Transformation Programme Board

Transformation Programme Board A meeting of the Transformation Programme Board will be held on Wednesday 29 November 2017 at 9.30 am in Committee Room One, Level 10, Ninewells Hospital. Apologies/enquiries to: Susan Taylor, Committee Support Officer, Direct Dial 01382 740764, extension 40764 or email: [email protected] AGENDA LEAD

OFFICER

REPORT NO

1. Welcome and Apologies

Prof J Connell

2. Minute of Meeting held on 1 November 2017

Prof J Connell Attached

3. Action Points Update Prof J Connell Attached 4. AAG Progress Report 4.1 AAG Recommendations 1 – 10 Update Mr G James Presentation 4.2 KPI Update Mr G James Presentation 5. Strategic Service Plans

a) Major Trauma Centre Update b) Elective Care Centres c) Shaping Surgical Services

Ms L Wiggin

TPB59/2017 TPB60/2017

Attached Attached Verbal Update

6. Record of Attendance

Prof J Connell Attached

7. Any Other Competent Business

8. Date of Next Meeting Wednesday 20 December 2017 at 9.30 pm in the Board Room, Level Ten, Ninewells Hospital

Professor J Connell Chairman November 2017 Distribution

mailto:[email protected]

Mrs Jenny Alexander, Partnership Facilitator Mrs Karen Anderson, Director of Allied Health Professions Mr Lindsay Bedford, Director of Finance Mrs Jenny Bodie, Director of eHealth Professor John Connell, Chairman Dr Alan Cook, Medical Director – Operational Unit Mrs Gillian Costello, Nurse Director Dr Andrew Cowie, Non Executive Member Mr Doug Cross, OBE, Non Executive Member/Vice Chair Transformation Programme Board Mr George Doherty, Director of HR and Organisational Development Mrs Jane Duncan, Head of Corporate Communications Ms Margaret Dunning, Board Secretary Mrs Judith Golden, Employee Director Mr Stephen Hay, Non Executive Member Mr Alan Hunter, NHSScotland Director of Performance, Scottish Government (for information) Mrs Vicky Irons, Chief Officer, Angus Health and Social Care Partnership Mr Gordon James, Transformation Programme Director Mr David Lynch, Chief Officer, Dundee Health and Social Care Partnership Mr Raymond Marshall, Unison Stewart Ms Kate McDermott, Staff Side Lead, Transformation Programme Ms Lesley McLay, Chief Executive Mr Bill Nicoll, Director of Strategic Change Mr Rob Packham, Chief Officer, Perth & Kinross Health and Social Care Partnership Mr Alan Pattinson, Transformation Programme Lead Mr Hugh Robertson, Non Executive Member Mrs Frances Rooney, Director of Pharmacy Professor Andrew Russell, Medical Director Ms Yvonne Summers, Programme Manager, Scottish Government Dr Drew Walker, Director of Public Health Ms Lorna Wiggin, Chief Operating Officer

ITEM 2 Minute NHS Tayside TRANSFORMATION PROGRAMME BOARD Minute of the above meeting held at 2:30 pm on Wednesday 1 November 2017 in the Board Room, Level 10, Ninewells Hospital & Medical School, Dundee. Present Mr Lindsay Bedford Director of Finance, NHS Tayside Professor John Connell Chairman, NHS Tayside Mrs Gillian Costello Nurse Director, NHS Tayside Mr Doug Cross OBE Non Executive Member, Tayside NHS Board Dr Andrew Cowie Chair, Area Clinical Forum, NHS Tayside Mr George Doherty Director of Human Resources & Organisational Development,

NHS Tayside Ms Margaret Dunning Board Secretary, NHS Tayside Mrs Judith Golden Employee Director, NHS Tayside Mr Stephen Hay Non Executive Member, Tayside NHS Board Mr David Lynch Chief Officer, Dundee Health & Social Care Partnership Ms Lesley McLay Chief Executive, NHS Tayside Mr Hugh Robertson Non Executive Member, Tayside NHS Board Professor Andrew Russell Medical Director, NHS Tayside Ms Lorna Wiggin Chief Operating Officer, NHS Tayside Apologies Mrs Karen Anderson Director of Allied Health Professions Mrs Jenny Bodie Director of eHealth, NHS Tayside Dr Alan Cook Medical Director - Operational Unit, NHS Tayside Mrs Vicky Irons Chief Officer, Angus Health & Social Care Partnership Mr Raymond Marshall Unison Steward, NHS Tayside Ms Kate McDermott Staffside Lead - Transformation Programme, NHS Tayside Mr Bill Nicoll Director of Strategic Change, NHS Tayside Mr Rob Packham Chief Officer, Perth & Kinross Health & Social Care Partnership Mrs Frances Rooney Director of Pharmacy, NHS Tayside Dr Drew Walker Director of Public Health, NHS Tayside In Attendance Mrs Jenny Alexander Partnership Facilitator, NHS Tayside Mrs Jane Duncan Head of Corporate Communications, NHS Tayside Mr Gordon James Transformation Programme Director, NHS Tayside Ms Caroline Lamb Chief Executive, NHS Education for Scotland Ms Lynsey Macdonald Project Officer, Scottish Government Mr Alan Pattinson Transformation Programme Lead, NHS Tayside Ms Yvonne Summers Programme Manager, Scottish Government Ms Susan Taylor Committee Support Officer, Chief Executive’s Office, NHS Tayside Professor Connell in the Chair ACTION 1. Welcome and Apologies Professor Connell welcomed all present to the meeting.

The apologies were noted as above. Professor Connell extended a welcome to Ms Lamb, Ms Macdonald and Ms

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ITEM 2 Minute NHS Tayside

Summers, Transformation Support Team and Scottish Government representatives.

2. Minute of Meeting held on 5 and 11 October 2017 The Minute and Action Note of the Transformation Programme Board

meetings held on 5 and 11 October 2017 were approved by Mrs Golden and Mr Hay.

3. Action Points Update Ms McLay provided the following update:

Item 3 Transformation Programme Initiative Finance Matrix 2017/18 Report to be submitted to the Programme Board meeting being held on 29 November 2017. Item 4 Corporate Management & Administration Review Report to be submitted to the Programme Board meeting being held on 29 November 2017. Item 5 Primary Care Programme Report Outstanding action to be discussed with Angus Chief Officer. Item 6 Winter Planning for Outpatients – Acute Ms Wiggin advised step down in outpatients would not be supported as the number of patients this would impact on outweighed the financial benefit. Report to be submitted to the Programme Board meeting being held on 29 November 2017.

