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NHS Shetland: Healthcare Planning Commission

HEALTH PLANNERS FINAL DRAFT REPORT

11th October 2012  

PROPERTY STRATEGY 2011 to 2016 Creating sustainability, Ensuring resilience, Securing the future. Date: July 2011 Version number: 1.1 Author: John McBeath Review Date: June 2014 If you would like this document in an alternative language or format, please contact Corporate Services on 01595 743069.

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NHS  SHETLAND  HEALTHCARE  PLANNING  COMMISSION    HEALTH  PLANNERS  REPORT        

1. INTRODUCTION  &  BACKGROUND  

1.1. Buchan   +   Associates   (B+A)  were   appointed   through   Frameworks   Scotland   as   Professional   Services  Contract   (PSC)   Healthcare   Planners   to   NHS   Shetland   during   February   2012   to   support   a   restricted  range   of   health   planning   activities.   The   scope   of   this   appointment   was   defined   by   a   range   of  

objectives,  these  were:    

• To  review  available  bed/capacity  data  and  other  information  

• To   identify   future   scenarios   for   service   models   including   the   future   scale   of   institutional  facilities  (within  5,  10  and  20  year  timescales)  

• To  assess  the  current  patient  model  and  hospital  performance  metrics  against  benchmarks  

• To  review  clinical  strategy  implementation  and  identify  further  opportunities  

• To  facilitate  a  1  day  workshop  re:  same  

1.2. This   report   provides   a   brief   overview   of   the   process   to   date   along   with   a   summary   of   the   data  collected/reviewed  and  a  series  of  recommendations  for  consideration  by  NHS  Shetland  in  respect  of  

the  analysis  undertaken.  It  has  been  constructed  to  follow  each  of  the  identified  objectives  as  closely  as   possible   in   order   to   provide   the   Board   with   clarity   around   commissioned   vs.   actual   activity,  including  any  limitations  this  has  led  to  within  the  subsequent  analysis.  

2. REVIEW  AVAILABLE  BED/CAPACITY  DATA  AND  OTHER  INFORMATION  

2.1.  In   reviewing   available   bed/capacity   data,   B+A   collected   information   from   a   number   of   different  

sources.  This  included:  

• Historical   data   from   Information   Services   Division,   NHS   Scotland   (ISD),   specifically   to   support  comparative  benchmarking  with  other  NHS  Board  areas  based  on  regular  data  returns  

• Local  data  from  Helix,  the  computer  system  used  by  NHS  Shetland  to  record/report  on  bed/other  activity  data  

• Anecdotal   information   from  the  wide  range  of  clinical,  managerial  and  support  staff  engaged   in  

informal  interviews  throughout  the  review  period  (Appendix  1)  

2.2. Historical  data  from  ISD  

2.2.1.  ISD  is  an  important  source  of  data  in  all  activity  monitoring,  particularly  where  benchmarking  is  required.   Unfortunately,   as   the   data   is   based   on   returns   from   all   Health   Board   areas   it   is  generally   not   as   current   as   the   data   available   locally.   The   specific   ISD   data   used   in  

benchmarking   activities   related   primarily   to   the   calendar   year   2010,   as   this   was   the   last  complete  year  of  data  available  to  support  the  review  process.    However,  historical  data  from  

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2008   and   2009   was   also   assessed   to   ensure   that   no   relevant   trends/data   anomalies   were  evident.  

2.2.2. It  is  important  to  note  that  ISD  data  is  based  on  returns  submitted  by  individual  Health  Boards  

and  can  therefore  be  subject  to  data  collection/analysis  errors.  It  is  also  important  to  note  that  it   is  not  possible  to  directly  compare  services  between  different  Board  areas  due  to  a  number  of  factors  e.g.  definitions  of  bed  types,  scope  of  surgery  undertaken,  geographical  location  and  

demography.  None   the   less,   ISD  data   is   the  best   source  of   information   for   comparing   similar  activities  between  NHS  Boards  areas  and  provides  a  basis  for  more  detailed  consideration  and  analysis.  

2.2.3.  ISD  data  has  been  used  to  understand  where  NHS  Shetland  would  appear  to  sit  relative  to  NHS  Scotland   overall   and   the   apparent   “best   performing”   Boards   in   terms   of   a   limited   range   of  indicators  highlighted  elsewhere  in  this  report.    

2.2.4. GRO  demographic  projection  data  was  used  to  understand  how  the  population  of  Shetland   is  likely  to  change  in  the  coming  years  having  confirmed  that  no  better  data  is  available  locally.    

2.3. Local  data  from  Helix  

2.3.1. Helix   is   the   information   system  used  by  NHS  Shetland   to   record/report  on  bed/other  activity  

data;   it   also   generates   daily   bed  management   reports   and   the   returns   submitted   to   ISD   for  national   reporting/bench-­‐marking   purposes.   Consequently,   the   data   reviewed   within   Helix  should  be  comparable  with  that  accessible  via  ISD.  

2.3.2. Data  acquired   from  Helix  primarily   related   to   the  most   recent  calendar  years  2009,  2010  and  

2011,  this  ensured  that  any  trends  in  capacity  utilisation/requirements  could  be  identified  and  validated.  

2.3.3.  Overall   the   Helix   system   provided   excellent   historical   bed   data,   although   it   was   impossible  within   the   time  available  and   limitations  of   the   system   to  cross-­‐reference  ward/sub-­‐specialty  

data.   i.e.   analysis  was  carried  out  by  ward,   for  example,   “Ward  1”,   rather   than   sub-­‐specialty,  e.g.  “acute  medicine”.  Recognising  that  wards  within  the  Gilbert  Bain  are  broadly  divided  into  medicine,   surgery,   maternity   and   elderly   care   indicates   that   this   is   unlikely   to   generate  

significant  variance  or  error.  

2.3.4.  Data  analysis  was  further  complicated  by  changing  bed  numbers  throughout  the  review  period,  there   was   also   a   mismatch   between   actual   beds   available   and   beds   reported   which   was  identified  quickly  and  addressed;   this   included  the  reporting  of  4  beds   in  maternity   (actual  5)  

and  26  beds  in  ward  1  (actual  24,  including  2  High  Dependency  beds).  

2.3.5.  The  most  significant  concern  relating  to  all  data  relates  to  the  fact  that  everything  is  based  on  12  midnight  bed  states  and  therefore  does  not  capture  activity  during  the  busiest  part  of   the  day.    

2.3.6.  Specifically  12  MN  bed  states  do  not  capture:  

o Day  surgery  patients  using  in-­‐patient  wards  

o Other  ward  “day  attenders”  

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o Periods   when   new   patients   may   have   been   admitted   prior   to   others   having   been  discharged  

o The  actual  “business”  of  the  ward  environment  as  measured  by  “beds  in  use”  during  

day  time  hours.  

2.3.7.    It   is   important   to  note   that   the  data   reviewed,   in   line  with   the  original  commission,   related  solely   to   the   Gilbert   Bain   Hospital   and   NOT   to   any   other   non-­‐NHS/other   beds/services   that  may  be  available  and  could  support  alternative  future  capacity  models.  

2.4. Anecdotal   information   from   a   wide   range   of   clinical,   managerial   and   support   staff   interviewed  

throughout  the  review  period    

2.4.1.  Although   identified  as  “anecdotal”,  B+A  believe  that   it   is   important  to  capture  the  opinion  of  clinical   staff   regarding   capacity   requirements,   recognising   that  data  alone  does  not  provide  a  complete  picture  of  service  delivery.    

2.4.2. These  experiences  provide  a  healthy  challenge  to  data  whilst  also  highlighting  the  wide  range  of  “softer”   issues   that  can  have  a  direct   impact  on  workload/capacity   requirements  as  has  been  the  case  here.    

2.4.3. This   information  was  gathered   from  a  wide   range  of   informal   interviews  with   individuals   and  small  groups  throughout  the  review.  

2.5. Bed  and  Capacity  Data  

2.5.1. Ward  1  (Surgery)  

2.5.1.1. Initial   Helix   data   identified   26   beds   in   Ward   1,   a   mixed   surgical   ward,  

although   clinical   discussion   highlighted   that   only   24   beds   are   actually   available  and  that  these  include  2  x  High  Dependency  Unit  beds.    

2.5.1.2. It  was  not  possible  to  separate  the  activity  associated  with  high  dependency  beds  from  the  remainder  due  to  limitations  within  the  Helix  system.  

2.5.1.3. Overall  occupancy  during  the  audit  period  averaged  around  60%  (within  the  

range  48-­‐72%),  less  than  the  NHS  Scotland  average  of  75.3%  (notwithstanding  the  recognised   uniqueness   of   the   Shetland   situation   and   caveats   related   to   ISD  benchmarking  noted  previously).  

2.5.1.4. Informal   interviews  highlighted   that   it   is  possible   that   the   inclusion  of  HDU  

beds   within   the   Ward   1   numbers   may   have   a   negative   impact   on   occupancy  overall,   whilst   day   surgery   (which   was   not   part   of   the   review)   may   have  insufficient  capacity  –  further  impacting  on  in-­‐patient  beds.    

2.5.2. Ward  3  (Medicine)  

2.5.2.1. Ward  3  is  a  mixed  medical  ward  with  22  beds.  

2.5.2.2. Overall  occupancy  during  the  audit  period  was  65.3%  (Within  the  range  54.7-­‐

77.9%).  This  is  less  than  the  NHS  Scotland  average  of  83.6%  (notwithstanding  the  

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recognised   uniqueness   of   the   Shetland   situation   and   caveats   related   to   ISD  benchmarking  noted  previously).  

2.5.3.  Maternity  

2.5.3.1. The   Maternity   Unit   within   the   Gilbert   Bain   Hospital   has   5   beds   with   an  

average  occupancy  during   the  period  of   the   audit   of   27%   (within   the   range  19-­‐35%).    

2.5.3.2. Whilst   this   is   very   low,   it   is   important   to   recognise   that   the  unit   is   small   in  size  and  that  this  represents  no  more  than  2-­‐3  beds  being  unoccupied  most  of  the  

time.   It   is   however   less   than   half   the   Scottish   average   occupancy   for   obstetric  units   which   is   around   60%   (notwithstanding   the   recognised   uniqueness   of   the  Shetland  situation  and  caveats  related  to  ISD  benchmarking  noted  previously).  

2.5.4. Ronas  

2.5.4.1. During   the   audit   period,   Ronas,   a  mixed   elderly   rehab   and   continuing   care  

ward  had  16  beds  in  total.  It  had  an  average  occupancy  of  74.5%  (within  the  range  68.8-­‐83.4%).  

2.5.4.2. 96%  of  admissions  to  Ronas  are  transfers  from  other  services  and  during  the  period   of   the   audit   3   or   more   patients   were   classified   as   continuing   care   –  

effectively   guaranteeing   “100%   occupancy   in   25%   of   the   available   beds”.   In  addition,  Ronas  ward  only  admitted  on  average  60  patients  per  annum  for  a  total  of  5856  bed  days  available;  this   is  a  very   low  patient  “throughput”  for  any  ward  

within  an  acute  hospital  setting.  

2.5.4.3. Since   Q3   2010,   occupancy   has   fallen   by   22%  with   stakeholders   identifying  that  this  is  likely  to  relate  to  the  commissioning  of  Montfield  Support  Services  at  this  time.  If  this  is  correct,  it  gives  an  indication  of  the  impact  of  this  development  

on   beds   within   the   acute   hospital,   highlighting   the   need   to   adjust   capacity   in  response  to  investment  in  other  areas.  

2.5.4.4. Recognising   the   unique   nature   of   Ronas  ward,   it   is   difficult   to   attempt   any  national   benchmarking,   even   with   those   caveats   highlighted   already,   although  

“Geriatric   Medicine”   beds   across   NHS   Scotland   have   an   average   occupancy   of  around  88%.    

2.6.  “The  Shetland  Factor”  

2.6.1. Throughout   this   commission,   staff   engaged   in   the   process   have   been   keen   to   highlight   the  uniqueness  of  Shetland  and  in  particular  why  it  is  not  appropriate  to  apply  normal  comparators,  

e.g.   occupancy   or   length   of   stay   (LOS)   to   an   assessment   of   current/future   capacity  requirements  in  the  islands.    

2.6.2. B+A   acknowledge   the   uniqueness   of   Shetland   and   have   sought   to   identify   its   actual  measureable  impact  on  capacity  planning.    

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2.6.3. Key  areas  where  Shetland’s  uniqueness  may  be  considered  to  have  an  actual   impact  on  those  parameters   used   to   determine   current   and   future   capacity   requirements   identified   by  

stakeholders  include:  

2.7. “We  are  the  single  point  of  admission  for  all  patients”    

2.7.1. The  Gilbert  Bain  Hospital  is  the  only  acute  health  facility  in  Shetland  and  as  such  must  manage  all   acute   hospital   admissions   that   may,   in   other   locations   on   the   mainland,   be   managed   in  different  ways/by  different  services.  These   include,  most  notably,  acute  paediatric  admissions  

and  acute  mental  health  admissions.  

2.7.2. The  specific  concern   is   that  mixing   these  patient  groups  has  a  negative   impact  on  admissions  and  occupancy  levels  due  to  a  tendency  to  manage  such  groups  more  conservatively  (“admit  to  be   safe?”)   and   a   potential   requirement   to   reduce   occupancy   levels   in   order   to   better/more  

safely  manage  the  diffuse  and  challenging  patient  cohort  (“manage  patients  in  multi-­‐bed  bays  by  themselves  when  no  single  rooms  are  available”).    

2.7.3. To  put  this  in  context:  

2.7.4. During   2011   there  were   349   paediatric   admissions   to   the  Gilbert   Bain  Hospital.   145  went   to  ward   1   (85   elective   and   60   emergency)   and   188   to   ward   3.   16   went   to   “other   wards”   -­‐  

essentially  the  maternity  unit.  This  equates  to  around  1  paediatric  admission  per  day.  

2.7.5. During  2011,  43  people  presented  to  A&E  with  a  primary  diagnosis  of  “psychiatric”  before  being  admitted   to  ward  3  or   transfer   to   the  Royal  Cornhill  Hospital,  Aberdeen.  This  equates   to   less  than  1  AMH  admission  per  week.  

2.7.6. Consequently,  it  is  our  view  that  whilst  these  admissions  are  disruptive  when  they  occur  –  and  

are  likely  to  have  an  impact  on  ward  staffing  levels  –  it  is  difficult  to  see  how  they  would  have  any  significant  measurable  impact  on  occupancy  levels  that  could  be  clearly  defined.  

2.8. “There  are  occasions  when  we  cannot  transfer  patients  off  the  islands  due  to  weather”  

2.8.1. This   issue   requires   little   explanation   but   is   an   important   consideration   in   that   it   highlights   a  further   reason   why   NHS   Shetland   must   always   be   able   to   provide   the   necessary   clinical  

capacity,   including   intensive   support   to   very   sick   people,   whilst   awaiting   transfer   to  other/specialist  units  on  the  mainland.    

2.8.2. Although   it   has   not   been   possible   to   identify   the   actual   bed   days   associated   with   patients  unable   to   be   transferred   from   Shetland   due   to   weather,   overall,   it   is   our   opinion   that   the  

number   is   likely   to   be   small,   with   only   a   very   minimal   impact   on   bed/capacity   available.      However,   it   is   acknowledged   that   this   has   a   significant   impact   on   staffing   and   services  particularly  where  patients  require  levels  of  support  not  normally  available  in  Shetland.  

2.9. “There   are   occasions   when   length   of   stay   is   extended   unavoidably   because   essential  

tests/investigations  are  not  available  promptly  due  to  staff  availability”.    

2.9.1. This  is  primarily  a  factor  of  the  very  small  number  of  people  available  to  perform  key  roles  and  the  impact  of  not  always  having  equivalent  cover  available.  In  reality,  it  is  extremely  difficult  to  

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identify   data   to   quantify   the   actual   impact   of   this   situation   on   length   of   stay   and   bed   days  required.  

2.9.2. Overall,  it  is  our  assessment  that,  whilst  this  is  clearly  a  problem  on  occasions  it  can/should  be  

minimised  through  appropriate  responsive  or  remedial  management  and  is  unlikely  to  have  any  significant  impact  on  length  of  stay  over  an  above  that  faced  by  any  other  Health  Board.      

2.10. “We  cannot  close  down  to  admissions  when  we  get  full!”    

2.10.1. Unlike  most  mainland  Health  Boards,   the  Gilbert  Bain  Hospital  does  not  have  the  choice  to  close  to  admissions,  irrespective  of  how  busy  it  becomes  –  reflecting  the  need  to  always  have  

available  operational  capacity  both  in  terms  of  physical  resources  (beds)  and  people  (staff).  

2.10.2. At   present   this   problem   is  magnified   by   the   number   of   separate   operational   units   (wards)  that   function   largely   independently   (from  a  capacity  management  perspective)  and   therefore  need  to  maintain  a  separate  and  independent  level  of  available  capacity  e.g.  spare  beds  in  the  

maternity   unit   or   Ronas   Ward   are   not   generally   available/suitable   for   the   use   of  medicine/surgery.    

2.10.3. The   situation   is   compounded   overall   by   the   historical   configuration/location   of   existing  wards,  lack  of  single  rooms  and  overall  lack  of  flexibility  that  this  creates.  

2.10.4. Diag.   1   (overleaf)   charts   the   number   of   in-­‐patient   admissions   to   the   Gilbert   Bain   Hospital  

against  the  number  of  times  that  it  happened  (occurrences)  on  a  daily  basis.  The  graph  shows  an   average   of   6   emergency   admissions/day   but   also   reflects   a   very   broad   range   (0-­‐16  admissions/day  or  up  to  nearly  25%  of  the  total  available  beds  at  the  highest  extreme).    

2.10.5. It  also  highlights  the  very  low  numbers  of  elective  admissions  into  in-­‐patient  beds,  largely  as  

a   result   of   the   widespread   use   of   day   surgery,   and   therefore   extremely   limited   ability   to  manage   any   short-­‐term   “bed   crisis”   through   cancellation   of   elective   admissions   –   unless   day  surgery  beds  (which  are  completely  unsuitable  for  in-­‐patient  admissions)  are  made  available  for  

this  purpose.  

2.10.6. This   situation   further   restricts   NHS   Shetland’s   ability   to   respond   to   short-­‐term   bed   crisis  through  an  operational  solution  that  is  routinely  available  to  almost  all  other  NHS  Board  areas  where  elective  admissions  to  in-­‐patient  beds  are  significantly  higher.    

2.10.7. Overall,   it   is   our   view   that   it   is   the   need   to   ensure   that   capacity   is   always   available  when  required,   through   Shetland’s   geographical   location,   that   is   the   most   significant   and   unique  factor  affecting  current  and  future  bed  capacity  requirements  at  the  Gilbert  Bain  Hospital  and  that  this  MUST  be  taken  into  consideration  in  all  modelling  activity.    

2.10.8. We  would  reinforce  that  this  “available  operational  capacity”  need  not  represent  fully  staffed  

but  empty  beds  –  particularly  when  information  is  available  to  suggest  that  this  is  the  case  -­‐  but  may  instead  represent  the  means  to  bring  such  resources  “on-­‐line”  as  and  when  required  or  to  achieve  an  improved  situation  through  realising  more  operational  flexibility  within  the  existing  

bed  base.  

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Diag.1.  NHS  Shetland  In-­‐Pt  Admissions  Vs  Occurrences  2011  (Source  Helix)  

 

3. ASSESS   CURRENT   PATIENT   MODEL   AND   HOSPITAL   PERFORMANCE   METRICS   AGAINST  

BENCHMARKS  

3.1. Methodology  

3.1.1. The  overall  bed  modelling  process  employed  by  Buchan  +  Associates  has  sought  to  be  as  robust  as  possible  within  the  confines  of  the  commission  and  has  involved  the  project  team,  with  the  support  of  the  wider  clinical,  management  and  technical  support  body,  undertaking  a  series  of  logical  stages  conducted  in  turn.  

 3.1.2. These  stages  included:  

 • Identifying  the  current  physical  and  staffed  in-­‐patient  bed  numbers  available  across  all  of  the  

areas  involved  in  the  review  

• Agreeing  broader  “bed  types”  in  order  to  optimise  future  planning  opportunities,  i.e.  plan  for  the  required  number  of  acute  beds  overall   rather  than  the  number  required   in  each  of   the  existing  wards  

• Calculating  theoretical  bed  days  available  per  annum  over  the  last  3  years  in  order  to  identify  

a  baseline  of  available  capacity  

• Confirming   actual   bed   days   available   (where   different)   in   order   to   determine   an   accurate  calculation   of   current   occupancy   and   highlight   areas   where   bed   numbers   may   have  changed/be   changing   (this   activity   identified   a   number   of   differences   between   actual   and  

recorded  bed  days  that  have  resulted  in  changes  to  some  bed  numbers  identified  within  the  Helix  system)  

• Identifying   actual   occupied   bed   days   over   the   last   3   years   from   available   Scottish  Medical  Records  (SMR  data)  

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• Reviewing   local   published   performance   indicators   provided   for   national   bench   marking  purposes  

• Calculating  historical  and  current  occupancy  

• All  things  considered,  including  what  has  been  identified  elsewhere  in  this  document  as  “The  

Shetland  Factor”,  suggesting  optimal  occupancy  on  a  service  by  service/ward  by  ward  basis  based  on:    

o Calculating   an   amended   baseline   number   of   beds   required   based   purely   on  optimising   occupancy   i.e.   how  many   beds  would   be   required   by   bed   type  without  

any  changes  to  clinical  process  or  practice  simply  by  optimising  occupancy  

o Reviewing   comparative   national   benchmark   indicators   where   available   in   order   to  highlight  exceptional  practice  and/or  potential  for  improvement  

• Generating   future   scenario’s   that   represent   “alternative   views   of   the   future”   based   on  demographic  change  in  order  to  support  future  modelling  and  sensitivity  analysis  

• Identifying   a   range   of   additional   factors   likely   to   affect   future   capacity   requirements   that  

require  the  NHS  Shetland  Board  to  agree  detailed  planning  assumptions  and  targets,  e.g.  Day  Case  activity,  accommodation  flexibility,  etc.  

3.2. Throughput  and  Length  of  Stay  

3.2.1. As  well   as   occupancy,   B+A   have   also   reviewed   throughput,   specifically   as  measured   through  “length  of  stay”.  

 

Diag.2.  Throughput,  NHS  Shetland  Vs  NHS  Scotland  (Source  ISD,  2010)  

3.2.2. Diag.  2  highlights   that   the  current  mean   lengths  of  stay  within  all   in-­‐patient  sub-­‐specialties   in  Shetland  are  higher  than  the  NHS  Scotland  average  and  considerably  greater  than  NHS  Board’s  reporting  the  shortest  lengths  of  stay.  

3.2.3. It  is  important  to  again  note  factors  that  may  influence  lengths  of  stay  and  to  recognise  that  a  

direct  comparison  with  any  other  Board  area  is  not  possible.  It  is  also  necessary  to  acknowledge  that,  whilst   there  are   reasons  why   it   is  not  unreasonable   to  expect  a   longer  stay   in  Shetland,  

e.g.  social  and  clinical  risk  issues  related  to  travel  distance  home,  there  are  other  reasons  why  

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the  average   lengths  of  stay  might  expected  to  be  shorter.  These   include;  the   limited  range  of  interventions  delivered  on  the   islands;  activity  transferred  to  NHS  Grampian  and  other  health  

board  areas;  and  high  levels  of  day  case  surgery.  

3.2.4. We  note  that  reported  NHS  Scotland  data  on  elderly  services  is  sub-­‐divided  into  long  stay  and  non-­‐long  stay  elderly  services,  with  Ronas  representing  a  mix  of  the  two.  In  order  to  provide  a  reasonable   comparator,   benchmark   data   has   been   modified   to   reflect   a   25%:75%   long-­‐

stay:non-­‐long  stay  which  is  broadly  in  line  with  the  continuing  care:  non  continuing  care  patient  mix  within  Ronas  during  the  period  audited.  

 

Diag.3.  Procedures,  NHS  Shetland  Vs  NHS  Scotland  (Source  ISD,  2010)  

3.2.5. Diag.  3  summarises  a  range  of  data  related  to  NHS  Shetland  in  comparison  with  NHS  Scotland.    

It  highlights   the   reduced  number  of  procedures  performed  overall   as  well   as   the   significantly  higher  percentage  of  procedures  performed  as  day  cases  in  Shetland.    

3.2.6. “BADS  as  D/C”   refers   to   the  percentage  of  procedures   identified  by   the  British  Association  of  Day  Surgery  as  being  suitable  for  day  surgery  that  were  actually  performed  as  day  surgery.  

3.3. Actual  Occupied  Beds  

3.3.1. An  important  element  of  understanding  true  available  capacity  is  to  monitor  the  actual  number  

of  occupied  beds  on  any  given  day  as  this  provides  a  considerably  more  accurate  interpretation  of   capacity   issues   than   average   occupancy   alone.   Diag.4-­‐Diag.7   (overleaf)   chart   the   actual  number  of  beds  in  use  in  each  of  the  different  wards  on  any  given  day  (using  12  MN  bed  data)  

vs.  the  number  of  occurrences.  

3.3.2. These  charts  show  an  even  distribution  of  activity  in  all  ward  areas,  with  activity  levels  that  are  well  within  the  available  capacity  and  never  actually  exceed  it,  even  at  peak  times.    

 

 

 

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Diag.4  Occupied  Beds  2011:  Ward  1  (Helix)     Diag.5  Occupied  Beds  2011:  Ward  3  (Helix)  

 

 

 

 

 

 

 

Diag.6  Occupied  Beds  2011:  Ronas  (Helix)     Diag.7  Occupied  Beds  2011:  Maty  (Helix)  

3.3.3. Diag.  8  shows  the  same  data  but  in  a  single  summary  chart  reflecting  whole  hospital  activity  on  a  daily  basis.  Once  again,   this   shows  an  even  distribution  of   activity  but  with   an  even  higher  

level  of  capacity  available  at  all  times.    

3.3.4. This   is   largely   the   effect   of   the   whole   bed   base,   which   is   showing   a   wider   spread   in   daily  activity,  and  the  reality  of  wards  having  different  occupancy  levels  at  any  given  time.  This  shows  the   potentially   significant   advantages   of   more   fluidity   within   the   bed   base   and/or   fewer  

functional   units   operating   in   relative   isolation   (effectively   a   larger   number   of   beds   able   to  better  cope  with  peaks/troughs  in  activity).  

 

Diag.8  Occupied  In-­‐Pt  Beds  2011:  Whole  Hospital  (Helix)  

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3.4.  The  Difference  Between  12MN  and  Daytime  Activity  

3.4.1. In   addressing   significant   concerns   from   stakeholders   regarding   the   use   of   12   MN   bed   state  occupancy  data  a  number  of  additional  actions  were  carried  out:  

o A   daily   occupancy   was   calculated   that   identified   the   “maximum   theoretical   in-­‐

patients”  in  each  ward  on  any  given  day.    

o A  sample  study  of  daytime  bed  states  was  undertaken  based  on  data  that  is  currently  collected   and   reported   on   a   daily   basis   but   that   does   not   feature/is   not   accessible  through  any  database  capable  of  identifying  trends.  

3.4.2. Diag.9   charts   what   has   been   identified   as   “maximum   theoretical   in   patient   occupancy”,   a  

numerical  calculation  that  sees  all  daily  admissions  and  “transfers  in”  added  to  the  previous  12  MN  bed  state;  this  identifies  the  absolute  maximum  number  of  recorded  in-­‐patients  that  may  have  been   in   the  hospital  at  any  given   time.  Whilst   it   is   clearly  not  capable  of   identifying   the  

impact  of  any  daytime  activity  not  recorded,  it  does  present  a  pessimistic  scenario  that  assumes  that  all  new  admissions/transfers   in  have  entered  the  ward  on  a  given  day  before  any  others  have   been   discharged/transferred   out   and   must   therefore   be   regarded   as   a   “worst   case  

scenario”  based  on  recorded  in-­‐patient  activity.  

 

Diag.9  “Max  Theoretical  In  Pt  Occupancy”  2011:  Whole  Hospital  (Helix)  

3.4.3. As   can  be   seen   in  Diag.   9,   the   impact   of   these  pessimistic   assumptions   is   to   shift   the  overall  activity  distribution  curve   into  a  higher  range,  moving  average  occupancy  from  40  to  48  beds  

and  median  occupancy  from  40-­‐45  beds.  Modal  occupancy  remains  largely  unchanged  (from  49  to   48)   whilst   95th   percentile   occupancy   (the   number   of   beds   required   to   manage   required  activity  95%  of  the  time)  increases  dramatically  from  49  –  61.  

3.4.4. Recognising   that   this   represents   a   pessimistic   numerical   assessment   of   the   impact   of   all  

admissions   arriving   in   the   hospital   before   any   are   discharged   on   the   same   day,   it   is   also  important   to   consider   the   alternative   optimistic   scenario   –   one   where   all   discharges   and  

transfers  out  occur  on  any  given  day  prior   to  new  admissions  and   transfers   in  arriving   in   the  ward.    

3.4.5. Diag.  10.  Charts  this  “minimum  theoretical   in-­‐patient  scenario”  which  has  the  opposite  effect,  shifting   overall   activity   distribution   into   a   lower   range.   In   this   instance   average   occupancy   is  

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seen   to   drop   from   40   to   32   beds,   median   occupancy   drops   from   40   to   32   beds,   modal  occupancy  drops  from  49  to  34  beds  and  95th  percentile  occupancy  drops  from  49  to  44.  

 

Diag.10  “Min  Theoretical  In  Pt  Occupancy”  2011:  Whole  Hospital  (Helix)  

3.4.6. Diag.   11   (overleaf)   summarises   each   of   these   different   scenarios,   highlighting   the   difference  between  12  MN  bed  data,  maximum  and  minimum  theoretical  in-­‐patient  occupancy.  Whilst  not  statistically   accurate,   the   “overall”   data   is   an   attempt   to   present  what  mean  occupancy  may  

look  like  using  maximum  and  minimum  calculations  rather  than  12  MN  bed  states.  

3.4.7. As   can   be   seen,   the   “overall”   data   summary   is   remarkably   similar   to   the   occupancy   data  identified   on   12MN   bed   states   with   the   notable   exception   of   95%   occupancy   which   is  significantly  higher  –  an  important  consideration  when  reflecting  upon  “The  Shetland  Factor”  in  

the  context  of  the  number  of  beds  actually  required.  

 

Diag.11  “Min  Theoretical/12MN/Max  Theoretical  In  Pt  Occupancy”  2011:  Whole  Hospital  (Helix)  

3.4.8. This  data  also  highlights  the  potential   impact  of  effective  operational  management  on  activity  levels   and   capacity   requirements   as   it   effectively   defines   the   “spread”   of   capacity   associated  with   the  crossover  of  admissions/transfers   in  and  discharges/transfers  out.   In  so  doing   it  also  

reinforces   the   need   to   review   admission/discharge   timings/protocols   and   to   consider  alternative  means  of  delivering  the  physical  capacity  to  support  them.  For  example,   it  may  be  more  appropriate  to  manage  peak  daytime  activity  as  well  as  the  transition  from  admission  –  

bed   –   discharge   through   the   provision   of   a   shared/appropriately   supported  admissions/discharge  lounge  rather  than  staffed  beds.  

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3.4.9. In   order   to   understand   the   actual   difference   between   12  midnight   bed   states,   daytime   bed  activity  and  theoretical  occupancy  a  sample  analysis  of  daytime  bed  states  was  also  undertaken  

using  data  currently  collected  and  reported  on  a  daily  basis  by  Medical  Records  staff  based  on  returns  completed  by  them  each  afternoon.  This  includes  actual  ward  capacity,  the  number  of  beds  occupied  at  the  time  the  audit  is  conducted  and  the  number  that  it  is  anticipated  will  be  in  

use  at  the  end  of  the  day.    

3.4.10. The   sample   included   20   days   data   from   throughout   2011   in   order   to   allow   a   direct  comparison   with   data   analysed   from   the   Helix   system.   20   days   were   identified   in   the   first  instance   in  order   to  determine  whether  a  wider  sample  may  be  required   for   further  analysis.  

This  does  not  appear   to  be   required  due   to   the  very   close   correlation  between   the   two  data  sets,  although  a  further  review  of  HDU  occupancy  is   indicated  as  this  data  presents  an  insight  into  the  use  of  HDU  that  is  not  available  through  Helix.    

3.4.11. Specifically,  the  HDU  data  available  from  this  report  appears  to  support  the  hypothesis  that  a  

low  HDU  occupancy  is  adversely  affecting  overall  reported  occupancy  in  Ward  1  and  a  specific  review   of   this   service   may   be   required.   (During   the   sample   period,   only   9   HDU   beds   are  reported  as  being  occupied  “now”  and  8  as  “anticipated  occupied  at  the  end  of  the  day”  out  of  

the  40  bed  days  available,  representing  an  occupancy  of  less  than  25%).  

3.4.12. Overall   it   is  possible  to  conclude  that  actual  daytime  bed  occupancy  as  reported  to  Medical  Records  staff  is  very  similar  to  the  calculated  overall  occupancy  figure  identified  previously  and  actual  midnight  bed  states  recorded.    

3.4.13. Average  (daytime)  occupancy  reported  on  the  20  sample  dates  was  40.85  beds.  The  lowest  

daytime   bed   occupancy   reported   was   29   beds   whilst   the   highest   daytime   bed   occupancy  recorded  was  50.  The  median  was  41.5  and  mode  42.  During  the  day,  for  those  dates  sampled,  unoccupied  beds  never  appeared  to  be  less  than  17  across  the  hospital  and  averaged  26.15  –  or  

around  the  size  of  at  least  one  of  the  largest  wards  at  the  Gilbert  Bain  Hospital.      

3.4.14. In   addition,   the   difference   between   beds   in   use   reported   “now”   and   “anticipated   in   use  later”  was  2  or  less  in  all  ward  areas  98%  of  the  time  with  the  overall  impact  assessed  as  around  0.25  additional  beds  “anticipated  in  use  later”  on  average.    i.e.  Across  the  hospital,  beds  in  use  

appeared   to   increase   slightly   later   in   the   day   rather   than   decrease   as   may   have   been  hypothesised.  

3.5. Summary  of  Current  Performance  

3.5.1. In  summary,   it   is  possible  to  conclude  that  over  the  last  year,  excluding  day  case  or  any  other  physical  beds  available,  across  Ward  1,  Ward  3,  Ronas  Ward  and  Maternity:  

• In-­‐patient  beds  available  =  67      

• Mean  (average)  occupancy  =  40-­‐41  beds/day  

• Median  (mid  range)  occupancy  =  40-­‐41.5  beds/day  

• “Actual  bed  utilisation”  as  recorded  at  12MN  never  exceeded  57  (a  “1  off”)    

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• “Maximum  theoretical  in-­‐patient  activity”  (actual  utilisation  +  all  transfers  in  +  all  admissions)  never  exceeded  70  (a  “1off”),  with  95th  percentile  =  61  

• “Minimum  theoretical  in-­‐patient  activity”  (actual  utilisation  -­‐  all  transfers  out  -­‐  all  discharges)  

never  exceeded  53  (1off),  with  95th  percentile  =  44  

• Mean  elective  admissions  =  2/day  (median  1,  mode  0)  

• Mean  emergency  admissions  =  6/day  (median  6,  mode  6)  

• Mean  total  admissions  =  8/day  (median  7,  mode  7)  

• Average  occupancy  =  67.7%  (at  67  beds)  

3.5.2. It  is  also  possible  to  conclude  (subject  to  those  caveats  already  noted)  that:    

• Occupancy  levels  in  all  wards  are  less  than  national  averages  

• All   lengths  of   stay   are   above  national   averages  despite  day   case   activity  being  higher   than  national  averages  

3.5.3. Overall,   it   is   our   assessment   -­‐   based   on   the   data   made   available   and   additional   activity  conducted  –  that  the  current  baseline  of  in-­‐patient  bed  activity  highlights  that:  

• A  lack  of  overall  physical  beds  is  never  currently  an  issue  for  NHS  Shetland  but  

• inflexibility  of  current  capacity  leads  to  short-­‐term  challenges  in  wards  at  peak  times.  

• The   low   level   of   elective   admissions   to   in-­‐patient  wards   does   not   lend   itself   to   supporting  

capacity  management.    

• There  is  currently  an  over  supply  of  around  10  beds  (prior  to  changing  any  other  parameters)  but  

• these  beds  could  not  be  released  without  identifying  the  operational  means  to  rapidly  “turn  on”   additional   capacity   if/when   required   to  meet   exceptional   peaks  and   a   re-­‐alignment   of  

the  existing  bed  base.    

• Any   re-­‐alignment   of   the   bed  base  must   reduce   the   number   of   operational   units  managing  beds  and/or  support  the  effective  “pooling”  of  beds  by  another  means.  

• The  current  physical  bed  base  (accommodation)  lacks  the  flexibility  required  to  manage  the  unique  range  of  patients  that  need  to  be  accommodated.  

• Existing  bed  configuration  and  operational  models  need  to  change  from  this  baseline  in  order  

to   release   staffed   capacity   that   appears   only   to   be   required   in   exceptional   circumstances.  Even  then,  it  could  be  concluded  that  such  capacity  is  only  required  to  deal  with  “exceptional  circumstances”  due  to  the  unique  geographical  situation  of   the   islands  and  the  subsequent  

requirement  for  NHS  Shetland  to  be  able  to  manage  such  crises  locally  within  the  Gilbert  Bain  Hospital.  

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3.5.4. It  must  be  highlighted  that  this  baseline  reflects  current  activity  levels  only  and  NOT  the  impact  of   any   changes   to   service   demand   or   any   other   parameters   likely   to   have   an   impact   (either  

positive  or  negative)  that  would  be  reflected  in  future  planning  scenarios.  

4. IDENTIFY   FUTURE   SCENARIOS   FOR   SERVICE   MODELS   INCLUDING   THE   FUTURE   SCALE   OF  INSTITUTIONAL  FACILITIES  (WITHIN  5,  10  AND  20  YEAR  TIMESCALES)  

4.1. Future  Scenario  Planning  

4.1.1. Whilst  B+A  would  normally  present   a   range  of   scenarios  based  on   “alternative   visions  of   the  future”,  discussions  at  an  early  stage  identified  a  desire  on  the  part  of  NHS  Shetland  for  these  

to   reflect   a   linear   progression   from  where   the  Board   is   now   to  where   it  may   aspire   to   be   in  future.  

4.1.2. Consequently,  scenarios  developed  are  bounded  by  2  axis:  

o The   baseline   impact   of   improving   performance   in   key   areas   such   as   occupancy   and  length  of  stay  

o The  projected  impact  of  demographic  change  over  time  from  these  alternative  baselines.    

4.1.3. These  scenarios  should  not  be  regarded  as  definitive  as  they  do  not  include  the  extensive  range  of   variables   that   require   consideration   –   particularly   related   to   future   change   –   but   rather  present  a  variety  of  projections  as   the  basis   for   such  detailed  work.  They  are  also   inclined   to  oversimplify   the   impact  of  performance   improvements  through  assuming  that   they  all   impact  

at  the  start  of  the  time  period  projected.    

4.1.4. Ultimately  a  definitive  scenario  will  need   to  be  developed  by  NHS  Shetland,  based  on  agreed  planning  assumptions  that  can  inform  the  basis  for  actual  bed  capacity  re-­‐alignment.    

 

Diag.12.  Linear  Scenario  Baselines  For  Future  Bed  Capacity  Projections  

4.2.  The  Baseline  Impact  of  Improved  Performance  

4.2.1. Diag.12   highlights   the   range   of   baselines   which   demographic   and   other   changes   can   be  projected  from.  These  start  from  the  current  baseline  (informed  by  the  review  data)  through  to  

where   the   Board   may   ultimately   aspire   to   be   (based   on   benchmarking   against   the   best  performing   Boards)   in   terms   of   occupancy   and   lengths   of   stay   alone.   A   number   of   different  

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levels   of   performance   improvements   are   identified   under   a   number   of   “baseline   scenario  titles”.  These  are:  

o “Where   the   Board   is   now”   –   the   actual   current   situation   regarding   beds,   occupancy   and  

length  of  stay.  

o “Where  the  Board  should  be  now?”  –   the   impact  of  simply   raising  occupancy   to   the   target  levels  identified  in  Diag.  13.  that  are  believed  to  be  reasonable  based  on  all    data/information  reviewed  thus  far  and  that  are  intended  to  reflect  Shetland’s  unique  situation.  

o “Where  the  Board  could  be  now?  (Getting  better)”  –  the  impact  of  raising  occupancy  levels  

to  the  targets  identified  in  Diag.13  whilst  reducing  length  of  stay  to  match  the  NHS  Scotland  average.    (Diag.14)  

o “Where   the   Board   could   be   now?   (Matching   the   best)”   –   the   impact   of   raising   occupancy  levels   to   the   targets   identified   in  Diag.13  whilst   reducing   length   of   stay   to  match   the   best  

performing  Boards  in  Scotland.    (Diag.14)  

o “Where   the  Board  may  aspire   to  be?”  –   the  visionary  but   immeasurable   impact  of  utilising  Shetland’s   uniqueness   to   develop   a   model   of   care   that   radically   changes   bed/capacity  requirements  in  a  way  unlikely  to  be  implemented  anywhere  else  in  the  country.  

 

Diag.13.  Suggested  “Target  Occupancy  Levels”  For  NHS  Shetland  

 

Diag.14.  Throughput,  NHS  Shetland  Vs  NHS  Scotland  (Source  ISD,  2010)  

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4.2.2. The  actual  impact  of  applying  these  measures  is  summarised  in  Diag.15,  which  reflects  a  huge  potential   theoretical   impact   on   baseline   bed   requirements   as   a   result   of   the   performance  

improvements   identified   (from   67   beds   at   present   to   a   potential   32   in   the   most   optimistic  scenario).  

4.2.3. In   reality,   it   is   unlikely   that   32   in-­‐patient   beds   would   be   able   to   cope   with   NHS   Shetland’s  demands  as  acceptable  occupancy  levels  would  need  to  drop  with  bed  numbers  to  ensure  that  

beds  are  always  available   to  manage  peaks/troughs   in  activity   -­‐   even   if   the   facility  existed   to  “switch  on”  additional  capacity  at  short  notice  if  required.  Equally,  it  would  not  be  possible  to  support   a   significant   drop   in   bed   numbers   without   a   fundamental   re-­‐alignment   of   existing  

wards/operational   units   as   the   equivalent   bed   numbers   highlighted   in   this   extreme   scenario  cease  to  be  viable,  safe  and  appropriate  in  their  existing  configuration.  

4.2.4. Nonetheless,  these  alternative  baselines  show  the  significant  potential  impact  of  even  modest  changes  in  practice  and  the  range  of  effects  that  such  change  could  have.  

 

Diag.15.  The  Range  of  Scenario  Baselines  For  Future  Bed  Capacity  Projections  

4.3. The  Projected  Impact  of  Demographic  Change  

4.3.1. Diagram  16  charts  the  anticipated  impact  of  demographic  on  Shetland  between  2008  and  2033,  highlighting  the  significant  challenge  affecting  the  islands  associated  with  an  ageing  population.  

4.3.2. In  summary,  whilst  an  overall  drop  in  population  of  8.37%  (1700  people)  is  anticipated  between  2008  and  2033,  the  number  of  people  in  the  0-­‐15  age  group  is  likely  to  fall  by  over  48%  whilst  

those  in  the  75+  age  group  is  projected  to  rise  by  57%.  Overall  there  is  a  substantial  decrease  in  the  population  aged  under  49  and  a  substantial  increase  in  the  population  aged  over  65.  

4.3.3. It   is   this   change   in   the   demography   that   is   of   most   concern   from   a   healthcare   planning  perspective   as,   aside   from   issues   related   to   staffing   services,   in   general   terms   older   people  

require  more  care  more  often.    

4.3.4. To  understand  the  future  anticipated  impact  of  demographic  change  on  bed  capacity  a  detailed  analysis   of   the   ages   and   lengths   of   stay   of   patients   accessing   services   in   current   wards   was  

undertaken.  The  projections  were  developed  to  clarify   the  additional  beds   required  based  on  an  altered  demographic  picture  by  ward  and  target  levels  for  future  occupancy.  

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Diag.16.  The  Impact  of  Demographic  Change  in  the  NHS  Shetland  Board  Area  

4.3.5. Diag’s   17-­‐20   graphically   represent   the   impact   of   anticipated  demographic   change  on  existing  ward  area  bed  requirements  over  time  based  on  the  alternative  scenario  baselines  highlighted  previously.      

 

Diag.  17.  The  Impact  of  Anticipated  Demographic  Change  on  Ward  1  (2008  –  2028)  Projected  From  Alternative  Scenario  Baselines  

 

Diag.  18.  The  Impact  of  Anticipated  Demographic  Change  on  Ward  3  (2008  –  2028)  Projected  From  Alternative  Scenario  Baselines  

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Diag.  19.  The  Impact  of  Anticipated  Demographic  Change  on  Ronas  Ward  (2008  –  2028)  Projected  From  Alternative  Scenario  Baselines  

 

Diag.  20.  The  Impact  of  Anticipated  Demographic  Change  on  Maternity  Ward  (2008  –  2028)  

Projected  From  Alternative  Scenario  Baselines  

4.3.6. Whilst   the   impact   of   demographic   change   is   substantial   in   all   current  wards,   it   is   particulalry  significant  in  medicine,  surgery  and  maternity.  Impact  on  Ronas  is  considerably  less  drammatic  due   to   the   very   low   patient   turnover.   The  maternity   data   drops   significantly   over   time   as   a  

result   of   the   significant   projected   drop   in     women   of   child-­‐bearing   age,   although   these  projections   do   include   other   factors   that   may   impact   on   birth   rate   and   consequently   the  capacity  required,  e.g.  the  size  of  families  and  age  range  of  women  having  babies.  

4.3.7. Ward   3   (Medicine)   appears   to   be  most   affected   by   demographic   projections   because   of   the  

high  number  of  older  patients  admitted  and  their  longer  lengths  of  stay  compared  to  younger  patients.  

 

Diag.  21.  The  Impact  of  Anticipated  Demographic  Change  on  All  Wards  (2008  –  2028)  Projected  

From  Alternative  Scenario  Baselines  

4.3.8. Diag.21.  presents  the  same  data  for  all  wards,  highlighting  anticipated  global  bed  requirements  within   NHS   Shetland   based   on   forecasting   alternative   baseline   scenarios   in   line   with  demographic  change  alone.  This  shows  a  steady  increase  in  capacity  requirements  over  time  in  

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all   scenarios,   however   in   the   “Could  be   (better)”   and   “Could  be   (best)”   range,   required  beds  don’t  equate  to  current  levels  even  by  2028  (52  and  46  respectively).  Even  the  “should  be  now”  

scenario  shows  that  current  bed  requirements  would  be  sufficient  up  to  2020,  peaking  at  72  in  2028.  

4.3.9. It  is  acknowledged  that  data  has  been  highly  simplified  and  it  does  not  include  any  analysis  of  additional  factors  that  may  affect  admission  or  length  of  stays,  however,  a  range  of  issues  have  

been   identified   that   are  worthy  of   consideration  and  are   likely   to  have  a  mix  of  positive  and  negative  impacts  on  future  bed  requirements.  These  include:    

o The  impact  of  re-­‐patriating  patients/activity  to  Shetland  

o The  impact  of  early  detection  of  cancer/screening  programmes  

o The  impact  of  improved  theatre  scheduling/reduced  overnight  stays  

o The  impact  of  reducing/providing  alternatives  to  admission  

o The  impact  of  increasing  bed  flexibility  

o The  impact  of  the  creation  of  an  admission/discharge  lounge  

o The  impact  of  other  improvements  in  global  service  delivery    

o The   impacts   of   other   changes   in   demography/medical   science/treatment   regimes   that   it   is  not  currently  possible  to  anticipate/model  

4.4.  Current  NHS  Shetland  Activity  Undertaken  by  NHS  Grampian  

4.4.1. Although  all  “future  impact  factors”  identified  above  require  further  detailed  consideration  and  

development  of  detailed  planning  assumptions  about  the  impact  on  capacity,  one  of  the  most  significant  and  immediate  could  be  re-­‐patriating  patients/activity  to  Shetland  that  currently  go  to  the  mainland.  A  high-­‐level  review  of  current  NHS  Shetland  patients  attending  NHS  Grampian  

for  care/treatment  was  undertaken  in  order  to  identify  the  “order  of  impact”  that  such  activity  could  have  on  current/future  bed  capacity.    

4.4.2.  It  is  important  to  note  that  it  has  been  difficult  to  collect  this  data  –  which  has  been  generated  from  ISD  returns  -­‐  and  that  there  are  still  concerns  over  its  accuracy.  Caution  should  therefore  

be   exercised   when   interpreting   it   and   additional   information   will   be   required   to   support  detailed  planning  assumptions.  Notwithstanding  these  cautions,  Diag.22  identifies;  the  number  of  in-­‐patient  episodes  (count  of  Length  of  Stay  –  LOS);  total  bed  days  (sum  of  LOS);  and  notional  

in-­‐patient   bed   requirements   for   NHS   Shetland   patients   attending   Grampian   whilst   Diag.   23  summarises  the  same  data  but  by  length  of  stay  rather  than  clinical  sub-­‐specialty.    

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Diag.  22.  NHS  Shetland  In-­‐patients  Seen  in  NHS  Grampian  (By  Sub-­‐specialty)  

 

Diag.  23.  NHS  Shetland  In-­‐patients  Seen  in  NHS  Grampian  (By  Length  of  Stay)  

4.4.3. In  summary,  it  appears  that  total  NHS  Shetland  in-­‐patient  activity  undertaken  by  NHS  Grampian  accounts  for  the  equivalent  of  around  14  beds  at  a  notional  occupancy  of  80%.  

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4.4.4. Trauma  and  orthopaedic  activity  utilises  the  highest  number  of  beds  (3.2),  followed  by  general  surgery  (1.4)  and  cardiology  (1).    

4.4.5. In   terms   of   clinical   sub-­‐specialties   where   significant   re-­‐patriation   could   be   targeted;  

gynaecology   activity   accounts   for   less   than   1   whole   bed   whilst   breast   surgery   would   be  included  within  the  general  surgery  total.  

4.4.6. This  data  tends  to  indicate  that  the  impact  of  any  re-­‐patriation  will  be  marginal  in  terms  of  beds  required   and   highly   unlikely   to   exceed   2-­‐3   in   the   short-­‐term,   although   further   analysis   is  

required  based  on  agreed  future  planning  assumptions.  

4.4.7. It   is  noted  that  more  than  1/3  of  the  beds  used  by  NHS  Shetland  patients  in  Grampian  (5.3  at  80%  occupancy)  are  associated  with  patients  who  have  been  there  for  10  or  more  days.    

4.5. Alternative  Future  Bed  Configurations  

4.5.1. A   key   challenge   for   NHS   Shetland   in   all   bed/capacity   planning   activity   is   the   requirement   to  provide   a   range   of   services   locally   that   is   disproportionately   higher   than   the   overall   volume  

available.   From   a   bed   perspective,   this   manifests   as   the   need   to   deliver   a   broad   range   of  services/sub-­‐specialties   from  a   limited  range  of  “functional  units”   (wards)   that  are  capable  of  supporting   appropriate   patient   group   separation   for   clinical,   social,   staffing,   operational   and  

other  reasons.    

4.5.2. Historical  bed  configuration  has  seen  separate  wards  supporting  medicine,  surgery,  elderly  care  and   maternity   services   for   very   good   reasons,   with   informal   interviews   highlighting   a   real  concern  on  the  part  of  many  clinical  staff  about  any  proposals  that  see  (in  particular)  medicine  

and  surgery  activity  being  combined  in  any  way.  

4.5.3. There   is   however   a   requirement,   particularly   in   light   of   the   data  modelled   here,   to   consider  how   the   existing   bed   complement  might   be   re-­‐configured   to   reduce   the   number   of   discrete  functional  units  and  the  potential  impact  on  service  sustainability.  

4.5.4. Diag.24   presents   a   simplistic   overview   of   the   current   ward   configuration   and   bed   numbers  

within  the  Gilbert  Bain  Hospital.  This   reflects  A&E,  along  with  operating  theatres  and  the  day  case  unit  on   the  ground   floor;  maternity  and   surgery  on   level  1;   and  medicine  and  Ronas  on  level  2.  

 

Diag.  24.  Current  Ward  Configuration  at  the  Gilbert  Bain  Hospital  

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4.5.5. A  key  issue  currently  is  that  the  surgical  ward  is  on  a  different  floor  to  the  operating  theatres,  impeding  optimal  surgical  journeys  through  the  need  to  use  a  lift.  Whilst  the  creation  of  a  day  

case   unit   alongside   theatres   has   attempted   to   improve   (rationalise)   the   journey   for   patients  requiring   the   shortest   stay   in   hospital,   anecdotal   evidence   from   informal   interviews   suggests  that   this  unit   lacks   the  space  and  capacity   required   to   support  even  current  day  case  activity  

effectively.  

