APPENDIX 1 – PROJECTS

  1. Long Term Conditions
  1. Mental Health
  1. Better Care Without Delay
  1. AberdeenCity CHP Redesign
  1. Health Campus
  1. Intermediate Care
  1. Anticipatory care to reduce re-admissions for over 65s (sub-set of Long Term Conditions programme)
  1. Continuation of the Unscheduled Care Demonstrator Project
  1. Reducing the length of stay in ARI Surgical areas
  1. Reducing the length of stay in ARI Medical areas
  1. Reducing the length of stay in Community hospitals
  1. Developing Orthopaedic theatres capacity
  1. Sustain and further improve outpatient waiting times
  1. Procurement best value

1

Project Title / 1. Improving Grampians Response to Long Term Conditions
What is the problem? / What is the link with existing initiatives?
Aging population and changing demongraphics
Culture change - expectation that people using our services will also have the capacity and capability to self manage
Possibility exists to overtreat and undertreat people in services
Inconsistent quality of care
Inequity of access to care and the delivery of care
Insufficient evidence of shifting the balance of care - hospital treatment still a regular default
Rising admission rates for >65
Lengths of Stay and ability of Acute sector to move people through the system and achieve early supported discharge
Workforce not consistently supported to work within the competency level required to manage LTC / Shifting the balance of care
Patient safety Programme
MCNs Diabetes/Stroke/CHD/Respiratory
Better Care Without Delay
Mental Health Collaborative
Keep Well - Health Inequalities
Financial framework of NHS Grampian, need to reduce burden on inpatient care where admission was inappropriate and ensure that community services are placed to deliver appropriate care
NHS Grampians workforce plan
Rehabilitation Framework/Employability schemes and reablement agenda
Self Management Strategy for Scotland
City Primary Care Redesign and Intermediate Care Project
What do we know about the problem? / What are the risks?
At Dec 08, emergency bed days >65 yrs across Grampian were 3622 per 1000 population against a trajectory of 3201 per 1000 population, with an increasing trend
At Dec 08, the emergency re-admission rate across Grampian was 45.1 per 1000 population against a trajectory of 33.9 per 1000 population
At Dec 08, emergency admission rates for Long Term Conditions – (COPD, ASTHMA, DIABETES, CHD) were noted to be 1696 hospital episodes per 100,000 population, against a trajectory of 1647 (when considered at local CHP level the gap between performance and trajectory is significant for AberdeenCity (1901) and Moray CHP(1927), with Aberdeenshire compliant and below target.
A&4 4 hour target is affected by the flow of this care group and the impact they can have on the systems ability to manage bed usage
Teams would wish to be more pro-active in their delivery of care but have concerns about how they will cope with an increase in volume or range of interventions within the community.
It is estimated nationally that by 2014 if we keep doing what we are doing we will require an increase of 24% in hospital beds, by 2031 this is 6000 more beds for Grampian, a new hospital
Population estimates stated in Better Health, Better Care say:-
The no of pensionable age people is projected to rise by 31% between 2006-2031
No of >75 yrs is projected to increase by 81% by 2031
Long Term Conditions and chronic disease management are of high concern nationally
Scottish Household survey 2005/06 notes that 23.6% of >16 yrs report a LTC, heatlh problem or disability
By aged 65 and over 2/3 have developed a LTC and by >75 27% have 2 or more LTCs
Add deprivation and people are more than twice as likely to develop an LTC compared with those people who experience affluence, add further social factors and we are faced with mental health and wellbeing issues adding to the challenges for health and social care, this group languishing with poor protective factors in their communites. / Of doing this?
If the community services are not sufficiently supported in transition to implement the changes required then Community Staff who are already overwhelmed with volume of work and may have difficulty balancing the changes in practice required and additional interventions required to be successful – poor staff moral and increased absence
Poor quality of care due to lack of time, organisation or resources, possible patient safety issues if whole systems modelling not adopted
Of not doing this?
Unnecessary admissions and re-admissions continue to rise
Opportunity to shift the balance of care and improve care for people within their locality lost
Organisation unable to meet obligations to population and organisation fails HEAT targets
Continue to get what we have got
Unable to solve todays challenges in a sustainable and effective way
Missed opportunity to be prepared and understand what we need to improve our response for the future
What are the proposed targets, measures and the impact on strategic objectives? / What are the recommendations?
Aim to achieve the LDP Target by improving anticipatory care planning processes and preventing unnecessary admission and re-admission
•Reduction in emergency bed days rates for patients >65 by 11% compared to 2004 figures
•Reduction in emergency re-admissions by 24%/1000 population
•Reduction in emergency re-admissions by 3% for people >65 with a long term condition (COPD,ASTHMA, CHD, DIABETES) for Grampian or by 14% in Moray and 13% in the City
•Achieve agreed number of inequalities targeted cardiovascular Health Checks during 2009-10
•Improved access to local care and improved experience
Priority Conditions for improvement: - CHD. Diabetes, COPD, Asthma, CKD, Osteoporosis and Falls
Time scales to be worked out in scoping for rate of reduction in 3-6 months / Long Term Conditions Programme continues over its 3 year cycle to work with all sectors and partners across Grampian to support the transition required to shift the balance of care
Detailed A3 plans with local and focusse measures are completed in accordance with specific projects
The local programme together with the support of the National Collaborative will provide appropriate service improvement inputs to teams as needed
The LTC Board will be accountable to the NHSG Board and will demonstrate the programmes activity and performance via standing organisational committees.
Public Health Intelligence systems will be prioritised to ensure that during the life of the programme sustainable systems of information flow are put in place and developed in a way that ensures the usefulness to teams on the ground
Financial forecasting/modelling expertise be provided to the programme to examine potential to maximise use of resource and support shifting the balance of care
Workforce development plan be implemented across Grampian to ensure key KSF in place
Project Title / 2. Grampian Mental Health Collaborative Programme
What is the problem? / What is the link with existing initiatives?
"Delivering for Mental Health" (2006) sought an acceleration in improvements to Mental Health Services, setting three, then four, HEAT Targets supported by 14 national commitments.
CEL 19 (2007) - National Improvement Support Programmes 2008-2011 - nationally funded programme developed to use tools and techniques for clinical systems improvement that will enable all staff to be involved in continuously improving the delivery of patient-centred services. /
  • Grampian Long Term Conditions Collaborative Programme.
  • “Towards a Mentally Flourishing Scotland”
  • “Keep Well”
  • Physical Wellbeing
  • Shifted the Balance of Care – and will continue to review.
  • Health Inequalities
  • City Primary Care Redesign
  • 3Rs; Child Protection; CAMHS; ICPs

