Final 15th March 2013
LDP Risk Management Plan
Health Board: Grampian
Use of Risk Management Plan
Boards should, as in previous years, use the LDP Risk Management Plan to provide
contextual information on key risks to the delivery of each targetand how the risks are
being managed.Within the template, the description of the key risk should be provided
in the first column and detail on how the risk is being managed should be provided in
the second column. Cross-reference to local plans should be made where necessary.
oDelivery and Improvement: briefly highlight local issues and risks that may impact on the achievement of targets and/or the planned performance trajectories towards targets and how these risks will be managed.
oWorkforce: brief narrative on the workforce implications of each of the HEAT targets where appropriate and relevant. This should include an assessment of staff availability to deliver the target, the need for any training and development to ensure staff have the competency levels required, and consideration of affordability cross referenced to the Financial Plan.
oFinance: Where applicable boards should identify and explain any specific issues, e.g. cost pressures or financial dependencies specifically related to achieving the target. There is no need to repeat generic financial risks that apply to all targets.
- Equalities: Where applicable, boards should outline any risks that the delivery of the target could create unequal health outcomes for people with protected characteristics, and/or for people living in socio-economic disadvantage; and how these risks are being managed.
Final 15th March 2013
HEATS TARGETS FOR 2013/14
To increase the proportion of people diagnosed and treated in the first stage of breast, colorectal and lung caner by 25%, by 2014/15At least 80% of pregnant women in each SIMD quintile will have booked for antenatal care by the 12th week of gestation by March 2015 so as to ensure improvements in breast feeding rates and other important health behaviours
Reduce suicide rate between 2002 and 2013 by 20%
To achieve 14,910 completed child health weight interventions over the three years ending March 2014
NHSScotland to deliver universal smoking cessation services to achieve at least 80,000 successful quits (at one month post quit) including 48,000 in the 40% most-deprived within-Board SIMD areas over the three years ending March 2014
At least 60% of 3 and 4 year old children in each SIMD quintile to receive at least two applications of fluoride varnish (FV) per year by March 2014
NHSScotland to reduce energy-based carbon emissions and to continue a reduction in energy consumption to contribute to the greenhouse gas emissions reduction targets set in the Climate Change (Scotland) Act 2009
Deliver faster access to mental health services by delivering 26 weeks referral to treatment for specialist Child and Adolescent Mental Health Services (CAMHS) from March 2013; reducing to 18 weeks from December 2014; and 18 weeks referral to treatment for Psychological Therapies from December 2014
Eligible patients will commence IVF treatment within 12 months by 31 March 2015
To deliver expected rates of dementia diagnosis and by 2015/16, all people newly diagnosed with dementia will have a minimum of a year’s worth of post-diagnostic support coordinated by a link worker, including the building of a person-centred support plan
Reduce the rate of emergency inpatient bed days for people aged 75 and over per 1,000 population, by at least 12% between 2009/10 and 2014/15
No people will wait more than 28 days to be discharged from hospital into a more appropriate care setting, once treatment is complete from April 2013, followed by a 14 day maximum wait from April 2015
Further reduce healthcare associated infections so that by 2014/15 NHS Boards’ staphylococcus aureus bacteraemia (including MRSA) cases are 0.24 or less per 1000 acute occupied bed days; and the rate of Clostridium difficile infections in patients aged 15 and over is 0.25 cases or less per 1,000 total occupied bed days
To support shifting the balance of care, NHS Boards will achieve agreed reductions in the rates of attendance at A&E between 2009/10 and 2013/14
95% of patients will wait less than 4 hours from arrival to admission, discharge or transfer for accident and emergency treatment by year ending September 2014
To increase the proportion of people diagnosed and treated in the first stage of breast, colorectal and lung cancer by 25%, by 2014/15
Executive Lead: / Mr Graeme Smith : Director of ModernisationDelivery and Improvement
Risk / Management of RiskUncertainty and variation:
The Detect Cancer Early (DCE) baseline estimates for NHS Boards, based on 2010 and 2011 cancer audit data submissions, are not finalised. The revised DCE baseline estimate for NHS Grampian may remain low relative to other NHS Board areas. The previous LDP 2012/13 trajectory required an increase in performance of almost 60% over a period of four years.
