocedureswithlowclinicaleffectiveness,improvingouruseofmedicinesandreducingvariationinclinicalpractice2.
Thesethemeswereexploredfurtherthroughtheconsultationprocessandwerebroadlysupported.Membersofthepublicconsideredthatmoreemphasisneededtobegiventoprevention,self-managementandrealisticmedicineapproachesincludingimportantconversationsaroundmedicalinterventionsandlikelyoutcomes.
Peoplealsowantedtounderstandwhatrealisticmedicinewouldmeaninpractice,forexample,inthedeliveryofcancercare.Ourclinicalstaffgavestrongsupportforrealisticmedicine,recognisingthatwithoutthiskindofapproachthestrategywouldnotworkandacknowledgingtheworkalreadybeingprogressedacrosstheBoardtoprogressguidelinesandimportantareasofworksuchasanticipatorycareplans.LikewisetheRoyalCollegeofNursingreiteratedtheirpositionofsupportingtreatmentwhichisminimallydisruptiveandbasedonrealisticoutcomes.Wheremedicationswerediscussed,peoplewerecomfortablewitharealisticmedicineapproach,usingthecheapestavailableifqualityisassuredandmaximisingtheuseofcheapergenericdrugswhereverpossible.
53Workstream Summaries
b Monklands
Key Point
NHSLanarkshireisnowpreparingabusinesscaseforamajornewdevelopmenttoreplacetheexistingMonklandsHospital,creatingamoderninfrastructurethatwillhelptosupporttheredesignofservicemodelsforbothhospitalandcommunitycare.Thiswasstronglysupportedduringourconsultationprocess.
Theplanningprocesswillcontinueinto2018andsubsequentbuildingworkwilltakeseveralyears.ThiswillprovideauniqueopportunitytoensureourspecialistacuteservicesandCentresofExcellencecanbedevelopedfurtherandfullyintegratedintocommunity-basedservices.
Intheshort-termweplantoenhanceourexistingfrontdoorfacilitiesandemergencydepartmentontheMonklandssiteandcreateimprovedfacilitiesfordaysurgeryandasame-dayadmissionsunit.
Wewillprepareplanstocreateasinglecentreofexcellenceforthegastrointestinal(GI)bleedingservice.
WeplantoconsolidatecancerservicesinacentreofexcellenceatMonklands.WhilecancercareforLanarkshireresidentswillcontinuetobeprovidedatHairmyres,Wishaw,theBeatsonCancerCentreandelsewhere,theplanningassumptionwillbethatwherecancerservicesaredevelopedinthefuture,anyexpandedcapacitywouldbeco-locatedwiththeexistingcancerservicesatMonklandsHospital(seealsosection4.10).
Longer-term,plannedorthopaedicsurgeryisproposedtobeconcentratedonasinglesitewhichislikelytobeeitherHairmyresorMonklands(seesection4.9).
c HairmyresHairmyresHospitalbecamethesecondinpatientunitinLanarkshire,alongsideWishawGeneralHospitalinaninterimreconfigurationoforthopaedicservicesin2016.Asstatedabove,longer-term,itisproposedthatelectiveorthopaedicswouldbeconcentratedonasinglesitewhichislikelytobeeitherHairmyresorMonklands(seesection4.9).Hairmyreswillalsoseenewfacilitiescreatedforophthalmology.
d WishawIntheshortterm,weplantoenhanceourexistingfrontdoorfacilitiesandEmergencyDepartmentatWishaw.
54 Achieving Excellence: Healthcare Strategy
InthelongertermNHSLanarkshireproposetocreateasingletraumasiteatWishawalongsideasecondelectivesite.ThissitewouldserveastheBoard’straumaunitwithintheWestofScotlandregionaltraumanetwork.
WhatWillSuccessLookLike?
SeamlesscareprovidedthroughcollaborativeworkingacrossLanarkshireinpartnershipwiththepatient,providingabetterpatientexperience
Specialistcareathomeespeciallyfortheelderly,minimalhospitalstayswithfollowupinthecommunity
Reducetheneedforadmissiontohospitalandinparticularexpandtherangeofpreventativeand/oracuteinterventionsprovidedinorclosetopeople’shomes
Emergencyservicesaccessedasalastresortensuringonlypeoplewhorequirespecialisthospitalcareareadmittedintoageneralhospital
Morepatientstreatedwithinplannedcare(urgent)servicesthroughimprovedaccesstodiagnostics,outpatientsanddaysurgeryprocedures
Rapidaccesstotreatmentsupportingimprovedclinicaloutcomesandminimumlengthofstayinhospitalfollowingsurgery
Centresofexcellencedeliveringthehighestpossiblestandardsofsafetyandclinicalcare
Furtherimprovingqualityofcareandclinicaleffectivenessbyreducingvariationinclinicalpractice
Enhanceourresearchanddevelopmentworktosupportimprovementsinclinicalpractice
Improvethetrainingsupportandenvironmentforhealthcareprofessionals
Wewillenhanceourabilitytorecruitandretainhighlyskilledspecialistclinicians
References
1 RealisticMedicine–AnnualReportbytheChiefMedicalOfficer;ScottishGovernment,2016
2 ANationalClinicalStrategyforScotland,ScottishGovernment,February2016.
55Workstream Summaries
OrthopaedicServices
Vision Orthopaedic services will be provided to a high standard comparable to any other UK service. Patients will enjoy a seamless treatment pathway from referral through to rehabilitation, and will spend the right amount of time in hospital. The service will be fully integrated with other health and social care providers in primary, community and acute. Our workforce model will be sustainable into the future as the needs of the population change.
CurrentServiceOrthopaedicservicesarethesecondlargestsurgicalspecialty,andarecurrentlyprovidedfromoutpatientclinicsinthethreeDistrictGeneralHospitals,withsurgerybeingperformedatHairmyresandWishaw.Over26,000peopleareseeninorthopaedicclinicseachyear.10,000peopleareadmittedtohospitalfororthopaedictreatmentaseitheremergencies(generallyreferredtoas“trauma”e.g.afracturedleg)orforplannedsurgicalprocedures(“elective”e.g.ahipreplacement).
NotallorthopaedicspecialistservicesareprovidedoneachofthethreeDGHs:theserviceissplitintosub-specialties(e.g.footandanklesurgery,paediatricsurgery)andtheseservicesareprovidedinsinglespecialistunitsatonelocationforallofLanarkshire.Also,nearly1000LanarkshirepatientsaretreatedattheGoldenJubileeNationalHospitaleachyearforelectivesurgery(mainlyhipandkneereplacements).
TheNeedforChangeAformalreviewoftraumaandorthopaedicserviceinLanarkshirebeganin2014followingthepublicationofthe“RapidReviewofSafetyandQualityofCareforAcuteAdultsinLanarkshire”carriedoutbyHealthcareImprovementScotland1.
Theconclusionsfromthatreview,andthecaseforchange,wereconsideredbytheNHSLanarkshireBoardinJuly2016.FurtherinformationisavailablethroughtheconsultationwebsiteandtheNHSBoardpapers:www.nhslanarkshire.org.uk/boards/2016-board-papers/Pages/July.aspx.
TheNHSBoardconsideredthecaseforchangefororthopaedicservicestoensure:
• improvedpatientoutcomes,• asustainablemedicalworkforce;and• futurepathwaysofcarethatmeetthechangingneedsoftheLanarkshire
population.
4.9
56 Achieving Excellence: Healthcare Strategy
TheviewofNHSLanarkshire,whichhasbeenconfirmedbythe2016reportfromtheAcademyofMedicalRoyalCollegesandFacultiesinScotland4,isthatmaintainingthestatusquowasneitherasustainableoption,norwoulditaddressthesafetyandqualityissuesraisedinthe2013HISRapidReviewreport.TheAcademyalsonotedthattherewasconsensusonthisopinionacrossEmergencyDepartments,Trauma&OrthopaedicsandCareoftheElderlyteamsacrossNHSLanarkshire.
WhilstinitialworkwithinNHSLanarkshire’sorthopaedicreviewfocussedonimmediatechangesnecessarywithintheserviceandhowtheycouldbedelivered,furtherconsultationwithcliniciansledtowideacceptancethatthestrategicdirectionistomovetoTraumaandElectiveworkonseparatesites.TheseconclusionshavebeenreinforcedbytherecentpublicationoftheNationalClinicalStrategyforScotland2.
TheNHSLanarkshirereviewofOrthopaedicservicesfocussedon4possibleoptionsforreconfigurationofservices.
MaintainTraumaandElectiveAcrossTwoSites
TraumaandElectiveonSeparateSites
• 50/50SplitbetweenWishawandHairmyres
• 50/50SplitbetweenWishawandMonklands
• WishawTraumaOnly
• HairmyresElectiveOnly
• WishawTraumaOnly
• MonklandsElectiveOnly
Furtherinformationandanalysisisavailablethroughwww.nhslanarkshire.org.uk/INVOLVED/CONSULTATION/ORTHO/Pages/Traumaorthopaedicchanges.aspx.
AlloptionsreviewedincludedWishawGeneralduetoitsproposeddesignationasatraumaunitwithinNHSLanarkshire.WiththeproposalstocreateamajortraumanetworkacrossScotland,onemajortraumacentrewillbecreatedattheQueenElizabethUniversityHospitalinGlasgow.NHSLanarkshire’sproposalforinclusioninthenetworkisthecreationofadesignatedmajortraumaunitatWishawGeneralHospital.Wishawisbestplacedforthisdevelopmentduetoitscentreofexcellenceforpaediatriccareandgeographiclocationwithacatchmentcoveringsouth/centralScotland.
ThescaleofchangethatisrequiredtoachievethiswithinLanarkshireischallenginganditisimpossiblethatasingletraumaunitcanbeachievedwithinthecurrentbedcomplementandEmergencyDepartmentfootprintatWishawwithoutcausingsignificantdisruptiontootherservices.Thepragmaticapproachisthereforetomovetowardsthisstrategicobjectiveinaphasedmannerbymovinginitiallytotwocombinedtraumaandelectiveunits.TheNHSBoardagreedtomakeimmediatechangestoorthopaedicinpatientservicesonthegroundsofclinicalsafetyandservicesustainabilityinJuly2016,andthiswasimplementedinNovember2016.
57Workstream Summaries
AnotherfactoristhecommitmentbytheScottishGovernment(2016SNPmanifesto)toinvestinaseriesofdiagnosticandelectivetreatmentcentrestoprovideconcentratedelectivesurgeryforarangeofprocedures,includinghipandkneereplacements.Theservicemodelforthesecentresisnotyetagreed,butwhatevertheirconfigurationthiswillchangethefutureserviceconfigurationforelectiveorthopaedicsurgeryforLanarkshire.
SustainingthemedicalworkforceAkeyissuenotedinthe2013HealthcareImprovementScotland(HIS)reportwastheneedforafundamentalreviewofthedistributionoforthopaedicservicesacrossNHSLanarkshiretosupporttheprovisionofsafe,person-centredandeffectivecare.Thereportnotedsignificantandpersistentissues,thesolutionsforwhichrequiredmodelsofcarebuiltaroundpatientsbutwhichtakeaccountoftheavailableworkforce.Onerousandstretchedoutofhoursandon-callrotasforconsultantsimpactingonrecruitmentandretentionwasidentifiedasachallengeofthecurrentclinicalmodelwhichhaselectiveandtraumaservicesprovidedacrossthreesites.
SinceMarch2014,theservicehasbeensubjecttoenhancedmonitoringbyNHSEducationforScotland(NES)onbehalfoftheGeneralMedicalCouncil(GMC)toensurethatthenecessaryqualityoftrainingandenvironmentofsafepatientcareinwhichtrainingisprovidedcanbeassured.Withoutthiscontinuedassurance,whichiscurrentlyatrisk,trainingrecognitionwillberemovedandtheservicewillnotbesustainablewithinNHSLanarkshire.
The2016interimmovetotwoin-patientunitshasassistedwithmanagingsomeofthemoreacutepressuresontheservice,butitisthecommitmenttolongertermsustainablechangeaspartofthemajortraumanetworkthathashelpedtoprovideassurancetotheregulatoryagenciesofcontinuedprogresstoacentreofexcellenceforbothtraumaservicesandelectiveoperating.
ThechangingneedsofthepopulationPlanningthefutureserviceprovisionwillrequireaccounttobetakenofanumberofsignificantchangeswhichwillimpactuponthedemandfortheserviceoverthenexttwentyyears.Thelargestfactoristheincreaseinover75s,recognisingthatpatientsarelivinglongerandtheaddedcomplexityofeachindividual’sclinicalpresentationduetoanumberofagerelatedfactors(seealsosection2).Orthopaedicactivityisexpectedtoincreaseby12.9%by2020andafurther11.7%by2025.Activityfor2015isshownbelowasabaselineforfuturedevelopmentaswellasthepredictedactivitylevelsfor2020and2025.
58 Achieving Excellence: Healthcare Strategy
PatientCategory 2016 2020estimate
2025estimate
DayCases 2,147ElectiveIn-Patients 1,578GJNHPatients 960ElectiveTotal 4,685Emergency/TraumaPatients 4,631OverallTotal 9,316 10,760 12,019
Theproposedmodelforchangecannotbeasinglestepprocess.Thecomplexityofchange,staffingandresourceimplications,impactonotherservices,physicalcapacityandnewmodelsofcareallpointtotheneedtomanageserviceredesignwithinasteppedprogrammeofchange.
TheagreeddevelopmentofacaseforanewhospitalatMonklandspresentsopportunitiesandflexibilitywithintheprogrammeinordertoensureappropriatecapacityisavailabletolocateserviceswhilstachievingtheintendedgoalofasinglesiteTraumamodel.LanarkshirewillsetoutthecaseforthedevelopmentofatraumaunitatWishawGeneralHospital,aspartofaLanarkshireemergencycareservicebasedonthreeEmergencyDepartments,andaWestofScotlandmajortraumanetwork.Thenationalcaseforthemajortraumanetworkidentifieshowthiswillsavelivesandreducesignificantdisabilities.
ThemovetothefinalconfigurationwillseealltraumasurgeryatWishaw,withallelectivesurgeryonanothersite.Thelocationofelectivesurgerywillbeshapedby:
• Thefinalservicemodelforthe5NationalElectiveTreatmentCentres(SNPmanifesto2016);
• ThefinalservicemodelfortheWestofScotlandmajortraumanetwork• Thecapacityforsurgery,diagnosticsetc.tobeprovidedbythe
developmentofMonklandsHospital(earliest7yearsinthefuture)whichwouldenablechangestobeds,theatresandcliniccapacityacrossLanarkshire.Thiswillalsoembedsufficientcapacitytomeetthefutureneedsofthepopulationforsurgery
• Theviewsofpatients,publicandotherstakeholdersthroughtheconsultationprocess.
Newservicemodelswillbeunderpinnedbyagreedpatientpathwaysandworkforceplanstooptimiseclinicalexpertise.
Outpatientcontactsaccountforgreaterthan85%ofallorthopaedicappointmentsandadmissions.Theservicewillremainlocalwiththevastmajorityofpatientsaccessingtheserviceattheirlocalhospital.TheinterimstepwascompletedinNovember2016,withorthopaedicoutpatientcareandcarewithinemergencydepartmentsprovidedacrossall3sites.OnlyinpatientanddaycasesurgerycurrentlyprovidedatMonklandswasaffected.
