Paper 2

NHS GRAMPIAN

Proposed Resource Allocation and Decision Making Framework for NHS Grampian

Aim

This paper summarises progress to date and plans for the continued development of the proposed Resource Allocation and Decision Making Framework (RA&DMF) for NHS Grampian, as part of the Health and Care Framework (H&CF). Members of the Grampian NHS Board are asked to note progress to date and approve the proposed plans for further development.

Strategic Context

NHS Grampian, like other public sector bodies are facing major challenges, one of which is lower funding increases, combined with growing expectations from the public, staff and partners, the strive for high quality carewhich meet population needs and the continued advancement in treatment and technology. It is recognised that difficult decisions must be made to ensure that funding is allocated effectively to maximise population health gain in Grampian. In addition to this, NHS Grampian requires to reduce projected revenue expenditure by more than £20 million in 2011/12, in order to stay in financial balance. This situation will naturally create increased scrutiny from staff, the public, partners and the media in how the organisation makes decisions and allocates current and future funding.

In October 2010, the Grampian NHS Board agreed that a key component of the H&CF will be the development of a RA&DMF. The main function of the RA&DMF will be to support and guide services, strategic groups and the organisation in making key decisions about resource allocation to ensure maximum impact of the strategy and the five strategic themes, as set out in the Grampian Health Plan for 2010-13¹. The Grampian Health Plan fully supports national strategy and in particular, the recent NHS Scotland Quality Strategy², of which is further embedded in the proposed H&CF³ and RA&DMF.

There have been several unsuccessful attempts over recent years to agree a more refined and sensitive organisation-wide framework for allocating resources and support decision making than currently exists. Due to increasing challenges, NHS Grampian must have in place a transparent and consistent approach at service and organisational level which ensures that allocation of resources and decisions are focussed on delivering good quality, sustainable and affordable services which maximise population health.

Discussion

  1. In order to appropriately deliver a good quality, sustainable and affordable health and care model in NHS Grampian, there requires to be much greater clarity at organisational, service, staff and public level regarding the basis for making sound and credible decisions. This requires to be undertaken in a consistent and transparent manner.
  1. In early 2010, the Board Executive Team agreed a number of key principles for delivering good quality, sustainable and affordable care. These principles were communicated publicly via the NHS Grampian Health Plan for 2010-13, (page 19). These principles are:
  • Improved health for the population, including addressing health inequalities
  • Improved clinical outcomes for patients
  • Improved patient safety
  • Improved patient experience
  • Underpinning the above is ensuring that workforce is appropriate and sustainable for the future and that best value (good quality, efficient and sustainable) for the money invested.
  1. The above principles are core to making organisational and service decisions, but this must be more explicit in terms of clear organisational criteria linked to outcomes. Currently anyone could make a case for just about anything based on the above principles.
  1. There are a number of anticipated outcomes and benefits to be gained in implementing a locally agreed RA&DMF. These are:
  2. At service and organisational level there will be consistency and transparency in prioritising available resources which relate to improving outcomes against the agreed principles.
  3. A mechanism to appropriately shift resource to support the implementation of a good quality, sustainable and affordable model of care across Grampian.
  4. Enhanced organisational management of service change and associated resource implications e.g. national policy, technological advances etc.
  5. Increased ability to prioritise and shift resource in order to implement the agreed strategy as set out in the Grampian Health Plan and the underpinning H&CF.

Progress to Date

  1. Appendix 1 outlines the high level plan underpinning the development of the RA&DMF. Appendix 2 summarises the process implemented and the progress made to date.
  1. A Prioritisation and Decision Making Sub Group was set-up in September 2010 to facilitate the development and testing of a RA&DMF on behalf of the H&CF Steering Group. The role of the Sub Group is to develop, test and recommend a RA&DMF which informs deployment of resources to best effect in supporting the Grampian Health Plan and the underpinning H&CF. This group is chaired by the Director of Finance and reports to the H&CF Steering Group, which in turn reports to the Strategic Management Team (SMT).
  1. Membership of the Sub Group is made up of clinical, staff side, public, delivery team, public health, planning, Efficiency and Productivity Programme Management Office (EPPMO), quality and finance representatives.
  1. To seek broader public involvement around this agenda, the Public Forum, Banff and Mearns Youth Forums have been engaged specifically to seek their views on what they feel are the most important measures to take into account in supporting decision making, from their perspective. The three groups were consistent in what they felt were the most important criteria. A report on the feedback has been produced and the outcomes have been fed into the overall development process.
  1. The Sub Group has proposed that there are four strands to the RA&DMF process. These are:
  2. Service prioritisation against new unfunded advances/technology within the pathway of care, within available resources. Where this is not possible within existing resources, prioritisation must be carried out at organisational level, prioritising across different service areas.
  3. Service review – supporting services to use the framework in evaluating current investments in the service before commissioning or decommissioning any part of the service.
  4. Organisational prioritisation of available resources by re-allocating resources between service areas.
  5. Service and organisational prioritisation of future additional resources by reviewing all new proposals for funding and prioritising these by way of the agreed RA&DMF.
  1. It is proposed that the RA&DMF will also oversee the implementation of a robust process for managing ‘difficult decisions on an individual patient basis’ (for example, a specific high cost drug or technological health care intervention), and the process for managing ‘out of area referral’ of Grampian patients.
  1. A RA&DMF template (see appendix 3) has been developed using the Modified Portsmouth Tool, which is based on the principle where several agreed criteria are used to decide whether or not to undertake a proposal. Criteria within the template have been focussed upon NHS Grampian’s strategic direction and strategic themes, as set out in the Grampian Health Plan for 2010-13. The RA&DMF template has recently been tested by a number of groups and is currently undergoing further refinement in order to be further tested.