What do we know about the problem? / What are the risks?
The Mental Health and Learning Disability Service has worked with local partners to address those targets and commitments.
"Delivering for MH" is due to be refreshed by the Scottish Government any time now, but the National Collaborative is vigorously pursuing the implementation of CEL 19 (2007), having provided the resources to focus upon the undernoted targets.
Crucially, that information and data are central to continuing our local progress, by contract and where this non-contract expenditure is for alternatives to items on national contract (LM/ATOS). / Of doing this?
  • Reduce Anti-depressants – increased risk of suicide? Increased waiting for Psychological Therapies?
  • Earlier diagnosis of Dementia – need additional hospital/community/voluntary services?
  • Reduce readmissions - need additional community/voluntary services?
  • Learning that present HEAT Targets are rough and not ready enough?
  • Complex, interlinked redesign within existing resource?

Of not doing this?
  • Do what we always did?
  • Lack of integration with Primary Care?
  • HEAT Targets, present and awaited, at risk of not being achieved!
  • A major, missed opportunity to continue to develop sustainable, quality services.

What are the proposed targets, measures and the impact on strategic objectives? / What are the recommendations?
Reduce the annual rate of increase of defined daily dose (DDD) per capita of antidepressants to zero by 2009/10 & put in place the required support framework to achieve a 10% reduction in future years.
Reduce Suicides in Grampian by 20% by 2013 (target already met)
– + 50% of key frontline staff in mental health, substance misuse services, primary care & accident and emergency trained in suicide assessment tools/suicide prevention by 2010.
Reduce the number of admissions within one year, for those that have had a hospital admission of over 7 days, by 10% by the end of December 2009.
Achieve agreed improvements in the early diagnosis & management of patients with dementia by March 2011.
Strategic Objectives – achievement of HEAT targets, Local Delivery Plan, Health Plan. /
  • Complete analysis and validate scale of opportunity. (LM/ATOS)
  • Continue to develop and implement MH Collaborative Programme.
  • Continue link with E.C.C. programme.
  • Develop improvement activity with Primary Care.
  • Develop joint work with LTC Programme.
  • Develop links with Public Health initiatives.
  • Continue with NHSG Programme Network.
  • MH&LDS continues to develop CSI beyond Collaborative Programme.

