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Annual Review 2010 Self-assessment
August 2010
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August 2010
NHS Lothian Annual Review 2010 self-assessment
Contents Page 1: Introduction 5
2: Progress on 2009 annual review action points 6
3: Improving the Quality of Care and Treatment 7
4: Improving Health and Reducing Inequalities 25
5: Primary Care 29
6: Finance, efficiency and workforce and Service Change 38
7: Challenges for the future 45
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NHS Lothian Annual Review 2010 self-assessment
1. Introduction
This report summarises the achievements and challenges faced by NHS Lothian in 2009/2010. We continue to make good progress on most fronts and are delivering high and ever-improving standards of healthcare. This report describes how: We have cut waiting times to their lowest-ever levels, hitting targets early
and then surpassing targets, while treating increasing numbers of patients Together with partners, we continue to reduce the number of patients
inappropriately delayed in our hospital beds We have achieved significant reductions in cases of C.difficile infection in
our hospitals We have made more progress towards improving health and reducing
inequalities Across our services, we continue to provide more care out of acute
hospitals and in community-based settings closer to people’s homes. The delivery of Capital projects such as such as Midlothian Community
Hospital and services is helping us provide the best possible care in the best possible environment
Innovative thinking and smarter ways of working are improving efficiency
and patient care, through initiatives such as our Lean in Lothian programme
Our pioneering 5 x 5 x 5 initiative shows us that this will further improve
our services and ways of working, with multi-disciplinary teams learning from best practice around the world and producing viable action plans for improvements in local services
It is a great tribute to the hard work of our 28,000 staff that they have achieved challenging targets at the same time as they introduced improvements and innovations across the health service, at a time of increasing financial constraint. Their endeavours are helping us make progress towards our goal of becoming one of the world’s top 25 healthcare systems.
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2. Progress on 2009 annual review action points
Alcohol Brief Intervention (HEAT target H4) We exceeded the target for Alcohol Brief Interventions and had excellent support from GPs in delivering interventions in GP practices across Lothian. (For more details, see page 27).
Mental Health Services Mental Health and Wellbeing remains a priority for NHS Lothian. (For details of progress and developments in the year, see page 14).
Deliver ‘Whole Journey’ – 18 Weeks Referral to Treatment We achieved our stage of treatment waiting times targets for key diagnostic tests, outpatients, inpatients and day cases, and continue to make good progress towards delivery of the whole journey 18 weeks referral to treatment targets. (For more details, see page 23).
Information for 18 Weeks RTT Measurements Our ability to measure the patient journey or pathway robustly has continued to make progress with improvements in our clinic outcome recording and increasing use of UCPN (Unique Care Pathway Number). (For more details, see page 23).
Capital Investment Programme and Projects Our capital projects programme is ambitious and wide-ranging, covering a variety of projects in acute and primary settings that help deliver high quality patient care in the best possible environments. (For an update on progress, see page 45).
Healthcare Associated Infections (HAI) Progress to tackle HAI has been achieved during the year, but we recognise that there is no room for complacency. (For more details of actions and progress during the year, see page 9).
5x5x5 Programme Our 5x5x5 programme has been showing good results and projects with potential benefits will be taken forward. (For more details, see page 43).
Finance NHS Lothian achieved its three financial targets for 2009/10 and we continue to maintain close contact with our Scottish Government Health Directorate (SGHD) finance colleagues. (For more details, see page 38).
Three Acute Hospitals We have continued to build on our commitment to three acute hospitals with the creation of the short stay elective surgical centre at St John’s in West Lothian, where construction is due to complete in December 2010.
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3. Improving the quality of care and treatment for patients Implementing the Quality Strategy 2010 NHS Lothian is committed to delivering safe, effective, high quality and person-centred care. Our five year plan and strategic aims demonstrate this commitment to the Quality Strategy, which aims to: Deliver care and treatment in the right place at the right time Improve health and reduce health inequalities Embrace advances in medicine, technology and information Be at the forefront of research and leadership Be an exemplar employer Achieve World’s Top 25 Clinical Standards Achieve World’s Top 25 Standards in how we use resources. During 2010/11 we plan to review our strategy in light of the Scottish Government’s Quality Strategy (2010). Measuring the quality of our care: Quality is at the heart of all we do. Quality, including patient safety, is a standing item on the Board agenda,
supported by a quality improvement report 2009/10 witnessed significant integration of quality programmes, such as
Patient Safety, Healthcare Associated Infections, Leading Better Care and Compassionate Care
Our quality improvement actions/commitments have been integrated into our Quality Improvement Team plans for 2010/11
Internal communications has raised staff awareness of the Quality Strategy and staff are actively engaged in quality improvement work which are also reflected in Personal Development Plans and Knowledge & Skills Framework (KSF) outlines We continue to deliver, monitor and evaluate key quality improvement activities and programmes set out in the NHS Lothian Quality Strategy, such as: Releasing Time to Care Compassionate Care Leading Better Care Patient Safety Programme, including a primary care pilot workstream Making services better for older people. This includes redesigning the
system ( using Lean methodology) to improve services for for stroke, geriatric orthopaedic rehabilitation, dementia and delirium and developing a generic older people’s pathway
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Governance systems At NHS Lothian we aim to provide services which are safe, effective and person centres, and where patients are treated with compassion, dignity and respect. These values are embedded in our strategic plans and operational improvement plans in the context of strong healthcare governance, risk management and quality assurance processes. We revise our quality improvement programme processes and systems annually to ensure continuous quality improvement across NHS Lothian. In the peer review against NHS Quality improvement Scotland Clinical Governance and Risk Management Standards in 2009, we achieved the highest level score (4 = reviewing stage) for the clinical effectiveness and quality improvement criteria. In 2009/10 our overall combined score the QIS standard increased from 5 to 9 (out of a maximum 12). Since then we have further improved our performance against a range of QIS condition-specific and service standards, including a:
25% improvement in compliance against Food, Fluid and Nutrition
standards. 20% improvement in the second round of selective review of Anaesthetics
standards. Clinical Governance and Risk Management We have independent evidence that our clinical governance and risk management systems and controls continue to improve. This was confirmed by an external review by Quality Improvement Scotland (QIS) in January 2010. The review says we have appropriate controls in place, that risks are adequately managed, and progress is continuing to be made to evolve and improve our systems. The Scottish Patient Safety Programme has added an additional dimension to the work being undertaken by NHS Lothian, with the emphasis on the prevention of harm. NHS Lothian has made considerable progress implementing this national programme during 2009/2010 Key performance indicators have also been developed and put in place to measure our performance against the Incident Management Policy and Risk Register Procedure. Risk Registers All risk registers throughout NHS Lothian continue to be systematically reviewed and updated. Redesign work has acted as a catalyst to this process, with a high level of revision being reported. The corporate risk register also continues to be systematically reviewed and updated by the relevant risk owners. Risk Registers have now been
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transferred onto Datix (patient safety software) and the format, in conjunction with users, has been updated. Training of staff on the production and maintenance of registers, including the use of the Datix system, continues to be delivered to all levels of the service. Incident reporting A review conducted by Internal Audit on Incident Reporting in December 2009 confirmed we had satisfactory arrangements in place. Complaints and Compliments Complaints and compliments are now recorded using Datix. This year has seen considerable improvements in consolidating this process. Root Cause Analysis (RCA) - The training course has again been revised and updated to reflect the Scottish Patient Safety Initiative. We are the only Board in Scotland to provide this training in-house. Newly Qualified Practitioners - A course on risk management is now delivered to newly qualified practitioners during their first six months in service. Awareness sessions are also being delivered by risk management staff to FY1s (the most junior doctors) at the Royal Infirmary, Western General and St John’s. Alerts Procedure During 2009/2010, a new system, the Datix Alerts Module, was piloted as to spread alerts electronically and to collate and monitor responses. If successful, this will increase the level of assurance on how the information in these notices is being implemented at an operational level. This work is due for completion in 2010/2011. Staff Cultural Survey A staff cultural/patient safety survey, based on Scottish Patient Safety methodology, was conducted across NHS Lothian this year, to evaluate the effectiveness of our risk management arrangements. The data is being used to obtain a baseline of the existing safety culture in staff groups and management areas. Healthcare Associated Infection Healthcare Associated Infection continues to be a key priority for NHS Lothian and is a standing item on the agenda at Lothian NHS Board meetings, which are held in public. Locally identified needs are incorporated into the programme of activities to monitor and reduce HAI. Progress is monitored by: Operational infection control committees Quality improvement teams The Lothian Infection Control Advisory Committee.