L Bedford M Dunning V Irons L Wiggin

The Programme Board • Noted the Action Points Update. 4. Key High Risk Areas 4.1 Workforce - Non Contract Agency Ms Wiggin spoke to the report Workforce – Non Contract Agency

copies of which had previously been circulated and advised that the purpose of the report was to provide an update to the Transformation Programme Board on the progress towards stepping down use of non contract agency nursing from 1 November 2017, as approved by NHS Tayside Board on the 31 August 2017. This report was a joint effort developed with the support of a number of individuals across Perth Royal Infirmary (PRI), Ninewells Hospital, Health & Social Care Partnerships (HSCPs) and staffside colleagues and outlined a number of actions that had been taken over the last six months to plan for reducing reliance on use of non contract agency. These actions have enabled a successful risk based approach to the step down of non contract agency across the Acute Services. Dundee and Angus HSCPs have also achieved stopping use. Perth and

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Kinross HSCP have a contingency arrangement in place to reduce the use of non contract agency for Tay and Stroke Wards at PRI which has been approved by the Integrated Joint Board (IJB) for this financial year. The Programme Board acknowledged that across both Ninewells Hospital and PRI Medicine Directorate, the use of agency staff to provide Registered Mental Health Nurses (RMN) support over recent months had increased. Ms Wiggin confirmed the clinical areas where there continued to be vulnerability towards maintaining staffing levels to meet patient demand and these were noted within the report presented. Risks continue to be mitigated through team discussion at local clinical area level and through site/cross site safety huddles four times daily. Mrs Golden asked that in relation to deployment ensure clarity that this is about flexible working protocols. Ms Wiggin confirmed this applied purely to Band 5 Registered Nurses. In relation to the Nurse Bank, Mrs Costello advised that the Nurse Bank was in a very different and improved position from that of a year ago. She confirmed the 18 National Services Scotland (NSS) recommendations from the NSS review of the Nurse Bank had now all been implemented and additional work had been progressed to strengthen process, management and capacity within the Nurse Bank. Whilst it was recognised that there was still work to do, the National Workforce Officer within the Chief Nursing Officer (CNO) Directorate had conveyed her confidence that she was content with progress being made around nursing and midwifery workforce planning in NHS Tayside. Mrs Costello reported that robust interim arrangements were in place to support the delivery of this objective. Governance arrangements were in place as expected with Mr Sinclair, Associate Nurse Director, leading this portfolio supported by Ms Andrew, Senior Nurse - Nurse Bank. Actions have also been planned, discussed and delivered with Partnership colleagues. Further work is being progressed to build upon the shape, role and function of the Nurse Bank including HR, finance and management support. Mrs Costello advised that the working agreement held by our current Nurse Bank workers has been reviewed, and it has been agreed to approach Nurse Bank personnel and invite them to consider formally contracting Nurse Bank workers as employees, creating the ability to agree to a minimum commitment of one shift per month. Existing workers will be offered the opportunity to maintain worker status or to transition to a contracted position. It is also proposed that all new Nurse Bank staff without a substantive NHS Tayside contract will be employed on a similar contractual basis. Offers of this new contract

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have been issued to existing Nurse Bank workers in October 2017. Mrs Costello reported that an internal recruitment campaign continues to be progressed to encourage more of the NHS Tayside substantive staff to join the Nurse Bank. A Communication Plan had been drafted including the use of staff messages in payslips, internal mail drop and email to all substantive Registered Nursing staff inviting them to join the Nurse Bank. Recruitment stands in the concourse and dining room were being planned. The use of Twitter and FaceBook communication bulletins and banners with strapline and briefings were all underway. Mrs Costello advised that the service and professional view remains that we can only stop using supplementary/non contract agency personnel where patient and staff safety is not compromised. Mitigating actions include reviewing staffing complements, skill and experience levels, patient acuity and dependency levels at established safety huddles within and across sites throughout the day 7 days a week. Professor Connell was keen to see this work escalated and given ultimate priority and Ms McLay, Ms Wiggin and Mrs Costello should take the opportunity to build on the work done around localisation of the Nurse Bank. Mrs Costello confirmed action was being taken and the infrastructure would be in place during November 2017. Professor Connell was delighted to see downward trend in the number of agency staff shift requests made and agency use and noted the progress made which had produced a reduction from 21% to 11.7% highlighting real progress. Mr Cross welcomed the report and was pleased to see professional and realistic assessment to maintain safe patient care going forward. Mrs Costello said that the organisation required to recognise that seasonal pressures and winter plans impact upon the current position, however, Mrs Costello gave confidence in the rigour provided by Ms Wiggin and Mr Packham’s teams. Monitoring and reporting supplementary staff use will continue and reporting will continue on a daily basis. Mrs Costello highlighted the gap in respect of the supplementary staffing fill rate and request rate and felt that this gap remained a significant safety issue, however risk assessment and mitigation actions were being taken. Mrs Costello advised a report would be submitted to the Executive Directors meeting on 13 November in respect of the analysis undertaken about use of RMNs and this report will be supported by Mr Jim Foulis, Mr Keith Russell and Mrs Diane Campbell who have been working with nursing, medical and AHP staff to gain a better understanding and inform the position. The Programme Board accepted Ms Lamb’s offer to explore the

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Mainframe and Server Network (MASNet) with respect to mental health agency nursing numbers. Professor Connell asked that the thanks of the Transformation Programme Board are conveyed to Mr Sinclair and gave assurance of the Programme Board’s continued support for staff and senior leadership.

The Programme Board: • Noted the safe achievement of the step down of use of non-

contract agency staff across the majority of wards and departments across NHS Tayside and the Health and Social Care Partnership.

• Approved the further actions for the eight wards where it is not clinically safe to stop use of agency personnel and supplementary staffing by 1 November 2017 and a further update will be provided at the Transformation Board on 29 November 2017.

L Wiggin

5. Transformation Programme Delivery Report 5.1 Transformation Programme Delivery Report: Workstream Report Mr James spoke to the Workstream Report copies of which had

previously been circulated. It was noted that the finance matrix was identical to what had been reported to the Board on 26 October. Mr James advised that following the previous discussion at the Transformation Programme Board a refresh had been undertaken with the addition of initiatives focused on the response to the Assurance & Advisory Group Staging Report. This was the first workstream report to cover the wider aspects of the Transformation Programme. The report has been renamed the Transformation Programme Delivery Report and covered: • Workstreams • Clinical Services • Health and Social Care Partnerships • Corporate Mr James thanked the support provided by Mr Pattinson, Ms Lyon, Ms McDermott and PMO Team. The Programme Board noted that additional programme resource was being sought and would be discussed at the Transformation Programme Executive Review Group huddle on 2 November. The Programme Board will be updated with the outcome of this discussion. Mr James advised that the £1.7m gap remained and work to identify further opportunities and initiatives to bridge that gap would continue and be reported to the Finance & Resources Committee and Transformation Programme Board.

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The Programme Board noted that 3 high level KPIs had been created - Revenue Outturn, Total Paybill Cost and Prescribing Savings and would be submitted to the Transformation Support Team.

The Programme Board: • Noted and commended the Transformation Programme

Delivery Report: Workstream Report.

6. Record of Attendance The record of attendance was noted. 7. Date of Next Meeting The next meeting of the Transformation Programme Board will be held on

Wednesday 29 November 2017 at 9.30 am in Committee Room One, Ninewells.

The meeting finished at 15:08 pm

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ITEM 3 Actions Points Update NHS Tayside Transformation Programme Board – 29 November 2017

No. Meeting Minute Reference

Heading Action Point Owner Status

1 1 June 2017 3 9

Clinical Services Strategy Development

Develop proposal for creating integrated clinical services strategy with timescales, resources and risks for delivery.

Medical Director/ Nurse Director

Regular progress updated to the Programme Board. Final Report to be provided in December 2017.

2 1 June 2017 4.1 Repatriation and Out of Area Treatment

Programme Board agreed formal workplan Director of Strategic Change

Update in 6 months time (January 2018).

3

5 October 2017

5.3.2 Corporate Management & Administration Review

Further update to future TPB. Chief Executive Directors agenda item 20 November 2017.

4 5 October 2017

6.2 Primary Care Programme Report

More detailed report to be provided to future meeting of Transformation Programme Board.

Angus IJB Chief Officer Future agenda item.

