CHANGE AND INNOVATION PLAN 2004-05

Introduction

The planned establishment of the single NHS system in Grampian from April 2004 is the foundation of our approach to improving health in Grampian as well as changing the way we provide health services. The management arrangements that will be put in place will enable us to have an increased focus on:

  • developing community health services through Community Health Partnerships and
  • increasing integration of primary care and specialist care and in particular strengthening managed clinical networks.

The new management arrangements and the activities aimed at developing NHS Grampian as an organisation will continue to ensure that:

  • there is active participation by patients and the public in the planning and development of services
  • clinicians have a central role in leading the creation of plans for developing services
  • we challenge any traditional boundaries of service delivery which limit our ability to change and develop services
  • when we do change services we do so in a way that is sustainable and put in place mechanisms to ensure sustainability
  • we develop our information systems to support changing patterns of care at the same time as ensuring that the rights of the public in relation to confidentiality are upheld

The approach being taken by NHS Grampian is one which addresses issues about how the NHS works as a system, for example how we organise our services for care which are not scheduled (emergency services) both in primary care and within hospitals; how we organise departments, for example general surgery or ophthalmology; and how we organise services in local areas of Grampian. To make sure that all of these are connected and co-ordinated, a committee of the NHS Grampian Board has been established - the Service Strategy and Redesign Committee (SSRC). This committee is chaired by a non-executive member of the NHS Grampian Board and consists of senior clinicians and managers within NHS Grampian. It will determine the priority issues to be addressed, take responsibility for the preparation and delivery of the Change and Innovation Plan and provide co-ordinated leadership to ensure delivery against our commitments. The contents of this plan will be significant elements of the Grampian Health Plan.

However, we recognise that we cannot deal with the change agenda outlined in this plan through a committee or small group of leaders and managers. Managers in the new single system arrangement throughout the organisation will be focused on the Service Strategy and its implications for their area. A large part of the work to develop the post – 1April 2004 arrangements is therefore addressing both service delivery today and change for the future.

The matrix explained later in this plan illustrates how there are interconnections between all the different types of service redesign activity and will be used to help us ensure that there is a connected, co-ordinated and collaborative approach. All managers will be responsible for determining the connections across the matrix that they personally need to make.

Service Strategy in NHS Grampian – HealthFit:

The principles underpinning the service strategy for the NHS in Grampian were set out in the HealthFit report of 2002. The agreements will fundamentally change the way that services are delivered, requiring existing practices and service configurations to be challenged and reshaped. They will be implemented through the major change programmes outlined in this plan and will be continually developed and refined in response to needs as they are identified.

The Grampian Health CARE System in 2010

  • Grampian will have combined the strengths of primary care and acute services through the use of managed clinical networks and clear patient pathways that cross traditional organisational and geographical boundaries. The needs of teaching and research will be integrated into these pathways. The public and communities will have direct influence on their health service through a new "bottom-up" approach to planning. Clinicians will have a much stronger role in planning workable responses to the challenges of service improvement.
  • 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.
  • Specialist acute hospitals will concentrate on providing services for defined patients or procedures that require the specialist skills and facilities that can only be provided in their central locations. This focus on hospital based acute service (rather than on community based acute services) will enable the reorganisation of services at Foresterhill, Woodend and Dr Gray's hospitals. This will streamline their work, enable them to reduce the pressure on their systems and make most efficient use of expensive resources.
  • The clearer definition of specialist services will stimulate the creation of a range of intermediate care services that is 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.
  • The development of rapid patient access through diagnostic and treatment centres will stimulate innovation, such as the introduction of mobile diagnostic facilities and increased use of telemedicine, and result in the reorganisation of services provided to communities, balancing the need to provide clinically safe services with local convenience and accessibility.
  • The development of diagnostic and treatment centres, 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. Allowing alternative funding opportunities to be exploited to provide improved local services.
  • 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.

