Healthfit – Tomorrow’s Health Today

An introduction to NHS Grampian

Who are we ?

NHS Grampian is the organisation responsible for leading efforts to improve the health of the people in Grampian, and for providing the NHS health care services which people need. We are the fourth largest Health Board in Scotland consisting of three Community Health Partnerships - AberdeenCity,

Aberdeenshire and Moray, and an acute sector, all supported by corporate

services such as Finance. A Board made up of representatives from the

Grampian community oversees our work assisted by a management team. Our headquarters are based in Summerfield House, Eday Road, Aberdeen.

What do we do ?

The purpose of NHS Grampian is to:

  • Improve the health of the people of Grampian (compared to the rest of Europe) and
  • Provide safe, high-quality treatment, based on clinical need in comfortable surroundings and within available resources.

We will only achieve this by working with our partners - staff, patients, carers,

communities, Community Planning Partners and organisations/groups - in Grampian, in the North of Scotland and nationally.

Where do our patients come from ?

We provide services to over half a million people from Grampian but around 6% of our specialist activity comes from the Western Isles, Highland, Orkney, Shetland and Tayside as well as other parts of Scotland and throughout the UK.

Where do we provide our services ?

We aim to deliver services as close to patients’ homes as it is clinically safe to do so. Services are provided in a range of community settings - workplaces, peoples’ homes, in one of the 91 GP practices or 19 Community Hospitals within our patch. Highly specialised care is delivered in our acute hospitals of Dr Gray’s, Woodend and Aberdeen Royal Infirmary. RoyalCornhillHospital provides inpatient and community support for mental health services. For women and children we provide specialist services at AberdeenMaternityHospital or the Children’s Hospital.

You may also want to look at our website for more background information.

The need for change

NHS Grampian must take account of national and regional NHS policies when

developing its Health Plan. Just like elsewhere in Scotland, we need to change our services or we will not meet the future needs of our population 1. Some of the reasons are as follows:

  • Changes in the population - we anticipate a 36% increase in those aged 71 years or over by 2018 - this will impact on the number of people available to work, more people living alone and fewer informal carers.
  • Changing health needs - there are an increasing number of people with long-term conditions e.g. diabetes, rising levels of obesity and increasing inequalities in health.
  • Productivity pressures and targets - there are challenging targets to improve access to treatments and to reduce the waiting time for treatment.
  • We have to comply with clinical guidelines to make sure services are of good quality as well as effective, and changing work patterns due to European legislation such as 48-hour working week.
  • Advances in medical and surgical practice.
  • Growing public expectations.
  • Rising costs - we must bring spend on services in line with our allocated budget 2. In previous years one-off sources of funding enabled NHS Grampian to provide more services (about 9% more) than our budget from the Scottish Executive would allow - this cannot continue in the future.

The case for change is compelling. To ensure that we build on our successes and learn lessons from elsewhere, we must plan this change as a single health system, with no professional barriers so that our focus is patients and their pathways of care, working locally, regionally and nationally to meet the needs of our population.

The Grampian response

NHS Grampian believes that to deliver the best health outcomes for our

population we must:

  • Tackle the root causes of ill-health with the help of others.
  • Work as one team integrating services with partners as appropriate.
  • Strive for continual improvement in the quality of our services and how they are delivered.
  • Make access to our services faster, more convenient and person focused.
  • Make best use of the available funding and resources.

In 2002 we began a process for redesigning health services in Grampian so that they meet the present and future needs of the population. We call this process Healthfit 3, and it involves working with the people we serve, and those who work with us, to agree a shared vision for health and healthcare services in the future. Our vision requires us to work differently if we are to take account of changes that will continue to happen such as advances in technology and a growing older population. Difficult choices must be made - we can only do more of one thing if we do less of another. Therefore this

Plan must be seen as a package if we are to deliver services fit for the future and within available resources.

To support this redesign, feedback suggests we must change the culture of NHS Grampian. We will do this through listening to staff, involving them in the development of new ways of working and we will support the development of new skills. It will require us to further develop how we work with the people we serve - giving you the chance to influence and contribute to change - working together to deliver tomorrow’s health today.

We have concentrated this Plan on our priorities for 2005/06 on which we will focus our effort in order to deliver more person centred, accessible, safer and efficient services. A performance framework 4 has been developed to monitor progress with implementation of this Plan and to ensure continuous improvement is made throughout our services. There is a significant amount of work required and underway that cannot be reflected but which underpins this summary. Fact sheets have been produced for services in which you have shown particular interest such as dental, children’s and substance

misuse services. We have also included references and hyperlinks at the end for those wishing greater detail.

Developing services

Our programme to redesign services is made up of nine projects 5 that we will

take forward over the short and medium term. Each will be led by a senior

clinician or manager supported by a team of people from across the health

(and in some cases social care) system. We discussed these proposals with

patients, the public and our partner organisations during 2004 and outline below what you told us, the current position and actions we intend to take.