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Staphylococcus Aureus Bacteraemia: Staphylococcus aureus Bacteraemia: MRSA and MSSA are now counted together as S.aureus Bacteraemia (SAB) We continue to reduce levels of SAB. The national HEAT target for S. aureus Bacteraemia (Meticillin Sensitive S. aureus and Meticillin Resistant S. aureus) reduction by March 2010 was 30%. By the end of the fourth year (April 2009 – March 2010) NHS Lothian achieved an overall reduction of 28% and a substantial reduction of 69% in Meticillin Resistant S. aureus bacteraemia. We will continue our efforts in this area to meet our target of a further reduction of 15% by March 2011.
The number of MRSA cases halved between 2008/09 to 2009/10 Clostridium difficile: We are making good progress in tackling C. difficile. NHS Lothian’s HEAT target for C. difficile episodes in patients 65 years and over is a 30% reduction by 2011. We have made excellent progress on this front, achieving a 50% reduction over two years and outstripping the HEAT target. By the end of year two the actual reduction in C. difficile was 50%. Between April 2007 and March 2010 the number of recorded C. difficile episodes in patients 65 and over fell from 102 to 44.
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Involving people, improving people's experience of care Patient Focus and Public Involvement (PFPI) governance and how these work Patient representatives and members of the public are valued partners in NHS Lothian and are involved in service redesign and improving care. Patient Focus and Public Involvement (PFPI) activity is reported to the: Involving People Group Improving the Patient Experience Group (to deliver Better Together and
pan-Lothian measuring patient experience) Clinical Information for People (sub-group of Improving Patient Experience
Group above). All of these groups include patient/ public representatives. The groups have reported to the Healthcare Governance and Risk Management Committee (a sub-committee of NHS Lothian Board) since their inception in January 2009. There is an update every six months on activity around the Involving People and Improving People’s Experience Strategy Action Plan and particular Patient Focus Public Involvement issues are reported as they arise. In March 2010, Lothian NHS Board agreed to establish a new sub-committee. This will be the Mutuality and Equality Governance Committee, and will provide leadership and strategic direction for developing and delivering mutuality, equality and diversity and spiritual care. The Involving People Group will report to the new committee and the Improving Patient Experience Group will continue to report to the Healthcare Governance and Risk Management Committee. Both committees will have patient/public representatives in addition to non-executive members. What progress has been made with the development of Public Partnership Forums (PPFs) and how are these influencing the design and delivery of services? Public Partnership Forums are influencing decisions on issues including transport, long term conditions, mental health and older people’s services. For example: Midlothian PPF with West Lothian PPF held joint meetings to discuss patient transport issues with the Scottish Ambulance Service and NHS Lothian and with North Edinburgh on podiatry. PFF members are represented on a range of groups, including Community Health Partnership (CHP) sub-committee, long-term conditions action group, joint Midlothian older people’s planning group.
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North Edinburgh PPF has a positive partnership with Edinburgh CHP. It is involved in the Mental Health Review Group in the CHP, Patient Experience Action Teams (PEAT), the Health Link (NHS Lothian community newspaper) Editorial Advisory Board, and the Podiatry Review and have developed a self-referral letter to the physiotherapy service. South Edinburgh PPF – the CHP approved the structure of the re-established PPF. The chair and vice chair were appointed in March 2010 and the first meeting of the steering group took place in April. The steering group has representatives from the City of Edinburgh Council Neighbourhood Partnerships health sub-groups and there are there are also thematic groups, covering issues such as disability. The wider PPF will have membership from the wider community. East Lothian PPF away day in December 2009 agreed the following areas for continued PPF priority: capital projects (e.g. in Haddington and Musselburgh); implementation of the Joint East Lothian Older People’s Strategy; working to address drug wastage and publicising the PPF. West Lothian PPF HC (Public Partnership for Health & Care) – representatives attended the Community Health and Care Partnership (CHCP) Development Event to help reflect on the CH(C)P’s achievements, learn from challenges and help inform the future focus and ways of working together. Part of this process was to look at the way the CHCP engages with the public and how to use the PPF effectively in doing this, which will form part of an action plan. The PPF HC has also revised their Working Agreement, which was formally signed off by the CHCP at the Board meeting on the 23rd of Feb 2010. The PPFs are jointly involved in, e.g. the Podiatry Review, patient transport and drug wastage, and will be seeking further areas to work together. What has worked well in progressing PFPI? Patients and the public have been involved in improving services across all parts of NHS Lothian. Specific projects include: Children aged three to six and aged six to 13 were asked about their ideas
for the new Royal Hospital for Sick Children (RHSC) Re-provision. An outside body was commissioned to work with children to develop their ideas through creative play and these will be incorporated into the design of the hospital.
Lothian’s innovative Compassionate Care Programme, which aims to promote compassion in nursing, has now expanded to other wards. The programme learns from patients and their families about what is important to them in improving their healthcare experience.
A joint patient and community involvement worker post between East Lothian CHP and East Lothian Community Planning partners has been appointed to increase the opportunity for joint engagement across service and strategy developments.
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As part of the 5x5x5 initiative, in 2009 a small project team undertook a literature review, mapping current activity, meetings with patients and staff to research the best way to obtain feedback from patients and carers’ in order to improve their experience. This complements learning from our Scottish Government funded programmes. A new way of capturing experience and feeding it back at ward level, using five key questions, will be piloted through the Senior Charge Nurse indicators.
Where further work is required: A participation database is being developed which aims to ensure a
greater variety of people are able to contribute to the development of a range of services and strategies. It will link with the PPFs to provide greater opportunities for involvement at the local level
A pan-Lothian review of complaints handling is currently taking place. This will lead to the modernising of the complaints process to ensure not only response times and the quality of responses are improved, but that lessons learned are shared across the organisation
We are working to ensure that evaluation of involvement processes in service planning is undertaken and learning is shared.
How public/patients have been supported to be involved and the difference it has made: There have been a number of strategies and service redesigns, which have involved patients, carers and the public during 2009-10 including: the Royal Hospital for Sick Children (RHSC) Re-provision, NHS Lothian Disability Equality Scheme, NHS Lothian Palliative Care Strategy – Living and Dying Well, redesign of stroke services, development of Lothian Dementia strategy and the Chalmers Sexual Health Centre. Their involvement through surveys, workshops, regular meetings of reference groups and representatives on the project boards has resulted in development of plans, services, strategies and designs for hospitals. Methods to support people to participate have included information in plain English, interpreters, going out to communities, reimbursement of travel expenses and provision of transport. Participants at workshops are invited to complete evaluation forms to help NHS Lothian learn whether people have been fully able to participate and whether engagement might be improved. Joint evaluation has taken place with the Scottish Health Council at some events.
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Mental Health Mental Health and Wellbeing remains a priority for NHS Lothian and the year witnessed good progress being achieved against HEAT targets. Dementia Register (HEAT target T9)
We exceeded the 2009/10 HEAT target, which is to have 5,707 patients with a diagnosis of dementia registered on the GP QOF register. Our final target for 2011 is 5,795 and we have set ourselves a stretched target of 6,380. We are well on track to deliver that. Actions we have taken include: education, training and awareness of staff across acute and mental health
services work to support patients and their carers in partnership with the dementia
services development centre. appointment of a nurse consultant in dementia through joint working with
Alzheimer's Scotland. recruiting to one of three Scottish allied health professional (AHP)
consultant posts in dementia embedding dementia-friendly design in our new buildings, i.e. Royal
Victoria Building The Stirling Dementia Service Development Centre (DSDC) Lothian Project is involved in a number of activities to enhance care and treatment for people with dementia and their carers including: Development and distribution of resources DVDs, two short films about caring for people with dementia in the acute
hospital; interview of a carer -"Dad's Story"
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CD ROM, Caring for People with Dementia in Acute Care Settings - includes three interactive modules for use with staff and useful resources such as pain charts, behaviour charts, basic information on dementia, and hints for providing care in a difficult environment under pressure.
Education and Training for staff Ten Lothian students are continuing with Dementia Services Development
Centre modules including seven on the certificate, two on the diploma and one on the MSc in dementia studies
Seven Lothian staff members also attended Best Practice facilitator and Manager as Leader training in February.