The DCE target is based on a cancer outcome event subject to random variation and biological variation. There is no weighting for the number of cases in each tumour group.
Issues include:
- variation in annual diagnosed cases;
- differences in rate of progression for individual tumours;
- clinical features may not be identifiable until later stages of disease;
- increased identification at all stages of existing prevalent disease; and
- compensation required across tumour groups - smaller potential improvements for breast and lung cancer.
A preliminary evaluation of National Awareness and Early Diagnosis Initiative (NAEDI) campaigns in England suggests that the expected downstaging at diagnosis may not have been achieved. ( DCE symposium 12th September 2012 ) / Secondary prevention aims to detect and treat existing disease at the earliest possible stage, based on evidence of improved patient reported and clinical outcomes.
NHSGrampian DCE actions will be reviewed and revised based on local monitoring and evaluation, emerging evidence, and reported learning from early diagnosis and treatment initiatives elsewhere.
Implementation and development:
Non-adoption of an integrated cross-boundary and whole system approach across Grampian.
Non-representative processes with insufficient engagement by clinicians and other key stakeholders. / The Grampian Cancer Care Network (GCCN) was established at the end of 2012. There will be ongoing development work during 2013.
Recurrent funding has been allocated to support the GCCN manager post.
GCCN sub-groups, aligned to discrete steps within the cancer care pathway, cover DCE objectives:
- ‘Community Engagement’;
- ‘Primary Care’; and
- ‘Screening and Diagnostics’.
There may be unnecessary duplication at national, North of Scotland Cancer Network (NOSCAN) and NHSGrampian levels. / Communication links will be improved.
Public awareness and individual decision making.
There may be:
No increase in the ‘positive view’ of cancer treatment and prognosis.
No reduction in ‘appraisal interval’ - delay to individual recognition of clinical features.
No reduction in ‘help-seeking’ interval - individual delay to seek medical advice.
No increase in informed participation in national screening programmes for breast cancer and bowel cancer. (Current participation levels in Grampian are approximately 60% for the bowel screening programme and over 80% for the breast screening programme.) / Local actions will continue to reinforce the content of the national social marketing campaigns.
A cross-sectoral approach has been adopted in partnership with cancer charities, local authorities, and voluntary organisations. Actions include: support for national campaign roadshow events; print and digital articles with signposting to local support services; local case studies, celebrity endorsement, and organisation targeting; interviews with local community radio stations; mail distribution of ‘empowerment’ leaflet to deprived area postcodes; local awareness events with specialist nurse input; and migrant population target group - materials translations and prioritised distribution points
Local primary care practices will be supported to deliver against the proposed SQOF 2013-14 objective to improve eligible practice population bowel screening uptake. Further information is awaited.
Symptom management and referral:
Non-specific clinical features,frequently occurring with other non-cancer conditions, which have a low positive predictive value (probability of disease given clinical features).
Increased ‘false positive’ patient flows through the diagnostic pathway - potential harm for these ‘true negative disease’ patients and inefficient use of scare resources.
Delay due to process barriers for referral or direct access investigations.
Inequity of access to cancer diagnostics due to misclassification of clinical need for Urgent Suspected Cancer Referral.
A proportion of cancer cases will not present with guideline ‘checklist’ symptoms and signs.
No reduction in proportion of cancer emergency admission diagnoses. / There are conflicts between certain identified risks.
As a principle, clinical suspicion and judgement in primary care will be supported.
Models for ‘risk-sharing’ with secondary care consultants will be further examined - individual cases and patient sub-groups.
Primary care leads for cancer and palliative care, aligned to five geographical areas (South Aberdeenshire, Central Aberdeenshire, North Aberdeenshire, Moray and AberdeenCity), will have an ongoing role in engagement with colleagues, local practice feedback mechanisms and dissemination of learning across Grampian.
Local electronic primary care cancer referral guidance will be co-ordinated by GCCN
Revisions to colorectal cancer referral guidance will be implemented during 2012/13.
A local QPQOF to support significant event audits of cancer emergency admission diagnoses will be further examined.
Further information is awaited :
ISD - individual practice cancer profiles.
Healthcare Improvement Scotland - Review of Scottish Primary Care Referral Guidelines for three tumour types completed by April 2013.
The Royal College of General Practitioners (Scotland) agreement to facilitate common approaches to influencing referral practice, education and awareness raising.
