DRAFT

Prioritisation in Grampian

Introduction

In February 2003 the Grampian Management Team commissioned work to develop a prioritisation process which would become an integral part of the developing NHS Grampian planning process and planning cycle. A short life group – the Prioritisation Group – was established to undertake this task and it has now provided an initial process to be further developed in line with the planning process.

There are many challenges that need to be taken into account in prioritisation in Grampian, and in any health system, as there are a range of pressures and opportunities. Developing a prioritisation process does not provide the answers to difficult rationing issues. It should, however, provide a framework within which considered judgement and decision making can be applied in a reasonably consistent way.

It is important not to confuse the prioritisation process with the planning process. The planning process includes the range of activities that support NHS Grampian in its move towards longer term objectives determined nationally or locally. Prioritisation within the planning process is the set of tools that are used to reconcile short term decision making with the longer term strategy, taking account of opportunities and constraints.

Aim

This paper submits information on the proposed prioritisation process to the NHS Board.

Discussion

1.Planning Process

The prioritisation process will be an integral part of the planning system in Grampian. The planning process is currently being developed and will provide clarity on the preparation of joint health improvement plans, the Grampian Health Plan, network plans, and links to the performance management system and accountability review process. Fundamental to the preparation of robust plans is, however, the need to be clear about what actions need to be taken to move the services, health system and infrastructure towards the long term goals of Grampian and the NHS in Scotland.

The planning process will have a number of key milestones throughout the year culminating in the agreement of the Grampian Health plan in March. In the forthcoming planning cycle for 2003/04 the first milestone will be in July when initial decisions will be made about commitments for the current year and beyond. A specific issue that will need to be dealt with is the legacy of previous decisions and ways of working, and a backlog of issues and pressures that require a co-ordinated approach.

2.Criteria

The prioritisation process will have a consistent set of criteria at its core. Draft criteria have been considered and approved by the Grampian Management Team (annex 1) but it is acknowledged that the criteria at this stage represent the start of the process of gaining the understanding and ownership of staff, the NHS Board and the public in Grampian. Opportunities have been taken to consult the public on the draft criteria and a specific session on the subject was held with the Community Forum on 31 May 2003. Further consultation will be undertaken in the coming months as it is only through refinement and understanding that the criteria will be an effective support to decision making.

  1. Limitations

The ideal prioritisation process would deal with a limited range of issues which are gathered at a specific time of the year to allow the application of a prioritisation tool. The new planning process should work towards this ideal, but the current reality is quite different.

The following are some of the factors that hinder the establishment of a rational process:

a)The number and diversity of issues that need to be addressed, from National priority developments in coronary heart disease or cancer to the requirement to deal with healthcare acquired infection and hospital cleaning services

b)The backlog of infrastructure problems that exist, e.g. in laboratory and imaging services, and primary care premises.

c)The problem of increasing demand that continues to impact on a number of services and which require responses throughout the year outside any prioritisation process e.g. the pressure on prescribing and the increased demand for specialist renal services. Such issues do not stand still long enough to be considered against criteria on a Grampian basis.

d)The increasing number of centrally driven priorities e.g. the requirement to improve working conditions for junior doctors, the directive to comply with sterilisation/disinfection standards, and the Health Department instruction to implement Liquid Based Cytology testing.

e)The earmarking of funding by the Health Department for specific purposes e.g. cancer services, CHD/Stroke, New Opportunities Fund. There is limited opportunity to balance proposals within these areas with other Grampian pressures.

f)The current financial position of Grampian has put the focus of effort into reviewing the value of existing provision and the balancing of risks rather than looking at service development on a Grampian basis.

g)There is a requirement to have a consistent level of provision across Scotland. An example of this is the avoidance of “post code” prescribing, but the principle applies to other services making it difficult for Grampian to stop providing a service to transfer resources to other higher priorities

The approach in the coming months must therefore deal with the above influences and, at the very least, ensure that the significant issues are dealt with in a structured way by the Grampian Management Team.