59Workstream Summaries
WherespecificinpatientcareisrequiredpathwayswereimplementedtoensurepatientsaretransferreddirectlytothenearestinpatientsiteandwheretheservicesofaMajorTraumacentreisrequiredforspecialistcareappropriatepathwayswereimplementedwithQueenElizabethUniversityHospital(QEUH)andtheScottishAmbulanceService(SAS).
Thisprovidesacomprehensivepackageacrossallof3acutesitesinNHSLanarkshireensuringpatientscanaccessthemajorityoftheircareasclosetohomeaspossiblewhilstconcentratingspecialistcaretoappropriatesitesinordertoimproveoutcomes.Evenwiththeeventualconsolidationoftraumaonto1site,orthopaedicswillretainapresenceacrossall3sites.
Thereareanumberofkeyprinciples/issueswhichwereaddressedintheplanningprocess:
• AnEmergencyDepartmentpathwayforpatientswithorthopaedicinjurytobeimplementedatanysitewithoutinpatientorthopaedicactivity.
• ScottishAmbulanceService(SAS)pathwaysforpatientsandprehospitalmanagementoftrauma&orthopaedicpatients.
• Workforceplanningforallclinical,non-clinicalandcommunitybasedstaffaffectedbychangestothecurrentservicemodels.
• Adetailedprotocol/pathwaywhichsetsouthowtheCareoftheElderly(COE)teamnowengageorthopaedicpatientsaspartoftheirworkloadandtotakeoverthecareofappropriatepatientsatamuchearlierpointintheprocess.
• AJointClinicalPathwayModelfororthopaedic,olderpeople’scareandlocalityservices.
• Managementoftheimpactonotherpriorityserviceswhichwereimpactedonbyimplementationofaservicereconfiguratione.g.theatres/anaesthetics,wardstaffing,traumaandout-patientclinics,localitybasedservices.
• Fullstaffengagementwithaffectedstaffandotherstakeholdersontheproposedservicemodelsthroughout.
ItwasalsorecognisedthatakeydriverinthischangeprocessisthedevelopmentandearlyimplementationofanewclinicalandsocialcarepathwaywhichdeliversimprovedaccesstoCareoftheElderly(COE)servicesandcommunitybasedservices.InparticularservicessuchasHospitalatHomeandcommunitybasedCareatHomewillimproveourabilitytosupportpatientswithinthecommunityandwillfacilitatethe‘HomeFirst’approachthatwillbeapplied.Thisfocussesonpatientsbeingtransferredhomewithappropriatesupporttomanagetheirongoingmedicalandrehabilitationneedsandimprovetheiroutcomes.Implementationofthisapproachwillensurethatthecareofelderlypatientsisnotdisruptedandalsothatthosepatientsthatdorequirealongerstayinhospitalaremanagedinthemostappropriatelocationunderthecareofthemostappropriateclinician.
Thisimprovementwilldeliverasignificantbenefitthroughimprovedpatientoutcomesaswemovecarefromhospitaltohome.Thereduceddependencyoninpatientbedswillfacilitatetheabilitytoaccommodateorthopaedicbedswithintheexistingbedallocationacrossthetwosites.
60 Achieving Excellence: Healthcare Strategy
StakeholderEngagementThroughouttheorthopaedicreviewprocessNHSLanarkshirehasbeencommittedtoensurethatitinforms,engagesandconsultswithstakeholdersandanorthopaedicplanninggroupwasestablishedtotakeforwardthisreviewprocess.Thisgroupincludedclinical,managerial,patientandstaffrepresentation.AspartoftheNHSLanarkshireReviewprocesstwokeystakeholdereventswereheldtoconsiderandunderstandthechallengesofthecurrentconfigurationoforthopaedicservicesandtoidentifyandappraiseoptionsforarevisedservicemodelwhichwouldaddressthereview’skeyobjectives.TheeventswereheldinDecember2014andinMarch2015witheachattendedbyapproximately60delegatesincludingpatients,patientrepresentatives,carers,clinicians,managers,andstaffrepresentatives.ScottishHealthCouncilrepresentativeswerealsoinattendance.
TheshortlistofservicereconfigurationoptionsfromtheDecemberworkshopwasdefinedindetailpriortothenextstageofformaloptionappraisal,whichtookplaceattheMarch2015workshop.Thedetailedprocessincludedidentificationandimpactassessmentofanychangesrequiredatindividualhospitalleveltofacilitateimplementationofanyoftheoptions.Italsotookaccountofworkingpractices,capacity,demand,bedrequirements,theatreavailabilityanddemographicchanges.
TheanalysisoffinaloutcomesconcludedthatoutpatientservicesshouldcontinuetobeprovidedacrossthreesitesandthatsurgeryshouldbelocatedatWishawGeneralHospitalandoneothersite.
AttheirmeetinginJuly2016theNHSBoardconsideredallevidencefromthereview,includingtheAcademyreport,furtherpeerreviewvisitsandfurtherreportsonthesafetyandsustainabilityofmedicalstaffingfromNES.Theyconcludedthatamovetoaninterimservicemodel(the50-50splitbetweenelectiveandtrauma)shouldbeputintoplaceimmediately,andthatMonklandsDGHcouldnotprovidesufficientcapacity(theatresandwards)toprovideinpatientservicesaspartofthischange.
InJuly2016athird(external)stakeholdereventtookplaceinadvanceoftheconsultationprocesswhichallowedpatient,carerandvoluntaryorganisationrepresentativestounderstandthecontinuingworkoftheorthopaedicsreview,thedecisionsmadebytheNHSBoardinJuly2016,andtheproposalsforthelongertermconfigurationofsingletraumaandelectiveorthopaediccentres.
WhatWillChange?
Interim Changes to Inpatient ServicesTheNationalClinicalStrategy2andtheNationalTraumaNetworkReport3setouthowconcentratingtraumaandelectivesurgeryonseparatesitescandeliverarangeofbenefits,bothintermsofclinicaloutcomesandtheeffectiveuseofhighlyskilledstaff.
61Workstream Summaries
Intermsofdeliveringserviceimprovementakeychangewillbethroughrecognisingthatalargeelementofthecareforthe65+agegroup,thelargestpatientgroupreceivingorthopaediccare,doesnotnecessarilyneedtobedeliveredinanorthopaedicsetting,andwillbemoreeffectivelydeliveredinrehabilitation/sharedcareenvironment.
Thenewmodelofcaresetsoutsignificantchanges:• improvedpatientpathwayfortheelderlypatients,leadingto• improvedclinicaloutcome,and• reductioninlengthofinpatientstay.
Theyoungerandtheelderlypatientgroupshavedifferentneedswhicharebestmetbydevelopingpatientpathwaysspecifictoeachgroup.
ThescaleofchangethatisrequiredtoachievethiswithinLanarkshireisverychallenging:asingletraumaunitcannotbeachievedatWishawGeneralHospitalwithinthecurrentbedcomplementatthatsitewithoutcausingsignificantdisruptiontootherhospitalandcommunityservices.TheNHSLanarkshireBoardagreedon14thJuly2016tomovetowardsthisstrategicobjectiveinaphasedmannerbyfirstmovingtotwocombinedtraumaandelectiveunits,whichwasachievedwithoutmajordisruptiontootherhospitalservices.Thiswillenablethedevelopmentandimplementationofaclinicalmodelwhichimprovesservicesforpatients,resultsinimprovementstothelengthofstayinhospital(LOS)andimprovesthesustainabilityofthehighlyskilledworkforce.
Thishadnoimpactonoutpatientclinics,fractureclinicsandfracturestreatedinthethreelocalEmergencyDepartments.
62 Achieving Excellence: Healthcare Strategy
Longer Term ChangesThetraumaworkoftheorthopaedicservicewillbecomepartoftheWestofScotlandmajortraumanetwork,focussedatWishawforLanarkshirepatients.Thiswassupportedbythosewhorespondedtotheconsultation.Thetimescaleforthisisdependentontheconclusionofnationalandregionalplanningforthenewmajortraumanetworks,andtheplanningofnew/refurbishedMonklandsHospital(whichwouldallowchangestoacuteservicestobemadebeyondthelimitationsofthecurrentbuildings).
Similarly,thefutureconfigurationofelectivesurgerymaybeaffectedbytheScottishGovernment’splansfordiagnosticandelectivetreatmentcentres.However,electiveorthopaedicsurgerywillcontinueinsomeforminLanarkshireandthiswouldbeconcentratedononesite,eitherMonklandsorHairmyres.
Therewasnoclearviewfromtheconsultationaloneastowhichhospitalthisshouldbe,andfurtherappraisalworkandstakeholderengagementwilltakeplacebeforeadecisiononthiscanbemade
Bothofthesenationalandregionaldevelopmentswillhaveabearingonthefuturelevelofservicesweprovidefororthopaedicsurgery,whichwhencombinedbytheincreaseintheneedsoftheageingpopulation-andanyopportunitiesfordevelopingsurgicalservicespresentedbythereplacement/refurbishmentofMonklandsDGH-meanthattheconfigurationofthesesurgicalservicesisnotyetfinalised.Impact at Monklands DGH
Key Point
TheNHSLanarkshireBoardhasmadeitclearthatMonklandswillcontinuetoprovidefullA&Eservicesthroughoutthecurrentandfuturechangestoorthopaedicservicesdescribedabove(seealsosection4.8).
TheMonklandsemergencydepartmentteamwillcontinuetotreatthemajorityoffractures(almost3,000eachyear),andreferthosepatientstothelocalfractureclinic–asatpresent.TheScottishAmbulanceServicenowtakesthesmallnumberofemergencycaseswithmajorfracturestothenearestappropriatehospital(Wishaw,Hairmyres,orintoGlasgow–asatpresent).Patientswhoself-referatMonklands(i.e.notsentbyaGPorbytheambulanceservice)andwhorequireimmediatesurgeryarestabilised,transferredandadmittedtoeitherHairmyresorWishaw.
Intotalthishasseenachangetothecurrentpathwayforemergencytreatmentforthreeorfourpatientseachday.
ThetotalreductioninactivityatMonklandsEDwillbearoundthreepercent,andsowillnotaffectthesustainabilityofthedepartment.
ThisisnowthesameprocesswhichallowspatientswhopresentataLanarkshirehospitalsitewiththeneedforothertypesofspecialistsurgerytobesafelymanaged–asatpresent.Forexample,specialistvascularsurgerycasesare
63Workstream Summaries
onlyoperatedonatHairmyres,urologyandENTsurgeryonlyatMonklands,paediatricsatWishaw,seriousburnsattheRoyalInfirmary,andseriousheadandspinalinjuriesattheQueenElizabethUniversityHospital.This’CentresofExcellence’modelhasshowntoprovidemuchbetterclinicaloutcomesandfasterrecoverythanprovidingallproceduresineveryDGH2.
WhatWillSuccessLookLike?
Improvedqualityofcareandoutcomesforpatients
Shorterhospitalstaysforpatientswithenhancedrehabilitationandhomesupport
Introductionofconsistentpracticewithinorthopaedicservices
Improvedsustainabilityofthehighly-skilledworkforce
Shorterwaitingtimesforpatientspriortosurgery
Buildingcapacitytomeetthefuturepopulationneedsfororthopaedicsurgery
References1 RapidReviewoftheSafetyandQualityofCareforAcuteAdultPatientsin
NHSLanarkshire;HealthcareImprovementScotland,20132 ANationalClinicalStrategyforScotland;pp67;ScottishGovernment,20163 SustainabilityandSevenDayServicesTaskforceInterimReport:
www.gov.scot/Publications/2015/03/7764/84 TraumaandOrthopaedicServicesinLanarkshire;AcademyofMedicalRoyal
CollegesandFacultiesinScotland,2016
64 Achieving Excellence: Healthcare Strategy
CancerServices
Vision To ensure high-quality diagnosis, treatment and care for patients, the work of clinical teams should ensure that care is provided consistently i.e. with less variation. This will take account of the patients’ views, preferences and circumstances when considering the clinical team’s advice on the care that is most appropriate for the patients’ conditions. There should also be clear communication pathways to include patient, GP and wider community teams, with documented evidence to reflect the discussions and outcome.
CurrentServicesThenumberofpeoplediagnosedwithcancerisrising,reflectingtheincreaseinScotland’sageingpopulationaswellasimprovementsindiagnostics.Astreatmentsimprove,morepeoplewilllivewithcancerforlonger(seesection2).
TheambitionsoftheNationalCancerStrategy1are:• Tomakeearlydetectionofcancerthenorm• Tohaveswiftdiagnosisandresultsforcliniciansandindividuals• Toenhancetheroleofprimarycareinbeatingcancer
Largermulti-disciplinaryclinicalteamsworkingacrosstheWestofScotlandwillbefurtherenhancedwhichwillimproveaccessto,andoutcomesfor,cancertreatment.
NHSLanarkshirehasaCancerStrategy2andthisissupplementedbyservicedevelopmentplanswhichcoverall9maintumourgroups:
• CancerPreventionandScreening• GeneticandMolecularTesting• ReferralandDiagnosis• Treatment• LivingwithandBeyondCancer
TheCancerStrategyImplementationSteeringGrouphasbroadrepresentationfromacrossLanarkshireanditspartnerorganisations.IthastakenforwardawiderangeofinitiativestoembedprimaryandsecondarycancerpreventionmessagesintheclinicalcommunityaswellaswithinthewidercommunityandhasactivelysupportedthenationalDetectingCancerEarlycampaignwork.
OneofthemostpressingkeyclinicaldriversforchangeacrosstheWestofScotlandhasbeenthesignificantincreaseinSystemicAntiCancerTherapy(SACT).SACTiscommonlyreferredtoaschemotherapy.In2015NHSLanarkshiresawa24percentincreaseandtheSACTRegionalExecutiveCommitteeprojectanincreaseofatleasteightpercentperannumtocontinue.
CurrentlyNHSLanarkshireprovidesalmost1,000SACTpatienttreatmentepisodespermonth.Theserviceisdeliveredinover60treatmentspaces
4.10
65Workstream Summaries
distributedbetweenWishaw,HairmyresandMonklandsHospitals,witheachspaceprovidingtwoorthreepatienttreatmentslotsperday.
ThechangesinthecurrentdeliveryofSACT,inrelationtothefrequencyofchemotherapyepisodesandcomplexityofregimenshaveresultedinanincreasedchairtimefromthreehourstofivehoursforsometreatments.Inaddition,patientsarealsobeingtreatedlonger,forexample,theintensityanddurationoftreatmentshassignificantlyincreasedthereforetheimpactonavailablecapacityhasbeenverydifficulttomanage.Onaweeklybasisthereisaneedtoscheduleandreschedulepatientstoensureallpatientscanhavetheirchemotherapysafelyaspernationalguidancewhichinvolvesdailycarefulco-ordination,includingpatientsrequiringsupportivecare(forexamplebloodtransfusion).