5 1 November 2017

4.1 Workforce – Non Contract Agency

Approved the further actions for the eight wards where it is not clinically safe to step down by 1 November 2017.

Chief Operating Officer Further update will be provided at the Transformation Board on 29 November 2017.

STaylor 29 November 2017 CorpServices/Groups and Committees/Transformation Programme Board /2017

Item Number 5a

TPB59/2017 Transformation Programme Board

29 November 2017 MAJOR TRAUMA CENTRE – EASTERN REGION UPDATE REPORT

1. SITUATION AND BACKGROUND

Following developments in England and the publication of a Report by the Trauma Working Group of the Royal College of Surgeons of Edinburgh, the Scottish Government commissioned work to be progressed to explore major trauma services in Scotland.

In June 2012 the National Planning Forum agreed that a subgroup would be established to undertake a review of Major Trauma in Scotland which concluded in 2013.

In November 2013, the NHS Chief Executives Group endorsed the National Quality Framework for Major Trauma Services along with the recommendations to establish a single national major trauma system which comprises four regional trauma networks, each with a major trauma centre (MTC) in Aberdeen, Dundee, Edinburgh and Glasgow. The report setting out the proposals indicates that this is an interim position and there will be a further review in the next two years which may result in further rationalisation of the number of MTCs in Scotland. These recommendations were signed off by the Cabinet Secretary in April 2014.

To support this national model, regional Major Trauma Networks are to be developed with Trauma Units continuing to provide trauma care for the majority of injured patients. The clinical evidence clearly supports that early access to definitive care in specialist centres saves lives. In Scotland, approximately one third of major trauma patients are currently transferred to more definitive care (Scottish Trauma Audit Group data) and there is evidence which shows that the outcomes for patients who are transferred, is worse than for those who access definitive care primarily. Ensuring major trauma patients access definitive care first time, wherever possible is clearly best for patients.

Major trauma is serious injury and includes such injuries as:

• multiple injuries to different parts of the body such as may be sustained as a result of

involvement in a road traffic collision or in a fall from a height. • major head injury. • severe knife and gunshot wound injuries. (N.B. the incidence of such injuries in Scotland is

very low) • spinal injury • traumatic injury requiring amputation of a limb • severe burns

Major Trauma is defined in the scientific literature using the Injury Severity Score (ISS), which assigns a value to injuries in different parts of the body and totals them to give a figure representing the severity of injury. An ISS greater than 15 is defined as Major Trauma.

Please note any items relating to Committee business are embargoed and should not be made public until after the meeting

In 2014, NHS Tayside established a Local Major Trauma Implementation Group, chaired by Dr Mike Johnston, Consultant Emergency Department. This group provides a forum where different professions and agencies contribute to the development and implementation of the programme to develop a major trauma service for the Eastern Region.

The Eastern region covers Tayside (population 413,800) and North East Fife (population 74,000) with a mix of Urban, Accessible Rural and Rural populations.

Tayside currently has in place arrangements whereby major trauma patients from Perth and Kinross and Angus are conveyed straight to Ninewells via long-standing protocols agreed with the Scottish Ambulance Service (SAS). To support this strategy NHS Tayside operates a Consultant-led pre-hospital ‘Trauma Team’ service, available 24 hours a day to provide back-up/ support for the SAS and provide critical care interventions at the scene of major trauma incidents.

NHS Tayside consistently participates in the National Trauma audit led by the Scottish Trauma Audit Group (STAG) and NHS Tayside has consistently been one of best performing boards in relation to trauma mortality.

In addition to the current ‘standard’ specialties (i.e. Emergency Medicine, Orthopaedic Surgery, General Surgery, Anaesthesia and Critical Care) Ninewells Hospital can also offer the following specialist services which are available on-site to contribute to the multidisciplinary management of seriously injured patients:

• Neurosurgery • Interventional Radiology • Plastic Surgery • Vascular Surgery • Urology • ENT • Maxillo-Facial Surgery • Obstetrics

Therefore, other than Cardiothoracic Surgery, all other service requirements as listed within the National Quality Framework document are provided on site at Ninewells Hospital.

2. ASSESSMENT

The Eastern Region has agreed and established the project structure and work groups are aligned to the Scottish Trauma Network's governance structure. The membership, role and remit, meeting dates and activities have been agreed for each of the work groups. The project structure can be found in appendix 2. A communications and engagement strategy and detailed programme have been developed in conjunction with the Implementation group and sub group members and are supported by the Project Board. The Project Initiation Document for detailed information on the current provision, purpose and aims, scope, roles and responsibilities and project controls is attached as appendix 3. The Scottish Trauma Network was established in 2017 to support each of the four regional networks, Scottish Ambulance Service (SAS) and Scottish Trauma Audit Group (STAG) to work together to establish a trauma network across Scotland. It will support the networks aim of “Saving lives and giving life back”. The team will work with the regions and relevant stakeholders to produce a national Implementation plan. Please refer to the Scottish Trauma Network model in appendix 1. The STN's mission statement is "To improve and optimise the health and wellbeing of the seriously injured. Helping them, their families, each other and our nation. Pioneering clinical excellence, health intelligence, innovation, education and research"

3. RESOURCE IMPLICATIONS

Scottish Government awarded the Scottish Trauma Network a budget of £5 million to allocate to health boards and the Scottish Ambulance Service for the creation of Trauma Networks across

Scotland in 2017/18. Funding beyond 2017/18 has not yet been confirmed but each region and Scottish Ambulance Service were asked to prepare funding bids for 2018/19 and beyond.

A set of minimum requirements were developed by the STN which defines what a Major Trauma Centre is and the minimum provisions that should be in place to qualify for MTC status. The Eastern Region benchmarked current service provision against the minimum requirements to identify where gaps existed. The finance bids were prepared to enhance existing services and address the gap between the 'Minimum requirements' of a Major Trauma Centre. The bids were submitted bids to STN in September 2017 and separated into four areas:-

Capital & Investment A dedicated Major Trauma Unit will be provided for up to 6 male and female patients across two separate bays. This unit will be provided within the existing footprint and the bids include high level construction, design fees and equipment costs. This funding has been requested on a non-recurring basis.

Co-ordination Funding has already been awarded for temporary appointments to support the delivery of this project through a Lead consultant, Project Manager and part time project support officer. The appointment of three Trauma Nurse Co-ordinators are also included within this bid and these new roles will are key to the successful co-ordination of a patients care from the point of admission to discharge and ongoing rehabilitation.

Trauma Unit (Staff) Nursing, support and AHP staff will work within the new unit and across other areas of the MTC providing care to Major Trauma patients. The medical staff appointed to the Major Trauma centre will take a clinical lead role to support the full patient pathway. Investment is required across a variety of specialties and the Major Trauma service will be hosted by the Surgical Directorate. The nursing model for the 6 bed Major Trauma Unit is based on a nurse to patient ratio of 1:3. Level 2 care in High Dependency is 1:2 patients and a trauma ward is currently a nurse to patient ratio of 1:6. Healthcare Support Workers in the agreed model will be a blend of Nurse and AHP support workers, so that patient’s have the benefit of their combined skills.

The rehabilitation team comprises of a rehabilitation specialist and a multidisciplinary team of AHP staff, including; occupational therapy, physiotherapy, speech and language therapy and nutrition and dietetics. The existing AHP service will be increased to provide rehabilitation services to Major Trauma patients at the weekends. There are no planned rehabilitation services available to major trauma patients during weekends at present. Training

A very small amount of funding was requested for this financial year which will allow six consultants to attend the European Trauma Course and 11 SCN's to attend the Advanced Trauma Nurse Course. Future training needs will be considered nationally at the STN Education & workforce sub group.