Current system-wide work

A considerable amount of redesign and service change is currently underway. Whilst these projects have been implementing change and responding to national initiatives, they have developed separately, have been established as a reaction to directives, and/or the effort is not yet co-ordinated on a Grampian basis with the aim of achieving common system goals. The following summary of current work is by no means exhaustive but gives an indication of the existing major projects and highlights issues that need to be taken into account in a new organised approach:

1.Diagnostic and Treatment Services:

This project was commissioned following the HealthFit event in 2002 and was primarily aimed at developing a number of diagnostic and treatment centres. Each centre would provide facilities and infrastructure for a wider range of services to be provided outside the main acute centres. The diagnostic and treatment centres project extended its remit to provide support to services that sought to move the boundaries of their service provision and move out from the main acute centres. Diagnostic and treatment pathfinder projects were approved by the Grampian Management Team in August 2003 and implementation is now underway through Pathfinder Projects.

These are ENT, Ophthalmology, Renal Services, Cardiac Services and some aspects of Physiotherapy. A number of other services expressed an interest in becoming pathfinder projects but require some additional preparatory work which is also underway.

A key feature of the change in the diagnostic and treatment centres project is the move to deal with service change in addition to the development of centres. The activity related to service change is similar to the emerging work on planned care (see below). During the coming year, the SSRC will be working to ensure that there is continuity of approach for the diagnostic and treatment services project and the broader agenda on planned care. This will also have a focus on waiting times.

In addition it will be necessary to expedite the process to develop diagnostic and treatment centres as these will be important facilities not only for elective services, but they could also play a fundamental part in the NHS Grampian approach to unscheduled care and the implementation of out of hours services in relation to the GMS contract.

2. Modernisation of Acute Services:

During the past 2 years, a programme of action has been taken forward aimed at streamlining the acute hospital system. This modernisation programme, which was taken forward through five specific sub-projects, has been reviewed and will now change to enable better co-ordination with other work and to reflect the developing single system agenda. The five projects are summarised below together with the recommendations on the way forward:

Junior doctors hours of work. This project has dealt with the implementation of Health Department directives. The majority of this activity will now be provided as a matter of routine to support management to implement the junior doctors’ changes. There does, however, need to be a strong link to the reshaping of services as the future implementation of the junior doctors’ directives will be a significant influence on the pattern of service delivery.

Interface with Diagnostic Services. This project sought to improve the flow of patients from specialties to the diagnostic services. Whilst there is a significant agenda within the hospital system, a consistent Grampian approach is required to gain understanding of and agreement on the use of capacity. The newly established system wide Diagnostic Strategic Services Forum will take on this change agenda to provide a Grampian perspective.

Critical Care. The main focus of this project has been to implement best practice in critical care and plan the development of level 2 (HDU) critical care services in line with the Health Department report "Better Critical Care". This level of care is provided entirely within the acute services and this work will therefore be taken forward by acute services management.

Bed Redistribution. The bed redistribution project team has mainly been focused on the short-term requirement to relocate the acute medical assessment unit with existing capacity at Aberdeen Royal Infirmary, requiring significant re-organisation of resources. Further bed re-organisation is required to ensure that ARI and Woodend operate at the level agreed through the HealthFit process. This work will also be taken forward by acute services management and will be linked to the development of critical care.

Emergency Admissions. Work within the modernisation programme focused on dealing with the year on year increase in medical admissions. This work will now be dealt with as part of a broader Grampian approach to unscheduled care, linking with the changes in primary care related to the GP contract implementation, NHS 24, the ambulance service and local authority services.

  1. Reshaping out of hours services:

The major stimulus for the reshaping of out of hours services has been the agreement of the GMS Contract and the potential need for NHS Grampian to provide a service as part of the contract implementation. This has been linked to the broader unscheduled care agenda and, following a HealthFit event in May 2003, it is agreed that unscheduled care will be sponsored as one of the main change projects for NHS Grampian.