Project Title / 3. Better Care without Delay
What is the problem? / What is the link with existing initiatives?
NHS G must improve the quality of patient experience
NHS G must establish whole patient pathways
NHS G must achieve 18 weeks by December 2011
NHS G must be able to measure and report on 18 weeks
NHS G needs sustainable methods of achieving and maintaining 18 weeks
NHS G must find consistent solutions which eliminate variation
NHS G needs solutions to be recognised, understood and implemented by all staff within a tight timeframe / BCWD objectives are consistent with and aligned to NHS G Strategic Objectives
BCWD is part of a complex set of interdependencies:
Whole system balance -
achievement of the 18 week pathway is inextricably linked to other national access targets eg cancer, A&E 4 hour wait and effective management of unscheduled care activity
Other Key Programmes-
Patient Safety initiative- BCWD consistent with intiative through focus on redesigning pathways to ensure patient sees right person in right place at right time resulting in consistent patient management and reduced admission to hospital.
Long Term Conditions - success of this programme will have a positive impact on the achievement of 18 weeks by reducing hospital admission and development of non-admitted patient pathways will support LTC management
Health Campus- redesign of services and modernisation of facilities require to go hand in hand to future proof service delivery
Intermediate Care - through redesign of patient pathway BCWD supports appropriate shift in balance of care.
New Patient Management System - drive to improve efficiency , patient experience and resource utilisation is dependent on the development of electronic systems to support patient management and tracking. In addition services need to redesign processes and flow in preparation for the implementation of the new PMS.
What do we know about the problem? / What are the risks?
18 weeks is good for patients.
18 weeks is a whole system challenge and impacts on primary and secondary care
NHS G has reduced waiting times, achieved current targets, reduced backlog and size of waiting list
NHS G has undertaken demand and capacity analysis to identify hot spots
NHS G has increased capacity through investment of Waiting Time Sustainability Programme
NHS G has sought and implemented learning from the English 18 week experience
No national solution or system to measure 18 weeks or track patient progress.
NHS G must develop its own solution by utilising existing systems
NHS G must redesign current admin processes to allow clinicians and admin staff to manage patients effectively and efficiently.
NHS G must improve communication and links between primary and secondary
NHS G must reduce variation, waste and unnecessary steps in process and practice to improve efficiency and consistent patient experience / Of doing this?
Impact of system wide change programme while having to maintain business continuity and existing access targets
Impact on staff of redefining roles and responsibilities through redesign
Financial cost
Of not doing this?
Failure to improve patient experience
Potential for current system to collapse
Continued reliance on waiting list initiatives and private sector capacity
Failure to modernise
Failure to support staff to be actively engaged in a significant change programme
Failure to maximise use of NHS G resources - human, financial, physical
Failure to meet a Scottish Government target
What are the proposed targets, measures and the impact on strategic objectives? / What are the recommendations?
National HEAT targets
March 2010 - 80% admitted patients - 18 weeks (record linkage via PAS)
- 85% non- admitted - 18 weeks (clock stops - recording of clinic outcomes)
- 90% of GP referrals to consultant led service triaged on line for clinical priority
Dec 2010 - 90% admitted patients - 18 weeks
- 95% non-admitted - 18 weeks
Dec 2011 - 100%
Issue: don't know how far off we are because don't have the ability to accurately record end to end pathway and waiting time performance.
Cancer targets
Reduced expenditure
2009/2010 - £700k
2010/2011 - £700k
NHS G Performance
Measures consistent with performance framework for acute sector eg Reduced variation in length of stay, Daycase surgery rate, diagnostic waiting times / For the nextg 3-6 months
- Clinical Guidance Intranet - Establish and develop the Clinical Guidance Intranet - key component of demand management strategy - supports GPs to refer accurately and get the patient on the right pathway.