The tables below provide summary information of the Capital and Revenue bids:

Table 1 - Capital Investment (non-recurring) 2017/18 2018/19 Total Capital Investment - Buildings & Infrastructure 40,000 352,402 372,402

Capital Investment - Equipment 148,577 148,577

Revenue Investment - Equipment (recurring - items under £5k) 18,680 18,680

Total Financial Investment 40,000 499,659 539,659

Table 2 - Revenue bids (recurring) 2017/18 2018/19 2019/20 Trauma co-ordination 135,000 277,236 203,153

Trauma unit (staff) 0 771,533 1,173,959

Training 13,800 9,000 9,000

Total 148,800 1,057,768 1,386,113 Less funding already allocated 140,000 97,500 0

Total Financial Investment 8,800 960,268 1,386,113 The above bids were collaboratively developed by members of the sub groups and endorsed by the Implementation Group and Senior project leads.

4. RISKS

Key risks associated with delivery of the project within the planned timescales are:

• Insufficient resources available to deliver the project activities • Failure to secure any/all requested project funding from Scottish Government • Inability to recruit staff to work within the MTC • Lack of resources to backfill

In light of the known risks and issues, the planned completion date for the project is December 2018.

5. RECOMMENDATIONS The Transformation Programme Board is being asked to:

• Consider the report for information • Note progress to date and agreed project documents • Note receipt /publication of report

6. REPORT SIGN OFF

Jill Beattie Michael Johnston Lorna Wiggin Project Manager Consultant in Emergency Medicine Chief Operating Officer

Date 20 November 2017

Appendix 1 - Scottish Trauma Network model which was approved by the Cabinet Secretary

Appendix 2 - Eastern Region Project Structure

Eastern Region

Major Trauma Centre Ninewells Hospital, Dundee

Project Initiation Document

Document Control Information -

Control Status Draft - For approval

Date Last Printed 9 November 2017 Version Number 8 Author Jill Beattie - Project Manager, Major

Trauma, NHST

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Appendix 3

____________________________________________________________________________________________________________

Table of Contents 1. Introduction .............................................................................. 3

1.1 Background ..................................................................................................................................................... 3

2. Strategic Objectives ................................................................. 4 2.1 National Strategy and Guidelines ................................................................................................................ 4 2.2 NHS Tayside Strategy ................................................................................................................................... 5

3. Service Provision ..................................................................... 6 3.1 Current Provision ........................................................................................................................................... 6 3.2 Proposed future provision ............................................................................................................................. 7 3.3 Perceived gaps ............................................................................................................................................... 8

4. Project Definition.................................................................... 10 4.1 Purpose and Aims ........................................................................................................................................ 10 4.2 Scope ............................................................................................................................................................. 10 4.3 Exclusions from scope ................................................................................................................................ 11 4.4 Success Criteria ........................................................................................................................................... 11 4.5 Constraints and Assumptions .................................................................................................................... 11

4.5.1 Constraints .......................................................................................................................... 11 4.5.2 Assumptions ....................................................................................................................... 11

4.7 Roles and Responsibilities.......................................................................................................................... 13 4.6 Project Organisation .................................................................................................................................... 15

4.6.1 Project Structure ................................................................................................................ 15

5. Project Controls ..................................................................... 24 5.1 Issue Management ...................................................................................................................................... 24 5.2 Change Management .................................................................................................................................. 24 5.3 Risk Management ........................................................................................................................................ 25

6. Project Budget ........................................................................ 25

7. Project Success Criteria ........................................................ 25

Appendices

1 – AHP Proposed staffing model 2 – Key Performance Indicators 3 – Unit staffing (Nursing and support) 4 – Minimum Requirements 5 – Summary Programme 6 – Implementation Group membership 7 – Equipment list 8 – Capital Works 9 – Issue Log 10 – Risk Log

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____________________________________________________________________________________________________________

1. Introduction 1.1 Background This document has been produced to describe the changes and improvements envisaged for NHS Tayside through the creation of a Major Trauma Centre for the Eastern Region (NHS Tayside and NHS Fife). The Project Initiation Document will set out the scope, timetable and requirements to implement change and illustrate how these changes are rooted in national policy. This document clarifies the inclusion/exclusion criteria, project scope, project structure and work groups and responsibilities that require to be met by NHS Tayside and its partner organisations. In 2017-18 the Scottish Trauma Network (STN) Steering Group was awarded a budget of up to £5 million, from the Scottish Government to allocate to health boards for the enhancement of trauma services across Scotland. Scotland will have four Major Trauma Centres which will be located in Edinburgh, Glasgow, Aberdeen and Dundee. NHS Tayside Board approved the Business Case for the Eastern Region in August 2015.

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____________________________________________________________________________________________________________ 2. Strategic Objectives 2.1 National Strategy and Guidelines Following a review by the National Planning Forum, the Scottish Government announced plans for an enhanced network of care for major trauma patients in Scotland. The network could save up to 40 lives per year as well as providing improved care and outcomes for 2,000 potential major trauma patients and 4,000 severely injured patients.

The plans include the setting up of four new specialist major trauma centres in Aberdeen, Dundee, Edinburgh and Glasgow. From 2018, these centres will operate as hubs within a national major trauma network. Designed to improve trauma care across all hospitals that deal with such cases, with all the surgical specialities and support services to provide consultant led care, 24 hours a day, 7 days a week.

Patients will be taken directly to one of these centres to be assessed and treated. If the patient cannot be taken to one of these centres within 45 minutes, they will be taken to a local hospital, with advice and support provided by the Major Trauma Centre as required.

'Saving Lives Giving Life Back' was published in January 2017 by the National Trauma Network Implementation Group. The Scottish Trauma Network is a national network, which will involve the Scottish Ambulance Service and hospitals across Scotland. The Network will oversee the development of four Major Trauma Centres in Scotland. In summary, the development of an inclusive trauma network for Scotland is in line with the aims and ambitions of the National Clinical Strategy, designed to meet the needs of the population of Scotland, working across traditional speciality and geographical boundaries to deliver better outcomes for patients.

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____________________________________________________________________________________________________________ 2.2 NHS Tayside Strategy The Eastern region based around Ninewells Hospital, Dundee already has a comparatively well developed set of arrangements for managing Major Trauma. In line with the national objective to improve outcomes for people experiencing Major Trauma across Scotland, the Eastern Region fully recognise further improvements are necessary to provide a coordinated, multi disciplinary and inclusive Major Trauma service. Making the right service improvements for this group of patients and developing the infrastructure to support patient management, will in turn improve outcomes for patients. For the Eastern region, these improvements will be achieved through developments working with:-

• Scottish Ambulance Service in patient retrieval • Enhanced infrastructure for initial reception • Enhanced acute management of patients and their immediate care • Better coordination and delivery of ongoing care and rehabilitation

All of these will build upon a system that is already managing c80 Major Trauma cases per annum.