1 Closing the ‘health gap’

We said:

There are five national measures of performance 6 to assess our progress in closing the gap in health status between people who are disadvantaged economically, socially or for other reasons, and those who live in affluent areas. Our local statistics show that health is not improving as fast in our most disadvantaged areas as it is in the most affluent areas. So what we call the inequality gap has widened. This is unacceptable and must be tackled.

You told us:

  • The local priorities should be obesity, mental health, smoking and reducing the harm caused by drugs and alcohol identified through the Health Improvement Healthfit 7.
  • We should concentrate on reducing inequality in the outcome (or result) of health care, as well as how easy it is to access it.
  • Patient transport systems must also be redesigned.
  • You did not support the redistribution of funds away from existing areas to tackle inequalities.

We will:

  • Assess how all future NHS Grampian strategy and plans will affect inequalities.
  • Gather more information on where inequalities exist in Grampian, and how we can monitor progress on reducing them.
  • Take forward local programmes that support the national priority of ‘social inclusion 8.
  • Concentrate action on the priorities identified through the Health Improvement Healthfit.

2 Self-care

We said:

People with long-term, chronic health problems are becoming expert in their own conditions. Having the knowledge and skills to help manage their own condition has a very positive effect on people’s quality of life and confidence. Evidence 9 suggests visits to GPs can reduce by 40% for high-risk groups and outpatient visits can be reduced by 17%. Above all, complications from chronic diseases reduce. Self-care can apply to us all, looking after ourselves, eating healthily, not smoking, being active, knowing how to care for minor ailments and what to do in an emergency.

You told us:

  • We need to agree what we mean by ‘self-care’.
  • Learning from what we know works, we should be more systematic in delivering self-care across Grampian.
  • We must strike a balance between technological developments (such as electronic patient records) and traditional methods (such as leaflets).

We will:

  • Hold a self-care workshop in June 2005 to examine in detail how self-care could be taken forward in a structured way in Grampian.
  • Use this to develop a strategy for self-care.
  • Set up some pilot projects by the end of 2005 to help us identify how best to roll out self-care across Grampian.

3 Unscheduled Care

We said:

Unscheduled care is the term given to health care provided when needed urgently, including emergencies, which can happen at any hour of the day or night. Our aim is to provide a 24-hour rapid and smooth response by a joined up service which involves primary care, hospital services and partner organisations such as the Scottish Ambulance Service, NHS 24, the voluntary sector and with our regional partners. There is plenty of evidence 10 to show that a whole-system approach to unscheduled care can result in a better experience for the patient (and carer), more effective use of staff time

and fewer unnecessary admissions to hospital.

You told us:

  • You support a single point of entry to health services in a medical emergency.
  • We should build on the successes of each service (G-MED, Accident & Emergency (A&E), Acute Medical Assessment Unit (AMAU)) when we bring these together.
  • More awareness in the public of what advice is available where and the impact of inappropriate use is required.

We will:

  • Participate in a national project called the Unscheduled Care Collaborative 10, which aims to achieve a maximum four-hour emergency waiting time target by 2007, a 24-hour target for operating on people with hip fractures and local targets for reducing the number of delayed discharge.
  • Further develop multi-professional teams, to make better use of non-medical health professionals (e.g. pharmacists) working out-of-hours, and more salaried G-MED doctors.
  • As part of the service redesign build a new integrated Emergency Centre for Aberdeen by 2008 to house G-MED, A&E and the AMAU.
  • Develop an integrated Emergency Centre at Dr Gray’s, Elgin to bring together A&E and G-MED.
  • Increase our efforts to raise public awareness of how people should use emergency health services.

4 Planned Care

We said:

Planned care includes planned appointments, treatments and operations. As part of re-designing across our whole health system, highly specialised acute hospitals will concentrate on providing services or procedures for patients who require those specialist skills or facilities. This will enable us to re-organise services at Aberdeen Royal Infirmary, Woodend and Dr Gray’s hospitals so that we manage patient flows and, eventually, eliminate queues. By the end of December 2005 no patient should have waited longer than 26 weeks for a first outpatient consultation or for any subsequent treatment, 8 weeks from urgent referral to treatment for all cancers and 8 weeks for angiography, 18 weeks for angioplasty or a coronary artery by-pass graft 11.

You told us:

  • We need an organisational culture which works as a single system, guided by ‘patient pathways’ of care from prevention through to highly-specialised treatment.
  • We should examine the Ten High Impact Changes 12 published by the NHS Modernisation Agency to see if they could be applied to Grampian.
  • We should encourage frontline staff to spot where changes could be made for the benefit of patients.
  • We should look at the information we have, and see how we can use it better, to help us focus on what will bring the biggest health benefits.

We will:

  • Reshape acute services 13 by taking forward four of the Ten High Impact Changes:

-increasing the number of people who are treated as day cases (target 75% currently at 52%)

-avoiding unnecessary follow-ups for patients (new to return ratio),

-maximising the use of operating theatres

-re-distributing beds by looking at bed management as a whole system, rather than dealing with each speciality separately.