DetailedanalysisshowsthatcurrentlycapacityacrossthethreesitesforSACTisadequatebutitisnotusedefficiently.Patientscanreceivetheirtreatmentsfrommorethanonehospital.Patientsfindthisconfusingandlessthanacceptablewhenfeelingunwell.
NeedforChangeNHSLanarkshirehasastrongtrackrecordoverseveralyearsofdeliveringcareinaccordancewiththenationalcancerdiagnosisandtreatmentwaitingtimestandards.WeareamongsttheverybestintheUK.Thishascontributedtomorepeoplesurvivingaftercancer.However,thegrowinglevelofdemandaspeoplelivelongermeansweneedtocontinuouslylookforthemeanstoprovideeffectiveandsafecare.
OnethirdofSACTtreatmentsarehaematologycancers,onethirdbreastcancer,andtheremainingthirdfromothercancers.Thegreatestincreaseby42percentwasseenincolorectalcancer,withanincreaseinactivityacrossallspecialtiesasillustratedinFigure10.
Figure 10: PatientTreatmentEpisodesperMonth
Year Averagemonthlytreatmentepisodes
Increasefrompreviousyear
2012/2013 674 N/A2013/2014 745 10.5%2014/2015 925 24.2%
WhatWillChange?ThefutureservicemodelforSACTtreatmentwillneedtomeettheclinicalneedsofthepeopleofLanarkshire.Thestandardsofclinicalcarewillbeworld-classtoensurethatwecontinuetoreducethemortalityratesforcancerwithinthepopulation.
Thereareindicatorswhichsuggestthataclinicalmodelwithclinicsandday-unitSACTtreatmenttypesconcentratedononesiteinacentreofexcellencewouldleadtobetterclinicaloutcomesandgreatlyimprovepatientandcarer
66 Achieving Excellence: Healthcare Strategy
experience.Thisoptionwouldrequireonlyonesiteasafocusforoncologyassessmentandtreatmentdelivery.MonklandsHospitalwouldbethespecialistsitetositalongsideclinicalhaematology,thenewLanarkshireBeatsonradiotherapyunit,LanarkshireMaggie’sCentreandthepotentialnewpharmacyasepticfacility(below).
Patientoutcomeswillbeimprovedfromthischangetocurrentservicesthrough:• SACTchairspacesandsomebedspacesusedmoreefficientlyandare
sufficienttomeetallfuturedemand• Dedicatedoutpatientanddiagnosticfacilitiestoensuretimelyandeffective
diagnosis• Multi-disciplinaryteamworkingimprovedthroughfulluseofexisting
(teleconference)andanynewtechnology• EffectiveandtimelyasepticpharmacyprovisiontoSACTUnits
Therewillbeaphasedapproachtoplanningandimplementingchangestothecurrentandfutureservicewhichenablesatransitionovertimetowardsthesinglesite,butwhichwillensurecontinuityofservicestopatients.
Furtherengagementwithpatients,carersandstaffwilltakeplacetoallowfuturechangestotheservicetoensuretheissuesofservicequality,patientaccessandstaffingrolesarefullyexploredbeforeanychangesareagreed.
InitialplanningworkbeganinFebruary2016withfurthercapacitymodellingleadingonfromareviewofSACTprovisionacrosstheWestofScotlandcancernetwork.Asthemajorcapacityissuesarewithincolorectaloncology,thefocuswasaroundthisspecialtyinthefirstinstance.Activityanddemandmodellinghasprovidedfurtherunderstandingofthecurrentpositionandthechallengesfacedbyservicesandidentifiedareaswhereimprovementanddevelopmentsarerequired.Smalltestsofchangeareunderwaywiththeaimofimprovingtheflowandcapacityofpatientsundergoingcolorectalchemotherapytreatmentsandforthosewaitingtocommence.Theoutputfromthelearningwillbeadoptedandimplementedwithinotheroncologyclinicstoimproveserviceefficiencyandpatientexperience.
Thereisalsoanopportunitytoconsiderasupportingpharmacyfacilitytothisproposal.Thenationalshared-servicereviewofpharmacyasepticserviceshasrecommendedthatasingleLanarkshireasepticfacilityshouldbebuilt,preferablyinthesitethatminimiseslinesofdistribution.ThiswouldprovidecomprehensiveSACTservicesforpatientswithinthesamebuildingcomplexandserveasanewCentreofExcellence.
Thiswillbeusedtoevidenceadirectbenefittopatientsandclinicalcareincluding:
• Consistencyofclinicaltreatment• Reductionindelays• Improvedpatienteducation• Improvedexperienceandpromptnessofchemotherapydelivery• Improvedskillsdevelopmentofstaff.
67Workstream Summaries
Thisworkwillunderpinthefurtherredesignofservicesandenablemoredetailedmodellingworktobeundertakentoidentifyandquantifyfutureresourcerequirements.
WhatWillSuccessLookLike?
Aserviceco-designedwithpatients,carersandfamiliestoensurebetteraccesstoservicesandtreatment
Sustainablehighqualitydiagnosis,treatmentandcareforpatientsdiagnosedwithcancer
Improvedcommunicationpathwayswithinthewiderhealthcareprofessionalteamstoreflectdecisionmaking,caremanagementandfollowuprequirements
Animprovementintreatmentoptionstoincludepalliativecare,whenconsideringthequalitycareaspectsofpeoplediagnosedwithcancerandtheirfamilies
Aradicalimprovementintheefficiencyofflowandchaircapacityforchemotherapydelivery
AsinglesiteofferingacentreofexcellencewithinNHSLanarkshireforchemotherapydelivery
Aperson-centredapproachtochemotherapydeliverythroughtheintroductionofoutreachmodelsthatincludetreatinginthecommunityorwithinanindividual’shome
Improvedskillsdevelopmentofstaff
Improvedpharmacyasepticservicessupportingcentreofexcellence
Continuetoworkinpartnershiptosupportandrecognisecarers’needstoenablethemtocontinueintheircaringrole
UtilisevoluntarydriverservicesandcontinuetolinkwiththeTravelandTransportworkprogrammeandimprovetransportforcancerservices
References1 BeatingCancer:AmbitionandAction.Edinburgh:ScottishGovernment,
20162 CancerStrategy–AFrameworkforLanarkshire,NHSLanarkshire,2013
68 Achieving Excellence: Healthcare Strategy
StrokeServices
Vision We will continue to provide excellent stroke care that improves the speed of access to the most appropriate clinical treatment and care resulting in improved outcomes for patients. This includes access to both acute stroke care in a dedicated stroke unit and effective rehabilitation to reduce the risk of longer-term disability. Wherever possible rehabilitation treatment and support will be delivered in a community setting.
Through improvement work, the Stroke Service will continue to deliver world-leading stroke care which is consistently person-centred, evidence-based and safe. We will consult and liaise with other clinical specialties, patient and carer groups and the voluntary sector. Communication with all service partners is key in being able to continue to deliver improvements.
CurrentServiceWhenmeasuredagainstotherpartsofScotland,NHSLanarkshirehasaconsistenttrackrecordofprovidingverysafeandeffectivecareforpeoplewhohavesufferedastroke.StrokeisthemostcommoncauseofsevereadultdisabilityandthesecondmostcommoncauseofdeathinEurope.Strokeincidencehasbeenrelativelystableoverrecentyearsandthisisnotexpectedtochangesignificantlydespitethechangingdemographicprofile.NHSScotlandspendsfivepercentofitsbudgetonstrokecare.Lanarkshirehasparticularchallenges,withayoungerstrokepopulationthantherestofScotland,resultinginagreaterneedforservicestobedeliveredtomeetthehealthandsocialchallengesthispresents.NHSLanarkshirecurrentlyhasthreeintegrated,comprehensivestrokeunits,oneoneachofthethreeacutehospitalsitesprovidingstrokecaretothelocalpopulation.In2015,995inpatientswereadmittedtotheLanarkshireStrokeService.
Rapidaccesstotime-criticalstrokecareisimportant.Thefocusofstrokeimprovementhasmovedtowardsmeasuringthequalityofstrokecarethroughdefinedaspectsofcareknownasthestrokecarebundle,i.e.agroupofspecificinterventions/processesofcarethatsignificantlyimprovepatientoutcomesifdonetogether.Insteadofmeasuringhowanindividualfaresagainstanyonestrokestandard,thebundlemeasureshowthatindividualfaresagainstallrelevantScottishStrokeCareStandards.Theseclinicallyevidencedinterventionsaimtoensurethatallpatientsreceiveallaspectsofhigh-qualitycarethatareproventoimprovetheoutcomeforpatients,reducingdeathanddisability.
Key Point
“Achievingacarebundleforischaemicstrokeisassociatedwithreducedmortalityat30daysand6monthsandincreasedlikelihoodofdischargetousualresidenceatsixmonths.”1
4.11
69Workstream Summaries
NHSLanarkshirehasmadecontinuousimprovementyearonyearinthedeliveryofthestrokecarebundle.Overthepastfiveyears,acontinuousimprovementinperformancehasresultedinNHSLanarkshireimprovingcompliancewiththestrokebundlefrom46percentin2010to83percentin2015.Throughthecooperativeworkingofstrokeclinicians,strokeunitstaffandtheStrokeManagedClinicalNetwork,thestrokeservicemodelhasdevelopedintoaneffectiveandefficientservicewithlengthofstayatleastfivedaysshorterthantheScottishaverageinallthreeunits.Weseektobuildonthisexcellentstandardofcareinthefuture.
TheNeedforChangeWithongoingchangestotheevidencebaseandstandardsbecomingmorechallenging,areshapeofelementsofthestrokeservicesisinevitableinordertorespondandcontinuouslyimproveoutcomesforpatients.
Alternativemodelsofdeliveringhospitalstrokecarewerereviewedin2015,includingconsiderationoftheconcentrationofacutestrokecareatonehospitalsiteinLanarkshire.Evidencesupportedthecurrentservicemodel(withthreestrokeunits)tobethemosteffectivemodelofstrokecareforNHSLanarkshire,withothermodelslikelytoleadtopooreroutcomesforpatientsincludinglongerinpatientlengthsofstayandincreasedmortality.Therefore,Lanarkshirewillcontinuetoprovidecomprehensivestrokeservicesateachdistrictgeneralhospital.
Howeverwedoneedtoconsiderourongoingchallengesacrossthepathway:• Interventionalradiologyforclotretrieval• Neurovascularclinicsandoutpatientcarepackages,includingsameday
treatmentanduseofnewdrugstreatingatrialfibrillation• StrokespasticitypatientscurrentlytreatedbyGlasgowservices• Strokeeducation• Carotidsurgery
WhatWillChange?By2020moreadvanced‘clot-busting’treatmentsinvolvingspecialistinputfromneuro-radiologyservicesarelikelytodevelop.Thebestmodelstodeliverthisinterventionnationallyarenotyetclear,andworkisongoingacrosstheUKtoexplorethis.ItispossiblethatsomepatientswillneedtobetransferredtoGlasgoworEdinburghforthesetreatments.Alternatively,telemedicine/technologyadvancementsmaymakemorelocaltreatmentfeasible.
Inneurovascularclinics,anoutpatientcarepackageincludingimaging,secondaryprevention,medicationsandlifestyleadviceisplannedfor2020.By2025,patientswillbetreatedonthedayoftheireventtofacilitatebetterpatientoutcomesandmoreefficientuseofhospitalbeds.Useofnewdrugswillallowspeediertreatmentofoutpatientswithatrialfibrillation(AF)andreducedstrokerisk.Itisexpectedthatby2020,allpatientswithnewlydiagnosedAFwillhavetheoptionofreceivingoneoftheseneweragents.Strokerateswillbereduced.
Inthedevelopmentofstrokespasticitytreatment,patientswillnolongerbereferredtoGlasgowservices.By2020,aservicemodelcomprisingofacentral
70 Achieving Excellence: Healthcare Strategy
Lanarkshireclinicwithhospitalin-reachisplanned.Thiswillbeacollaborativeventurewithcolleaguesinthetraumaticbraininjuryteamthroughreorganisingcurrentstaffingandotherresources.
Strokeeducationwillcontinuetoplayanimportantrole,witheducationinitiativesfortheScottishAmbulanceService,emergencydepartmentsandcommunityteamshelpingtoensureeffectiveknowledge,skills,attitudesandconfidenceinstrokecareprovision.
Evidencesuggeststhatthemostbenefitforastrokepopulationcomesifcarotidsurgeryisperformedearly.Thereisanationalstandardthat80percentofpatientsshouldundergosurgerywithinthistimeframeandNHSLanarkshire,incommonwiththerestofScotland,currentlymissesthisstandard.By2020,throughcollaborationwithradiologyandvascularcolleaguesandwithserviceredesignandpathwayoptimisationNHSLanarkshirewillconsistentlymeetthistarget.
WhatWillSuccessLookLike?
Deliveringmoreutilisingcurrentresources:BydeliveringaserviceacrossLanarkshirecomprisinghigh-qualitycareforpatientsandcontinuingtorespondtomorechallengingevidence-basedstandards.
ImprovethecapacityandcapabilityofcommunityteamstodelivercomprehensivestrokerehabilitationinacommunitysettingsupportedbyaSpecialistStrokePractitionerwhosemainroleissupportingVocationalRehabilitation(includingworkingwithOccupationalHealthServices)anddeliveringself-managementtopatientsacrossLanarkshire.
Bydeliveringmoreintensiverehabilitationforcomplexcasessupportedbyspecialistpractitionersworkingwithgenericcommunityteamstobuildcapacityandcapabilityintotheseservicesthroughmentoring,practicalsupportandongoingeducation.
BydeliveringefficientsecondarypreventionclinicsinlinewiththeNationalStrokeStandardswhichfacilitatetheprovisionofcuttingedgeservices.Thesewillbeledbyhighlytrainedspecialists,acrossNHSLanarkshire.
Deliveringtargetedearlyintervention:byprovidingspeedyaccesstothelatestclot-bustingtreatments,eitherlocallyorregionally,inlinewithemergingnationalstandards.
Consistentlyprovidecarotidinterventiontoallappropriatepatientswithintwoweeksofsymptomsinlinewiththenationalstandard.
71Workstream Summaries
References1 ImplementingaSimpleCareBundleisAssociatedWithImprovedOutcomes
inaNationalCohortofPatientswithIschaemicStroke.Turner,M.etal,ScottishStrokeCareAudit,2015
Deliveringamoreresponsiveneurovascularclinic:providingpatientswithspeedieraccesstoimagingandappropriatesecondaryintervention,thusreducingstrokerates.
Deliveringalocaltonemanagementservice:providingalocalserviceforpatients,improvingtheoutcomeforpatientswithspasticityfollowingstroke.
72 Achieving Excellence: Healthcare Strategy
PalliativeCare
Vision NHS Lanarkshire and its partners will meet palliative care needs and provide services in the setting of patient/carer choice, wherever possible. For the majority of people this will be in their own homes or their care home of residence. Admission to an inpatient bed will only happen where absolutely necessary, with discharge facilitated as quickly as possible. There will be an increased range of suitable alternatives to hospital admission, involving partner organisations (NHS Lanarkshire, North and South Lanarkshire Councils, health and social care partnerships, hospices, voluntary and independent sectors and other West of Scotland NHS Boards).