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____________________________________________________________________________________________________________ 3. Service Provision 3.1 Current Provision The Eastern region covers Tayside (population 413,800) and North East Fife (population 74,000) with a mix of urban, accessible rural and rural populations. NHS Tayside operates a Consultant-led pre-hospital ‘Trauma Team’ service, available 24 hours a day to provide back-up/support for the Scottish Ambulance Service and critical care interventions at the scene of major trauma incidents. Tayside's major trauma patients from Perth and Kinross are conveyed straight to Ninewells via a long-standing agreed SAS bypass protocol. These ‘by-pass’ protocols for Stracathro Hospital in Angus and Perth Royal Infirmary have been in operation for almost 20 years. NHS Tayside has consistently participated in the National trauma audit led by the Scottish Trauma Audit Group (STAG) with there being no gaps in collection of data since joining STAG in 1996. NHS Tayside has consistently been one of best performing boards in relation to trauma mortality and anticipates that the continuation of this performance will be reflected within the Scottish Trauma Audit Group Annual Trauma reports. An established rehabilitation service for patients with serious brain injury is located at the nearby Royal Victoria Hospital which is less than 2 miles from Ninewells Hospital. Plans are well advanced to develop and redesign this service in a way that also accommodates the rehabilitation needs of patients with multi-system or musculo-skeletal trauma. This will ensure specialist rehabilitation input to all trauma patients early in their care. In addition to the current ‘standard’ specialties, (i.e. Emergency Medicine, Orthopaedic Surgery, General Surgery, Anaesthesia and Critical Care) Ninewells Hospital can also offer the following specialist services which are available on-site to contribute to the multidisciplinary management of seriously injured patients:

• Neurosurgery • Interventional Radiology • Plastic Surgery • Vascular Surgery • Urology • ENT • Maxillo-Facial Surgery • Obstetrics

Therefore, other than Cardiothoracic Surgery, all other service requirements as listed within the National Quality Framework document are provided on site at Ninewells Hospital.

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3.2 Proposed future provision The Diagram below (Figure 1) illustrates the proposed patient pathway for a Major Trauma Service.

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It is planned that patients who are assessed by the Pre-Hospital Major Trauma Triage Tool (MTTT) are likely to have sustained major trauma and will be transferred directly to the MTC if within a 45 minute transportation time. If the transfer time is likely to be over 45 minutes or the patient requires a life saving intervention that cannot be provided in the pre-hospital setting, the patient will be transferred to a Trauma Unit for stabilisation and immediate care. Patients triaged to MTC care will be pre-alerted to the Ninewells Emergency Department by the Scottish Ambulance Service. As per current practice it is also possible that the Tayside Trauma Team will be involved pre-hospital with seriously injured patients and accordingly on such occasions there will also be a doctor-to-doctor pre-hospital alert. The hospital Trauma Service will employ a 2 tiered initial response to the reception of pre-alerted trauma patients.

• Tier 1 will be Emergency Department based and will be Consultant-led. • Tier 2 will be activated in response to a ‘Code Red’ pre-hospital notification.

This response will mandate the assembly of a Consultant-led multispecialty team consisting of the following:

• Consultant in Emergency Medicine • Emergency Medicine senior trainee • Consultant or senior trainee in Anaesthesia/Critical care • Consultant/Senior trainee in General Surgery • Consultant or Senior trainee in Orthopaedics

The duty Consultant in Diagnostic Radiology will be notified via switchboard and will arrange for attendance of the duty Consultant in Interventional Radiology. Additional support from Blood Transfusion staff will also be activated using Code Red. The duty Neurosurgical Consultant will be contacted in instances involving concern over decreased conscious level/head injury. All trauma patients will spend as little time as possible within the Emergency Department thereby expediting emergency imaging and surgical intervention as may be necessary. Diagnostic Radiology and the Interventional Radiology Suite are located close to (same floor) the Emergency Theatre Suite.

3.3 Perceived gaps Although c80 major trauma patients are received each year at Ninewells Hospital, there is no dedicated Major Trauma Service coordinating the patient journey from admission to the Emergency Department until discharge. New appointments will be created to employ Major Trauma coordinator roles, with responsibility for managing the patients care throughout their entire journey. These posts may be filled by nursing or AHP staff. Additional AHP staff will be appointed to provide rehabilitation as soon as appropriate to enable patients to achieve their functional potential. A Key Performance Indicator requires each patient, to have a draft rehabilitation plan written within three days of admission. This service is not currently provided by the Eastern Region and will require additional resources with the appropriate in-house training to provide. (Further detail can be found under appendix 2). The current AHP service currently operates five days a week but the minimum requirements for a Major Trauma Centre states that AHP services should be provided for Major Trauma patients seven days a week. The revised AHP staffing compliment will have the capacity to provide this additional service.

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____________________________________________________________________________________________________________ Tayside currently use the Major Trauma Triage Tool (MTTT) and a training scheme is underway in North East Fife for Scottish Ambulance Service staff. The scheme will continue to be rolled out across the Fife Region and the other regional Trauma networks. Continual assessment will be undertaken to monitor the successful application of the MTTT. The Scottish Trauma Audit Group (STAG) will roll out work on a national level and in line with the new Key Performance Indicators (KPI's) to collect data for Major Trauma cases (See appendix 2). The eSTAG system is expected to be implemented in November 2017 which will allow data to be collected electronically. At present manual records are maintained. A dedicated Major trauma unit will provide six beds, which can be divided into male and female areas. Some works are required to provide an access controlled area with the necessary bedhead services and equipment required to for this level of care. A staffing model has been agreed for this unit at a 3:1 patient to staff ratio. (Further detail can be found under appendix 3). Patients should have access to a CT scan and receive a written report within an hour of the CT scan. CT scans are not currently provided on a 24/7 basis from Ninewells Hospital but an 'Out of hours' rota system is in place to ensure that staff can travel to Ninewells within 30 minutes of a Major Trauma being reported. No additional provision is required for the Eastern Region to comply with the minimum standards. Consultant led Major trauma teams will be set up and a recruitment timetable agreed. Applications for investment were submitted to the STN for consideration at the STN Steering Group in October 2017. The areas where further funding is required are provided below:-

• To provide additional rehabilitation staff • To provide a dedicated six bed Major Trauma Unit • To recruit additional nursing and support staff who will work within the MT Unit • To provide training to SCN's and MT coordinators • Consultant training (European Trauma Course) • New works to adapt existing accommodation at Ninewells Hospital, Dundee • Additional equipment for the MT Unit and dedicated MT emergency Department bay

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4. Project Definition 4.1 Purpose and Aims A sub group of the Scottish Trauma Network (STN) developed a set of 'minimum requirements', outlining the key priorities for each of the regional networks to be able to operate as a Major Trauma Centre. Please refer to appendix 1 for full details of the draft minimum requirements. Please refer to appendix 4 for the approved version from STN. The initial phase of this project is to create a service which meets the minimum requirements by August 2018. Subsequent project phase(s) are required to develop the Eastern Major Trauma Network, in line with the National Standards outlined in the 'NPF, Major Trauma Quality Framework' and the agreed Key Performance Indicators. 4.2 Scope

Project activities have been identified and a programme has been developed in collaboration with project leads through detailed discussion at the various project sub groups. The plan is yet to be approved by the Eastern Region Project Board. Please refer to appendix 5 for the summary Major Trauma programme. The full programme of activities is available under separate cover. The key areas of work are outlined below:-

1. Recruitment

• Second an AHP, to lead the delivery of project activities for the Rehabilitation sub group

• Appoint staff to work within the MT Unit - Nursing and Support staff • Appoint 3 MT Coordinators to work for the Major Trauma Service from Patient

admission into the Emergency Department across all specialties and within the Major Trauma Unit.