  • Work with our regional partners to jointly plan planned care in the North.
  • Develop Managed Clinical Networks for specific services - ENT, cardiology, mental health, obstetrics and gynaecology - across the North of Scotland, to improve access, make best use of available resources and ensure the sustainability of these services in the region.
  • Review the role of Dr Gray’s Hospital in Elgin, as part of the North of Scotland health infrastructure 14,15.
  • Extend skills and knowledge to improve knowledge based service planning.

5 Intermediate Care

We said:

After careful consideration of the needs of the patient, evidence of good practice and the opportunities afforded by the new contractual arrangements within NHS Grampian we are developing a new approach to care with clinicians, patients and others. We call this intermediate care because the aim is to provide enhanced services in the community for patients who require more support than is normally provided at GP practice level, but who do not require the specialist services of the acute hospitals.

We are piloting this approach in Orthopaedics and Dermatology. In both services, general practitioners supported by consultants are treating patients, providing faster

more local access and increasing local professional knowledge and skills. A dermatology pilot in Banff and Buchan reduced waiting times by eight weeks. Data suggests that up to 40% of activity currently dealt with in our acute hospitals could be treated in the community by suitably trained practitioners. With financial support from the Scottish Executive we have established a Community Outpatient Project 16 to further develop this model. The project, working as part of the planned care project (see above), aims to develop new ways of working to manage demand, improve patient booking, reshape

the workforce through extending professional roles and ultimately to improve the service whilst also reducing waiting times.

You told us:

  • Proposed shifts in activity must be based on evidence of benefits, avoid creating inequalities (for example, for different areas of Grampian) and be effective in being ‘as local as possible as specialised as needed’.
  • As activity shifts to new locations, we will need to change how patient transport works.
  • You support Diagnostic and Treatment Centres (DTC) for those elements of intermediate care which need expensive and hi-tech facilities and/or equipment. This could be the Foresterhill site for Aberdeen, Dr Gray’s for Moray and a community hospital network in Aberdeenshire. While this proposal is welcome, we need to discuss with local communities the potential impact on some of our community hospitals.

We will:

  • Take forward the Community Outpatient Project pilots in ENT, orthopaedics, plastic surgery, dermatology and neurology by March 2006.
  • Introduce a referral management system by October 2005.
  • Have a training and accreditation programme for General Practitioners / Practitioners with Special Interest by May 2005.
  • Get IT infrastructure and medical equipment in place at agreed geographical locations (Diagnostic and Treatment Centres) by December 2005.
  • In line with our Older People’s Strategy 17, release long-stay beds to create an intermediate care area by December 2005 to free up capacity in hospital to care for patients with specialised needs.
  • Develop a patient transport system which supports the change programme by holding a Transport Summit by Autumn 2005.

6 Developing Clinical Infrastructure

We said:

If we are to shift the balance of care into the community, and at the same time

ensure clinical quality of our services, we must invest in the technology and systems which support this such as the electronic health record, Picture Archiving and Communications Systems, mobile diagnostic facilities 18. We know we can reduce the need for tests by removing duplication from the system. Patients are then less likely to be admitted to hospital for tests alone, waiting times are shorter, and patients have more choice about when and where they have their appointments.

You told us:

  • We should use the same principles of service redesign in developing this infrastructure, namely evidence of impact, a better-integrated system and care delivered locally where appropriate.
  • You support the roll out of the Picture Archiving and Communications System.
  • We need better technology to gather the data we need to help the planning of services.

We will:

  • Roll out the Picture Archiving and Communications System across Grampian by 2007/08.
  • Roll out the necessary equipment to support GPs with a special interest to lead community outpatient clinics e.g. sterilisation equipment, digital imaging equipment, endoscopes and phototherapy equipment, by December 2005.
  • Replace the Magnetic Resonance Imager (MRI scanner) at Aberdeen Royal Infirmary by March 2006, increasing the use of this modern technology from 72 to 110 procedures per week.
  • Replace the existing Cardiac Catheter Laboratory at Aberdeen Royal Infirmary. On a North of Scotland basis consider ( in July 2005) location of additional capacity to meet the projected 7% increase in angiography and 15% increase in angioplasty.
  • Develop a business case for an Integrated Clinical Manager system (to support the electronic patient record, on-line requests, electronic prescribing and clinical protocols across primary and secondary care).

7 Aberdeen Health Campus Development

We said:

Work has been going on to look at the health facilities and services which are located in Aberdeen but which act as a regional centre for specialist and trauma services and to date have provided intermediate care services for Aberdeen and to a lesser extent Aberdeenshire. We know that there will need to be some change and modernisation if we are to provide reasonable access to quality and affordable premises to support the delivery of modern health and social care throughout Grampian and the North of Scotland.