Facing the FutureSandy WatsonChairman

Andrew RussellMedical Director

Gerry MarrChief Executive

The Current Context

• 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

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

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

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

“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

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

A A Key Challenge

• 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!

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

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

Medical Workforce

• Greater transparency

• Greater objectivity to job plans

• Commitment to support appraisal process/revalidation

Access Joint Clinical Board

• Waiting times • Clinical Pathways & Communications

Group• Clinical dashboards• Cancer Overview Group• Access to knee MRI • Dental pathways

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

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

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

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

Evidence of Waste in Healthcare Systems

• 27% of New Outpatient appointments are being wasted!

Question 1 – Are there significant Outpatient Capacity losses?

Increase Capacity of Outpatient Clinics?

Opportunity?

0.0

5.0

10.0

15.0

20.0

25.0

Discharged AWAITING TESTRESULT

REFD OTHERCLIN/HOSP

DNA-Total Could Not Wait - FA REFER TO OTHERHOSP

%

New

Return

Question 1 – Are there significant Outpatient Capacity losses?

Increase Capacity of Outpatient Clinics?

P&K OP Clinics

Actual Capacity Cancelled, 23.86%

Total Attendance, 34.31%

Total DNA, 2.64%

Other, 39.19%

Angus OP ClinicsActual Capacity

Cancelled, 9.85%

Total Attendance, 59.96%

Total DNA, 3.72%

Other, 26.47%

Dundee OP Clinics

Actual Capacity Cancelled, 8.64%

Total Attendance, 67.46%

Total DNA, 6.48%

Other, 17.43%

Community ServicesCommunity Services » 6 out of 18 Community Hospitals are below 70%

utilisation and 72,000 unused staffed days were identified.

With Occupancy Data

Community Hospital Utilisation

0%10%20%30%40%50%60%70%80%90%

100%

Hospital

Util

isat

ion

-

10,000

20,000

30,000

40,000

50,000

60,000

70,000

average occupancy %

occupied bed days

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

DistrictDistrict Nursing Nursing

Comparison of band 6 and band 5 activity

0%5%

10%15%20%25%30%35%40%45%50%

Band 6

Band 5

Evidence of Clinical Variation in

Healthcare Systems

0

200

400

600

800

1000

1200

1400

1600

GP Practices

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

Community Hospitals

• The Average Length of Stay in Community Hospitals was 21 days (ranged from 17 days in Pitlochry to 30 in Crieff)

% of patients with length of stay >60/>90 days

02468

10121416

Community Hospital

%ag

e

% with LOS> 60 days

% with LOS >90 days

• 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

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

Improving Quality and Reducing Costs

Our Choice

Surviving – the 5%

Thrive – the 95%

Steps to Better Healthcare

Mental Health

OutPatients

Theatre Capacity / Planned

Care

Workforce Older people

Shifting the

Balance of Care

Optimisation of Health Facilities across Tayside

Prescribing and

Medicines

Finance Support

Workforce Support

Scenario Planning, Financial Baselines, Benefits Tracking, Business Cases

Workforce Modelling, Engagement & Communications with staff

Comms SupportCommunications with public and staff

Other

OE SupportOrganisational Effectiveness support

Labs

Maternity

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.

Transforming Older People Services Improvement Programme

• Self care and enablement• Planned care for “at risk”

patients to avoid admission• Rehabilitation and recovery

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

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.