4.Prioritisation in Grampian

The elements of the prioritisation process are proposed below:

a)The Grampian Management Team will sponsor and co-ordinate the planning process and will ensure that the work of the Efficiency Savings Board is incorporated into the planning process. This is important to ensure that all decisions that are made – in relation to investment and dis-investment – are consistent with the criteria for decision making.

b)The wide range of proposals and pressures outline above will be organised by a sub-group of GMT. This will ensure that issues that emerge – opportunities, pressures and directives – are managed as efficiently as possible within the management and planning structure in Grampian. A specific proposal to deal with this is set out in Annex 2.

c)The identification of clear roles within the management structure for the sponsorship of issues through the process and taking ownership of the outcome of the decision making process is essential.

d)A prioritisation support team will be established to provide objective advice on proposals for change. Such proposals will be submitted to the support team by the management structure. A summary of the operation of the support team is set out in annex 3. The support team will bring together Public Health, planning, health intelligence, health economics and other expertise as appropriate. The support team will be part of the expert advice that will be available to the Grampian Management Team when making prioritisation decisions. Other sources of advice will include the Asset Investment Group, New and expensive Drugs Committee, etc.

e)A standard Grampian format for the submission of proposals for change will be adopted (proposed format set out at annex 4).

f)Plans and strategies developed by networks, regardless of the source of funding, will be submitted for consideration by GMT to check for fit with the overall Grampian criteria and to ensure that central earmarked funding is used to maximum effect.

g)A practical prioritisation tool that can be applied to a range of decision making processes is being prepared by the Health Economics Research Unit. There are currently a number of activities underway in Grampian that are using, or have used, prioritisation tools. These include the diagnostic and treatment centres project, medicines committee, and the agreement of capital priorities. In future Grampian should have a standard methodology, linked to agreed criteria which can be amended for specific tasks to avoid different groups duplicating work. When the tool is agreed, NHS Grampian should assert this methodology as the standard to be applied where service changes are being considered in the area, including changes being taken forward by networks.

h)Review of capital priorities with the aim of preparing proposals for a revised capital plan in July. This process will produce integrated proposals that deal with the NHS capital block allocation, GMS premises and other capital issues currently within the remit of the GPCT Redevelopment Agency. The process will be developed in detail by the Asset Investment Group.

Summary/Conclusion

The adoption of prioritisation framework will assist in the organisation of decision making within the planning process. The framework will ensure that changes are adequately controlled through the application of a structure, and that decisions on service changes are in line with the agreed criteria and direction for NHS Grampian.

The proposals to be considered within the prioritisation framework will emerge from work undertaken within the planing cycle and, in the current year, from the efficiency savings activities aimed at improving the financial position.

Annex 1
Criteria to Assist Decision Making

NHS Grampian is moving towards more integrated management and decision making processes. This will assist the development of a more consistent approach to service change, and support the organisation of services and networks in the area.

A number of prioritisation processes undertaken in the past using similar criteria. Set out below is a collation of the criteria to start the move towards having one core list of agreed criteria for Grampian. The criteria are divided into three categories:- Strategic, System and Best Practice.

Strategic Priorities

Strategic priorities are related to services that are identified as priorities nationally or locally.

  1. CHD
  2. Stroke
  3. Cancer
  4. Mental Health
  5. Children
  6. Older people
  1. Health Improvement
System Priorities

Move towards the system described in the Healthfit report i.e. (these may need to be summarised):

  1. Grampian will combine the strengths of primary care and acute services with the strong traditions of teaching and research, to provide a system that other NHS areas seek to emulate.
  1. Patient flow will be organised to ensure that each element of the system operates effectively and efficiently in relation to acute, intermediate and primary care.
  1. The local planning and delivery of health services in Grampian will be central to the success of the health system. Empowered localities and communities will influence and take responsibility for health and social well-being within a Grampian framework for health improvement and development.
  1. The focus of services will be on networks of care that fully integrate the contribution of all clinicians. The North of Scotland networks will develop to maximise the sharing of services, facilities and educational opportunities. The formalisation of networks will result in the appropriate organisation of specialist services in Aberdeen, Inverness and Elgin to maintain the highest standards of clinical governance and will provide stability for tertiary services in Grampian and indeed, throughout Scotland.
  1. Specialist acute services will concentrate on providing services for defined patient conditions which require specialist skills and facilities that can only be provided in central locations. This clarity of role will enable the reorganisation of services at Foresterhill, Woodend and Dr Gray’s Hospitals to concentrate on the provision of specialist services as part of the Grampian system and has reduced the pressure on these services.
  1. The clearer definition of specialist services will stimulate the creation of a range of new intermediate care services that are provided jointly by primary and secondary care clinicians. Intermediate care services will deliver treatment and care for patients who require more support than is normally provided at GP practice level, but do not require the specialist services of the acute hospitals.
  1. The development of rapid access, diagnostic and treatment centres will stimulate innovation such as mobile diagnostic facilities and the increased use of telemedicine and result in the reorganisation of services provided to communities, balancing the need to provide clinically safe services, as well as local convenience and accessibility.
  1. The development of diagnostic and treatment services, combined with a shift in the balance from long-term NHS care to more innovative and integrated community-based health and social care services, will change the form of community hospitals across Grampian. The modernisation of services will stimulate a range of different community solutions, including NHS, local authority, voluntary and private sector partnerships, sharing skills and resources and allowing alternative funding opportunities to be exploited to provide improved local services.
  1. Joint working between the NHS, local authorities, the voluntary and private sectors will be developed to provide an integrated, joined-up health and social care system for the people of Grampian based on their individual needs.
  1. New roles will be developed in recognition of the need to make best use of existing skills, and the scarcity of others. The contribution which nurses, and the other professions allied to medicine, can make to treatment and care will be extended and supported. The education and training organisations in Grampian and the North of Scotland will also develop integrated approaches to support new ways of working in the health system.
Best Practice Criteria