- Electronic triage - implement electronic triage - key HEAT target, necessary step in establishing electronic system to record, track and measure the 18 week RTT. Important to support change in practice in preparation for introduction of new PMS
- Implement clinic recording - supports measurement of 18 week RTT- demonstrates our current excellent performance - non-admitted patient pathways currently achieved within 12 weeks.
Programme Strategy
A.Implement 5 high impact changes:
1. Actively manage referrals and diagnostic pathways:
- end to end pathways designed through primary/secondary care collaboration - the Hub
-develop CGI to support referral practice, improve information on referral choices and support shift in balance of care - e-health task force
- implement e-triage
- Develop electronic, generic patient pathway which supports patient tracking and pathway measurement
- Support implementation of clinic outcome recording as key step in pathway measurement and tracking
- provide focus for diagnostics given critical contribution to 18 weeks and ensure alignment of diagnostic development and service planning with 18 weeks/Cancer/UCC
2. Actively manage admission to hospital - support implementation of pre-assessment
3. Day surgery as the norm - daysurgery plan submitted to SGHD - support local implementation
4. Actively manage discharge and length of stay - link to UCC and EDD work
5. Actively manage follow up - address N:R variation, through pathway redesign develop alternative sustainable ways to support patients post discharge.
B. Formalise and implement programme of service redesign and transformation based on speciality based 18 week readiness self assessment , hub process, A3 project planning, BCWD prog board approval, resource identification, implementation embedded in speciality work plan. (see example of process attached and project planning framework attached)
C.Involve staff in pathway development and service transformation- the Hub
D. Ensure consistent ongoing communication strategy to support behaviour change
Project Title / 4. AberdeenCity CHP Redesign
What is the problem? / What is the link with existing initiatives?
Recent history of destabilised practices
Additional pressures due to demographic change and shifting the balance will further detriment the situation
Problem of increasing demand and insufficient capacity or wrong capacity
Boundaries of practices not efficient or best matched to reducing inequalities
Premises not adequate for current demand, far less future demand / Direct link with “Keep Well” through Keep Well GP Sub Group (National Health Inequality Programme)
• Direct link with” LTC” programme through creating capacity in City to manage long term conditions in primary care
• Direct link with city “Intermediate Care” by creating capacity to avoid hospital admission and enable earlier, safe discharge either to home or community hospital
• Direct link with “BCWD” through referring less to secondary care by increasing primary care alternatives and diagnostic capacity and capability reducing queues for outpatients and relieving pressure on inpatients
Review of nursing in the community
Framework for rehab (AHPs)
Senior Charge Nurse Review
What do we know about the problem? / What are the risks?
  • We know the GPs want to address the issues
  • We know practices are keep to reassess their boundaries
  • We know we need to refer approx 40% less of outpatient activity and move 25% of inpatient activity.
  • We know the City has significant health inequalities and challenges due to drug abuse etc
  • We know the new GMS contract disadvantages inner city practices and some are not financially secure.
  • We have completed a primary care workforce survey and know the challenges.
  • We know the impact of increases chronic disease
  • We have a premises survey and know what the issues are and the challenges of getting sites in areas of deprivation
  • We have considerable “hands on” experience of supporting GP practices in crisis
  • We know how the practice workforce is changing and about impending retirals in the next 5-10 years
  • We know about population trends (e.g.. increasing elderly population), associated co-morbidity and the impact this has on practice resources
  • We know that some premises are inadequate for current demands; we know some are inadequate for anticipated future demand
/ Of doing this?