Dementia in Acute General Hospital Settings is a one-year audit project to improve the outcomes and experience of people with dementia, and their carers, while in the acute hospital. The first two phases of the audit have now been completed, and includes data gathered on: number of people with dementia discharged from hospital (during Nov 09) average length of stay number of wards / department moves for patient use of psychotropic (sedative) medications catheterisation number of people with dementia discharged to care home from hospital carer satisfaction questionnaires staff questionnaires. Phase three and four of the audit have now started in the six chosen wards, developing "beacon" areas of good dementia practice in the acute setting. This entails: regular weekly clinics in each chosen ward to discuss any current patients
with dementia providing a dementia awareness / training programme for staff "hands-on" coaching of staff working with some of the more "challenging"
patients with dementia providing information for staff and carers implementing screening tools for delirium, dementia and depression, as
well as pain. providing advice and support on safety and risk for people with dementia
(including reviewing complaints) Reduction in Psychiatric Admission (T4) Our target for the end of 2009 was a 10% cut in readmissions, within a year, among patients who have been in psychiatric hospital for more than seven days. NHS Lothian delivered the target and has continued to reduce the re-admissions. We also achieved the largest decrease of any health board in readmissions beyond the target 10% reduction for year ending December 08. (34%)
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Continuing progress on readmissions is due to redesigned mental health services, including the move from institutional care to supported, community-based care provided by multi-disciplinary professional teams to support more people at home. We have continued to exceed the target, an achievement supported by the development of our Intensive Home Treatment Teams (IHTT) and taking forward the redesign of Royal Edinburgh hospital and associated services.
Psychiatric Readmissions
Ongoing work with implementing the generic Integrated Care Pathway
(ICP) is also aimed at supporting this target. The generic ICP will be implemented in all areas by October 2010.
At the end of June we had our first variance analysis report on three measures and one supporting measure. These are: Completion of initial care plan within 24 hours Senor medical review within 24 hours Clinical Global Impression scale (CGI) Estimated date of discharge Reduction in Anti-Depressant Prescribing (T3) NHS Lothian is an efficient prescriber and one of the better performing boards in Scotland in this area. The HEAT target is to halt the growth in anti-depressant prescribing to 25.3 defined daily doses (DDDs) per head per year by March 2012. The Scottish position, at 31 December 2009, is 35.7.DDDs per capita per year. The current Lothian position is 32.5 DDDs. The Lothian integrated care pathway for depression guides prescribers on suitable management according to clinical assessment. Action to deliver this target includes: Implementation of the depression ICP (Integrated Care Pathway),
including an audit in the pilot practice.
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Protected Learning Time event on depression in November 2009 with approximately 300 general practice staff attending
Awareness/education sessions in general practice to promote the depression Integrated Care Pathway and alternatives to prescribing
Focused work around access to psychological therapies/waiting times, in line with the depression Integrated Care Pathway Conducting prescribing audits in those practices which prescribe the most to look at compliance with formulary and impact/patterns of chronic prescribing.
We are also developing a Psychological Therapies Delivery Plan to support the delivery of an increase in access to effective psychological therapies by a suitably trained workforce supervised and supported to deliver the range of evidence-based therapies and therapies that are effective but have a limited published evidence base. This plan covers: Key areas within Adult Mental Health services and within services for
children, young people and families Some aspects of Long Term Conditions management and physical health
care. Key actions from the plan will be progressed in 2010/11. Two key messages of the draft plan are: The skills of the workforce delivering psychological therapies, matching
skills and competencies to the complexity of needs of individual service users, are key to the success of this plan
NHS Lothian is committed to enhancing the evidence base through a robust research programme designed specifically to enhance our knowledge and contribution to research.
Releasing Time to Care Releasing Time to Care (RTC), a project to make wards work more efficiently to free up nursing staff for frontline patient care, is currently being undertaken in four continuing care wards, one inpatient care unit (IPCU) and five acute wards. The In Patient Care Unit in St John’s is about to start. All ward staff have had training. Initial foundation models have been completed in five acute wards. Star Wards A Star Wards audit – a method of looking at mental health services from a user perspective – showed that more was being done to promote a recovery approach to care. Much of the activity has focused on increasing the level of therapeutic and recreational activities offered and opportunities for reflective practice for nursing staff. All but two wards at present have reflective practice meetings facilitated by someone outwith the clinical team. Plans are being made for the remaining two wards to have this embedded in practice. Compassionate Care Last year Craiglea Ward at the Royal Edinburgh Hospital undertook the Compassionate Care project, with the senior charge nurse trained in
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Leadership of Compassionate Care. This was a successful project that developed the use of emotional touch points. This is a mechanism which allows patients to articulate their feelings and views about the care they are receiving and what they wish to receive. This has increased patient / nurse collaboration with patients who it difficult to engage in support. Following the success of this project in Craiglea, the rehabilitation service is now involved and members of the multi-professional team are being trained as leaders in compassionate care. Queen Margaret University has agreed to help the service to undertake research on the efficacy of this approach and to assist in publication. Achievements 2009-10 Improving Information, including two dedicated websites (edspace and midspace) dedicated to local mental e-health resources; the South East ED Network - www.ednses.com - providing useful information for patients and carers and links to other helpful websites; regular newsletter, and Refhelp regularly updated, with links to social prescribing initiatives Promoting positive mental health Improving Students' Mental Health: the 12s project – six projects underway
targeting 12 further and higher education establishments in Lothian (representing approximately 11% of the population in Lothian
Lothian Alliance Against Depression – focus on older people and depression
Lead partner in Arts and Film festival – working with 13 partners this year Branching out Project – a partnership with the Forestry Commisson to
support patients accessing outdoor woodland space Community Gardens at the Royal Edinburgh Hospital Community Mental Health services and networks Alternatives to prescribing Book prescribing across Lothian in partnership with libraries Guided self-help Intensive Home Treatment Team (IHTT) – team of the year shortlisted by
Royal College of Psychiatry Partnership with Depression Alliance Scotland Further shift in balance of care in West Lothian – developing independent
living accommodation Acute Care Pathway review – smaller wards; greater integration with
Intensive Home Treatment Teams; realignment of consultant job plans Midlothian Mental Health Service – winner of Scottish Social Services
Council’s Care Accolades 2010 Promoting inclusion ACTIVATE – redesign of vocational rehabilitation to individualised services
securing employment, placement or education and providing rehabilitation Review of 3rd sector – meaningful activities; education and employment
opportunities
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Work with women offenders – the Willow Project in partnership with Criminal Justice and SACRO (Safeguarding Communities, Reducing Offending)
Veterans 1st Point, which supports people leaving the armed forces Establishment of national hub for people with sensory impairment Equally Connected Lothian - learning informing integrated care pathway
for depression Gender based violence – routine inquiry - piloted in mental health team Improving patient experience Substantive peer support workers posts Recovery Across Lothian Network Education and training – accredited modules “The Journey” newsletter, with an editorial group of people with lived
experience Annual conference – now in 4th year Working with colleagues in substance misuse services Vehicle for cultural / transformational change “Oor Mad History” Project – 20 years of collective advocacy Improving detention – report by Edinburgh Users Forum Service user-led research – people with a diagnosis of personality disorder
and staff working with people – production of a Toolbox which will be used in the delivery of joint training.
Increasing productivity Development of Psychological Therapies Delivery Plan Aligning all we do with workforce planning and KSF / Job Plans Using the Mental Health Knowledge Transfer Partnership – the
Transformation Station – to promote evidence-based practice and practice-based evidence.
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Access to Services Waiting times Cancer
All Cancers: 62 Days
The HEAT target is 95% of patients who have cancer who have been urgently referred should be treated within 62 days of referral. The NHS Lothian position as at December 2009 is 96.6%. Throughout all quarters, in 2008 & 2009, Lothian performed better than the Scotland average figure. A&E waiting time (4-hour standard)
The graph above shows the percentage of A&E patients who were seen and treated in under four hours since 2006. During 2009/10 we experienced
A&E 4 Hour Waits
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challenges around maintaining the 98% target, particularly given the additional pressures posed by H1N1 flu and adverse weather. Local targets including Child and Adolescent Mental Health Services (CAMHS) and drug treatment
Local Targets
Services for patients in Mental Health and Drug addictions have been exempt from national targets. We set our own local target to deliver by 31 March 2010: a maximum wait of 18 weeks from referral to appointment for patients in mental health, substance misuse and learning disabilities services. A number of the teams have now achieved this, including the Veterans Service, the Perinatal Service and the Psychotherapy service. There has been an overall decrease from 3,400 patients waiting a year ago to 125 at the end of this March. The delivery of this local target will provide a foundation to deliver against a number of the 2010/2011 Local Delivery Plan access targets including those in drug treatment services and Child and Adolescent Mental Health Services.