CurrentServicesPalliativecareisanapproachtoimprovethequalityoflifeofpeoplefacinglife-limitingillness.Itisnolongerprovidedjustattheendoflife,ratherneedsareidentifiedfromdiagnosisonwardsbasedontheentiretyofaperson’scircumstances.Palliativecareisnotjustconcernedwithphysicalsymptoms,itextendsbeyondthepatienttotheirfamiliesaswell.
Themajorityofpalliativecareneedsaremetbygeneralists(e.g.carers,communitynurses,GPs)supportedbyasmallteamofpalliativecarespecialists.Canceriscoveredinsection4.10,butotherpeopletransitionintopalliativecarewiththeirowncondition-specificteams(e.g.respiratory,heartfailure,renal).Additionaladvice/inputisavailablefrompalliativecarespecialists,mostlytowardstheendoflife,andsupportedbythenationalpalliativecareguidelinespublishedin2014.
Thescopeofpalliativecareserviceshasgrowninrecentyears,inlinewithour2013strategy1.Thefocushasbeenongreateravailabilityofarangeofsupportsfordyingpeopleandtheircarers,includingexpansionofthecommunityMacmillanservicetoseven-dayworking,IntegratedCommunitySupportTeamsinSouthLanarkshire,LocalityModelling/ResponseTeamsinNorthLanarkshireandanticipatoryprescribingvia‘JustinCase’boxes.
TheNeedforChangeThereareanumberoffactorswhichmeantheservicemustcontinuetoimprove:
• People’swishes:around70percentofpeoplesaytheywanttodieathome(DyingMatters2),yetonlyaquarterdidsoinLanarkshirein2011
• Changingpersonalcircumstances:smallerfamiliesprovidingsupport,ornofamilylivinglocally(5percentofpeopleagedover85livedalonein2012)andtheageingLanarkshirepopulation(seesection2)
• Publicationofthenational‘StrategicFrameworkforAction’3and‘RealisticMedicine’:thePalliativeCareManagedClinicalNetworkisexploringhowthesecanhelptofurtherdevelopthequalityofourservices,withafocusonendoflifeinterventionsandgreaterpublicdiscussionofbereavement,
4.12
73Workstream Summaries
deathanddying.RealisticMedicine4involvesinformationandchoice,andnotprovidinginterventionswhichdonotaddvalueforpatients.
• TransferofresponsibilityforhealthcareprovisionfromNHSGreaterGlasgow&ClydetoNHSLanarkshire:thereisaneedtoassessthepreferredplaceofcareforpeoplefromRutherglen/CambuslangandtheNorthernCorridor
WhatWillChange?• Moresupportisneededtoenablethosepeoplewhowishtodieathome.
Thismayincludearapidresponsetoavoidbreakdownofcareathome,helpforelderlycarerswhocannotcurrentlycopewithpalliativecareathomeanddedicatedpalliativecarehospitaldischargesupport
• InlinewiththeshiftofcaretoincreasesupportforcareathomeorinahomelysettingtheHSCPscommissioningstrategiesmaychangetheconfigurationofpalliativecareinpatient(hospice)beds
• Newsupportsarebeingintroducedtoinformdecision-makingtowardstheendoflifetoensureoptimalcareandtreatmentchoicese.g.HospitalAnticipatoryCarePlanning5,RecordofEndofLifeCare.Agoodexperienceofhospitalpalliativecarecanprovidetheassurancesthatfacilitatedischargeandmaintaincareathome
• Lanarkshirehasbeendeliveringastructuredconversationtoenablepeopletobemorecomfortabletalkingaboutdeath,dyingandbereavement.ThiswillberolledoutfurthertosupportStrategicFrameworkforActionimplementation
• Earlydiscussionshavetakenplacearoundthepotentialimpactoftelehealthinpalliativecare.Initiallythismayinvolvesimpletextmessagingtoallowpalliativecarespecialistnursestomaintaincontactwithsomepatientsremotely,thusincreasingserviceefficiency.Therangeofothertelecaresupportforpeopleathomeprovidedthroughcarepackagescontinuestoevolveandimproveinqualityandsophistication.
WhatWillSuccessLookLike?
Peopleareroutinelyaskedwhatmatterstothemandthisformsthebasisofallpalliativecareplanningi.e.peopleareatthecentreoftheircareplan
Peopleaccessthepalliativecareservicesthatmeettheirneedsinallcaresettings,includingfuturedevelopmentssuchastelehealth
Peopledieintheirownhomes,iftheywishthis,withthelevelandrangeofsupportstheyrequire,includingsupportfortheircarers
Peopleapproachingtheendoftheirlivesundergoonlythoseinterventionsthatareeffective,thusoptimisingtheirqualityoflife
Allstaffarecomfortabletalkingaboutdeath,dyingandbereavement
74 Achieving Excellence: Healthcare Strategy
References:1 NHSLanarkshire(2013)PalliativeCareStrategywww.nhslanarkshire.org.
uk/Services/PalliativeCare/Documents/Palliative%20Care%20Strategy%20Aug%2013.pdf[accessed29.6.16]
2 DyingMatters[accessed9.12.15]www.dyingmatters.org/page/frequently-asked-questions
3 TheStrategicFrameworkforActiononPalliativeandEndofLifeCare.Edinburgh:ScottishGovernment,2015
4 ChiefMedicalOfficer(2016)RealisticMedicine:CMOAnnualReport2014-15.www.gov.scot/Resource/0049/00492520.pdf[accessed29.6.16]
5 Taylor,DR(2014)COPD,endoflifeandCeilingofTreatment.Thorax0:1-3.doi1136/thoraxjnl-2013-204943
76 Achieving Excellence: Healthcare Strategy
CROSSCUTTINGSERVICES
Pharmacy
VisionAll patients, regardless of their age and setting of care, will be supported to ensure they get the best possible outcomes from their medicines while avoiding waste and harm. This will be delivered through pharmacy working in collaborative partnerships with patients, carers, medical and nursing colleagues and the other relevant health, social care, third and independent sector professionals.
Pharmacy Services will support NHS Lanarkshire, North and South Health and Social Care Partnerships to deliver the most appropriate and cost effective, evidence-based treatments, interventions and services to meet the needs of patients. Clear procedural and governance systems which quality assure how services are developed and resourced will be part of the routine practice.
CurrentServicesTreatmentwithmedicinesisthemostcommonhealthcareinterventionintheNHS.WithinNHSLanarkshireover11millionprescriptionsaredispensedeachyearatacostofover£150million.Thisindicatesthatthevastmajorityofpeoplewhoseekhealthcareadviceandtreatmentwillaccesspharmacyservicesatsomepointduringtheircarejourney.
Teamsofpharmacistsandsupportstaffwithineachofthe143communitypharmacieslocatedacrossNHSLanarkshiredispensethesemedicinestopatientsandprovideadviceandhelptoprescribers,patientsandtheircarersabouthowtousetheirmedicinessafelyandtothebesteffect.Thecommunitypharmacyserviceisgovernedbyaseriesofnationalandlocalcontractswhichsetoutthestandardsfortheseservices.Inadditiontodispensingmedicinescommunitypharmacistsalsoprovidecompletepackagesofcarewithouttheneedforreferraltoothers,thisincludessmokingcessation,emergencycontraceptionandthesupplyofmedicinestotreatself-limitingminorailments.Manypharmacistsarenowalsocontractedtoworkasindependentprescribersacrossabroadrangeofareassuchasaddictionservicesandpolypharmacyreviews.
Thesethemesarereplicatedwithinhospitalpharmacypracticewhereteamsofpharmacists,techniciansandsupportstaffprovidearangeofservicesincludingmedicineprocurementandsupplyandspecialistdispensingservicessuchasasepticandcancerchemotherapydispensing.Thisissupportedbywellestablishedclinicalpharmacyandmedicinesinformationservicesinwhichclinicalpharmacistsarefullyintegratedintothespecialitymedicalandnursingteamstoprovidecareforpatientsthatisfocussedonachievingthebestoutcomesfrommedicines.Asincommunitypracticemanyofourhospitalpharmacistsarequalifiedindependentprescribers.
5.1
5
77Cross Cutting Services
ThePrescribingManagementTeamworkswithinprimarycaretoprovideanalysis,adviceandsupporttomanagementteams,generalpractitionersandotherhealthcareprofessionalsinordertopromotehighqualityandcosteffectiveprescribing.ThePrescribingManagementTeamisparticipatinginthePrimaryCareTransformationProgrammewhichwillseetheintroductionofgeneralpracticeclinicalpharmacistindependentprescribersintoasubstantialnumberofGPpracticesacrossNHSLanarkshire{seesection4.1).
TheNeedforChangeAcrosstheNHStheuseofmedicineshascontinuallyincreasedoverrecentyears.Whilemedicineshaveasignificantimpactonimprovingpatientoutcomestherearerisksandthepotentialoveruseofmedicinesisacauseforconcern.Takingmoremedicinesthanrequiredmaybeharmfulinthatitcanincreasetheriskofdruginteractionsandadversedrugreactions,togetherwithimpairingmedicationadherenceandqualityoflifeforpatients.Unlessthedrugsprescribedtopatientsarereviewedregularlybyclinicianswithup-to-dateknowledgethereisariskthattreatmentmaybeineffectiveatbestandharmfulatworst.IndeedeachyearinScotlanditisestimatedthat61,000non-electiveadmissionsareduetoamedicine-relatedissue1.Tosupportthecontinuedsafe,effectiveandefficientuseofmedicinesrequiresthattherearerobustmedicinegovernancesystemsinplacesothatallprescribersinLanarkshirehaveaccesstoinformationandsupportnecessary.
FiguresrecentlyreleasedbyHISsuggestthat20percentoftheScottishpopulationistakingfiveormoreprescribedmedicinesonaregularbasis1.
78 Achieving Excellence: Healthcare Strategy
LanarkshirehasanunenviableandconsistentpositionofseeingahighervolumeofprescribingperheadofpopulationthananyotherNHSboardarea.
TherearedriversatbothUKandScottishGovernmentlevelswhichwilldirectchangesinpracticeanditisessentialthatwetakethisopportunitytoimprovetheusemedicinesforthebenefitofourpatients.RecentdocumentspublishedbytheScottishGovernmentsuchas‘PrescriptionforExcellence’2and‘RealisticMedicine’3makethisclear.Inparticularitisrealisedthatthereisscopeforpharmacistsandotherhealthcareprofessionalstoworktogethertobetterutilisetheirconsiderabletrainingandexpertiseandcontributemoretohowourhealthcaresystemandpatientsusemedicinestobesteffect.TheMedicinesAct1968isthebasisformuchcurrentpracticeandthisisreservedtotheUKGovernment.In2013theUKGovernmentestablishedtheRebalancingMedicinesLegislationandPharmacyRegulationProgrammeBoard4.Thisisduetoreportinlate2016withrecommendationstoremovesomeofthebarriersthatexistwithincurrentlegislation.
WhatWillChange?WithinNHSLanarkshirewewillembracetheopportunitiesprovidedandwilladoptthemtoourlocalenvironment.Forexample:
• Thepharmacyworkforcewillbesupportedanddevelopedtoensurethatitsuniqueskill-setisabletobeutilisedtodeliversafeandeffectivepatientcareandserviceefficientlyacrossallhealthandsocialcaresettings.
• Wewillcontinuetodevelopandbuilduponourfoundationoflocallynegotiatedcontractswithcommunitypharmacists,particularlyintheareasofminimisingharmsfrommedicinesandprovidingsupportforvulnerablepatientsintheirownhomes.IncreasinglythisworkwillbecoordinatedwithHealthandSocialCarePartnershipssothatthecontributionofthepharmacistsaugmentsthecontributionofallothermembersofthehealthandsocialcareteams.
• Wewilldevelopservicesandsupportmaterialstohelppatientsandtheircarersunderstandthebenefitsandrisksofmedicationandsopavethewaytoempowerpatientstomakefullyinformeddecisionsabouttheirmedicationtreatments.
• WewillbekeypartnersinthePrimaryCareTransformationprogrammeanddeliverserviceswhichwillseepharmacistsandsupportstaffcontributemoretothesafeandeffectivetreatmentofpatients,andwhichwillalsoempowerotherhealthcareprofessionalssuchasnursingstaff,physiotherapistsandoptometriststodolikewisewhentheyaccessandusemedicinestocarefortheirpatients.
• ThenewPrescribingQualityandEfficiencyProgrammewillrefreshthegovernanceandfinancialmanagementsystemsformedicineswithinNHSLanarkshiretoensuretheyremainfitforpurposeforthenewopportunitiesandchallengeswhichchanginglegislation,structuresandtheavailabilityofnewmedicineswillbring.
References1 www.scottishpatientsafetyprogramme.scot.nhs.uk/Media/Docs/Medicines/
SPSP%20Medicines%20Infographic.pdf2 PrescriptionforExcellence;ScottishGovernment,20133 RealisticMedicine–AnnualReportbytheChiefMedicalOfficer;Scottish
Government,20164 www.gov.uk/government/groups/pharmacy-regulation-programme-board
79Cross Cutting Services
WhatWillSuccessLookLike?
Everypersonisabletogetthebesthealthoutcomethattheycanfromtheirmedicines
Patientsareabletomakeinformeddecisionsabouttheirmedicinesanddiscussthemwithanyoneinvolvedintheircare
Patientsareabletoaskforhelpiftheyhaveaquestionoradifficultywiththeirmedicines
Harmfrommedicinesisreduced
Treatmentsoflittlevaluearenotused
Medicinesnolongerrequiredarestopped
Lanarkshireachievesgreatervaluetheformoneyinvestedinmedicines
80 Achieving Excellence: Healthcare Strategy
Property
VisionAll facilities will be designed to meet the clinical and care needs of the population we serve. We are investing in primary care facilities that support the drive towards delivering care closer to home, without affecting longer term changes being considered for acute and elderly care service models. There will be continuing investment in existing buildings that will improve the quality of health and social care provision and patients’ experience.
NHSLanarkshire’sExistingEstate1
NHSLanarkshirehasarelativelylargeexistingestatecomprisingageographicallyandfunctionallydiversepropertyportfolioprovidingover296,000m2ofaccommodation.
Primaryhealthcareisprovidedinthecommunityfromhealthcentres/clinics,communityhealthcentres/dayhospitals,aswellasfrompremiseshousinggeneralpractitioners(GPs),dentists,pharmacists,optometrists,healthvisitorsandawiderangeofalliedhealthprofessionals.Someoftheserepresenthighqualityestatethatisdesignedformodernhealthcarewhileothersdonot.Overall,NHSLanarkshireservicesareprovidedfrom59locationswithatotalof174buildingsonthesesitesranginginsizefrom15m2to65,000m2.However,themajorityofthesebuildingsarerelativelysmall,with112buildingslessthan1,000m2valuedatcirca£155million.InadditionwedeliverhealthcarefrompropertieswhicharenotownedbytheNHSBoardthroughPrivatePublicPartnership(PPP)/PrivateFinanceInitiative(PFI)agreementsandcommercialleases.