Capacity and managing demand:
Demand and capacity mismatch due to increased patient numbers and patient flows.
Performance against cancer access standards not sustained. / DCE recurrent funding allocation:
- Increased CT and ultrasound capacity: radiologist 0.50 wte; nurse 1 wte; sonographer 1wte; and administrator 0.25 wte.
- Increased CT colonography capacity: radiologist (reporting) 0.20 wte; radiographer (Scanning) 0.60 wte; and administrator 0.25 wte.
- Increased lower GI endoscopy capacity: nurse endoscopist 1 wte. Appointment will support flexible responses to meet variable symptomatic and screen positive referrals demand.
- Increased pathology capacity: pathologist 1 wte; Biomedical Scientist 1 wte; and consumable costs.
Data Collection and Reporting:
Insufficient appropriately skilled capacity and contingency cover, to meet the mandatory reporting requirements for DCE and Cancer Quality Performance Indicators (QPIs). / The previous North East Scotland Cancer Co-ordinating & Advisory Group (NESCCAG) Cancer Audit Team will be realigned within the GCCN structure.
There will be a review of local cancer audit data processes, multi-disciplinary team (MDT) data collection, electronic data storage, data validation, and data extraction.
NHS Scotland standardised definitions and measures will be applied for all local cancer data processes.
DCE recurrent funding allocation to increase cancer audit capacity: cancer audit data collector 1 wte and cancer audit data analyst 1wte.
Mandatory cancer audit data will be submitted within the required timescales.
Ad hoc cancer data requested by ISD will be provided within reasonable timescales.
Workforce
Risk / Management of RiskNon-optimal cancer care pathways due to workforce capacity, processes or patterns of working. / Necessary service development changes will be incorporated into workforce planning processes.
Targeted training support will be provided.
Processes for benchmarking and dissemination of learning will be supported within Grampian.
Finance
Risk / Management of RiskUnpredictable peaks or patterns in service use.
Level of DCE funding available insufficient to meet net resources requirement. / Available DCE funding, and other resources to support cancer care services modernisation, will be subject to a prioritisation process.
Equalities
Risk / Management of RiskPoor impact for individuals and communities in relative and absolute deprivation or disadvantage.
Poor impact for the Grampian population who reside in ‘accessible rural’ or ‘remote rural’ areas ( > 30% based on Scottish Government 6 fold Urban Rural Classification). / A proportionate and whole population approach will be adopted. Communication and marketing resources will be prioritised towards local high-risk target groups.
An asset-based approach will be adopted - working with individuals and communities to identify and strengthen skills, knowledge, resources, and networks - to build resilience and a sense of coherence to effect positive change.
Specific actions to mitigate the identified risks are included within the previous Public Awareness and Individual Decisions section.
Final 15th March 2013
At least 80% of pregnant women in each SIMD quintile will have booked for antenatal care by the 12th week of gestation by March 2015 so as to ensure improvements in breast feeding rates and other important health behaviours
Executive Lead:Board Lead: / Dr Pauline Strachan: Chief Operating Officer
Mr Andrew Fowlie: General Manager Moray CHP
Delivery and Improvement
Risk / Management of RiskReplacement of Patient Management System has taken longer than expected with compromise in data availability/quality / We are deploying additional resources to clear data processing backlogs.
High midwifery caseloads and workload may diminish ability to attain target fully. / Workforce redesign is in process to increase capacity and ensure even spread of midwifery care.
Our full understanding of the effectiveness of our interventions is at an early stage. / We will ensure evaluation of interventions within our improvement framework.
Workforce
Risk / Management of RiskThe spread of midwifery services is historical rather than planned on a needs-based service approach. / We are in process of rebasing resources to create an equitable service.
The social context of antenatal care delivery is not fully integrated into our model of delivery. / We will take forward a training and development plan with NHS Education Scotland and other stakeholders.
Finance
Risk / Management of RiskThe redistribution of resources to areas of greatest need will take time. / The NHS Grampian Maternity Review is complete and will guide resource allocation.
Equalities
Risk / Management of RiskApproach may be based on incomplete needs assessment and data analysis. / The full analysis will be completed by June 2013. We have involved local ethnic and diversity communities in the Maternity Review and impact assessed the consultation document.