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Diagnostic Waits
The waiting time for diagnostic testing has reduced from nine weeks in March 2008 to six weeks in March 2009 and by March 2010 we met the four weeks target.
Outpatient Waits
The graph above shows the maximum wait for outpatients, which in March 2006 was 26 weeks. 12 weeks was delivered by March 2009 and maintained all year with the exception of some patients in a highly specialised area of scoliosis.
Work to bring down waits will continue until December 2011 as we make progress towards delivering the whole journey 18 weeks from referral to treatment pathway target.
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Inpatient Waits
The graph above shows the maximum wait for inpatients and day cases, which in March 2005 was 26 weeks. As at March 2010 no-one waits longer than nine weeks, with the exception of scoliosis patients who are exempt from the guarantee
18 Weeks Referral To Treatment- progress towards delivery In 2009/2010 we continued to work on service improvement and redesign towards the delivery of the 18 Weeks Referral to Treatment Standard by December 2011. Work took place throughout the year in many specialties to assess the potential for improvement in referral and administrative processes, and outpatient pathways. Key achievements included: Centralised booking introduced in Gynaecology which has reduced waiting
times for outpatient appointments from 16 weeks to six weeks without using any additional capacity. It has also led to more effective use of capacity and ensures that patients are seen by the right person first time.
Waiting times for Physiologist-led Nerve Conduction Clinics have continued to reduce from 13 weeks at the start of 2009/2010 to three eeks
Same-day triage has been implemented in Oral Surgery where there were delays of up to 14 days; and in Orthopaedics where delays of up to four weeks have been reduced to three days.
18 Weeks Referral To Treatment – Information for pathway measurement In 2009/2010 we were challenged to introduce the recording of pathway information – known as outcomes – for outpatient attendances. Recording outcomes in this context provides information on whether a patient’s Referral To Treatment clock stops or continues to tick, and also information about next steps in the pathway. Simple codes were developed and piloted in General
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Medicine specialties in June 2009. These codes were then developed further and implemented gradually in other specialties throughout the year with training provided to consultants and administrative staff. By the end of March 64% of all outpatient appointments had an outcome recorded on TRAK (the electronic patient information system). 2009/2010 also saw the introduction of the Unique Care Pathway Number (UCPN) – a number added to every referral received in Lothian which enables us to link all of the subsequent stages of each patient pathway together and is essential for measuring and managing whole patient journeys. This was piloted in Cardiology in April 2009. Training and awareness sessions were held for other areas and the UCPN implementation is in progress in TRAK. These developments have enabled us to exceed the targets set by the Scottish Government of achieving 70% Completeness for Admitted patient journeys by 31st March 2010. We achieved 74%. GP access The latest available data, from Better Together Patient Experience Programme GP Survey 2009/2010, shows that 89.6% of patients gained access to a GP practice team within 48 hour access target (90%) and 74.4% of patients were able to book an appointment in advance within 48 hours against a target of 90%. The Community Health (and Care)Partnerships will continue to work proactively with the cohort of practices where patients report issues with access to a GP or an appropriate healthcare professional. We will achieve this by providing dedicated support to practices using the new national guidance / demand management toolkit being launched by Scottish Government / RCGP in autumn 2010. NHS Lothian continues to show an improved level of participation by GP practices in the GP/Nursing extended hours directed enhanced service. The latest available data (31 May 2010) shows 66% (83/126) of practices are participating in the GP extended hours scheme, with 41 practices offering additional consultation hours in the early morning, 52 in early evening and 10 on Saturday mornings. Dental access We continue to improve access to dental services. NHS adult dental registration figures have increased to 67.9% for Lothian’s population (at December 2009). The Scottish figure is 66.3%.
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4. Improving health and reducing health inequalities Life expectancy in Lothian In Lothian, life expectancy for women in the most deprived areas declined during the 1990s and improved from 2001-2005 (according to latest validated data). Life expectancy for men in the most deprived population has not increased and this is largely due to alcohol.
Life expectancy at birth in most and least deprived areas in Lothian1,2
Most deprived = Greendykes and Niddrie Mains, Least deprived = Comely Bank1
50
60
70
80
90
1994-1998 1996-2000 1999-2003 2001-2005
YearMost deprived Female Most deprived Male
Least deprived Female Least deprived MaleSource:
1 Life expectancy is calculated at Intermediate Geography level by ScotPHO. The figures presented here are the life expectancies in the Intermediate Geographies that contain the most deprived and least deprived datazones in NHS Lothian. 2 Based on SIMD 2006. Life expectancy in Lothian, at birth, has improved by 3.9% between 1998 and 2008 (75.8 years in 1996-98 and 78.8 years in 2006-08)
All cause mortality age-sex standardised rate per 100,000NHS Lothian 2005 - 2009
550
600
650
700
750
2005 2006 2007 2008 2009
Year
Mo
rta
lity
ra
te p
er
10
0,0
00
EASR
Death rates (all causes) have reduced from 725.0 per 100,000 population
in 2005 to 633.5 per 100,000 population in 2009
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Age-Sex Standardised Amenable Mortality Rate per 100,000NHS Lothian 2005 - 2009
50
70
90
110
130
150
2005 2006 2007 2008 2009
Year
Am
en
ab
le m
ort
alit
y r
ate
pe
r 1
00
,00
0
EASR
Amenable mortality rates have reduced from 101.4 per 100,000 population in 2005 to 79.3 per 100,000 population in 2009 (source General Registers Of (Scotland) and Health Intelligence Unit)
Age-Sex Standardised Amenable Mortality Rate per 100,000NHS Lothian 2005 - 2009
(by SIMD 2006 quintile - Q)
0
5
10
15
20
25
2005 2006 2007 2008 2009
Year
Am
en
ab
le m
ort
alit
y ra
te p
er
100
,000
Q1 - least deprived Q2 Q3 Q4 Q5 - most deprived
Sources: GRO(S) Death records 2005 - 2009 (2009 deaths are provisional) and GRO(S) Small Area Population Estimates Amenable mortality rates have reduced in all SIMD (Scottish Index of Multiple Deprivation) areas with the greatest relative reduction in the most deprived quintile (Q5)
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Health Inequalities Health improvement targets due for delivery in 2009/10 Inequalities targeted health checks (H8) NHS Lothian exceeded the HEAT Target H8 (Keep Well) of carrying out 2,246 inequalities-focused cardiovascular health checks in 2009/10. We carried out 3,434 Keep Well checks. With the success of the Edinburgh pilot, Keep Well has expanded to five practices in West Lothian, and to key vulnerable groups such as prison leavers, black and ethnic minority groups and travellers. Health improvement targets due for delivery in 2010/2011 Alcohol Brief Interventions
Alcohol Brief Interventions (ABIs) are evidence-based interventions to target individuals who are drinking alcohol at harmful or hazardous levels. NHS Lothian is one of the highest performing boards in Scotland and has exceeded the HEAT target by 15% at end of March 2010. The 2009/2010 target was 11,798 Alcohol Brief Interventions and we delivered 13,636. Smoking cessation Our redesigned smoking cessation services and public relations campaign has led to increased numbers of Lothian smokers deciding to quit.. Services have been proactive in improving engagement, particularly with people in lower socio-economic groups. In addition to increasing the number of open access groups offered and to encourage settled minority ethnic groups and migrant communities to engage, we address transcultural tobacco use and offer stop smoking groups in Polish. As a result of these actions, the number of people making a quit attempt rose from 7,044 in 2008/2009 to 8,796 in 2009/2010.