• Appointment of AHP posts, including a rehab 'specialist' • Appoint an Orthopaedic Consultant

2. Training

• Train nursing staff within the MT Unit • Provide training for consultants providing Acute Care • Identify training needs for Acute Care staff

3. Service and Organisational Development

• Reconfigure existing AHP services to provide a 7 day service for MT patients • Develop, test and implement procedures to create patient Rehabilitation Plans • Develop and implement Operational Policies and procedures within Acute Care

and the Inpatient Care • Ensure all policies are approved and in line with Clinical Care Governance

processes • Communicate new ways of working to staff and provide opportunity for

engagement and feedback

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• Develop and implement a Communications Strategy • Develop an Equality Impact Assessment

4. Capital Works

• Create a 6 bed dedicated unit for Major Trauma patients adjacent to the

Orthopaedic ward • Create a MT resuscitation bay within the Emergency Department • Seek Capital approvals for funding and expenditure • Develop and agree equipment requirements

5. Planning, monitoring, reporting, risks and issues

• Agree an implementation plan with allocated resources for all associated project

activities • Monitor progress and report to the various stakeholders • Highlight and manage all risks and issues

4.3 Exclusions from scope Exclusions from the scope of the project:

• Paediatric Major Trauma Centre Care • Major Incident Planning

4.4 Success Criteria The success of this project will be measured by its ability to provide a dedicated Major Trauma service. To succeed, this should be done to the agreed timeframe; budget and quality to deliver the above. 4.5 Constraints and Assumptions

4.5.1 Constraints The project must be delivered within the approved programme as agreed by the project board. The project should be delivered within the agreed funding allocation. Recruitment of staff should be in line with the plans to develop a Major Trauma Service. 4.5.2 Assumptions For the purpose of completing this document, the following has been assumed:

• all the necessary approvals and appointments will be secured in line with planned dates

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• all the necessary, suitably experienced staff will be available to deliver the project activities as required

• the clinical and legislative requirements will not be subject to significant change

other than those already identified

• initial cost estimates are complete and accurate

• The organisation prioritises this project and commits the necessary resources to deliver

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4.7 Roles and Responsibilities 4.7.1 Scottish Trauma Network The following diagram (Figure 2) illustrates the Scottish Trauma Network model which was approved by the Cabinet Secretary.

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The STN Governance structure is provided below and illustrates the organisational relationship across the STN and all of the STN National sub groups (See figure 3 below)

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4.6 Project Organisation 4.6.1 Project Structure

The Project Team, with close help and support from the Senior Clinical Lead and the Project Manager, will lead this project. Both will be given strategic guidance and senior management support by the Project Board and Project Sponsor. There will be full consultation with all interested parties throughout the entire project life cycle. Figure 4 shows the proposed project structure.

(1) Scottish Trauma Network - Steering Group

(4) Implementation Group/Project Team

(13) Communication & Engagement Sub Group

(5) Links to other committees - Transformation Programme Board - NoSPG - MTC - SEAT Regional Planning Group

(2) STN Core Group (Sub Group of STN Steering Grp)

(3) Eastern MTC Project Board - 2/3 monthly meetings

(9) Acute Care Sub Group

(12) Rehabilitation & Long Term follow up Sub Group

(6) STAG/KPI's Sub Group

(11) New Works Sub Group

(8) Paediatric Sub Group

(7) Pre Hospital Care Sub Group

(10) Inpatient Care Sub Group

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____________________________________________________________________________________________________________ (1) STN Steering Group The STN Steering Group will provide strategic leadership, direction, audit and assurance for the Scottish Trauma Network, and will commission and prioritise implementation and investment in trauma care. It will ensure that the ethos of the network is met and that improved outcomes are demonstrated against a nationally agreed suite of key performance indicators. The steering group shall be representative of the different professional disciplines from the trauma community, and will work with NHS Boards, regional networks and SAS to implement a bespoke trauma network for Scotland, suited to the country’s needs and geography. It will support and encourage public and professional engagement to enhance care and inform service developments. Members will consist of:

Chair (Board Chief Exec) Clinical/ Planning representatives from each of the 4 Regional Trauma Networks and SAS ScotSTAR lead (national retrieval service) SGHSCD Finance SGHSCD Policy STAG/ Data Lead Workforce/Education Lead Public Health (Prevention) Lead Rehabilitation Lead Paediatric Lead Resilience Lead Trauma expert (impartial reference) Network Programme Associate Director Network Programme Manager Network Programme Support Officer Network Lead Clinician

Other relevant clinical network representation (seconded as part of a subgroup as required, e.g. Rehabilitation Programme Manager and Lead Clinician). A copy of the STN's Terms of Reference is available on request. (2) STN - Core Group The STN Core Group is a sub group of the Scottish Trauma Network and has the following representatives:-

Programme Associate Director Lead Clinician for each region Planning Lead for each region SAS Regional lead for planning SAS Regional lead for clinical Network Co-ordinator

All network teams will be expected to work closely together as part of an overall national collaborative. The STN Core Group will report and make recommendations to the STN Steering Group regarding the development of the network, including initial agreement of requirements, guidelines and strategies for approval by the STN Steering Group. The STN Core Group will delegate work to the working sub groups to ensure the delivery of the STN objectives. The Core Group has produced a 'Draft' terms of reference and will be focusing on particular areas of work to be delivered on a national level.

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(3) Eastern Major Trauma Project Board (Tayside and Fife) The Project board will meet every 2 to 3 months and the Chairperson (Project Sponsor) may decide to hold additional meetings or defer a meeting with the agreement of the Project Board members. The dates will ideally be scheduled to coordinate with 'key dates' within the project programme. The Project Board will review progress reports from the Project Manager, ensure an agreed project plan is followed and that risks, issues and changes are being identified and managed effectively. A copy of the project progress reports will also be sent to the Transformation Programme Board for information by the Project Manager. Issues which cannot be resolved at Project Team level will be escalated to the Project Board or Senior Clinical Advisory Group for guidance and/or resolution. The Project Board will also have responsibility to ensure that the Project is adequately resourced. A finance update will be prepared by the finance lead(s) to allow the Project Board the opportunity to monitor expenditure against the planned budget. The chairperson will submit papers to Tayside NHS Board or Fife Health Board, where decisions are required to be made for matters reserved for Health Board authorisation.

Membership

Project Sponsor (chairperson) – Lorna Wiggin, Chief Operating Officer, NHST Lead Consultant – Michael Johnston, Consultant in Emergency Medicine, NHST Senior Service Lead - Inpatient Care - Arlene Wood, General Manager, Surgery, NHST Senior Service Lead - Acute Care - Carol Goodman, General Manager, Medicine, NHST Senior Service Lead - AHP's - Karen Anderson, Director of Allied Health Professions, NHST NHS Fife Lead - Edward Dunstan, Director of Surgery, NHS Fife Senior Nursing lead – Sarah Dickie, Associate Nurse Director, NHST Finance Lead - Lindsay Bedford, Director of Finance, NHST Scottish Ambulance Service, Peter Lindle, SAS Judith Golden - Employee Director, Staff Side, NHST

(In attendance) Jill Beattie – Project manager, Major Trauma, NHST Anna Michie - Senior Communications Manager, NHST

Quorum No business shall be transacted at a meeting of the Major Trauma Project Board unless the following are present:

One Lead Consultant One Senior Service Lead One north East Fife Lead Director of Finance or Representative

A minimum of 4 Project Board members must be present in order to be quorate.