AnanalysisoftheexistingpropertyownershipshowsthatthePPP/PFIhospitalsatWishaw,HairmyresandStonehouseaccountforoveronethirdofthegrossinternalarea(GIA)occupiedbytheBoard.ThisisoneofthehighestproportionsforanyNHSBoardinScotlandandsotheproactiveperformancemanagementofPFIContractsisakeyfeatureoftheworkofPropertyandSupportServices.Figure11showsthatnon-hospitalspaceisapproximatelyathirdoftheestate,reflectingatrendofmovingservicesintothecommunity.However,itmustberecognisedthatNHSLanarkshirewillcontinuetohaveahigherratioofhospitalareastoprimarycareareasthanthosecomparableNHSBoardswhichhaveonlyoneortwodistrictgeneral1hospitals.
5.2
81Cross Cutting Services
Figure 11:Ananalysisoftheexistingestatebybuildingtype2014/15
Area(GIA)sq.m
%ofTotalArea
Hospitals–Acute(3) 171,093 58%Hospitals–Community(12) 35,438 12%CorporateSites* 19,134 6.5%NorthLanarkshire:HealthCentres,ClinicsandOffices 39,660 13%SouthLanarkshire:HealthCentres,ClinicsandOffices 31,089 10.5%Total 296,414 100%
28thApril2016,Source:EstateManagementSystem
*CorporatePremises:KirklandsHQ,LawHouse,BeckfordStreet,WestLaundry
MonklandsDGHhasgreatlyexceededitsdesignlifewhichposesmanyoperationalandfinancialchallenges.By2018amajor£20mprojectwillbecompletedwhichwillseetherefurbishmentofMonkland’soperatingtheatresandIntensiveCareUnit(ICU).However,thereremaintensofmillionsofpoundsofupgradingwhichwouldbenecessaryinordertobringallareasofMonklandsaccommodationandservicesupto21stcenturystandards.
WhatWillChange?
Key Point
InJanuary2017NHSLanarkshireapprovedthefirststageinthebusinesscasetoreplacethecurrentfacilitiesatMonklandsDistrictGeneralHospitalwithnewhospitalaccommodation–eitheronthecurrentsiteoronanewlocationinNorthLanarkshire.
WiththeapprovaloftheScottishGovernment,thiswillprovideafacilitywhichwillservethepeopleofthewholeofLanarkshireforthenext40years,andwilllikelyseeover£400minvestedintheLanarkshirehealthcaresystem.Theplanningandapprovalprocesshasbegunonthisexcitingnewproject,withexpectationthenewfacilitieswillbeopenedinsevenyears’time.
AcrossLanarkshire,wewilldevelopafit-for-purposeestatethatsupportsashiftinthebalanceofcarefromacute/residentialfacilitiestocommunity/primarycaresettings.
Withthecontinuousdevelopmentofdigitaltechnologiestherewillbeanincreaseinthenumberofclinicalcontactswhichdonotneeddedicatedspecialistfacilities.Atthesametimetherewillbeareducedneedforstaffofficeaccommodationandclinical(paper)recordsstorage.
82 Achieving Excellence: Healthcare Strategy
Maintainingourexistingestatetoensureasafepatientenvironmentisakeypriorityincluding:
• Investinginbacklogmaintenanceandstatutorycompliancetocontinuethetrendtowardsreducingtheassociatedpropertyrelatedrisks
• Rationalisingtheexistingbuildingportfoliotoensurethemosteffectiveandefficientuseofbuildingstosupportservicedelivery
• Incorporatingallassetsintotheinvestmentprioritisationanddecisionmakingprocesssothatresourcescanbefocussedongreatestneedandbenefit
• ContinuedinvestmentinimprovingfacilitiestofurtherreducebacklogmaintenanceandstatutorycompliancerisksatMonklandsHospital,withknowledgeoftheintenttoreplacethiskeyfacilityinduecourse
• Continueddeliveryofariskbasedapproachtoimprovementstootherexistingfacilitieswithoutstandingbacklogmaintenanceandstatutorycompliancechallenges.
Thelimitationsoncapitalfunding(seesection8)willhaveanongoingimpactontheabilityofNHSLanarkshiretoprovidenewhealthcarepremises.Neverthelesssomeprioritieswillbeprogressedwhichwillinclude:
• PlanningthepermanentreplacementofMonklandsDGH;• ConsolidationofSouthLanarkshireinpatientmentalhealthatHairmyres
Hospital;• PrimaryandcommunitycarepremisesimprovementsintheNorthern
Corridor(Stepps,MuirheadandMoodiesburn);• Improvedophthalmology,dermatologyandneonatalfacilitiesinourDGHs;• Regional/sharedasepticpharmacyproduction;• Changestoaccommodationwhichhelptoimprovepatientflowinour
DGHs.
Inthisrapidlychangingenvironmentofhealthandsocialcare,revisedgovernancearrangementswillbeusedtoensurethecorrectallocationofspacetoservicesarebeingrefreshedandastandardisedandconsistentapproachshallbeappliedtoensurethecorrectallocationofspacetoclinicalneed.Thiswillreflectnationalhealthcarestandardsandtheactualneedsofserviceswhichalignforeffectivedeliveryofthehealthcarestrategy.
83Cross Cutting Services
Therehavebeenmajorchangesinthehealthcareestateinthelastdecade,especiallyacrosstheprimarycare,administrationandmentalhealthfunctions.Withrecognitionthatapproximatelyone-thirdoftheBoard’sexpenditureisstillonpropertyandassociatedmaintenance,thereisidentifiedscopetomakebestuseoftheestate.Buildinguponinformationwhichwillbecollatedinthepropertygazetteerrelatingtohowspaceiscurrentlyallocated,arollingprogrammeofspaceutilisationsurveysshallbeundertaken.Thiswillidentifyanypotentialoverorunderallocationofspace,withaviewtoreallocatingthisspacetoclinicalprioritiesor,whereapplicable,considerationofdeclaringsomespacesurplusfordisposal,withassociatedsavings.Thisworkwillbeundertakeninpartnershipwiththecommunityplanningpartners.
WhatWillSuccessLookLike?
Monklandswillbereplacedbyafacilitydesignedtobeanintegralpartofdelivering21stcenturyhealthandsocialcare
Primaryandcommunitycarewillbeprovidedfromfit-for-purposebuildingsabletomeetthefutureneedsofthepopulation
Allofourpropertieswillbefullyefficientlyusedwithlittleunderutilisationorovercrowding
NHSLanarkshirewillmeetorexceedourcarbon-reductiontargetsintermsofheating,lightandpower
Optimiseopportunitiesforsharedaccommodationwithotherpublicandthirdsectorpartners
References1 NHSLanarkshireProperty&AssetManagementStrategy2013–2017
84 Achieving Excellence: Healthcare Strategy
eHealthandDigitalTechnologies
VisionMeeting the 2020 Vision for Scotland and the ambitions set out in the National Clinical Strategy for Scotland1 requires a well-trained and highly motivated workforce that is supported with modern, adaptive and sustainable eHealth and digital technologies. We need to strengthen our ambition to use technology to enable safer, more efficient delivery of services and provide the ability to collect and analyse data to guide service planning and treatment decisions.
eHealth and digital technologies will support the transformation of patient care enabling further self-care /management supporting patients and their carers.
NHS Lanarkshire recognises the growing impact that eHealth and Digital Technologies (eHealth) is bringing to the delivery of healthcare around the world today. eHealth and Digital Technologies are making healthcare systems more efficient and more responsive to changing healthcare needs and expectations.
CurrentServiceNHSLanarkshirehassuccessfullyimplementedarangeofeHealthanddigitaltechnologiestosupporttheprovisionofcare.eHealthsystemsareoperationalacrossprimaryandsecondarycare.Ratherthaninventinglocalsolutions,wherepossiblenationalITsystemshavebeenadopted.
TheNeedforChangeOurlongtermvisionistoprovideasingleelectronichealthrecordforourpatients,however,moreworkisrequiredtodigitisepaperrecordsandcasenotes,sharesummaryinformationbetweenservicesandpartners,andmanageworkflowacrossboundaries.
Thecurrentlimiteduseofelectronichospitalprescribingandadministrationsystemsneedstobeextendedtoreplaceexistingpaperbasedsystemstoensurepatientsafety;andworkisinhandtodoso.Electronicreconciliationofmedicationrecordsisrequiredbetweenhospitals,GPsystems,andcommunitypharmaciststoensurethatacommonuptodateelectronicmedicationviewisavailable.
Improvedelectronicinformationsharingisrequiredbetweenhealthandsocialcareprovidersandtheirthirdsectorpartnerstoensurethatthepatientreceivestherightlevelofcarebasedonalltheinformationavailable.Electronicsystemswillincreasinglyneedtosupportcrossboundaryworkingasweconcentrateandintegrateresourcestodeliverthebestavailablecare,andsupportmobileaccesstomeetpatientandclinicians’needs.
5.3
85Cross Cutting Services
WhatWillChange?Modernclinicalinformationsystemscanhelptocontributetoimprovementinpatientcare,efficiencyandclinicaleffectiveness.Adoptionofdigitaltechnologiespresentstheopportunitytoredesignandstandardisehealthcareprocessestomeethealthcarepractitionerandpatientneeds.WhenappliedintherightsettingsITsystemscandeliverefficienciesandfreeupmuchneededresourcestosupportfrontlineservices.
Telehealthcanhelpsupportpatientslivelongerlivesathomeorinahomelysetting.MoreadvanceddigitalservicesincludingeConsultation,andhomemonitoringandvideoconferencingcouldsupportGPsandenhancecapacitywithincommunityservicesovertimebutwillrequirewholesystemschange.Theworldofwearabletechnologyincorporatingmedicaldevicesrepresentsenormouspotentialtorevolutionisecurrentmodelsofcare.Overthenext5years,therewillbeaseismicshifttowardsproactivehealthcaremonitoringandmanagement.Thiswillbedriveninpartbytheconsumerisationofthemarketplaceprovidingadvancedcapabilityatlowcost.Thistechnologywillbedisruptive;itwillbegintotrulyempowerpatientswithmedicalgradeinformation.TheNHSwillneedtoharnessthiscapabilityandadaptmodelsofcareaccordingly.
ClinicalportaldevelopmenthasfacilitatedelectronicinformationsharingacrosstheWestofScotlandprovidingstaffwitheasyaccesstoessentialpatientinformationandhistory,andisincreasinglybeingmadeaccessibletoGPsandstaffinthecommunity.ClinicalPortalisacriticaltoolinprovidingaccesstopatientrecordsaspatientscrossboundariesforcaretoGlasgow,theNationalWaitingTimesCentreandbeyond.
Theopportunitytoincludedigitised“live”healthrecordswithintheClinicalPortalwillprovideasingleviewofthepatient’srecord,accessiblereal-time24/7
86 Achieving Excellence: Healthcare Strategy
andwilleradicatemanyoftheproblemsexperiencedwiththetraditionalpaperrecord.
Theintroductionofahospitalelectronichospitalprescribingandadministrationsystem(HEPMA)willprovideclinicaldecisionsupportimprovingpatientsafety;thesystemwillreducedrugerrors,speedupthemedicationreconciliationandimprovethenotificationofallergies,druginteractionsandduplicatetreatments.
Wewillstarttocaptureclinicalinformationelectronicallyatthepointofcare.Thiswillreducetheneedforhandwrittenpatientrecords.Significantbenefitswillbedeliveredincluding;legiblerecords,increasedavailability,easiertoshare,easiertosecure,manageandmonitor.
Primarycarerepresentsanareawherethereareconsiderableopportunitiestoimprovepatientcare,efficiencyandclinicaleffectivenessthroughtheintroductionofmodernITsystems.ModernsystemsprovidefullintegrationbetweenGeneralPracticeandthewidercommunitysetting.TheneedtoadoptacommerciallyviablecommunityITsolutionwillenabletheshiftinthebalanceofcareandsupportthe2020VisionandimplementationoftheHealthcareStrategy.Improvedelectronicinformationsharingisrequiredbetweenhealthandsocialcareandtheirthirdsectorpartnerstoensurethatthepatientreceivestherightlevelofcarebasedonalltheinformationavailable.Electronicsystemswillincreasinglyneedtosupportcrossboundaryworkingasweconcentrateandintegrateresourcestodeliverthebestavailablecare,andsupportmobileaccesstomeetpatients’andclinicians’needs.
PatientonlineaccesstotheirpersonalhealthrecordisstillonlypossibleinLanarkshireinverylimitedcircumstances.Forexamplesomediabetespatientscanaccesstheirrecordson-line.Theneedtoextendaccesstopatientrecordsisakeystrategicobjective.
PlansareinplacetosignificantlyimprovethesituationwithpatientaccessinScotlandwithinthenextfewyearsthroughthecreationofapatientportal.Thiswillgiveaccesstoasummaryelectronicpatientrecord,personalisedhealthinformationanddigitalservicesforeverycitizeninScotland.
ThereisagreatopportunitytoensureITsystemsareinplacethatwillmaketheNHSsafer,moreefficientindeliveryofservices,moreeasilyaccessibleandprovidetheabilitytocollectandanalysedatatoguideserviceplanningandtreatmentdecisions.
Theintroductionofrealtimebusinessintelligencedashboardshasmadeperformancemanagementmuchmoreeffective.Thisapproachshouldbeextendedtocovercriticalareasforexampleimprovingpatientflowandprovidingkeyperformanceinformation.
Weaimtodeliverasingleelectronicpatientrecordthatisaccessiblebyallappropriateclinicalstaff,operatinginmultipleclinicalsettings,tosupportthedeliveryoftimely,consistentandhighqualitypatientcare.
87Cross Cutting Services
TheNHSLanarkshireeHealthStrategyisaboutbalancingprioritiestodeliverimprovedserviceoutcomesaroundthesevenaimsintheScottishGovernmenteHealthStrategy2014–20172.
Thisisparticularlyimportantaswereshapeservicestomeetthechangingneedsofourpatientsandstaff:increasingdemand;providing24/7services;morecareawayfromthelargerhospitals;andpatientshavingaccesstokeyinformationtohelpthembettermanagetheirowncare.Resourceswillcontinuetobeusedtoensuretheserviceandthepatientcanmakethebestuseoftechnologyaroundsafety,quality,efficiencyandeffectiveness.
Anelementofthepopulationis‘digitallyexcluded’becausetheylackinternetaccessorhavelowlevelsofdigitalliteracy.Digitalexclusionisakeybarriertoprogressbecausethepeoplewiththegreatesthealthcareneedsareoftenlesslikelytohavethetechnologyandskillstoengagewithandbenefitfromdigitalservices.
NHSLanarkshirewillaimtoensurethatourpatientsarenotdisadvantagediftheyaredigitallyexcluded.Thismeans,forexample,thatwewillnotassumeallpatients,relativesandcarershaveaccessto(orcanmakefulluseof)internetserviceswhendevelopingdigitalservices.
WhatWillSuccessLookLike?