Next Steps

  1. Two of the groups who were testing the RA&DMF and guidance from the option appraisal/service review perspective, advised that the criteria setout areoverall appropriate but, the RA&DMF process requires to be modified to better support the aim of option appraisal/service reviews. This will be workedup and further tested in the coming months.
  1. The Sub Group agreed at their meeting on the 7th March 2011, that the RA&DMF template and underpinning guidance requires to be further tested as part of the development of the H&CF. Specific areas agreed for testing are:
  2. Agreeing the preferred health and care options within the preferred pathway of care for the Forres population as part of the Forres Pathfinder Project.
  3. Agreeing the preferred options within the preferred pathway of care for the Inverurie population as part of the Inverurie Pathfinder Project.
  4. The development of the proposed H&CF Action Plan for submission to the Board in October 2011.

In addition to the above, the Sub Group alsoagreed to test the RA&DMF in relation to the allocation of Public Health funding for 2011/12.

  1. An update on the progress to date and proposed plans for further development of the RA&DMF were submitted to the Service Strategy and Redesign Committee (SSRC) on the 16th March 2011 and the SMT on the 18th March 2011. Both committees recommended the submission of the proposed plans to the Grampian NHS Board.
  1. It was also agreed at the SMT meeting on the 18th March 2011, that NHS Grampian requires to:
  2. Explore the use of the emerging RA&DMF within the context of the Change Fund and the Integrated Resource Framework.
  3. Review and recommend suitable governance structures to oversee and support the various strands of the RA&DMF as set-out in paragraphs nine and ten.
  1. Following stage three testing as outlined in paragraphs 12 and 13, the RA&DMF will be further evaluated and refined before being re-submitted to the SSRC and the SMT in September 2011 for recommendation to the Grampian NHS Board in October 2011. An Equality Impact Assessment and Health Impact Assessment will be undertaken as part of the evaluation in summer 2011.

Resource Implications

The development and testing of the RA&DMF has been absorbed within existing resources. The resource implications of implementing the proposed RA&DMF will be further clarified as part of the testing process, although it is anticipated these should be minimal and that the perceived outcomes from a successful RA&DMF will create a more focussed use of all resources to deliver the strategy as set out in the Grampian Health Plan and underpinning H&CF.

Key Risks

The development and agreement of the RA&DMF is linked to reducing a number of strategic risks, although if successful will have the biggest impact on strategic risks 851 (Delivery Strategies are Unrealistic Given the Resource Position of NHS Grampian), 1115 (Alignment of Service Delivery to H&CF) and 1116 (Meeting expectations of the Health Plan), as set out in the NHS Grampian Strategic Risk Control Plan6.

There are a number of risks associated with the development and implementation of a RA&DMF, these include:

  • The organisation and supporting groups do not have the appetite to test and evaluate the RA&DMF.
  • The collective willingness of the organisation to agree a RA&DMF due to its complexity and the need to follow a more formalised decision-making process, particularly when this has not been successful in the past.
  • Services and parts of the system do not apply the agreed RA&DMF to routine practice on a consistent basis.
  • The organisation’s ability to manage the change process demanded by the framework’s conclusions.
  • If a RA&DMF is not developed, agreed and applied to routine business within NHS Grampian, the organisation is at significant risk of failing to have a consistent, transparent and robust approach in place to ensure well informed decisions are made and resources are allocated to deliver the strategy and the proposed health and care model.

Conclusion

The RA&DMF is being developed as part of the H&CF as agreed by the Grampian NHS Board in October 2010. The aim is to support and guide services, strategic groups and the organisation in making key decisions about resource allocation to ensure maximum impact of the strategy and the five strategic themes, as set out in the Grampian Health Plan for 2010-13 and the underpinning H&CF. It is essential to have a consistent and transparent approach, particularly with the increasing scrutiny from staff, the public, partners and the media in how the organisation makes decisions and allocates funding.

The process to develop the RA&DMF is ongoing and further testing will be carried out in the coming months as part of the development of the H&CF Action Plan and the pathfinder projects. The output of the testing will support the evaluation and refinement of the proposed RA&DMF, prior to being submitted to the SSRC and SMT for recommendation, before submission to the Grampian NHS Board in October 2011.

Recommendations

Members of the Grampian NHS Board are asked to:

  1. note the progress and mechanisms for developing the RA&DMF
  2. approve the proposed plans for the further development of the RA&DMF and the re-submission of the RA&DMF to the Grampian NHS Board in October 2011.

Background Papers/Supporting Information

¹ NHS Grampian Health Plan for 2010 – 2013. (April 2010). NHS Grampian.

² NHS Scotland Quality Strategy. (May 2010). Scottish Government Health Directorate.

³ Health and Care FrameworkPaper. (March 2011). NHS Grampian.

 Public Involvement Report in Developing the RA&DMF. (March 2011). NHS Grampian.

 Review of Tools Used to Assist Prioritisation in the NHS – Produced by Dr Okpo.

(October 2010). NHS Grampian

6NHS Grampian Strategic Risk Control Plan. (March 2011). NHS Grampian.

Executive Lead

Alan Gall, Director of Finance/Deputy Chief Executive and Chair of the RA&DMF Sub Group

Contact

Lorraine Scott, Service Planning Lead for Public Health and Planning.

28 March 2011

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Paper 2

Appendix 1

Proposed Development Plan for the Resource Allocation and Decision Making Framework (RA&DMF)

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Paper 2

Appendix 2

Process and Progress To Date in Developing the NHS Grampian Resource Allocation and Decision Making Framework (RA&DMF)

The table below outlines the process implemented to date, along with the progress made in the development of the RA&DMF.

Stage / Progress Update
Establish a Sub Group
(Oct 2010) / A Sub Group was set up in October 2011 to oversee the development andtesting of the RA&DMF. The Sub Group is made up of clinical, staff side, public, delivery team, public health, planning, quality, EPPMO and finance representatives. A member from the Health Economics Research Unit (HERU) at the University of Aberdeen is also supporting us in this work.
The minutes of the Sub Group and regular updates are provided to the H&CF Steering Group.
Agree a process, criteria and RA&DMF documents for testing
(Oct - Dec 2010) /
  • Process for the development of the RA&DMF was agreed by the Sub Group in October 2011.
  • A workshop was held to agree criteria, criteria definitions and also gain a consensus on the level of importance of the criteria. Criteria were based on the principles within the Grampian Health Plan for 2010-13.
  • Two methods for applying the RA&DMF, along with guidance for applying the RA&DMF were developed for testing.

Engage the public on the proposed criteria
(Nov 2010 – Feb 2011) / Views of the public were sought via the Public Forum and two Youth Forums (Banff and Mearns). Each group were asked to advise us what they thought of the criteria and also what level of importance they gave the criteria. All three groups were consistent with regards to their top three/four criteria which further supports the initial consensus of the Sub Group. A report on the feedback has been produced and will be made available on the H&CF webpage in April 2011.
Stage 1 testing of the process and RA&DMF documents
(Dec 2010 – Jan 2011) /
  • The Diabetes Managed Clinical Network (MCN) undertook initial testing of the RA&DMF documents.
  • Based on the feedback from the MCN, the Sub Group amended the process, the criteria and RA&DMF templates. One single method was agreed for further testing.

Stage 2 testing of the process and RA&DMF documents
(Feb – Mar 2011) /
  • A number of groups (Respiratory MCN, Cardiology MCN and Maternity Pathfinder) tested the RA&DMF process and documents to varying degrees. A representative from the test groups attended the Sub Group meeting on the 7th March 2011 to discuss the findings from the testing process.
  • The Sub Group agreed that a number of changes were required to the RA&DMF template and guidance and that this would be further tested as part of the development of the H&CF. The Sub Group also agreed that further work on the RA&DMF process is required to ensure this supports services undertaking option appraisals and service reviews.
  • The Sub Group agreed to evaluate and refine the proposed RA&DMF based on the findings of further testing and impact assessments, prior to submitting to the SSRC and SMT in September 2011 for recommendation to the Grampian NHS Board in October 2011.

Appendix 3

Template and Criteria Used to Test the Proposed NHS Grampian Resource Allocation and Decision Making Framework (RA&DMF)

The template below was tested by a number of groups as part of the stage two testing process of the RA&DMF. This template is currently undergoing refinement, along with the supporting guidance based on the recent feedback from the test groups.

Criteria / Criteria score / Total Score Assigned (a) / Weighting (b) / Total Weighted Score / Justification for Rating
Low / Mid Scale / High
Improved Health for the Population / 20%
Potential to improve population health:
  • Number of individuals/population affected by the condition or covered by a service
  • Trends in numbers of individuals affected by the condition
  • Number of individuals potentially benefiting from the proposal
/ 1 point
Little or no potential to improve population health / 5 points
Moderate potential to improve population health / 10 points
High potential to improve population health
Potential to prevent ill health:
  • Extent to which proposal aims to prevents of ill health.
  • Extent to which prevention strategy are already in place
/ 1 point
Little or no impact on preventing ill-health / 5 points
Moderate impact on preventing ill-health / 10 points
High impact on preventing ill-health