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These improvements to the service resulted in a 34% increase in successful outcomes (4,018) compared to the same period in 2008/2009 (2,995). Nevertheless, the target remains challenging, with 4,205 successful outcomes required in 2010/2011, and considerable effort is needed to sustain and build on progress to date. Exclusively breastfed at 6-8 weeks Our target was to increase the proportion of children exclusively breastfed at 6-8 weeks from 26.6% in 2006/2007 to 33.3% by 2010/2011. In 2009/2010 we reached 37.5%. Dental registrations for three to five-year-olds (H2) The national HEAT target is to have 80% of three to five-year-olds registered with an NHS dentist by 2010-2011. We stretched the target to 83% and last year hit 91.5%. The latest available data shows we hit 95.3% at December 2009. Suicide prevention The number of staff to be trained by 31st Dec 2010 is 3,342. The target number of staff to be trained by June 2010 is 2,272 (34%).The number of staff trained by 31st May 2010 is 1,952 (29.2%). Our target for end of June 2010 is 34%. Shared local outcomes – working in partnership The development of Single Outcome Agreements (SOAs) through Community Planning Partnerships continues to build on the extensive partnership working within NHS Lothian. The Single Outcome Agreements for 2009/2010 were agreed through Community Health (and Care) Partnership governance structures and by Lothian NHS Board, endorsing our commitment to support delivery of the shared outcomes. This joint approach enabled a focus on tackling inequalities across Community Planning Partnerships, particularly in relation to early years, with specific outcomes within Single Outcome Agreements to ensure children get the best start in life. This aligns with the Equally Well test site in East Lothian “Support from the Start” and the implementation of the Family Nurse Partnership work in Edinburgh. In terms of progress against delivery of the targets within the four Single Outcome Agreements for 2009/2010, the following represents the key achievements for each Community Planning Partnership: 49% of indicators are on target for delivery 13% of indicators have made some progress towards delivery 17% of indicators are currently off target 21% of indicators are not reportable due to issues with data.
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5. Primary Care Community Health Partnerships East and Midlothian Community Health Partnership Infrastructure development Continued development of service infrastructure Progress with building new health centre in Dalkeith, Progress on case for adaptation to Penicuik Health Centre Planned completion of the new Community Hospital in Midlothian ahead of
schedule. Approved business case for Musselburgh Primary Care Centre Progress on proposals for reprovision of an East Lothian Community
Hospital. Local implementation of Lothian strategies: mental health and older people Consolidation of mental health services with inpatient facilities relocated to
Royal Edinburgh Hospital and a further shift of the balance of care to the community
Investment in 24/7 community focused services – joint mental health team, intensive home treatment team
Continuing recovery team Early intervention crisis response service (health in mind) 24/7 residential rehabilitation Development of Midlothian Rapid Response Team as part of partnership programme with Midlothian Council addressing Long Term Conditions Innovation and performance Physiotherapy self-referral service for musculoskeletal problems
introduced Achievement of waiting times in outpatient physiotherapy services Implementation of a programme to prevent falls in older people Introduction of PACE – Physical Activity and Community Education - a
new model that uses physical activities and education to support rehabilitation and self care
Introduction of Midlothian Active Choices – lifestyle coaching in partnership with Midlothian Council to increase physical activity for adults with BMI >30
Successfully piloted the roll out of Community TRAK Continued exploration of Telehealth and Telecare with funding secured for
a pilot Telehealth project to support care for pulmonary rehabilitation. Quality improvement/investing in people and partnership with the public Progress towards implementing Investors in People framework Achieving Bronze Healthy Working Lives Award
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Providing additional support to both East Lothian and Midlothian Public Partnership Forums
CHP committee meetings held in public Major programme of audit and quality improvement ,engaging staff and
patients, carers and public in healthcare provision. Learning Disability Services Implemented initial phase of re-design in line with Lothian Learning
Disability Strategy. Relocated day hospital services to a new community-based centre
Strengthened joint working with Edinburgh Health and Social Care (new clinical Discharge Facilitator within Learning Disabilities services reduced delayed discharges from 12 to three)
A major programme of refurbishment has been undertaken in four inpatient centres
Community Learning Disability Teams have achieved 18 week RTT targets.
Substance Misuse Services Supported the development of Alcohol and Drug Partnerships in all
partnership areas Major role in implementation of Hepatitis C Managed Care Network and
action plan Worked to achieve 18 week Referral To Treatment and started a major
programme of redesign service-wide and across all partnership areas to help achieve target of three weeks referral to treatment by 2013
Lead role in working with voluntary sector to define pathways of care and define Service Level Agreements (SLAs).
Lothians and Edinburgh Abstinence Programme (LEAP) project to develop its role and client base further – both case mix (drugs and alcohol dependence) and geographic coverage
Lothian Unscheduled Care Service (LUCS) Contacts to LUCS continue to rise – by 19% in 2009/2010 We continue to identify elements of care that can be delivered by non-medical clinicians. Four pharmacists have been supported through both Acute Illness and Non-Medical Prescribing courses in 2009/2010. Edinburgh Community Health Partnership Part of Joint Directorate of Health and Social Care with City of Edinburgh
Council. Combined budget approx £440m Combined staffing approx 5,000 Joint Board of Governance oversees the work of the partnership Achievements in 2009/2010 include Rapid growth in telehealth and telecare services including continued roll
out of telecare through the council, a 200 patient trial of telehealth in
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Chronic Obstructive Pulmonary Disease patients and the introduction of joint telecare services for fallen patients.
Continued reductions in emergency admissions of older people and occupied beds days for older people admitted as an emergency as part of the Community Health Partnership’s long term conditions priorities.
Introduction of a general practice service in Accident and Emergency at the Royal Infirmary in order to support delivery of the 4 hour target and HEAT T10 target on A&E attendances.
Achievement of Delayed Discharge target. Construction of the £9m Chalmers Centre for Sexual Health has started.
This will bring together Family Planning and Well Woman services with Genito Urinary Medicine services in the former Chalmers Hospital. The centre will provide an integrated sexual health service for Lothian.
Establishment of GP-provided minor surgery and cryotherapy service at Leith Community Treatment Centre in partnership with University Hospitals Division’s Dermatology Service in order to divert inappropriate referrals away from Dermatology to enable specialists to focus on priority work e.g. cancer and to meet waiting time targets.
Re-establishment of South Edinburgh Public Partnership Forum. Introduction of local GP practice specifications for services in support of
long term conditions actions e.g. emergency admissions and anticipatory care plans.
Management of Keep Well programme to exceed targets on number of assessments.
Establishment of joint approach to tackling health inequalities in eight most deprived areas of the city through definition of core inputs required by CHP and Council and commencement of process to commission these inputs.
Establishment of project to introduce and mainstream “Outcomes” approach in health and social care assessments and care management. Use of “Talking Points” tool in nurse case management service.
Physiotherapy telephone triage pilot with NHS 24. Opening of new premises for Lauriston Medical Practice funded through
premises modernisation fund. West Lothian Community Health and Care Partnership West Lothian Community Health and Care Partnership (CHCP) West Lothian CHCP employs approximately 2,220 Health and Social Care staff; has a combined budget of approximately £170 million; comprises 25 GP practices and encompasses community-based health services and social policy services. West Lothian Council and NHS Lothian Primary & Community Partnership Committee have approved the CHCP’s Framework of Governance. Partnership achievements include: Shared e-information system across Health, Social Work and Housing
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In West Lothian the aim to share information has been helped greatly by the development of the C-me electronic system, enabling information about the child to be seen by all relevant professionals within Health, Education and Social Policy, with appropriate user permissions. The police also can see agreed information if the child has been referred to them. C-me services are now available in every school, health centre, hospital and social work centre in West Lothian, with professionals specifically trained in its use at each site. The pilot scheme uses C-me to undertake electronic integrated assessments, carried out where the needs of a child or young person require additional input from more specialist services such as educational psychologists, allied health professionals, health visitors and social workers. This improves collaborative working and efficiency and saves time. Other achievements include: Integrated assessment framework Reducing delayed discharge Anticipatory care in Care Homes First Steps to Health and Wellbeing Adult and Child Support and Protection Tobacco Alcohol and Drug Partnership outcome-based commissioning Health Improvement Team/initiatives GP Extended Hours Enhanced Service Childsmile/Lifesmile The CHCP manages Allied Health Professionals in primary care and St
John’s Healthcare needs study Keep Well West Lothian Community Safety Model Safe at Home assessment tool Over 3,500 households are supported by a Home Safety-enhanced
package of lifeline, pendant and sensors, making West Lothian the biggest user of telecare in Europe
Life Stages Planning model Shifting the balance of care NHS Lothian is one of four pilot sites for the Integrated Resource Framework, a system to help all agencies understand resources and activity. We are doing this in partnership with all four local authorities. Three partnerships have identified projects around supporting older people and the fourth (West Lothian) has identified work around supporting children in households whose parents misuse substances and also children with Asperger syndrome. Making progress We have mapped nearly all healthcare activity and finance and are near to completing mapping social care activity and finance. This will help to inform and support the projects and also assist other areas of work.
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Shifting the Balance of Care is a key priority across NHS Lothian and with our partners. A programme of continuous improvement to embed the high impact changes in all our work programmes has been underway for the past two years. The CH(C)Ps and acute division are integral to the delivery of this and steps have been taken in the past year to help them work together. Maximise flexible and responsive care at home with support for carers. Several services across Lothian provide rapid response services to prevent admission and provide care in patients’ homes. The IMPACT service in Edinburgh CHP provides case management for those at risk with long term conditions and multiple co-morbidity. The development of a rapid response service in Midlothian has further targeted care for patients at home. Following the success of the General Practice enhanced service for carer support, each CH(C)P in Lothian is working to identify and provide support to more carers through the work of their Long Term Conditions action teams Integrate health and social care for people in need and at risk The aim of long term condition interventions is to maximise independence through targeted anticipatory care, proactive planned care and early assessment and intervention so that people are supported to stay well and at home. In NHS Lothian, CH(C)Ps have demonstrated a desire to develop more fully integrated services for anticipatory and intermediate care that manage frailty and transitions at the interface.This includes enhanced community response, rehabilitation and re-ablement services with greater outreach of specialist services, falls prevention and support to care homes. These services deliver continuous, supportive care through a single point of assessment and co-ordination with a multidisciplinary, multiagency team centred on named GP practices. Intensive home treatment teams for individuals most at risk with mental health problems are now rolled out through Edinburgh, East & Midlothian CHP’s. Reduce avoidable unscheduled attendances and admission to hospital NHS Lothian has developed a generic anticipatory care plan (ACP) for use by, and for sharing amongst, healthcare professionals. ACPs are plans that anticipate significant changes in a patient (or their care) and describe actions which could be taken to manage the anticipated problem in the best possible way. ACPs are about improving communication across care settings and care providers, thus minimising risk. NHS Lothian has implemented a Care Homes Enhanced Service for GPs that encourages improved ways of working with patients in adult care homes – including development of anticipatory care planning systems. East Lothian CHP has focused long term conditions funding on the ELDER Day Hospital project, which provides a rapid access to MDT care and
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diagnostics and a direct alternative to admission. Evaluation based on admissions avoided and patient experience has been positive and the service will develop in 2010/11 to align it with in-reach, outreach and case management of high risk patients. Improve capacity and flow management for scheduled care Within NHS Lothian an audit project was undertaken by a cohort of 26 GP practices, who were asked to review their medical emergency admissions during 2007/2008 and 2008/2009.The aim was to gain a better understanding of the range of factors influencing these admissions and develop action plans to reduce future admissions. The 26 practices reviewed over 1,000 medical emergency admissions over the two years. GP practices have developed individual action plans to reduce future medical admissions based on this audit and covering the following themes: Identification of and intervention with at-risk patients Improved patient education Better communication and data provision to practices Better integration of care packages Influencing professional and patient behaviours.
Extend the range of services outside acute hospitals provided by non-medical practitioners In 2009 Edinburgh CHP invested long term conditions funding to provide a rapid access specialist physiotherapy-led service targeting the management of exacerbations of Chronic Obstructive Pulmonary Disease (COPD). Non medical prescribing (NMP) within the community has enhanced the
services available to individuals who may otherwise have to attended hospital for management of exacerbations (attacks). At present there are 106 independent/supplementary prescribers, 400 community practitioner prescribers and five physiotherapist supplementary prescribers contributing to this work in Lothian.
Self-referral clinics for patients requiring access to physiotherapy in Lothian is now rolled out.. East & Midlothian have implemented a self-referral pathway for individuals in this area.
Pulmonary Rehabilitation services are now part of core service delivery across all four CH(C)Ps. This service, delivered by allied health professionals, such as physiotherapists, promotes wellbeing and managing long term conditions closer to home. Strong links across acute and primary care are in place to promote appropriate referral and pathway management.
Improve access to care for remote and rural populations NHS Lothian is leading developments to advance telehealth care in both urban and remote and rural areas. To date 137 telehealth portals have been
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installed in the homes of patients with COPD and heart failure and the telehealth programme board is overseeing a programme of rapid expansion. Improve palliative and end of life care During 2009/2010, NHS Lothian and its partners developed the Lothian Palliative Care Strategy and our response to the national Living and Dying Well programme. These developments aim to support the delivery of high quality palliative and end of life care in Lothian, in all care settings (home, hospital, care home and hospice), and for all who require it. In particular our strategy for 2010 – 2015 aims to shift the balance of care towards more care in community residential settings. Our Living & Dying Well Delivery Plan and our strategy implementation plan for 2010 – 2015 focuses on supporting community-based care, whilst also improving systems of care in all settings. Actions undertaken in 2009 2010 that support shifting the balance of care include: Forming working groups across each of the CH(C)P’s, in the acute sector,
and in paediatrics. Taking forward the Direct Enhanced Service (DES) for palliative care in
Lothian. Piloting and subsequently launching the Electronic Palliative Care
Summary (ePCS). Leading improvements to palliative care and end of life care provided in
care homes. Improve joint use of resources (revenue and capital) As mentioned earlier NHS Lothian is one of four pilot sites for the Integrated Resource Framework. NHS Lothian is also hosting Scottish Government Self Directed Support (SDS).Pilots will take place this year to support individuals in the community, increase flexibility, choice and control over the care they receive and promote living independently in their own home. The initial pilot will focus on individuals with long term conditions receiving complex care budgets who are in the transition from paediatric to adult care; those with neurological conditions, particularly first stroke episode, multiple sclerosis and acquired brain injury.
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Reshaping care for older people Lothian elderly population (those over 65 years) is projected to increase by 35 % by 2018.
Lothian Population Totals by Age Group Age Group 2009 2018 2028 Inc. 2009-28 Over65-74 64,357 79,598 93,738 46%(29,381)
75-84 42,127 48,043 63,159 50%(21,032) 85-90 10,997 13,208 16,904 54%(5,907) 90+ 4,818 8,023 13,467 180%(8,649)
TOTALS: 122,299 148,872 187,268 53%(64,969) Source: General Register Office for Scotland -2008 based Population projections for Scottish areas – Feb 2010
NHS Lothian hosted a national event on 23rd June 2010 to support the Reshaping Care for Older People engagement agenda. Nearly 100 people attended and gave their views on the structured questions developed by the government. Preparatory work is underway on pathways for orthopaedic rehabilitation, stroke, general medicine and dementia, which were announced at a Planning for the Future event in early 2010. This includes implementation of a model of care for older people across the health and social care system. Modernising Community Nursing NHS Lothian is continuing to explore ways that services can be delivered more effectively to manage the modernisation and development of community nursing services. The work is being taken forward across the whole of Lothian and builds on work underway in each of the CH(C)Ps as well as specific projects – for example Family Nurse Partnership in Edinburgh CHP, You First in Midlothian CHP and HealthCare in Schools in West Lothian CHCP. Each CH(C)P is leading its own modernisation work that reflects local priorities. It has been agreed that there will be two service models: children and families and adult services. All CH(C)Ps are working on the principles of cluster working (with GP practice alignment, more corporate caseloads and a more geographic way of working) and skill mix within teams. Other work completed over the last year includes: A small pilot of a band 5 generalist role undertaken with staff nurses in
South East and North West Edinburgh was completed in December 2009. Feedback from the staff nurses was collated into themes and the overwhelming message was that staff enjoyed participating in the programme and found it a positive learning experience, despite some initial anxieties and reservations. The report recommends that staff nurses new to the community should spend time working across disciplines to
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develop their understanding and competency to provide holistic care within the community
124 community staff have participated in the Leading Better Care Programme (LBC) to date, including those in Cohort 8, who started at the end of May. There have been a further 36 nominations received with confirmed places on the final two Cohorts 9 and 10. The chief nurses have welcomed the regular progress reporting from LBC participants and the ongoing opportunities to nominate staff.
A one year pilot of a clerical assistant to support a cluster of district nursing teams began in December 2009. An audit undertaken before the pilot indicated that out of the possible 183.75 number of working hours available to the team in the week that the audit was done, a total of 49 hours (27%) was spent on non-clinical activity. This pilot will link in with Releasing Time to Care work.
Staff are being asked to be at the forefront of redesigning their services to better reflect and meet the health needs of the community they serve – teams by design rather than default – as part of the community nursing contribution to achieving the policy underpinning Better Health, Better Care. Community Pharmacy The NHS Lothian Pharmacy Strategy 2009-12 is committed to provide outstanding patient-centred pharmaceutical care, including pharmaceutical care needs assessment, minor ailment scheme, chronic disease, attendance support and health improvement. The 182 community pharmacies in NHS Lothian continue to provide local access to all pharmacy services. Pharmacy-delivered smoking cessation services contribute 19% of NHS Lothian’s HEAT target and the emergency hormonal contraception and chlamydia treatment are routinely accessed by patients in Lothian. A series of training sessions have supported community pharmacy deliver all these services. In particular, the sessions relating to sexual health have been tailored to fulfil the needs identified by the University of Edinburgh in a collaboration looking at the chlamydia testing and treatment service. In September 2009, across NHS Lothian, there were 97,484 patients (approximately 11% of Lothian’s population) registered for the minor ailments service. Nationally, on average, about 12% of patients registered with a GP in Scotland are registered with a pharmacy for a minor ailment service. The formal SGHD directions and implementation plan for the chronic medication service (CMS), a scheme which allows patients who need regular repeat prescriptions to have more care provided by their community pharmacist, were published in May 2010. The first phase of the implementation plan lasting until 31st December 2010 has been agreed between Community Pharmacy Scotland and Scottish Government Health Directorate.
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6. Finance and efficiency, including workforce planning and service change Financial Performance 2009/2010 overview As in previous years, NHS Lothian achieved its three financial targets for the year as demonstrated in the table below; Target Achievement Revenue outturn £ 146 k surplus over the break even
target Capital outturn £ 191 k below the agreed limit of
£72,063m Cash drawdown £898k below the limit of £1.289bn In addition, efficiency savings of £38.4m were delivered and reinvested in patient care. NHS Lothian is fully committed to continuing to achieve financial balance in respect of services provided to the Lothian population and beyond, while also achieving key quality and activity targets. However, the current distance from NRAC (National Resource Allocation Committee) parity (£69m) will make this a particular challenge. Capital The major capital projects undertaken during the year include: £0.95m was spent on transferring the direct access X ray service to the
Lauriston Building from Chalmers £1.25m was spent on expansion and refurbishment of the Acute Receiving
and Assessment Unit at the Western General £18m of new medical equipment was purchased during the year Appointment of Principal Supply Chain Partners for the Royal Hospital for
Sick Children Project, Royal Victoria Building and the new Short Stay Elective Surgery at St John’s Hospital.
Clinical space was released as part of our wider moves to improve efficiency by reducing the number of corporate offices through moves to Waverley Gate and Pentland House.
Efficiency Agency nursing (local target) Spending on agency nurse use was cut from £10 million in 2004/2005 to £2.2 million in 2009/2010 – a clear example of driving down cost while driving up quality. Having outstripped the target for the reduction in agency usage in 2007-2008 and 2008/2009, the targets set in 2009/2010 was to eliminate non-registered
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agency – against which there was 97.7% compliance, and to eliminate the use of off-contract agency (outwith acknowledged specialities) – against which there was 87.4% compliance. Bank Nursing The use of the staff bank remains fairly consistent year on year. The reduction in use of agency workers has resulted in a greater proportion of the supplementary staffing supply arising from bank sources - increasing from 78% to 93% between 2005/6 and 2009/10. Use of CHI identification numbers The target was for 97% of radiology requests to include patients’ CHI (unique identifier) numbers. Lothian reached 99% by March 2010 and this continues to be maintained. Same day surgery (E4)
BADS Target
The British Association of Day Surgery (BADS) set levels for particular procedures to be carried out in the day case setting – this is a key measure of efficiency.
We aimed to ensure that 80% of these procedures were carried out as a day case by March 2010 – NHS Lothian has achieved this.
Emergency inpatient average length of stay The target is to reduce to 3.3 days for an emergency inpatient average length of stay by December 2010 and we achieved this in September 2009, a year ahead of the target.
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Review to new outpatient attendance The target is to reduce the review to new outpatient attendance ratio to 1.85 by March 2011 (which means fewer people coming back for second or further appointments) and we achieved this in September 2009. Our workforce Sickness and absence In 2009/2010, our average sickness absence level was 4.46% compared to 4.61% in the previous year. The NHS Scotland average for 2009/10 was 4.75%. We were the best performing large teaching hospital board, with levels of absence consistently lower than all other teaching boards. Human resources and organisational development (HR&OD) NHS Lothian Board approved a three-year HR&OD strategy in November 2008. The strategy highlights are to: Improve performance in health and safety Tackle bullying and harassment and improve performance in on equality,
diversity and human rights Develop coaching as part of an engaging leadership approach Workforce and recruitment strategies based on social inclusion Create competency-based development programmes for frontline
supervisors and middle managers Introduce a technology-based service model for employee relations Review and streamline recruitment processes. During 2009/10 some of the key achievements under the HR Strategy were as follows: The Board’s first Health and Safety Annual Report was developed and
approved A number of Health and Safety Policies including Glove Selection,
Radiation Protection, Blood Borne Virus and Staff Screening were implemented
Phase One of the implementation of the Coaching Programme was also successfully completed and Phase Two will be rolled out during 2010/11
A Black and Minority Ethnic Group Mentorship Pilot Programme was launched
Significant progress was made towards the target in the strategy of 100 people being offered employment from a mental health or learning disability background during the life of the strategy.
A Modern Apprenticeship Scheme was launched within the Estates function with five successful applicants.
Investing in our staff NHS Lothian is committed to investing in our staff. This investment is aimed at:
Enhancing service user care, patient experience and safety
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Middle management competencies Staff engagement.
It integrates specific examples of initiatives that underpin these priorities within key HR and organisational development strategic themes for investment: Living values Engaging leadership Delivering quality Resourcing NHS Lothian Developing and retaining talent Building skills and capacity to support change Introducing new ways of working. Agenda for Change (AfC) Within NHS Lothian, 2,257 posts were submitted for review covering 10,758 staff. During 2009/10 significant progress was made in the review process. With the exception of a few staff groups where there are consistency issues all informal reviews were completed during 2009/10 and the formal reviews also started. All reviews were due to be completed by the agreed target date of 30 June 2010. Personal development We achieved our Knowledge and Skills Framework (KSF) personal development plan target by May 2009. During 2009/10 we have focused on the e-KSF target to be achieved by March 2011. Training has been undertaken and we aim to achieve the roll out of e-KSF by the due date. Service change/innovations eHealth We continue to exploit the benefits of eHealth in the delivery of patient care. In 2009/2010 we: Continued with the roll-out of TRAK (a hospital patient management
system): maternity services across Lothian are now using TRAK as their core clinical record: TRAK is now supporting practice of district nursing teams in East & Midlothian; cancer tracking features have been developed in TRAK as has electronic ordering in outpatients
Introduced wireless network and bedside computing at St John’s Hospital Introduced Telehealth allowing patients to carry out self-monitoring under
the supervision of a clinician – currently covering about 400 patients. Telestroke allows on-call consultants at home to assess patients by video. Acute services - University Hospitals Division Short Stay Elective Surgery Centre
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The creation of a Short Stay Elective Surgical Service (SSESC) facility at St John’s Hospital is part of the second phase of a plan which started with a state of the art endoscopy suite. The SSESC will be used by all specialities at St John’s Hospital to support improved theatre utilisation and to allow an additional 1,500 day-cases to be undertaken at St John’s. Clinical Research Imaging Centre (CRIC) This joint venture with the University of Edinburgh, became operational in the last year. It contains a state of the art 320 slice CT scanner, a 3T MR system and a PET(positron electron tomography scanner)/128 slice CT system. Advanced Critical Care Practitioners We are supporting 14 whole time equivalent nurses to undertake a structured programme in advanced clinical decision-making and independent prescribing to ensure a safe service in the future as numbers of medical staff reduce. Royal Victoria Hospital pilot A pilot at the Royal Victoria Hospital showed that enhancing levels of rehabilitation staffing reduced the amount of time patients had to spend in hospital until they were "ready to go" by 30%. This offers the potential for significantly reducing packages of care required through early intensive intervention in a step-down rehabilitation hospital. Lean in Lothian – empowering staff to improve services Our innovative management programme, Lean in Lothian, now in its fourth year, has benefitted patients and staff by improving the way we plan and deliver healthcare. The programme involves training and empowering staff to spot opportunities for beneficial change and empowering them to make that change. During 2010/2011, the main focus of the lean programme will be on redesign of older people’s pathways to improve flow, reducing length of stay and patient experience. Examples of benefits delivered over the last year: The reformatted Lean training programme now better equips staff to
undertake their own local projects – it features protected time to plan projects and ongoing support from the training and modernisation teams.
Common feedback from all projects is that rapid improvement events lead to improved communication within teams and across services, and instil an ethos of continuous improvement to benefit patient care.