Safer,andmoredependablehealthandsocialcareservices
Personcentredinformationacrosssectorsandboundariesofcarewhichspeedsupcare
Digitalpatientinformationwithminimaluseofpaper,andmoreefficientclinicalservices
Ultimately,asingledigitalhealthandsocialcarerecordwiththemanybenefitstopatientcarethiswillbring
Increaseuseofstructureddigitaldatatoenableclinicaldecisionsupport,leadingtobettercareandtreatment
Increasedhomemonitoringallowingearlierclinicalinterventionsandsupportingcareathome
References:1 ScottishGovernment.ANationalClinicalStrategyforScotland.Edinburgh:
ScottishGovernment,20162 ScottishGovernment.eHealthStrategy2014–2017.Edinburgh:Scottish
Government,2015
88 Achieving Excellence: Healthcare Strategy
Transport
VisionNHS Lanarkshire is committed to supporting patients, carers, visitors and staff to access our facilities in a manner which is as straight forward and cost effective as possible. We will work with our partner organisations and a wide range of stakeholders to develop and implement a sustainable transport and travel policy.
CurrentSituationAverylargeproportionoftheresponsestothe2016consultationontheHealthcareStrategyfocussedontransporttoorbetweenoursites.
Patients,carers,visitorsandstafftraveltohealthcaresitesbyanumberofdifferentmodesoftransport.Surveyinformation,initiallyundertakenbyStrathclydePartnershipforTransport(SPT)thenfollowedupinahospitalsurveyin2016,indicatedthefollowing:
Modeoftransport Patients/Visitors/Carers StaffPrivatecar–asdriver 71.53% 81.82%Privatecar–aspassenger 10.57% 3.38%Privatecar–carshare 0.00% 0.78%Bus 5.70% 4.68%Train 0.80% 4.16%Taxi 5.70% 0.78%Walk 5.70% 3.12%Cycle 0.00% 0.78%Other 0.00% 0.50%
Theabovetableindicatespreferredmodeoftravelforpatients,carersandvisitorsandalsoforstaff.Theresultsforthevariousgroupsareverysimilarandsetoutthecontextwithinwhichasustainabletransportandtravelpolicyrequirestobedevelopedandimplemented.Thesurveydataconfirmsthat82%ofpatients,carersandvisitorsand85%ofstafftraveltooursitesbyprivatecar.
TheNeedforChangeAs“AchievingExcellence”isimplemented,theworktoestablishfurthercentresofexcellence(seesection4.7)needstobeunderpinnedbycontinuedimprovementinaccesstopublictransportandimprovedmanagementofcarparkingatoursites.Thiswillmakeiteasiertomovebetweenourhospitalsitesandassistpatients,carers,visitorsandstafftoaccessthesesites.ThisreflectstheScottishGovernmentstrategicintentiontoreducerelianceoncaruseandtoimproveourcarbonfootprintbyimprovingsustainabletransport.
Thereisalsorecognitionthatsupportingpeopletousetheirownpreferredchoiceoftransportisakeyelementofensuringpatientchoice.Withinthis
5.4
89Cross Cutting Services
processthereisaneedtoimproveaccesstopatienttransportwhichmaybeprovidedbyanumberofagencies,includingtheScottishAmbulanceService.TheScottishAmbulanceServicewillcontinuetoprovidetransportforpatientswhohaveaclinicalrequirement,andwillworkcollaborativelywithhealthcarepartnersandtransportproviderstoformulateacohesivetransportstrategy.Ourformalengagementwitharangeofstakeholdershasidentifiedthattheprimaryareasofconcernforpatients,carers,visitorsandstaffareaccesstocarparkingandavailabilityofpublictransport.Themajorityofpeopleaccessingoursitesdosobyprivatecarandtheirspecificconcernsrelatetoavailabilityofparkingandcongestionwithinoursites.
WhatWillChange?Ourimplementationprogrammewillfocusinitiallyonthefollowingfourareasofworkastheseareseenaskeyelementswhichwilldeliveranimprovementforstakeholders:
1 Parking at our SitesItisourintentiontodevelopinconjunctionwithallrelevantstakeholdersadefinitiveparkingpolicyduring2017/18,asameanstoresolveanumberofissueswhichhavebeenraisedbypeopleasbarrierstothemaccessingclinicalservices.Inparticularthepolicywillconsiderandsetoutmechanismstoprovide(whereappropriate):• Designatedpatientparking,• Designatedstaffparking,• Arrangementstopreventinappropriateparkinge.g.railcommuters,• Protectedparkingforspecificpatientgroupse.g.renaldialysis,cancer,• Protectedparkingforparticularstaffgroupse.g.on-callclinicians,• Parkingforcarsharevehicles,• Parkingfordesignatedpoolvehicles.
Itisproposedthatthefinalagreedpolicywillbeimplementedaftercompletinganappropriateapprovalsprocesswitheffectfrom1stApril2018.
2 Public TransportWewillcontinuetoworkwithkeystakeholderssuchasStrathclydePartnershipforTransport(SPT)toensurethateachofoursitesissupportedbyappropriatepublictransportslinks,andthatdetailsofallavailablepublictransportarewidelypublicisedviaappropriatemedia.Thereareclearservicecriteriaregardingthelevelandtypeofpublictransportavailableanditisourintentiontoensurethatthesecriteriaaremetforeachofoursites.
Akeyelementofthisprocessistoensurethatcommunicationfortransportandtravelinformationisdeliveredaseffectivelyaspossible,anditisourintentiontodevelopandimproveexistinglinkstoensurethatserviceproviderandtimetableinformationisavailablequicklyandeasily.ThiswilltaketheformofimprovedaccesstoTravelineScotland’slivetimetableandtravelplanninginformationwithspecificplanstoensurethatthisisreadily
90 Achieving Excellence: Healthcare Strategy
availableonanumberofplatforms.Thiswillinclude:• NHSLanarkshirepublicwebsite,• TravelineScotlandwebsite• TravelineScotlandsmartphoneapps,• Accesstoliveinformationonpublictransportservicesatkeyhospital
locations.
3 Scottish Ambulance ServicePatienttransportprovidedbyScottishAmbulanceServiceisakeyelementinthedeliveryofclinicalservicestothewiderpatientpopulation.Whilstthenumberofpatientswhorequirethisserviceislow,(recentsurveydatasuggests2%)thisisacriticalserviceforthosepatientswhorequiremedical/clinicalsupportduringtheirjourneyto,orfrom,healthcarefacilitiesfortreatment.
ScottishAmbulanceServicehaveacommitmenttoprovideappropriatetransportforpatientswhomeettheireligibilitycriteria,andwewillensurethatthereisappropriateparkinganddropofffacilitiesatoursitestoenableScottishAmbulanceServicetocontinuethiscriticalwork.WewillalsoworkcloselywiththeScottishAmbulanceServicetoensurethatoptionsareavailableforthepatientswhocontacttheambulanceservicefortransportbutdonotmeettheireligibilitycriteria.
Wewillalsoimproveourappointingsystemstotakecognisanceofpatients’geographicallocationwhenmakingappointmentsfirstthinginthemorningorlateintheafternoonasthiscanbeaffectedbyavailabilityofpublictransport.
4 Integrated Transport HubTherecurringthemefromstakeholdersthroughtheconsultationhasbeenaconcernthatthewiderprovisionoftransportfromallserviceprovidersisnotwellintegratedandthataccesstoinformationonserviceprovisioncanbechallengingtoaccessquicklyandeasily.Third-sectorandvoluntarytransportprovidersprovideimportantservicestopatientsandrelatives,butplanningforthisisnotintegratedwithambulanceandpublictransportoptions.Therearealsoconcernsthatpatientswhohaveverylimitedaccesstopublictransport,areunabletoaccesspublictransportorthosewholiveinremoteorrurallocationsanddonotmeettheScottishAmbulanceServiceeligibilitycriteria,havenoaccesstosupporttotraveltohealthcarefacilities.
Ourvisionistoestablishanintegratedtransporthubwhichwillachievethefollowing:• Improvethetransportexperienceforusersoftransportservices• Improvethecoordinationandefficiencyoftransportforhealthand
socialcarewithinLanarkshire(NHS,thirdsector,commercialandlocalauthority)
• Providetransportbaseduponneed• Reduceinappropriatejourneys• Demonstratevalueformoney
91Cross Cutting Services
Withinthisstrategicintentionandrecognisingthatmostpatientstraveltohospitalbycar,itiskeythat:• PatientswhorequiretransportviaScottishAmbulanceServiceareableto
accessthis• Patientswhorequirepublictransportareabletoaccessthiseasilyand
quickly• PatientswhodonotmeettheScottishAmbulanceServiceeligibility
criteriabutdorequiresomesupportareprovidedwithanoptionwhichiseffectiveandaccessible(e.g.thirdsector)
Intentionthereforebecomesthedevelopmentofahubwhichwillactasasinglepointofcontactforbooking,schedulingandplanningallofNHSLanarkshirepatienttransport.Wewilldevelopthisproposalduring2017–18.Thiswill:• Increasecapacitythroughmoreappropriateuseofallpatienttransport• Improvepublictransportinformationtopatients,relativesandstaffand
prioritiseSASresourcestoensurethatthemostappropriatepatientsareabletoaccessthem
WewilldevelopthisserviceinconjunctionwithSPTandotherpartnersastheyhavesignificantexpertiseandknowledgeofoperatingcontactcentreservices.ItisanticipatedthatthecontactcentrewillbephysicallylocatedwithintheexistingSPTcontactcentreinGlasgowandwilloperateinparallelwiththeScottishAmbulanceServicecontactcentre.Theintentionistopromoteauniquecontactcentretelephonenumberforpatients,relatives,carersandstaffinorderthattheycancallthecontactcentreiftheyhaveahealthrelatedtransportrequirement.Contactcentrestaffwill:• Provideuptodateaccurateinformationonpublictransportavailabilityto
thecaller,• TransferthecallertoSAScontactcentreifappropriate,• Identifyandarrangealternativetransportprovisione.g.community
transport,volunteerdriver,localauthoritycapacity
WhatWillSuccessLookLike?
Clearandunderstandableparkingpolicyatoursites
Improvedpublictransportlinkstoourfacilities
Improvedpatientandcareraccesstoaccurateandup-to-datetravelinformation
Improvedjoint-planningwithambulanceservice
DevelopmentofanIntegratedTransportHubprovidingasinglepointofcontactforpatients,carers,visitorsandstaff
93The Workforce of the Future
THEWORKFORCEOFTHEFUTURE
VisionThe NHS in Scotland has one of the most skilled workforces in the world, and a proud tradition of education and training. Overall the numbers of doctors, dentists and nurses have increased but we know that in many specialties there are challenges in employing the numbers of highly skilled staff we need to meet ever changing levels of demand.A National Clinical Strategy for Scotland, Scottish Government 2016
NHSLanarkshire’sworkforcewillbeinstrumentalinthesuccessfuldeliveryoftheLanarkshireHealthcareStrategythroughmakingbestuseoftheskillsandcapabilitiesofitsstaff.Theworkforce,inallprofessionsandatalllevels,willhaveaparttoplayandstaffwillbesupportedanddevelopedtoensuretheycanfullyengageandcommittotherevisedservicedeliverymodels.Thefutureworkforcewillbebasedonteamsofstaffratherthanindividualpractitionerstodevelopeffectivemulti-disciplinaryteamsworkingwiththeappropriateknowledgeandskills.Itwillintegratemorecloselytheworkofhospitalbasedspecialtiesalongsidecommunitybasedteams,withaclearunderstandingandvalueofeachother’srolesandaculturewhichsupportspeoplewithlongtermconditionsandtheircarerstobetheleadpartnersindecisionsabouttheirhealthandwellbeing.
Theroutemaptothe2020VisionforHealthandSocialCareoutlinestheScottishGovernment’svisionforimprovingqualityandmakingmeasurableprogresstowardshighquality,sustainablehealthandsocialcareservicesinScotland.IndevelopingtheHealthcareStrategywewillcontinueouractionstosupportthefiveprioritiesoutlinedwithinEveryone Matters1.
Figure 12:Everyone Matters5Priorities
6
2020 Workforce Vision
Our 20 20 V
ision for Health and S
ocial Care
Capable workforce
Effective leadership and management
Integrated workforce
Healthy organisational culture
Sustainable workforce
94 Achieving Excellence: Healthcare Strategy
Thefuturemodelfortheworkforcewillberealisticandconsidertheworkforceavailability,adaptabilityandaffordabilitytodelivertherevisedclinicalmodelinthespecifiedtimeframe.Ineffect,theworkforcemodelrequires:
• Earlyprojectionandpreparationofstafftomeetthefuturedemandifdifferentskillssetsarerequired
• Adequateopportunityforstafftobedevelopedtomeettheserequirements• Allthistobeframedwithinafinanciallyviableworkforcemodel
StaffGovernanceNHSScotland’scommitmenttostaffgovernancewasreinforcedbythelegislativeunderpinningwithintheNHSReform(Scotland)Act2004.TheStaffGovernanceStandardFrameworkisthekeypolicydocumenttosupportthelegislationwhichaimstoimprovehowNHSScotland’sworkforceistreatedatwork.ThefourtheditionwasdevelopedtotakeintoaccountdevelopmentswithinNHSScotland,toreflecttheimplementationoftheHealthcareQualityStrategyforScotland,thethreeQualityAmbitionsandQualityOutcomesandtheStrategicNarrativesettingoutour20:20Visionforhealthcare.TheStaffGovernanceStandardsare:
• wellinformed;• appropriatelytrainedanddeveloped;• involvedindecisions;• treatedfairlyandconsistently,withdignityandrespect,inanenvironment
wherediversityisvalued;and• providedwithacontinuouslyimprovingandsafeworkingenvironment,
promotingthehealthandwellbeingofstaff,patientsandthewidercommunity.
TheStaffGovernanceStandardsprovidethefoundationforengagementwithourstaffinshapingthefutureWorkforcetodelivertheHealthcareStrategy.TheFairWorkvisionisthat,by2025,peopleinScotlandwillhaveaworld-leadingworkinglifewherefairworkdrivessuccess,wellbeingandprosperityforindividuals,businesses,organisationsandsociety.TheFairWorkFrameworkreinforcestheNHSStaffGovernancestandardsasitdescribesthesignificanceofprovidinganeffectivevoice,opportunity,security,fulfilmentandrespect;thatbalancestherightsandresponsibilitiesofemployersandworkersandthatcangeneratebenefitsforindividuals,organisationsandsociety.
WorkforceAvailabilityMedical StaffingCurrently,thereareongoingissueswithmedicalstaffingavailabilityinLanarkshireandacrossScotland.Thisisparticularlyacuteingeneralpractice(seesection4.2).Withanincreasingolderpopulationandsubsequentincreaseinhealthcareneeds,thecontinuationofclinicalservicesdeliverybasedonthecurrentworkforcemodel,withthesamelevelofrelianceonmedicalstaffing,isunsustainable.MostoftheworkstreamsintheLanarkshireHealthcareStrategyrecognisethisandplantoadoptaworkforcemodelwherebythereishigherrelianceonarangeofAdvancePractitionerroles.Theseroleswilldevelopfrom
95The Workforce of the Future
severalprofessionalbackgrounds(nursing,alliedhealthprofessionals,pharmacyandphysicianassociates),willbetrainedtotakeontraditionalmedicalroles/tasksandwillbecomeasignificantcomponentofthefutureNHSLanarkshireworkforce.