  1. Achievement of Waiting Time Targets:

Until now GUHT has had sole responsibility for the achievement of waiting time targets. It is clear that as targets become more challenging, there must be a co-ordinated Grampian approach to the development of elective services, with the development of systems and changes in clinical practice aimed at reducing waiting times being at the core of a broader strategy. Some consideration has been given to the development of a strategy for planned care which will be consistent with the work already done by the diagnostic and treatment services project. This will be a major priority for the SSRC over the coming year.

  1. Winter Planning/Implementation of the Older People's Strategy:

The Grampian Winter Planning Group has worked towards the achievement of the Health Department's delayed discharge targets. This has required close working with the local authority agencies to target the funding provided by the Health Department to implement initiatives aimed at minimising delayed discharges. Many of the initiatives relate to the provision of services for older people whilst a parallel process has been taking forward the implementation of the Grampian older people's strategy "Ageing with Confidence". To provide a more focused approach, and for economy of effort, we plan more streamlined arrangements to deal with this unified agenda. We will not only seek to co-ordinate the development of services for older people, but in doing so put in place sustainable measures that are closely linked to acute inpatient services to ensure that delayed discharges are maintained at optimum levels.

Re-organised Approach 2004-05:

As outlined already much of the redesign and change activity outlined above was stimulated in response to pressures or directives and was begun at a time when we were beginning to work as a single system. The organisation structure did not always support that way of working and at times hindered it. The new single system approach for NHS Grampian will take the lead from the HealthFit vision of the health care services in 2010. It will use current pressures, initiatives and directives as tools to help us to move in a consistent direction, with change projects and supporting activities commissioned by the Service Strategy and Redesign Committee on behalf of the NHS Board. This will ensure collaboration and maximum co-ordination and connection.

The approach will also recognise the financial position of NHS Grampian over the next five years. The programme of action summarised below, in addition to re-shaping the system and services, will be the process by which NHS Grampian re-shapes its future to be consistent with the financial and workforce resources available. This integrated approach will avoid the development of parallel processes and ensure that all management effort is directed in a consistent way.

The 7 levers model (see Appendix 1) will be utilised by the project teams to develop a robust project plan with focused outcomes supported by real and objectives measures of success. The first step is to create a shared understanding of the strategic intent of the project ie. what is it you are trying to achieve in embarking on the project. Then it is important to clarify what the specific results are that you expect from the change ie. how will you know when you have achieved your goal. Each project team should then consider what actions it needs to plan and the consequent outcomes it expects around each of the 7 key areas as follows:

  1. Leadership
  2. Values and Culture
  3. Work Process and Business Systems
  4. Organisation/Job/Team Design
  5. Management Processes and Systems
  6. Reward and Recognition
  7. Individual and Team Competence

A set of more detailed questions to prompt thinking is attached in Appendix 2.

The major strategic programmes of change are summarised below. More detailed project planning and development will take place when clinical leaders and project support staff are identified:

1 Unscheduled Care:

Strategic intent Develop an integrated approach to emergency care to improve the care for patients in order to achieve the following outcomes:

Outcomes:

  1. Ensure appropriateness of admissions to ARI and Dr Gray’s
  2. Develop primary care capacity consistent with the GMS Contract
  3. Establish new out of hours care services in line with the implications of the GMS Contract from January 2005
  4. Integrate NHS 24/Out-of-Hours/A&E services
  5. Integrate hospital emergency receiving services
  6. Project future activity levels

Clinical leaders and project support staff for the next stage of this programme will be:

Clinical Lead: George Crooks

Project Lead: Kathleen Simcock

Medical/Clinical Director:Roelf Dijkhuizen

Chief Executive:Alec Cumming

2 Planned Care:

Strategic intent The managing and matching of demand for planned healthcare with the capacity to deliver services. This will be achieved through radical redesign of outpatient, diagnostic, treatment, and inpatient and day case services in order to:

  1. optimise the use of resources ie. skills and facilities
  2. deliver sustainable change
  3. fully integrate across primary and secondary care and all relevant partners
  4. support the achievement of national and local waiting time targets

Early actions to deliver the above include: