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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