Ageing Population Theageingpopulationwillnotonlychangetheservicedemands,itwillalsobereflectedintheavailabilityoftheNHSLanarkshireworkforce.Ineffect,wewillhaveanolderworkforcein2025andahighervolumeofretirementsyearonyear.Withthis,NHSLanarkshireisconsideringapproachestosupportolderstafftoremaininemployment(e.g.lessphysicallydemandingroles,reducedhours,etc.)whilerecognisingandsuccessionplanningforpotentiallossofskillsandknowledge.AWorkingLongerinNHSLanarkshirewebpagewillbelaunchedinSpring2017.
Service DeliveryToprovidesafe,effectiveandperson-centredcare,theworkforceof2025shouldmatchtheworkloaddemandsinthecarecontext,locationandhoursofservice.Thiswillseeashiftinstaffingintothecommunityworkforceandwillrequireachangefromtheexistingpatternsofworktowards24x7dayworking.
Recruitment & RetentionNHSLrecognisestheimportanceofbeinganEmployerofchoicewhichattractsandretainsstaff,supportedby,recruitment,selections,induction,performancemanagement,strongleadershipandstaffdevelopmentprocesses.
Tomaximiseworkforceavailabilityandreduceagency/locumspend,NHSLshouldpromoteLanarkshireasaplacetoworkandwherepossiblereviewworkforcestrategiesandpoliciestoreflectandsupportthisbothforsubstantiveandbankstaff.
WorkforceAdaptabilityCommissioning New Roles NHSLanarkshirewillundertakedetailedmulti-professionalworkloadandworkforceplanning.Effectiveuseofexistingresourceswillbeessentialaswillgaininganunderstandingofcurrentutilisationoftheworkforceandthelikelyimplicationsforretentionoftheexistingworkforce,manyofwhomwillremainpartoftheworkforceforthenext5-10years.Thiswillprovideessentialbaselinedataforfutureremodellingwork.Theidentificationofskillsandcompetencygapswillbeequallyimportantinensuringappropriatetraininganddevelopmentisongoingtoensuretheworkforceisappropriatelypreparedandsupportedforthefuture.Itcantake18-24monthstotrainaqualifiedhealthcareprofessionaltoadvancedpracticelevelandthereforeitiscriticalthatthisisinitiatedasearlyaspossible.
Asimilarapproachwillberequiredtodefinethegenericsupportworkerrole.Itmaynotbepossibletodeterminetheexactnumbersofeachrolerequiredandsoaninitialestimateofneedshouldbeagreedandusedforthepurposesof
96 Achieving Excellence: Healthcare Strategy
development.Todothis,itisessentialthatprofessionsareabletodefinetheiruniqueprofessionalcontributionandidentifytaskswhichcanbeprescribedandcarriedouteffectivelybysupportworkers,thusbuildingsafeandeffectivecapacity.
Influencing Undergraduate ProgrammesOngoingworkisrequiredwithRegulators,ScottishGovernmentandHigherEducationalInstitutions(HEIs)toensurethatthedevelopmentofundergraduateprogrammesisdesignedinlinewiththefuturehealthcareneed,withsufficientfocusoncommunitycare.
Development of existing staff skillsItisenvisagedthatadvancedpracticeroleswillbeanintegralpartofbuildingcapacityandcapabilitywithinthecommunity.Thedevelopmentsforextendedroles,suchasintravenoustherapy,advancedpractice,nonmedicalprescribingandextensionofhealthcaresupportworkerrolestosupportthefuturecommunitycarewillrequireengagementwithHEIsinconjunctionwithNHSLanarkshire’sPracticeDevelopmentTeamandGPpractices.NHSLanarkshireisfullyengagedinthenationalagendatodeveloptherolesofcommunitypractitionerswithaviewtoensuringitmeetstheneedsofpeopleusingourservices.TheframeworkbelowhasbeendevelopedbyNHSEducationforScotlandforcommunitynursingandoutlinestheelementsrequiredforsafe,effectiveandpersoncenteredcareandsupportinthecommunity.Whileitfocusesonnursinginthecommunity,itreflectsthedirectionoftravelinourapproachacrossallprofessions.
FRAMEWORK FOR MODERNISING NURSING IN THE COMMUNITY
Safe, effective & person-centred care
CHILDREN,YOUNG PEOPLE
& FAMILIES
WORK & WELLBEING
ADULTS & OLDER PEOPLE
Using care pathways
Promoting health
& addressing inequality
Building workforce capacity
& capability
Achieving an outcome-focused
approach
Strengthening leadership
& team working
Utilising Telecare & Telehealth
Improving quality
& efficiency
Enabling & supporting
self care
Anticipating health needs & responding
earlier
Working with other agencies & disciplines as
partners
Providing choice
& care in the right setting
Working with clients, carers
& patients as partners
INFORMINGPRACTICE
WITH POLICY,RESEARCH AND
EVIDENCE
DEVELOPINGSKILLS AND KNOWLEDGE
THROUGH EDUCATION
Figure 13:FrameworkforModernisingNursingintheCommunity
97The Workforce of the Future
WorkforceAffordabilityImprove efficiencyTomaximisetheefficiencyofservicedelivery,severalworkforceredesignfactorsarebeingconsidered:
• Avoid duplication–opportunitiestointegrateandstreamlinepatientpathwayswillbeconsideredandwherepossiblegenericsupportworkersintroducedbothacrosshealthandhealth/socialcare(AHP,nursing,socialcare).Thisalsohastheaddedbenefitofprovidingagreatercareerstructureforthestaffinvolved.
• Work to “top of licence”(registeredandsupportstaff)–rolesrequiretobereviewedwithstaffsupportedanddevelopedtoworktothe“topoftheirlicence”.Thisoffersthepotentialtoincreasestaffnumbersandredistributetheworkloadtolowerbandedbutappropriatelytrainedstaff,thusavoidinganincreaseincost.
• Extended scope –tostreamlinethepatientjourneyandminimise“hand-offs”,certainroleswillrequiretoextendtheirscopetoprovidesomeadditionalaspectsofcareandavoidreferringontoadifferenthealthcareproviderorintoacuteservicese.g.communitynursesdevelopingIntravenous(IV)therapyskillstoallowpatientstobecaredforinthecommunity;extendingpsychologicalcareapproaches,growingtheresilienceofpeopleusingservicestoeffectivelyself-careandsupportingconcordancewithagreedpersonalisedtreatmentplansreducingdemandsonunscheduledcare.
• Roles appropriate to skill–toensureefficiency,appropriatelyskilledstaffshouldundertakerolese.g.adminstaffundertakingadminroles,notclinicians.Staffdevelopedtoconductproactiveengagementwithpatients,theirfamiliesandcarersaboutwhatmatterstothemandhowtheyfeelbettersupportedtoaccessservicesandtoself-carewhentheyareable;staffempoweredtopromotehealthylifestylesandprovidesupporttopatientsandcarerstomeetsocialchallengessuchasfinancialsecurityandemployment.
Inaddition,thereareotheropportunitiesforefficiencywhichwouldsupporttheworkforce:
• Improvementsintechnologysuchaselectronicpatientrecords,mobiletechnology(tabletcomputers),etc.wouldsupportgreaterworkforceefficiency
• Innovativepracticeusingexistingtechnologybasedplatforms(e.g.NHSInformMATS)anddevelopingotherweb-basedaccesstoservicesforearlyadviceandself-management,influencingacultureofself-efficacywhichdeflectsdemandawayfromhealthcareservicesandintoupstreamservicese.g.leisure,voluntaryandthirdsectorservices.
• NHSLanarkshire,NorthandSouthLanarkshireHealthandSocialCarePartnershipswillcontinuetoworkwiththirdsectorcolleaguestofocusonsupportingandtestingoutnewapproachesforthedeliveryofcommunity-basedsupportforpeoplewithcomplexandmultipleconditions.Thiswillincludedeliveringanintegratedapproachthatcomplementsmainstreamservicesbyotheragencies,isfullylinkedintolocalityplanningarrangements,continuingtofocusonbuildingcommunitycapacityandlocalinfrastructuretosupportthedeliveryoflocalservicesand
98 Achieving Excellence: Healthcare Strategy
furtherdevelopsthecommitmenttocarersupportthroughastructuredprogrammeofassessmentandsupport
• Integratemorecloselyallcontractordisciplinessuchascommunitypharmacists,dentists,optometristsandcareproviderstoenablepatientstobetteraccessappropriatecareandadvice
• IntroducepharmacistsinGPpracticeswithadvancedclinicalassessmentskillstosupportthecareofpatientswithlongtermconditionsandbettermanagetheirmedications
TheworkforcetosupporttheLanarkshireHealthcareStrategywillnotbe“moreofthesame”.TheworkforcewillbeolderandhaveagreaterrelianceonAdvancedPractitionersandroleswithextendedscope.Allstaffgroupswillworktothe“topoftheirlicence”withworkalignedtotheirskills.Theworkforcemayrequiretoberedistributedtomatchtheincreasedworkloaddemandinthecommunity.
Itisdifficultatthisstagetoindicatetheexactnumbersanddevelopmentrequirementsforeachroleuntilmoredetailedworkloadandplanninghasbeenundertaken.TheworkstreamswithinthisstrategyhaveidentifiedkeyareasofrolerequirementsthathavealreadybeendevelopedinotherareaswithinNHSLanarkshireandtheapproachcanbeusedtosupportthedevelopmentandextendtherolesofourexistingstaff.Inaddition,leadershipandteamdevelopmentapproachesarewellembeddedwithinNHSLanarkshireandcanbeutilisedtofurtherdeveloptheknowledgeandskillsrequiredtoachievetherequiredoutcomes.
References1 ScottishGovernment.EveryoneMatters:2020WorkforceVision.Edinburgh:
ScottishGovernment,2013.
100 Achieving Excellence: Healthcare Strategy
PLANSFORSERVICECHANGE
IntroductionInreviewingthefuturehealthcareneedsoftheLanarkshirepopulation,thereisarangeofchangestothescopeanddispositionofclinicalservicesnecessarytoachievetheobjectivesofthestrategy,ensuringallofourservicesareperson-centred,safeandeffective.
Someofthesechangesrepresentanimmediatechallengetotheseobjectivesandwillbeimplementedsoon,butotherswilltaketimetoplananddevelopbeforeimplementationispossible.NHSLanarkshire,inconjunctionwithHealthandSocialCareNorthLanarkshireandSouthLanarkshireHealthandSocialCarePartnership,willdevelopaphasedplanforservicechangeoveranumberofyears,beginningin2017.
ThissectionoftheStrategydescribesthepossibletimescalesforthesignificantchangestoserviceswhicharedescribedearlierinthedocument.However,manyofthesechangesareatanearlystageofdevelopmentandfurtherengagementanddiscussionmaybenecessary,alongsideclarityoftheresourcingandfinancialimpactofsomeofthesedevelopments.
4.1 Primary Care Transformation Programme• Carryouttests-of-change2017–18• ImplementchangesrequiredbynewGPcontract2018–21• Implementmulti-professionalworkforcedevelopmentplans2018–21• ImplementaprogrammetospreadchangesacrossLanarkshire2021–26
4.2 Long Term Conditions• Newmodelsofcarefinalised2017–18• Implementworkforceplanstobuildcommunitycapacity2017–20• SpreadgoodpracticeacrossLanarkshire2017onwards
4.3 Older Peoples Services• EnhancedLocalityteamsestablishedby2019• Intermediatecareservicesdefined2017onwards• CommunitysupportandinterventionsspreadacrossLanarkshire2017
onwards
4.4 Mental Health and Learning Disability• Developintegratedcommunitymentalhealthservices2017onwards• DevelopandimplementaCrisisandDistressInterventionsservicemodel
2017onwards• Developtwo-sitemodelforacuteadmissionsfor2020• Completeinpatientmodernisationplanforolderpeople’spsychiatry2017• Reviewofforensicservices2017onwards
7
101Plans for Service Change
• AllwardswillestablishaQualityImprovementGroupin2017• Reviewofrehabilitationandrecoveryservicemodel2017onwards• EnhancementalhealthliaisoninDGHsby2019
4.6 Alcohol and Drugs• ImplementationofagreedstrategiesaspartoftheSingleOutcome
Agreements2017onwards• MonitorandreportLanarkshire’sprogressinaccordancewiththenational
recoveryindicators2018onwards
4.7 Maternity, Early Years, Children and Young People• Developingtherolesandcapacityofcommunitypaediatricteams2017
onwards• Changingservicemodelformaternityandpaediatricstoreflectchanging
demographicsofthepopulation2017onwards• Ensuretheneonatalunitaccommodationisenhancedin2017• Developanewservicemodelforpaediatricemergencycareby2019
4.8 Planned and Unscheduled Care• Developplanswhichshiftclinicalcarefromunscheduledtoplanned(but
urgent)modelsofcare2017onwards• Prepareabusinesscaseforthereplacementorredevelopmentof
MonklandsDGH2017–24• EnhanceemergencydepartmentcapacityatMonklandsin2017• Developaproposalforagastrointestinalbleedscentreofexcellence2017
onwards• FurtherdevelopthecancercentreservicemodelatMonklands2017
onwards• EnhanceemergencydepartmentcapabilityatWishawin2017• DeveloptheservicemodelformajortraumaservicesintheWestof
Scotland2017onwards
4.9 Orthopaedic Services• Consolidatetheinterimchangestoinpatientservicesduring2017• Inconjunctionwithnationalandregionalstrategies,in2017/18prepare
aproposalfortheestablishmentofamajortraumacentreatWishawGeneralHospital
• Developaservicemodelforelectiveorthopaedicswhichwillformpartoftheemergingproposalsfordiagnosticandelectivecentresofexcellencethrough2017/18
102 Achieving Excellence: Healthcare Strategy
4.10 Cancer Services• ReviewtheservicemodelforSACTtoimproveaccessandqualityofcare
by2017• Prepareaproposalin2017fortheestablishmentofaSACTcentreof
excellenceatMonklands• Implementtheconclusionsofthenationalsharedservicesreviewof
asepticdrugproductionby2020
4.11 Stroke Services• Developaservicemodelforadvancedclot-bustingtreatmentsby2020• Implementanoutpatientserviceforneurovascularconditionsby2019• Developaservicemodelforlocalstrokespasticitytreatmentby2019• Enhanceprofessionaleducationforstrokecare2017onwards• Developaservicemodelforearlycarotidsurgeryby2020
4.12 Palliative care • Developarapidresponseserviceforsupportathomeby2020• Agreeacommissioningstrategyforhospiceinpatientservicesby2018• Improvesupportforhospitalstafftoassistpatients’decisionmakingby
2020• Deliverastructuredconversationpackageby2019• Developtheuseoftelehealthtosupportpatientsandfamiliesby2019
5.1 Pharmacy• Enhancetheskillsandcapabilityofthepharmacyworkforce2017onwards• Maximisetherolesofcommunitypharmaciststhroughrevised
contracting2017onward• Developimprovedinformationforpatientsandcarers2017onwards• Developprofessionalrolesfurtheraspartoftheextendedprimarycare
teams2017-20• Refreshthegovernanceandfinancialmanagementofmedicines
prescribinginprimarycareandhospitalsfrom2017onwards
5.2 Property• Supporthealthandsocialcareteamstodevelopthefuture
accommodationneedsforMonklandsDGH2017to2024• Developtoolsandtechniquestoimprovetheefficientuseandallocation
ofspaceinourpremises2017onwards• Deliverasafeandefficientbacklogmaintenanceprogrammeacrossall
areas2017onwards• Supportservicedevelopmentsinprimarycare,hospitalservicesand
supportservices2017onwardstosupportrealignmentofservices
103Plans for Service Change
5.3 eHealth and Digital Technologies• Provideasingleelectronicpatientrecordwhichcanoperateinallclinical
settingsby2020• DevelopideasandproposalsfortheuseofeConsultation2017onwards• Adaptmodelsofcaretoenablepatientstopersonalisetheirhealth
informationby2020• Enhancetheclinicalportalsystemfrom2017onwards• Introducethehospitalprescribingandadministrationsystemby2020• Developtheuseofpoint-of-careinformationsystemsby2020• ProvideafullyintegratedprimarycareandcommunityITsolutionby
2020• Providerwiderelectronicaccessforpatientstotheirownhealthcare
recordsthroughthenewpatientportalby2020• Developreal-timebusinessintelligencethroughonlinedashboards2017
onwards
5.4 Transport• Improveaccesstoparkingforpatientsandvisitorsathospitalsitesby
2019• Providebetterinformationonpublictransporttothosewhouseour
facilities2017onwards• Furtherdevelopeffectiveuseoftheambulanceservice2017onwards• SupportthedevelopmentofanIntegratedTransportHubin2017/18
105Financial Resources
FINANCIALRESOURCES
NationalPositionTheScottishbudgetsetsouttheoverallScottishGovernmentfundingfor2016/17until2019/20.Overthatperiodthetotalrevenuebudgetissettoincreasefrom£26.098billionto£26.468billion,whichaveragesoutat0.47%perannum.Healthbudgetshavesofaronlybeenannouncedfor2016/17,witha3–5yearbudgetexpectedlaterintheyear.Meanwhile,NHSBoardshavebeenadvisedtouseahigherplanningpercentageof1.8%perannumwhensubmittingtheirfutureyearplans.