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____________________________________________________________________________________________________________ Project Sponsor The Project Sponsor is identified as the senior manager with the most to gain or lose by the success or failure of the project. The Sponsor is the project “Champion” and is recognised (both internally and externally) as the project figurehead. As such the Sponsor must be able to demonstrate a clear understanding of the project’s strategic objectives, success criteria and timeline. The Sponsor chairs the Project Board and will have the casting vote should a vote be required to carry a proposal. The Sponsor focuses on strategy and performance and should provide the project with direction and senior management “clout” as required. The Sponsor is accountable for ensuring the project team use agreed standard processes to identify, track and resolve issues, risks and changes in line with project governance. In chairing the Project Board meetings, the Sponsor will review the overall project performance, assist in the resolution of issues and risks (both internally and externally) and provide on-going strategic support and guidance to the Project Team. Lead Consultant The Lead Consultant is ultimately responsible for delivering the project successfully in their area of expertise, in this case Major Trauma. The Lead Consultant represents the Eastern Major Trauma Centre on the Scottish Trauma Network and is responsible for sharing information with members of the project teams and work groups. The Lead Consultant will chair the Implementation Group and seek guidance on matters which cannot be resolved at Project Team level. They will also be a key member of the Eastern Programme Board and must be present when decisions are required. The Lead Consultant will work closely with the Project Manager to ensure that regular updates and information sharing is provided following Scottish Trauma Network Meetings. Timetables for the appointment of clinical staff and development of operational procedures or other key documents will require approval by the Lead Consultant and members of the Implementation Group. Senior Service Lead(s) The Senior Service Leads will provide resources to facilitate and participate on various work groups and provide strategic advice and guidance to the Project Board as required. The Senior Service Leads are responsible for signing off key project documentation. The Senior Service Leads are listed below:-

• Inpatient Care - Arlene Wood, General Manager, Surgery, NHST • Acute Care - Carol Goodman, General Manager, Medicine, NHST • AHP's - Karen Anderson, Director of Allied Health Professions, NHST

Project Manager The Project Manager (PM) is ultimately responsible for planning and coordinating the project activities. The PM manages on a day-to-day basis, all aspects of the project including the individual sub groups, tasks, plans, risks, issues and change. The PM is responsible for the introduction and consistent use of standard processes designed to identify, track and resolve issues, risks and changes. This includes setting up meetings to allow

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____________________________________________________________________________________________________________ one-to-one sessions with Project Leads, one-to-all meetings with the project team and at least one meeting per quarter with the Project Board. The Project Manager, with assistance from the project support officer will record various meetings and monitor progress against the programme. The PM will ensure that the project plan and supporting project documentation is updated regularly and meaningful and measurable reports are produced before each Project Board. Proposals for resolution of issues relating to the project in general, the time line and risks likely to affect the project (including external influences) will be prepared by the PM and presented to the Project Board, Implementation Group, Scottish Trauma Network and various sub groups as required. (4) Implementation Group/Project team The Implementation group/Project Team members are responsible for carrying out planned project activities in their area. The deliverables from these activities should be in line with the detailed programme approved by the project board. They are also responsible for identifying, developing and conducting training in their area as required. The Implementation group/Project Team members will ensure that regular updates are provided to staff working in their area through various means such as staff briefing sessions and team meetings. The Implementation group/Project Team will consist of a number of staff from across various departments with responsibility for the delivery and co-ordination of all activities within the project plan. Some of the Project Team members will have responsibility for managing the workload of the sub groups and delivering particular pieces of work. The meeting will be chaired by the Lead Consultant and each individual sub group lead will provide a verbal or written update on their area of work. Progress of each sub group will be monitored against the detailed implementation plan and any issues requiring a senior clinical or management steer will be escalated to the Project Board for guidance through the Lead Consultant or Project Manager. For full membership details, please refer to appendix 6 (5) Other Regional and Tayside Committees The project Manager will provide update reports to the Transformation Programme Board to inform them of progress in the project delivery. These will be provided via Sue Muir who is the programme lead for development of NHST's clinical strategy. The Major Trauma Project Sponsor is also a member of the Transformation Programme Board so there will be a direct link with this group. A NoSPG exists for the provision of a Major Trauma Centre (MTC) in Aberdeen and a project team and structure are already in place. The NoSPG team are responsible for creating the MTC for Grampian, Highlands and Islands regions. Information will be shared between the Eastern Region and all other regional MTC regions, mainly through the Scottish trauma Network. (6) STAG/KPI A national STAG representative is a member of the Scottish Trauma Network and they are responsible for providing advice and guidance on implementation of new processes for each of the regional Trauma Networks. There is not a requirement at this stage to have a separate work group for this area but Susan Henderson, STAG Local Audit Coordinator, will be a member of the Implementation Group to ensure that all matters which may have an impact on data collection and reporting are discussed and information is widely shared.

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____________________________________________________________________________________________________________ (7-13) Sub Groups The primary focus of the sub groups will be to confirm membership, agree and document the role and remit of the group and monitor progress against the detailed project programme. Participants of these groups are responsible for delivering the individual activities within the programme. The Project Manager will provide assistance to ensure that the sub groups remain focused on particular work areas and document progress against the agreed programme of work. The project management information will be used to form the project update reports which will be shared with the Project Board, Implementation Group, STN and Transformation Programme Board. Each of the sub group lead(s) or a deputy will be a member of the Implementation Group to ensure that information is shared across all the work streams. The frequency of meetings will depend on the remit, number and complexity of activities and availability of resources for each work group. (7) Pre Hospital Care Sub Group Kenny Freeburn, Scottish Ambulance Service is responsible for the Specialist services desk. Peter Lindle is the consultant Paramedic and Project Manager recently appointed to coordinate a plan to provide a specialist services desk 24/7. It is assumed that sub group meetings will be arranged in line with the project demands and regular meetings are not necessary at this stage of the project delivery. Kenny Freeburn is a member of the Implementation Group and Peter Lindle is a member of the Eastern Region Project Board. (8) Paediatric sub group Colin Donald is the current chair of this group. There is no plan to have a dedicated paediatric Major Trauma Centre in Ninewells but the group will look at mirroring practices for Major Trauma adults wherever possible. Ninewells will continue to be a Trauma Unit for children. Colin Donald is also the Eastern Region representative on the STN Paediatric sub group and will arrange meetings as necessary. (9) Acute Care sub group The role and remit was agreed by the Acute sub group members and is provided below:-

Develop procedures and protocols for all members of the Major Trauma Team dealing with the initial patient reception and acute treatment care. Identify the roles and responsibilities of the Major Trauma Team members and team leader and establish procedures to transfer the patient to the appropriate, ongoing, inpatient care. Organise trial runs with the necessary staff and various departments to test the procedures, prior to the service going ‘live’ in August 2018. Identify any works required to create a Major Trauma resuscitation bay within the Emergency Department, specifying all equipment and accommodation requirements.