4.5.6. In   addition,   there   is   a   distinct   lack   of   single   rooms   throughout   the   facility   which;   severely  impacts   upon   the   ability   to   cope  with   the   diverse   range   of   patients   that  must   be  managed;  reduces   operational   flexibility;   and   provides   challenges   regarding  mixed   sex   accommodation  

and  the  wider  NHS  Scotland  privacy/dignity  agenda.  

4.5.7. Recognising  the  dilemma  relating  to  balancing  “sub-­‐specialism  and  sustainability”,  a  number  of  alternative  future  bed/ward  configurations  have  been  highlighted  through  informal  interviews  that  are  worthy  of  further  consideration.  All  present  future  bed  configurations  that  see  capacity  

delivered  from  2  rather  than  4  wards/units  and  are  shown  graphically  in  diagrams  25-­‐27.  

4.5.8. It   is   important   to   note   that   these   options   are   not   exhaustive;   require   substantial   further  consideration   in   the   light   of   agreed   future   bed   modelling;   and   are   presented   simply   as  examples   of   how   future   configuration   could   change.   It   is   also   essential   to   note   that   these  

options   (or   any   proposed   reduction   in   “functional   units”)   need   not   reduce   the   “identity”   of  existing   sub-­‐specialties   –   given   that   they   relate   to   building/operational  management  models  rather  than  clinical  service  delivery  models  i.e.  the  maternity  unit  could  still  exist  as  a  separate  

clinical  sub-­‐specialty  operating  out  of  designated  rooms/support  spaces  within  a  larger  “ward”.  

 

 

Diag.  25.  Future  Ward  Configuration?  (Medical  Unit/Surgical  &  Obs  Unit)  

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 Diag.  26.  Future  Ward  Configuration?  (Male  Unit/Female  Unit)  

 

     

Diag.  27.  Future  Configuration?  (Short  Stay  Unit/Long  Stay  Unit)  

4.6. The  Medical  and  Surgical  Unit  Model?    4.6.1. The  Medical/Surgical  Unit  option   is  most   similar   to   the  current  configuration,   suggesting   that  

the  core  identity  of  any  2  future  units  might  broadly  split  medical  and  surgical  services,  with  the  elderly   beds   associated   with   Ronas   being   managed   as   part   of   the   “medical   unit”   and  maternity/obstetric  area  accommodated  within  the  surgical  “unit”.  

 4.6.2. The  relationship  between  maternity  beds  and  the  surgical  unit  would  most   likely  be  the  most  

challenging  aspect  of  this  model  although;  there   is  a  unique  established  relationship  between  maternity  and  surgery  in  Shetland  due  to  the  surgeon’s  role  in  caesarean  section  and;  as  noted  previously,  a  combined  unit  should  not  result  in  a  loss  of  identity.  

 4.7. The  Male  and  Female  Unit  Model?    4.7.1. The  Male/Female  Unit   option   sees   sex   as   the  main  determinant   of   two   functional   units   and,  

whilst   this   could   address   mixed-­‐sex   issues   –   and   provide   a   better   location   for   a   maternity  facility  -­‐  it  may  also  mean  medical  and  surgical  nursing  expertise  being  “watered  down”.      

       

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4.8. The  Short  Stay  Unit  and  Long  Stay  Unit  Model?    4.8.1. Diag.   28   shows   that   existing   patient   length   of   stay   (before   any   improvement   that   may   be  

targeted)   represents  an  almost  50:50   split  between   those  patients   staying  5  days  or   less  and  those  patients  staying  more  than  5  days.  It  also  highlights  the  high  number  of  patients  spending  10  or  more  days  in  an  acute  hospital  facility  and  the  huge  number  of  beds  associated  with  them  (23.8  or  more  than  1/3  of  the  available  bed  capacity  at  current  levels).  

 4.8.2. This   model   recognises   that   there   may   be   a   clinical   and   operational   benefit   associated   with  

separating   the   hospital   into   separate   short   (up   to   5   day)   and   long   (over   5   day)   units.   These  include   the   ability   to   “gear”   staff   and   processes   to   delivering   the   best   kind   of   care   possible  based   on   short-­‐term   and   rehabilitative   needs   as   well   as   the   opportunity   to   close   beds   at  weekends  through  structuring  the  short  stay  unit  as  Monday-­‐Friday  only.  

 4.8.3. Whilst  this  may  have  merit,  it  is  not  always  possible  to  identify  an  anticipated  length  of  stay  on  

admission  and  the  unit  could  also  suffer  from  core  skills  being  “watered  down”.      

 

Diag.  28.  In-­‐patient  Length  of  Stay  at  the  Gilbert  Bain  Hospital  (Source:  Helix)  

4.8.4. It   is   important   to  emphasise   that   these  options  are  neither  exhaustive  nor  definitive  and  are  

presented  here  simply  as  examples  of  how  a  reduced  number  of  functional  bedded  units  could  be   delivered   to   ensure   improved   short   and   long-­‐term   sustainability   along   with   revenue  optimisation.  

5. REVIEW  CLINICAL  STRATEGY  IMPLEMENTATION  TO  IDENTIFY  FURTHER  OPPORTUNITIES  

5.1. NHS   Shetland   developed   a   clinical   strategy   in   2011   that   defines   the   Board’s   “direction   of  travel”  for  clinical  services  for  the  next  3  years.  This  document  has  been  considered  as  part  of   the   overall   review   process   –   although   it   has   not   been   reported   in   detail   as   it   would  require  an  extensive  review  process  in  it’s  own  right.  

5.2. The  Clinical  Strategy  document  and  process  that  its  development  followed  are  characterised  

by   extensive   public   involvement   and   an   engagement   process   that   appears   to   have   been  extremely  robust.  The  key  “themes”  that  it  identifies  are:      

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o Reducing  unnecessary  patient  journeys,  particularly  to  Aberdeen;    

o Integrating  community  and  hospital  services  especially  nursing;    

o Developing  a  one  stop  shop  approach  to  making  appointments,  starting  with  the  hospital;    

o Retaining  GP  services  in  their  current  locations;    

o Developing  a  more  responsive  mental  health  team;    

o Proceeding  with  a  formal  process  to  close  NHS  inpatient  services  on  the  Montfield  Hospital  

site;    

o Strengthening  the  resilience  of  healthcare  on  non-­‐doctor  islands;    

o Remodelling   clinical   staffing   to   respond   to   the   national   shortage   of   junior   doctors   and  challenges  to  the  recruitment  &  retention  of  staff.  

5.3. The  elements  of  this  vision  for  sustainable  service  delivery  set  out  in  the  Clinical  Strategy  are:  

o To  sustain  core  services  and  maintain  viability;    

o To  ensure  the  future  retention  and  recruitment  of  staff;    

o To  enhance  training  and  development  opportunities;    

o To  develop  partnership  working  with  other  agencies;    

o To  strengthen  and  develop  health  promotion  and  education;    

o To  enhance  primary  care  services;    

o To  provide  care  in  the  most  appropriate  setting;    

o To  maximise  the  benefits  of  new  technology;    

o To  improve  the  environment  of  healthcare  facilities.  

5.4. The  principles  on  which  the  vision  is  based  on  are  summarised  as:    

o Emergency   care   services   must   be   maintained   locally,   including   medicine,   surgery   and  

maternity;    

o Care   should   only   be   provided   in   a   hospital   setting   if   it   cannot   be   provided   safely   and  effectively  in  the  community;  

o Patients  should  only  be  sent  out  with  Shetland  for  healthcare  if  it  cannot  be  provided  safely  

and  effectively  in  Shetland;    

o Attendance  at  hospital   for  diagnostic   tests,  outpatient   consultations  and  minor  procedures  should  be  kept  to  a  minimum;  

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o Healthcare  should  be  provided  in  multi-­‐professional  teams,  with  reliance  on  individuals  kept  to  minimum.  

5.5. The  Clinical  Strategy  also  presents  a  range  of  “proposals”  that  are  summarised  as:    

o Right  clinician,  right  place,  right  time  

o Seamless  care  between  hospital  and  community  

o Matching  bed  capacity  to  demand  

o National  difficulties  in  recruiting  junior  doctors  to  staff  hospital  rotas  

o Hospital  at  Night  and  OOH  service  provision  

o Develop  the  skills  of  generalists  to  work  with  children  

o Develop   the   skills   of   midwives,   surgeons   and   obstetric   GP’s   to   provide   as   much   care   as  possible  locally  

o Better  co-­‐ordination  of  services  between  health,  local  authority  and  the  voluntary  sector  

o Partnership  working  with  other  health  boards  

5.6.  The  themes,  vision,  principles,  proposals  and  the  more  detailed  work  behind  them  recognise  both  national  strategic  direction  as  well  as  an  understanding  of  the  key  challenges  facing  all  services.  It  is  important  to  note  however  that  the  overall  strategy  is  characterised  as  much  by  what  must  stay  the  same  as  what  should  change;  there  is  a  lack  of  detail  about  how  this  change  should  happen;  who  should  be  responsible;  what  the  timescales  are;  and  what  the  anticipated  impact  for  planning  purposes  should  be.  This  is  not  surprising  as  the  document  represents  the  strategic  “direction  of  travel”  and  identifies  that  a  separate  implementation  plan  will  be  developed.  