Increased productivity and quality will result in cost efficiencies – the projected impact of 2009/2010 projects is at least £500,000 over 12 months.
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Patient Experience •New process for West Lothian Substance Misuse Services, now titrates methadone patients within 3 weeks rather than 12
•One stop cryotherapy clinic developed (previously patients waiting up to 12 weeks – now treatment starts at first outpatient appointment)
•10% reduction in meetings frees up 155 hours of clinical time for psychological therapies in Midlothian
Clinical/Corporate Governance •Paediatric GI – 234 OP slots released for new patients
•Capacity and demand analysis for MRI pan Lothian resulting in service achieving 4 week target
•93% of Dermatology referrals now triaged within 24 hours of receipt (17,000 referrals per year)
•1300 extra OP slots released in Dermatology
Process Improvement Culture •39 major projects now completed in a diverse range of acute and community settings
•Over 850 staff participated in lean events to date
•25 local lean projects undertaken by trained staff
Skills Transfer & Staff Experience •Over 200 staff trained in lean tools
•New in house training programme implemented
•80% satisfaction score for Lean training
•80% satisfaction score from Lean project participants
Our aim – to be among the best in the world Our aim is to be in the world’s top 25 healthcare systems, an aim that stems from our shared aspiration to give people and communities the best service we are able to deliver. The following examples show our commitment to this ambitious aim and the steps we are taking towards achieving it: 5x5x5 initiative IN 2009/10 we launched the 5x5x5 initiative, which involves five multi-disciplinary teams of five staff members each, and each team addressing one of five key challenges to improve services for patients. The five themes were: Achieving the world’s best clinical quality Patient experience Cost versus quality in a new economic context Building community capacity to tackle health inequalities Demand management, focusing on unscheduled care. All of the projects and their recommendations have been accepted by the Executive Management Team and were presented in April to more than 200 staff at our annual planning event. The recommendations are now being implemented and through these we hope to see service improvements in delivery of services to older people, in stroke management, in health improvement around diabetes, managing demand better through unscheduled care and knowing more about (and being consistent in relation to how we collect and use) information on patient experience.
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In 2010/11 NHS Lothian will build on the 5x5x5 programme by providing a senior leadership programme for 50 staff. Known as the Harvard programme run jointly with Harvard business school and Napier business school. Healthtracker NHS Lothian’s participation in the development of the McKinsey Healthtracker Global Healthcare Community over the past 18 months demonstrates our commitment to compare our local health system and services with international best practices. Healthtracker measures both the delivery of health services and the health status of the local population and strives to make the logical connections between the two via examination of care pathways. This makes it radically different from other sources of international comparisons, which either focus on service delivery and outcomes, or the health status of local populations – but seldom generate the connections between the two The Healthtracker system has been designed and is being implemented around a cluster of well-defined measures where all participating organisations can deliver high quality data. This rigorous quality control further sets the Healthtracker system apart from other broad benchmarking and performance management systems. By the end of 2010 there will be 17 health regions from Europe, North America and south east Asia participating in Healthtracker community – including all health regions in Australia. The timescale for the full development of the Healthtracker system is five years.
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7. Challenges for the future Key drivers for the next five years Changing demography of the public and our workforce – projections of
53% increase in elderly population between 2009 and 2028 Rising demands for healthcare – increase in cancer, diabetes, renal,
orthopaedics and impact of migration Tackling the causes and consequences of obesity, drugs and alcohol Reducing the widening gap in health inequalities Economic downturn and Scottish economy and its effect on health and
services Shifting the balance of care – 95% of care to be delivered in the
community, local access, workforce regulations and training Patient experience and maintaining a mutual NHS. Local Delivery Plan 2010/2011 Our Local Delivery Plan sets out how NHS Lothian will contribute to improving Scotland’s health. It is available at www.nhslothian.scot.nhs.uk. Longer-term strategic aims Over the next five years we aim to: Invest in national priority services (such as primary care) and in areas
requiring further development (e.g. Learning Disabilities) Continue to review effectiveness of services ensuring quality and
efficiency Continue with service redesign work in areas such as access, mental
health, drugs and alcohol, theatre efficiency and delayed discharge processes
Deliver on the capital projects, set out in the capital plan. Major Capital Projects Royal Hospital for Sick Children: The Outline Business Case, which recommended the development of a new children and young person’s hospital at Little France, was approved in August 2008. Work is underway to develop the design with a view to making a planning application in the autumn of 2010. The hospital is due for completion in 2013. Midlothian Community Hospital: The project started on site in March 2009 and is expected to be fully operational by September 2010, a month earlier than planned. The new hospital will replace Rosslynlee and Loanhead hospitals. Musselburgh Primary Care Centre: The Full Business Case was approved on 20 May 2010. The planned date for starting construction work on site is October/November 2010. Assuming that excavation works of Roman ruins
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are completed within the anticipated timeframe of 18 weeks the opening of the new hospital is planned for spring 2012. Royal Victoria Hospital Re-provision: The Full Business Case was approved on 20 May 2010 and full planning consent was received on 7 April 2010. This project provides the opportunity to develop assessment and rehabilitation accommodation for older people with 100% single rooms. Construction is programmed for completion by March 2012 and the service is expected to transfer to the new Royal Victoria Building on the Western General site in June 2012. East Lothian Community Hospital (Haddington Hospitals): This project to reprovide the existing Roodlands and Herdmanflat Hospitals in Haddington as an integrated community hospital will improve accessibility to services by providing a one stop healthcare facility appropriately located in the community. The Outline Business Case is being developed in line with East Lothian council’s Joint Older People’s Strategy Royal Edinburgh Hospital: A master plan review of the Morningside site has been undertaken and a full report is awaited from the architects. The review set out to consider a number of areas, alternative uses for existing REH buildings; to develop a generic ward accommodation design to suit a variety of patient groups and to establish how the site might be developed in an incremental way over a number of years. Completion of this review will allow a revised Initial Agreement to be developed by the project team Chalmers Hospital Redevelopment: Refurbishment and renovation works to create the Chalmers Sexual Health Centre on the site of Chalmers Hospital began on 10 August 2009. Construction is due to be completed in late 2010 or early 2011. Clinical Neurosciences Vision 2012: The reprovision of the Department of Clinical Neurosciences is now not being provided as a joint build with new Royal Hospital for Sick Children. As a result of this other options are now being explored. A revised Outline Business Case is being prepared to take this forward. Waverley Gate and Pentland House: Our new administrative offices at Waverley Gate and Pentland House will contribute towards increased staff efficiency by enabling more flexible ways of working and allowing a far larger number of staff to be accommodated in an open plan building. These moves are the first stage in our longer term plans to reduce our admin office building from 13 to 3, and reduce our carbon footprint by having more energy efficient offices. Financial challenge National Resource Allocation Committee (NRAC) As consistently highlighted during 2009/10, the new method of agreeing how much funding should be given to health boards in Scotland (NRAC - National
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Resource Allocation Committee) means that NHS Lothian is a substantial “gainer”. One of the main factors in determining the level of NRAC funding is population size, and NHS Lothian is one of the few areas of Scotland to have an increasing population and an increasing birth rate. At present we are £69million from NRAC parity - the most significant gap, in both percentage and absolute terms, of all health boards in Scotland. This means that NHS Lothian will have to deliver potentially significant cash-releasing efficiency savings from a lower cost base than other health systems in Scotland. We appreciate that full NRAC implementation is unlikely over the next two to three years, given the current economic climate and constraints across the wider public sector. There is a strong case, therefore, for differential levels of uplift between NHS boards. This would recognise the current low funding base of NHS Lothian in relation to other health systems. Other challenges Whilst it is imperative NHS Lothian meets the HEAT targets for efficiency: to operate within the agreed revenue resource limit; operate within the capital resource limit; and to meet the cash requirement; it is recognised that there are other factors influencing the financial strategy of the organisation the patient safety and quality agendas which support greater efficiency
through less ‘waste’ of resources the ongoing capital investment programme to support the reprovision of
premises which are not fit for purpose to deliver 21st century healthcare the national and local objective to shift the balance of care between the
acute and primary care sectors the requirement to increase the proportion of the population free from
disability at age 65 years. the aspiration to be one the world’s Top 25 healthcare organisations and
the investment priorities this requires Critical to the delivery of the Financial Plan and success of the efficiency programme is the management of workforce levels and the extent to which we can reduce staffing where appropriate, with cognisance of any associated risk impact.
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