Facing the Future

1. Facing the Future Sandy Watson Chairman Andrew Russell Medical Director Gerry Marr Chief Executive

2. TheCurrentContext • Public expectations • Modernisation agenda • Outcomes-based approach • Commitment / leadership; responsiveness / consultation; sound governance; sound management of resources • Review and option appraisal • Partnership / accountability • Rationalisation and consolidation • Rights / standards / standardisation • Financial burdens

3. NHS Tayside - Financial Position • An element of budgetary growth – but less than inflation • £25m saving? • Focus on public sector pay • VAT already up to 20% • Could take till 25/26 for Scottish public expenditure to return to 09/10 levels

5. Points from Finance Secretary’s Budget Statement • Commission on the Future Delivery of Public Services • SG working to 3 overriding priorities: • Scotland’s economic recovery • Frontline public services • Climate change • Reinforcement of social contract • Full removal of prescription charges • Freeze in Council Tax – 4th year in succession • Maintaining eligibility criteria for concessionary travel

6. Public Services need to: • be user focused and personalised • drive up quality and encourage innovation • improve efficiency and productivity • address waste and variation in the system • join up services and minimise separation • strengthen accountability

7. “Fortunes are NOT made in the boom times...That is merely the collection period.  Fortunes are made in depressions or lean times when the wise man overhauls his mind, his methods, his resources, and gets in training  for the race to come.” George Bacon Wood

8. The Non-Executive View: Some Priorities • Greater clinical input into the thinking of the Board • Emphasis on quality and on improving measurement techniques • Valuing and investing in E-Health support for teaching, research and clinical practice • Strong focus on mental health, dementia and CAMHS • Finalise the shape of mental health provision in Murray Royal and Stracathro • Review of management and committee structures • Health Equity Strategy – focusing on the practical, achieving ownership by the executive team and the public • New Change Fund – provision for older people with Councils and Community Planning Partnerships • Communication with staff and public • Review of the Commissioner role

9. A KeyChallenge Large growth in over 65’s across Scotland 65+ increase by 18% over next 10 years 85+ increase by 45% over next 10 years Additional 148 beds required by 2016, and 517 by 2031 NHS Tayside will require a new 500 bed hospital if we don’t adopt new ideas!

10. Changing Culture – The Process • Honest analysis of strengths and weaknesses. (Does this organisation really know where it is?) • Vision • Development of a powerful top team • Importance of communication • Maintaining progress

11. Clinical Assurance • Review of clinical evidence offered to public • Establishment of clinical quality group • Focus on fundamentals of care and experience • Greater focus on management of clinical risk • Celebrate success

12. Medical Workforce • Greater transparency • Greater objectivity to job plans • Commitment to support appraisal process/revalidation

13. Access Joint Clinical Board • Waiting times • Clinical Pathways & Communications Group • Clinical dashboards • Cancer Overview Group • Access to knee MRI • Dental pathways

14. Surgical Joint Clinical Board • Strategy for Surgical Services • Strategy for Orthopaedic Services • Strategy for ENT service redesign • Implementation of the Equity Strategy • Leadership and Governance for HAI • Leadership and governance for the workstreams under the aegis of Steps to Better Healthcare • End to End patient pathways

15. Mental Health Joint Clinical Board • Maximising capacity - reconfiguration of community units - benefits of new inpatient investment • Development of clinically useful real time data • Improved assessment process • Respond more efficiently to co-morbidity in substance misuse

16. Medicine Joint Clinical Board • Medicine for the Elderly Redesign Project • Acute and general medicine redesign project, PRI • Diabetes LES (Tayside wide) • HAI, HEI performance scrutiny • Waiting times • Redesign of the CAHMS, gynaecology, gastroenterology pathways

17. Primary Care • Closer working conference June 2011 • Medicines leadership • Work with Access Directorate to develop the Business Support Unit and the development of dental pathways • Support primary care teams to look at data development • IT interface in optometry / community pharmacy

18. Evidence of Waste in Healthcare Systems

19. Increase Capacity of Outpatient Clinics? Question 1 – Are there significant Outpatient Capacity losses? 25.0 20.0 Opportunity? 15.0 New % Return 10.0 5.0 0.0 Discharged AWAITING TEST REFD OTHER DNA-Total Could Not Wait - FA REFER TO OTHER RESULT CLIN/HOSP HOSP • 27% of New Outpatient appointments are being wasted!

20. Actual Capacity Cancelled, 8.64% Total Attendance, 67.46% Angus OP Clinics Actual Capacity Cancelled, 9.85% Other, 26.47% Total DNA, 3.72% Total Attendance, 59.96% Increase Capacity of Outpatient Clinics? Question 1 – Are there significant Outpatient Capacity losses? P&K OP Clinics Dundee OP Clinics Actual Capacity Cancelled, 23.86% Other, 17.43% Other, 39.19% Total DNA, 6.48% Total DNA, 2.64% Total Attendance, 34.31%

21. Community Services • 6 out of 18 Community Hospitals are below 70% utilisation and 72,000 unused staffed days were identified. With Occupancy Data

22. District Nursing • There are approx 430,000 District Nurse Visits in a year (56% of District Nurse time was non-patient facing)

23. Evidence of Clinical Variation in Healthcare Systems

24. COST CUBE Cost per Head by GP Practice 2006/07 (incl. GMS)

25. Community Hospitals The Average Length of Stay in Community Hospitals was 21 days (ranged from 17 days in Pitlochry to 30 in Crieff) • In Community Hospitals there are an average of 7.4% of patients whose Length of Stay exceeds 60 days, and 2.7% whose stay exceeds 90 days

26. Examples of Variation in Clinical Practice • Poly Pharmacy • Rates of admissions in over 65 years • Lengths of stay in over 65 years • Referral patterns into acute specialist care

27. Improving Quality and Reducing Costs Our Choice Surviving – the 5% Thrive – the 95%

28. Steps to Better Healthcare Out Patients Theatre Capacity / Planned Care Workforce Older people Shifting the Balance of Care Optimisation of Health Facilities across Tayside Prescribing and Medicines Other Mental Health Labs Maternity Finance Support Scenario Planning, Financial Baselines, Benefits Tracking, Business Cases Workforce Support Workforce Modelling, Engagement & Communications with staff Comms Support Communications with public and staff OE Support Organisational Effectiveness support

29. Transforming Older People Services Analysis of 2000 admissions: • Average length of stay of 27 days – equating to 54,000 bed days or 95% Occupancy. • Large variation in GP referral practices – high numbers of inappropriate referrals. • Poor control and planning of discharge dates - no evidence of Estimated Discharge Dates being used. • Approximately 40% of bed days are used by medically fit patients awaiting discharge. • The standard process leads to high amounts of referrals to expensive acute services, leaving community and support services underutilised.

30. Transforming Older People Services Improvement Programme • Self care and enablement • Planned care for “at risk” patients to avoid admission • Rehabilitation and recovery

31. The Benefits So Far: • Reduced inappropriate admissions • Reduced average length of stay from 27 to 18 days • Lower readmissions • Reduction in bed days lost to delayed discharges • Closure of 2 wards, offering £1.4million p.a. in net savings • Released staff used to fill vacancies and offset supplementary staff costs

32. Future Focus • Stronger emphasis on Steps to Better Healthcare • Reduce reliance on traditional cash releasing savings • Investment in our staff to build capacity and capability to support service improvement and redesign.