We have appointed 3 bi/tri-lingual Health Link Workers to reach out to non-English speaking communities and feed back on healthcare needs.
Final 15th March 2013
Reduce suicide rate between 2002 and 2013 by 20%
Executive Lead:Board Lead: / Sir Lewis Ritchie: Director of Public Health
Ms Julie Fletcher: Interim General Manager Mental Health and Learning Disability
Delivery and Improvement
Risk / Management of RiskAchievement of the target is affected by demographic changes and by NHS Grampian’s lack of influence on other stakeholder agencies and the general public. / We have partnership arrangements in place through Mental Health Partnership/Strategic Outcome Groups and the Choose Life Groups covering Moray and Aberdeen City/Aberdeenshire. To strengthen the pan-Grampian approach a Grampian Suicide Monitoring Group has also been convened.
The Choose Life Action Plans for Moray and for Aberdeen/Aberdeenshire provide a detailed record of work to manage risk across the Grampian partner agencies
A Memorandum of Understanding is in place with Grampian Police to ensure appropriate and timeous information sharing in-year.
The reduction in the suicide rate continues to fluctuate due to small numbers and demographic factors. / Fluctuation in the rate due to small numbers is inevitable. The Suicide Monitoring Group and local partnerships will ensure detailed analyses of available data to inform our understanding and guide future action.
Workforce
Risk / Management of RiskTraining time for suicide prevention skills are not prioritised against other statutory and mandatory training, in particular for staff in primary care. / We will continue to deliver Suicide Prevention Training to front-line staff and offer Protected Learning Time sessions for primary care staff. Community and Primary Care staff will be encouraged to participate in such training. We will seek specific training for GPs subject to funding.
The cost of such training and release of frontline staff, however, remains an issue in General Practice.
Finance
Risk / Management of RiskThe cost of releasing front-line staff from their posts for training is prohibitive. / Staff release will be raised with all internal and external partners with a view to encouraging and supporting a network approach to learning.
Equalities
Risk / Management of RiskThere is variation in suicide rates within different local authority areas. / Low numbers mean it is not possible to draw any meaningful conclusions from this variation.However, this is captured in local Choose Life and other planning. The Suicide Monitoring Group will prepare an annual position statement following publication of the national statistics. This will inform future planning.
Final 15th March 2013
To achieve 1,556 completed child health weight (CHW) interventions over the three years ending March 2014
Executive Lead:Board Lead: / Sir Lewis Ritchie: Director of Public Health
Mrs Caroline Comerford: Nutrition Co-ordinator
Delivery and Improvement
Risk / Management of RiskThe lower number of eligible completions (above the 91st centile), due to lower than Scottish average rates of overweight children, increases the challenge of delivering the target. / Prevalence will continue to be monitored closely and actions reviewed as required.
Failure to meet the requirement for 40% completions in two most deprived SIMD quintiles, 1 and 2, by local SIMD datazone in more remote and rural areas. / We will use available local intelligence and learning from the implementation of other programmes and work with Community Planning Partners to continue to target the programme and monitor progress through existing performance mechanisms.
Delivery of CHW services is currently dependent on ring-fenced, time limited resource. This factor, combined with service capacity limitations, poses a challenge for mainstreaming targeted interventions within clinical services and the school based intervention into school settings. / We are working with Education colleagues to discuss the viability of the long term sustainability of the school-based intervention.
We will continue to embed the Child Healthy Weight Pathway into routine practice. There will be strong Nursing and Allied Health Professions leadership to encourage delivery.
The collection of accurate and verifiable data, provided in a timely fashion is critical to the success of the CHW programme. Data will be collected via the Child Health Surveillance Programme and the worthiness of the collected data will be dependent on the performance of data providers. Potential risks include inaccurate data entry and the unsuitability of Business Objects for the provision of accurate and useful reports. The data collected for the programme must also relate to the correct time period and be available when required, in a form that can be subsequently analysed. / We will monitor the data collection processes and tools continuously by reviewing quality and completeness of data received. This will be done through regular contact with all data providers in Grampian. We will also continue to work closely with Scottish Government, ISD and others to progress and monitor work.
Commissioned research identifies negative issues around programme that need to be addressed. / We will maintain links with AberdeenUniversity to ensure early identification of findings, including any areas of concern.
Workforce