These criteria need to be applied to adhere to best practice in decision making:

  1. Health Benefit

This criterion refers specifically to proposals which are anticipated to lead to direct improvements in health. For example, prevention of an adverse health event (such as an unwanted pregnancy, alcohol or substance misuse, tobacco use, wound infection); reduction in morbidity (such as better control of pain, improvement in social functioning, better control of chronic illness); reduction in mortality (such as fewer deaths from coronary heart disease, cancer, etc). Proposals which do not offer direct improvements to health will score nothing under this criterion, for example: proposals primarily aimed at securing improvements in the quality of service environment or the process of care for which there is no evidence that they will result in direct health benefit.

  1. Effect on Quality of Service Environment or Process of Care
  • Proposal will achieve compliance with statutory standards / physical condition requirements
  • Proposal will achieve improvement in environment for patients or the quality of the process of care
  • No change
  1. Number of people gaining direct benefit

How many people are likely to gain direct benefit from the proposal? (NB It is the number of people likely to gain the anticipated benefit which is important, not the number of people whose care might be effected by the proposal.)

  1. Timing of occurrence of benefits

When are the benefits likely to be experienced?

  • Impact likely to occur in less than one year
  • Impact unlikely to occur within one year
  1. Effect on Equity

How will this proposal effect equity?

  • Proposal will reduce differences in access to services within Grampian Health Board
  • Proposal will reduce differences in access to services between Grampian Health Board and the rest of Scotland
  • No impact on equity

(Benchmarking will be a key feature to ensure that there is a requirement to examine current peerformance)

  1. Value for Money

This criterion refers to the degree to which the development proposal represents value for money in relation to improving health and reducing the effects of illness for the population of Grampian. The overall impact of the development on the Grampian health care system should be assessed, including the impact the proposal will have on other directly or indirectly related services.

To what extent do you judge this proposal represents value for money?

  1. Degree of Certainty about Benefits

This criterion will be assessed by a technical group expert in appraising the quality of evidence, and the scores supplied to the assessment panel for inclusion in their overall assessment.

The quality of evidence of effectiveness supporting a proposal will be scored. It is intended to use the levels of evidence documented in SIGN Publication No. 50

Annex 2

Interim process for dealing with emerging issues and service changes

Principles:

  • Recognise current financial reality
  • Assess proposals on a Grampian wide basis i.e. open scrutiny and transparency
  • Service change proposals to have clear leadership from, and sponsorship by, the clinical management structure
  • Innovation and creativity to be supported
  • Proposals must demonstrate exploration of potential for self funding
  • Assessment must be rigorous and consistent

Outline Process

  1. Sub-committee of GMT to be established to manage issues in a consistent way on a Grampian basis. See annex 2(a) for sample pathway.
  1. Only issues that have a significant impact on the level of service provided by NHS Grampian, the financial strategy, another part of the service in Grampian e.g. the adoption of a service change in an acute service which will have an impact on primary care or vice versa, should be submitted to the GMT sub-committee. All other service change issues should be dealt with by the management structure or networks.
  1. Proposals that are submitted to the sub-committee should be sponsored by a senior clinician and manager e.g. associate medical director/assistant chief executive, or lead collective chair/general manager
  1. Proposals to be submitted in the standard format (see Annex 4). This standard format should be used for proposals that have revenue and/or capital implications.
  1. All proposals submitted should be exposed on the intranet for a period of at least two weeks for general comment and scrutiny within NHS Grampian before being considered by the GMT sub-committee.
  1. The GMT sub-committee should minimise the number of issues to be submitted to GMT for decisions outside the agreed milestone dates in the planning cycle.

Annex 2(a)