NHSLanarkshireFutureResourcingNHSLanarkshirereceivesacoreallocationatthestartoftheyear(£1105min2016),followedbyaseriesofin-yearfundingadjustmentsforspecificpurposes.Thedetailsofthespecificfundingfor2016/17havenotyetbeenconfirmed.
HealthbudgetshavetraditionallybeengivenadegreeofprotectionandinrecentyearsBoardshavebeenadvisedtoplanonreceivinganupliftequivalenttoaneconomicindicatorknownastheGDP(GrossDomesticProduct)deflator.IfcostswithinthehealthservicewererisingatthesamepaceasGDPdeflator,thiswouldallowthehealthservicetocontinuetoprovidethesamelevelofserviceinfutureyears.Anyefficiencyorproductivitygainscouldthenbeusedtoprovideadditionalserviceontopofthatallowedbyanynewin-yearallocations.
In2016/17healthcostswillrisefasterthantheGDPdeflatorof1.7%.Thepaybill,whichmakesupjustunder50%ofthetotalcostsisforecasttoriseby3.4%throughthecombinedimpactofnationalinsuranceincreases,abasicpayriseof1%andagreementstoassistthelowerpaid.
Around20%ofthebudgetisnowspentondrugs.Expenditureondrugsprescribedroseby22.8%inhospitalsduring15/16andGPprescribingby4.9%(seesection5.1).
Otherfactorsdrivinganaboveinflationarycostriseincludeanationalshortageofdoctors,causinganincreasedrelianceonhighercostlocumsandincreasedexpenditureneededtomaintainwaitingtimes.Evenwiththegeneralallocationupliftedby1.7%NHSLanarkshirewillneedtosave£43min2016/17inordertostaywithinbudget.Apartfromthoseareasthatreceivedspecificadditionalfunding(e.g.primarycare)anyclinicalservicechangewouldneedtobeachievedwithintheexistingbudgets.
8
106 Achieving Excellence: Healthcare Strategy
Atpresent,theestimateofwhattheNHSBoard’sunderlyingfinancialpositioncouldbeovertheperiodto2019/20isasshownbelow.
2016/17(£m)
2017/18(£m)
2018/19(£m)
2019/20(£m)
Allocationupliftat1.8% 19.3 19.7 20.1Paybillincrease 8.7 6.4 6.5Othergeneralsuppliesincreases 6.7 6.8 6.9Increaseindrugsexpenditure(lowestimate)
10.3 11.2 12.1
Minimumgaptobemetfromefficiencysavings
-43.0 -6.3 -4.7 -5.4
Therearestillmultipleuncertaintiesaboutthisprojection.
Thekeyvariablesare:• TheextenttowhichNHSLanarkshirecangenerate£43mofrecurring
savingsin2016/17.AsofJune2016therewasstillagapof£19mrecurringly.• WhethertheScottishGovernmentwouldbeabletogiveabudgetrise
of1.8%totheexistinghealthservicesgivenitsownbudgetpositionandcompetingdemands.
• Whethertheriseinhospitaldrugcostswillreducefromitsrateof22.8%in15/16.Thefinancialplanaboveassumesonly10.6%from2016/17onwards.A22.8%risewouldbeover£7.7mmoreeachyear.
Giventhecontextofcontinuedconstraintonpublicsectorfundingatanationallevelandthehistoricriseindrugscosts,theaboveforecastrepresentsthemoreoptimisticendoftherangeofrealisticforecasts.Evenstill,itindicatesthatcontinuedefficiencygainswillbeneededandeachareaofservicedeliverywillhavetomaximiseproductivityandtheuseofexistingresources.
CapitalInvestmentVariousservicechangesmayneedcapitalorothertransitionalfundingtosupportaservicereconfiguration.AreplacementforMonklandsHospitalwillbebyfarthemostsignificantelementofthecapitalrequirementbutintheshortertermtherewillbearangeofsmallerscalerequirements.NHSLanarkshire’s2016/17corecapitalallocationof£12.9m,evenoncesupplementedbyanadditional£3mofcentralsupport,isalreadyovercommitted.ThefuturecapitalrequirementsoftheHealthcareStrategywillbemappedoutindetailanddiscussedwiththeScottishGovernment.Inparticular,abusinesscasetosecure£400mininvestmentinMonklandswillbeprepared.
108 Achieving Excellence: Healthcare Strategy
LISTENINGTOYOURVIEWS
EarlyDevelopmentWorkNHSLanarkshirehasbeeninvolvingpublic,patientandcarerrepresentatives,aswellasclinicalstaff,indevelopingitshealthcarestrategysincetheoutsetofthedevelopmentprocess.
InrecognisingtheneedforthedevelopmentofahealthcarestrategyforLanarkshire,astrategygroupwassetupin2015totakethisworkforward.IndividualworkstreamsweredevelopedtoreviewservicesledbyNHScliniciansandmanagers,withinvolvementfrompatientrepresentatives,specialinterestgroupsandthethirdsector.
Capturingthepatientexperienceofserviceshasbeenattheheartofthereviewprocesstoensurethatanyserviceproposalsareaimedatprovidingbetteroutcomesforpatients.NHSLanarkshireisgratefultothosewhotookpartinthisearlydevelopmentworkandfortheirinvestmentandcommitmenttotakingthisworkforward.
Aspartoftheprocess,NHSLanarkshirespoketopatients,families,carersandstafftoexplorehowwellcurrentservicesmeettheirneedsandidentifywayswecandothingsdifferentlytobettermeettheseneedsinthefuture.
Throughouttheearlydevelopmentworkengagementtookplacewithintheindividualworkstreams,inlocalitiesandonaLanarkshire-widebasis.TwomajorstakeholdereventstookplaceinAugust2015andNovember2015toshareanddiscusstheearlyemergingviewsonfutureserviceneeds.
Inaddition,aHealthcareStrategyEngagementGroup-whichincludedpatient,carerandthirdsectorrepresentatives-andaClinicalReferenceGroup–madeupofleadcliniciansfromallprofessions-wereestablishedtoreviewtheoutputsfromtheclinicalworkstreamsandoverseethedevelopmentofthisdocument.AnonlinequestionnaireonSurveyMonkeywascarriedoutinFebruaryandMarch2016toinformthedevelopmentofthedraftstrategy.
Throughthiscollaborativeapproach,thedrafthealthcarestrategy‘AchievingExcellence’wasproducedinsummer2016.
TheConsultationProcessAformalthree-monthconsultationprocessonthedraftstrategyranfrom2Augustto1November2016involvingawiderangeofstakeholders.NHSLanarkshire’soverarchingaimfortheconsultationprocesswastoconsultonthedrafthealthcarestrategyinordertoreceivemeaningfulfeedbackfromstakeholderstoshapethefinalstrategy.
NHSLanarkshireworkedcloselywiththeScottishHealthCounciltoensuretheapproachtakenwasinlinewithCEL4(2010)‘Informing,EngagingandConsultingPeopleinDevelopingHealthandCommunityCareServices’setsouttheprocesstobefollowedbyNHSorganisationsintheplanningandimplementationofservicechanges.
9
109Listening to Your Views
TheScottishHealthCouncilcarriedoutqualityassuranceoftheconsultationprocesswhichincludesseekingtheviewsofstakeholdersontheprocessitself.NHSLanarkshirehasreceivedareportoftheconsultationprocessfromtheScottishHealthCouncilconfirmingthatitwassatisfiedthattheconsultationprocessmettherequirementsofCEL4(2010).
NHSLanarkshiresetouttoconsultwidelytoensureawiderangeofstakeholdersfromacrossLanarkshirehadanopportunitytobeinformedoftheconsultationandcommentontheproposals.
TheconsultationexerciseaimedtoprovidetheopportunityforthepeopleofLanarkshire,ourpartners,staffandpoliticalrepresentativestounderstandthecontextinwhichourserviceswilldevelopinthenextdecade.
Theintentionwastoinitiateaconversationonwhatthiswouldlooklikeintermsofchangingthewaysinwhichtheseservicesmayneedtochangeasaresult.Theexercisethereforesetouttogatherawiderangeofideasandopinionsthatwouldbeinvaluableincompletingawell-roundedstrategicvisionandimplementationplan.
Theconsultationplanincludedabroadrangeofcommunicationandfeedbackmethodstoensurepeoplehadarangeofopportunitiestobeinformedandprovidetheircommentsonthecontentsofthestrategy.
Thisincluded:• Consultationdocumentsinarangeofformats.• ConsultationquestionsonlineasaSurveyMonkeyquestionnaire–435
responses.• E-Newsletter–Threeissuesemailedto464stakeholdersduringthe
consultation.• Mediareleases.• Advertisementsforthepublicmeetingsinlocalnewspapers.• NHSLanarkshirepublicwebsiteAchievingExcellencewebpages.• DigitalpostersonNHSLanarkshireelectronicdisplayscreensinthethree
acutehospitals.• Printedposterswithpublicmeetingdetailsdisplayedinhospitals,health
centresandlibraries.• Awarenessraisingroadshowsattheentrancesandrestaurantsofthethree
acutehospitalsreachingapproximately200people.• Fivepublicmeetingswereheld(Wishaw,EastKilbride,Cumbernauld,
LanarkandAirdrie).• 10localityeventswereheldbytheSouthLanarkshireHealthandSocialCare
PartnershipandHealthandSocialCareNorthLanarkshire.• 27additionalmeetingsfeaturedtheconsultation.• Arangeofstaffcommunications.
YourFeedbackThroughthisactivityfeedbackwasreceivedfromawiderangeofstakeholdersincludingpublic,patients,staff,electedrepresentativesandorganisationsduring
110 Achieving Excellence: Healthcare Strategy
theconsultationprocess.Throughouttheconsultation,strongsupportwasexpressedforthedirectionoftravelandvisioninthehealthcarestrategy.Therewasalsoagreatdealofusefulandconstructivecommentsabouthowbesttoachievethese(seelinkbelow).Theseviewstheninformedthepreparationofthefinalversionofthisstrategy.
NHSLanarkshirewouldliketothankeveryonewhotookthetimeparticipateintheconsultationprocessforthethoughtandefforttheyputintoprovidingawealthofvaluableandconstructivefeedback.
ThefullconsultationresponsesweremadeavailabletomembersoftheLanarkshireNHSBoard.Inaddition,allthespecificanddetailedcommentsmadeonthevisionsandplansforindividualworkstreamsandcrosscuttingissuespresentedinthehealthcarestrategyweresharedwiththeworkstreamleadstoinformandshapethisfinalversionofthestrategyalongwiththeimplementationplansandprocesses.
Inadditiontotheconsultationresponsesreceived,theAcademyofMedicalRoyalCollegesandFacultiesinScotlandwasaskedtoundertakeareviewofAchievingExcellence.TheacademyoutlinedthatthestrategywasconsistentwiththeNationalClinicalStrategyforScotlandandrealisticmedicine.
ThefullNHSLanarkshireconsultationreport,whichwasendorsedbytheNHSLanarkshireBoardon30November2016,canbefoundat:www.nhslanarkshire.org.uk/boards/2016-board-papers/Pages/November.aspx
We’llbepublishingregularbulletinsonhowtheimplementationoftheambitionssetoutin“AchievingExcellence”arebeingtakenforward;pleasecheckourwebsitewww.nhslanarkshire.org.ukforfurtherupdates.
Ifyou’dliketocontactuswithanyquestionspleasewriteto:
HCS ViewsPlanning&DevelopmentDepartmentNHSLanarkshireHeadquartersFallsideRoadBothwellG718BB
111Listening to Your Views
GlossaryofAbbreviations
A&E AccidentandEmergencyDepartment(nowknownasED)ADP AlcoholandDrugPartnershipAF AtrialFibrillationAHP AlliedHealthProfessionalCAHMS ChildandAdolescentMentalHealthServicesCHD CoronaryHeartDiseaseCHPs CommunityHealthPartnershipsCS CaesareanSectionDAISy DrugandAlcoholInformationSystemDGH DistrictGeneralHospitalED EmergencyDepartmentENT EarNose&ThroatERAS EnhancedRecoveryAfterSurgeryGDP GrossDomesticProductGI GastrointestinalGIA GrossInternalAreaGIRFEC GettingitRightForEveryChildGP GeneralPractitionerHEI HigherEducationalInstitutionHIS HealthcareImprovementScotlandHoC HouseofCareHSCP Health&SocialCarePartnershipICU IntensiveCareUnitIJB IntegrationJointBoardIV IntravenousLENS LanarkshireEye-healthNetworkServiceLOS LengthofStay(inhospital)LTC LongTermConditionMCN ManagedClinicalNetworkMH MentalHealthMH&LD MentalHealthandLearningDisabilityNHSL NHSLanarkshirePFI PrivateFinanceInitiativePPP PrivatePublicPartnershipQEUH QueenElizabethUniversityHospitalSACT SystemicAntiCancerTherapySCP SocialCarePartnershipSPT StrathclydePartnershipforTransportSVD SpontaneousVaginalDeliveryTEC TechnologyEnabledCare