 5.7. In  so  far  as  the  principles  identified  within  the  Clinical  Strategy  document  remain  robust  

and  that  the  bed  modelling  undertaken  to  date  has  identified  the  need  for  more  detailed  assumptions  to  be  developed,  it  seems  appropriate  that  a  version  of  the  clinical  strategy  implementation/action  plan  could  inform  the  detailed  assumptions  required  around  the  timescale  and  impact  of  future  proposed  change  under  the  heading  of  “Matching  bed  capacity  to  demand”.  Specifically,  identifying  the  anticipated  impact  of  the  redesign  elements  proposed  on  future  bed  requirements  or  the  factors  that  will  affect  this,  most  notably  admission  numbers  and  length  of  stay  e.g.  what  are  the  detailed  proposals  relating  to  re-­‐patriation  of  patients  to  Shetland  from  Grampian,  the  impact  on  beds  anticipated  and  the  timescales  involved.  

 6. TO  FACILITATE  A  1  DAY  WORKSHOP  RE:  OPPORTUNITIES  FOR  CHANGE  

6.1. This   workshop  was   facilitated   by   B+A   on   the   24th   August   2012.     A   copy   of   the   agenda   is  included  at  Appendix  2  and  note  of  the  attendees  at  Appendix  3.    

6.2. As  it  was  the  subject  of  a  separate  report,  the  workshop  is  not  described  in  detail  here.  

 

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7. SUMMARY  AND  RECOMMENDATIONS  

7.1.1. Based  on  all  work  undertaken  to  date  including  meetings,  informal  interviews,  workshop,  data  review,   bench-­‐marking   and   projections,   B+A   offer   the   following   summary   comments   and  

recommendations  for  the  consideration  of  NHS  Shetland:  

1. Available  data  highlights  that  the  current  bed  capacity  within  the  Gilbert  Bain  Hospital  needs  to  change  and  –  particularly  in  the  short  term  –  to  reduce.  Analysis  also  identifies  that  this  cannot  happen   effectively   without   a   fundamental   transformation   in   the   way   that   existing  

wards/operational   units   operate/are   configured   and   actual   (or   operational)   rationalisation   to  realise  increased  flexibility.  The  Board  should  consider  reviewing  the  number  of  operational  units  within   the   Gilbert   Bain   Hospital,   rationalising   these   where   appropriate   in   order   to   realise  

improved  flexibility  and  occupancy  of  a  reduced  bed  base.  

2. Aside  from  operational  issues,  the  current  physical  accommodation  at  the  Gilbert  Bain  Hospital  is  not   flexible  enough   to   support   the   range  of  different  patient  groups   in   the  same  physical   local  without   conflict/compromise.   The   Board   should   consider,   along   with   their   review   of   how  

operational   units   deliver   services   in   future,   the   improved  physical   options   available   to   support  improved  flexibility  and  making  the  bed  base  more  useable.  In  particular,  it  should  identify  how  each   option   could   optimise   the   number   of   smaller   bays   and   single   rooms   available   whilst  

maintaining  the  identity  of  individual  clinical  sub-­‐specialties,  e.g.  Maternity.  

3. The  main  element  of  “The  Shetland  Factor”  which  impacts  on  actual  bed  numbers  required  is  the  inability   of   the   Board   to   close   to   admissions   at   any   time.   This   is   a   very   real   issue   and   causes  understandable  concern  within  the  clinical  body.  Currently  however,  it  translates  in  simple  terms  

into   staffed   beds   being   available   at   all   times   –   even   when   they   are   not   required.   The   Board  should   consider   the   alternative   physical   and   operational   means   available   to   bring   additional  capacity   “on   line”  promptly   as/when   required   to  deal  with   infrequent  activity  peaks  and  allow  

the   bed   reductions/increased   occupancy   proposals   suggested   to   be   implemented  without   risk  e.g.  unstaffed  beds.  

4. Based  on  available  data,  NHS  Shetland  appear   to  utilise   the  equivalent  of  14   in-­‐patient  beds   in  NHS  Grampian  at  any  given  time  (or  more  than  20%  of  the  local  bed  capacity).  Around  5  of  these  

beds  relate  to  patients  who  have  lengths  of  stay  of  10  days  or  more.  The  Board  should  consider  undertaking   a   detailed   analysis   of   this   activity   in   order   to   i)   Support   the   effective   re-­‐design   of  patient  pathways   ii)  Support  the  development  of  agreed  assumptions  around  re-­‐patriation  that  

will   inform  detailed  bed  capacity  planning  now  and  in  the  future  iii)  Support  an  appropriate  re-­‐profiling  of  service  level  agreements  (and  associated  costs)  with  NHS  Grampian.    

5. Reviewing  12MN  and  daytime   in-­‐patient  activity  along  with  admission  data  has  highlighted   the  extremely  high  percentage  of  patients  who  “turnover”  within  the  Gilbert  Bain  Hospital  on  a  daily  

basis  and  the  potential   impact  that   this  can  have  on  both  bed  capacity  and  staffing.  The  Board  should   undertake   a   more   detailed   review   of   admission/discharge   timings   and   protocols   and  consider   the   alternative  means   that   could   be   employed   to   deliver  ward-­‐based   capacity   during  

peak   periods   as   an   alternative   to   staffed   beds,   e.g.   the   creation   of   an   admission/discharge  lounge.  They  should  also  model  the  additional  impact  that  such  a  facility  would  have  on  overall  bed  requirements  and  staffing.  

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6. 12  MN  bed  state  monitoring  is  not  an  effective  way  to  understand  how  well  beds  are  being  used  and  is  already  supplemented  in  Shetland  through  the  publication  of  daytime  data  made  available  

to   relevant   managers.   The   Board   should   consider   augmenting   long-­‐term   bed  monitoring/management  through  the  inclusion  of  trend  data  in  daytime  bed  states.  

7. Sample  data  related  to  daytime  bed  activity  supports  all  of  the  capacity  planning  data  contained  within   this   report   whilst   highlighting   an   apparent   under-­‐utilisation   of   HDU   beds.   The   Board  

should  consider  a  more  detailed  analysis  of  the  use  of  HDU  beds  in  order  to  identify  the  overall  future  impact  of  level  1  and  level  2  care  on  future  bed  modelling  scenarios.  

8. NHS   Shetland   has   developed   an   extensive   clinical   strategy   based   on   a   robust   and   inclusive  consultation  process,  although  it  is  currently  impossible  to  understand  what  the  global  impact  of  

its   implementation   is   likely  to  be   in  all  areas   including  bed  capacity.  The  Board  should  consider  developing  a  detailed  action  plan  that   translates   the  clinical  strategy  document   into  a  series  of  SMART   (Specific,   Measurable,   Achievable,   Realistic   &   Time   bound)   activities   under   defined  

accountable  officers  in  order  to;  i)  ensure  the  translation  of  agreed  intent  into  action,  ii)  identify  the  “target  impact”  of  changes  to  services/pathways  identified  and  iii)  allow  this  “target  impact”  in   key   areas   such   as   admissions   rates,   length   of   stay,   admission   on   day   of   surgery   activity,  

repatriation,   etc   to   be   factored   into  more   detailed   assumptions   around   actual   future   capacity  requirements   and   an   agreed   definitive   planning   scenario.   In   so   doing,   the   Board   have   the  potential  for  a  “Clinical  Strategy  Action  Plan”  to  become  the  means  to  both  quantify  and  realise  

such  an  agreed  definitive  future  planning  scenario.    

9. Recognising  that  this  review  has  looked  at  in-­‐patient  bed  capacity  in  isolation,  the  Board  should  consider   reviewing  capacity/performance   in  all  other  areas   to  ensure   that   the  global   impact  of  any  changes  to  in-­‐patient  beds  is  understood  and  can  be  managed  in  a  global  context.  Key  areas  

requiring  further  review  are  likely  to  include;  the  day  case  unit;  imaging;  out-­‐patients;  operating  theatres;  A&E;  and  community  based  resources.  

10. In   recognition   of   all   of   these   issues/considerations   the   Board   should   consider   undertaking   a  formal   “option   appraisal”   process   that   considers   in   detail   the   relative   strengths,   weaknesses,  

opportunities   and   threats   associated   with   a   full   range   of   alternative   future   service   delivery  models/configurations.  This  option  appraisal  process,  as  a  component  of   the  development  of  a  “Programme   Initial   Agreement”,   could   inform   optimal   future   strategic   investment/dis-­‐

investment  decisions  related  to  the  Gilbert  Bain  Hospital.    

11. Despite   the  extensive   consultation  undertaken   in   support  of  Clinical   Strategy  development   the  review  process  has  highlighted  a  sense  that  the  clinical  body  has  historically  felt  disengaged  from  strategic  planning,  particularly   in   relation   to  capacity  and  staffing  management.  There  has  also  

been  an  acknowledgement  that  the  work  around  this  review  has  begun  to  address  this  situation.  The  Board  should  continue  to  review  how  best  to  secure  clinical  engagement  at  all  levels  in  order  to  address  future  challenges.  

Norman  Sutherland    Associate  Director  Buchan  +  Associates  4th  October  2012