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____________________________________________________________________________________________________________ The complete list of activities and agreed timescales can be found within the project programme under appendix 5. Mike Donald is the lead consultant for this group and future meetings are to be arranged. The membership of the group may be extended to include the Clinical Services Manager and Head of nursing for this area to support staff engagement and assist with implementation of new working practices. (10) Inpatient Care sub group This group is chaired by Gavin Love, orthopaedics Consultant and includes representatives from the following:-

• Head of Nursing - Orthopaedics • Clinical Service Manager - Surgical Directorate • Head of Nursing- Theatre Services • Clinical Services Manager - Anaesthetics • Head of Nursing - Surgery • Physiotherapy Team Leader • Clinical Services Manager - Orthopaedics • Consultant(s) Anaesthetics department • Consultant - Elderly Medicine • Workforce

The role and remit of this group is to establish the Major Trauma Unit with the appropriately trained nursing and support staff. The unit will build strong links with rehabilitation staff working within the unit and across the rest of the hospital, providing support to Major Trauma patients. This group will take a lead in the recruitment of all staff working within the unit, including the appointment of an Orthopaedic Consultant. Group members will share information to staff working within their teams and provide regular project updates. The inpatient subgroup will also create policies and procedures for staff and develop admissions criteria for the unit. The proforma for Multi disciplinary meetings will be developed and tested through this work stream. A full list of activities and timescales can be found within the project programme under appendix 5. A workforce plan has been agreed for the nursing and support staff required for the six bed Major Trauma Unit and a workforce lead attends meetings to advise on the recruitment processes. An additional Orthopaedic Consultant will be appointed to provide a 24/7 Major Trauma consultant led service. A recruitment timetable has been agreed to ensure that all nursing, AHP and support staff are in place and details can be found in the project programme. The consultant appointment timescales are yet to be identified and planned accordingly. It is not possible to agree consultant timelines in advance as an external adviser must be involved in the recruitment process and may require around 6-8 weeks notice to participate in the selection process. (11) New works sub group

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____________________________________________________________________________________________________________ The scope of works is yet to be finalised but indicative works have been scoped and costed. Exact costs will not be known until:-

1. The brief is agreed by clinicians 2. Detailed designs are signed off 3. A contractor has submitted a tender for the works

In general, the works include:-

• Creation of a six bed Major Trauma Unit with secure access • Create a nurses work station • Provide the necessary bedhead services (High level estimates confirmed at this stage) • Procurement of equipment for six beds including - beds, monitors and trolleys etc (See

appendix 7 for the draft equipment list) Equipment and capital works for the Major Trauma Unit has been identified and costed and the application for funding has been submitted to the STN for approval. Please refer to the attached appendix 8 for estimated costs) The group membership and lead is still to be agreed and future meetings set up. (12) Rehabilitation & Long Term follow up Sub Group Rehabilitation support is provided from a variety of professions including:-

• Physiotherapy • Occupational Therapy • Brain Injury • Speech and Language Therapy • Repatriation protocols

The rehabilitation group will develop a procedure to repatriate patients back to North East Fife (or other boards) for rehabilitation. At a later stage in the project, engagement with third party care providers and local authorities will be undertaken to smooth processes for patients moving out of hospital care and back to their home environment or place of work. AHP's are currently managed under the Health and Social Care Partnerships and a recruitment timetable has been agreed. Staffing levels have already been assessed and a request to fund the AHP staff on a 24/7 basis has been lodged. The outcome of the Eastern Region's funding request is expected in October 2017. An AHP lead will be seconded to lead the work of this sub group. (13) Communication & Engagement sub group This group has met and developed a draft 'Communications and stakeholder engagement plan'. Members include:-

Name Role Board Jill Beattie (Chair) Project Manager NHS Tayside Dr Mike Johnston Consultant in Emergency Medicine NHS Tayside Arlene Wood General Manager, Surgery NHS Tayside Matthew Kendall Interim Head of AHP’s NHS Tayside Sharon Birrell Project Support Officer NHS Tayside

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Anna Michie Communications Lead NHS Tayside Allyson Angus Public Involvement Manager NHS Tayside Hazel Caroll Clinical Services Manager NHS Tayside Santosh Chima Head of Corporate Equalities NHS Tayside Ann McLean Head of Nursing, Surgery NHS Tayside TBC Comms lead, NHS Fife NHS Fife TBC Service lead, NHS Fife NHS Fife Judith Golden Staff Side Representative NHS Tayside

Organisational Development would ideally participate on this work group, however, there are no available resources until post December 2017. Organisational development is committed to the work of the Transformation Programme Board as this remains the priority for the organisation. The communications plan identifies the project stakeholders, both internal and external. Various forms of media will be used for progress updates and allow the opportunity for interested parties to provide feedback. The communications & engagement sub group discussed the need for an 'Equality Impact Assessment' (EQIA) and will make a recommendation to the Eastern Project Board that an EQIA is not applicable for this type of project. Section 1A, of the EQIA Policy has been completed and shared with Santosh Chima to share the sub group member's views and provide reasons for the recommendation. The Project Board will also be requested to endorse this recommendation. Once the Communications and engagement Plan is signed off by the project board, the project manager and communications lead(s) will continually monitor the plan to ensure that it is adhered to.

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____________________________________________________________________________________________________________ 5. Project Controls 5.1 Issue Management Issues will be managed using the standard issue management process and materials. Once an issue is identified, the issue will be captured electronically on the project issue log (see appendix 9). The following information is captured against each issue:

• unique sequential reference number • description

• date raised • by whom

• issue owner • priority 1 thru 5

• target resolution date • progress reports

This log is reviewed at least fortnightly and issues are resolved, progressed or escalated as necessary by the Project Manager. A management summary of outstanding issues will be produced for review by the Project Board / Steering Group and contained within the project update report. 5.2 Change Management Changes will be managed using the standard change management process and materials. Once a variation is identified, the person requesting the change will complete a change request form. The following information is captured against each change:

• unique sequential reference number

• detailed description and reason for change • date raised and by whom

• risk assessment (both of implementing the change and of not) • impact assessment (as above)

• cost assessment (as above) • quantifiable cost saving / benefit of change

• sign off at each stage Change requests will be reviewed frequently and escalated rapidly where necessary. A management summary of open changes will be produced for review by the project Board / Steering Group. The project board must authorise all changes for any key documents which have previously been approved, especially those which have an impact on timescales, resources or quality.

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____________________________________________________________________________________________________________ 5.3 Risk Management Risks will be managed using the standard risk management process and collateral materials. A full risk assessment exercise will be carried out by the Implementation Group/Project Team. During this workshop, risks will be identified, impact and probability assessed and an outcome agreed. Risk owners will be appointed who will be responsible for developing and implementing risk reduction strategies. Each risk will be captured on the project risk log (see appendix 10). Risks will be reviewed frequently and escalated to the Project Board where necessary. A management summary of open risks will be produced for review by the project Board/Steering Group within each progress update report. 6. Project Budget To be reviewed in line with previous and future funding bids - Outcome expected November 2017?

7. Project Success Criteria

• The project must create a Major Trauma Centre, capable of providing current and predicted service demands as detailed in section 4.

• The facility is to be delivered per the timescales in the finalised project plan.

• The project must be delivered within the financial allocation

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Appendix 1 - AHP Staff

A further appointment will be made for a Rehabilitation Specialist whose role is yet to be defined.

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Appendix 2 - Key Performance Indicators Section 1: Pre Hospital Care Pre hospital care encompasses the response from the call alerting the emergency services, to on-scene care, triage and primary transfer and (if required).

1.1 Pre hospital Triage

Description Patients who have suffered significant trauma are assessed by the Scottish Ambulance Service (SAS) using the SAS Trauma Triage Tool (SASTTT).

Rationale The Trauma system relies on the need of the patient and the capacity of the service being matched and triage will help deliver this (5-13).

Numerator Number of major trauma patients who are assessed by the SAS, using the SASTTT.

Denominator Number of major trauma patients who arrive by the SAS.

Data source Numerator = SASTTT = yes Denominator = Major trauma patient (ISS > 15); and Mode of arrival (MOA) or Air transport = SAS.

Note Await the implementation of triage tool.

The triage tool will be reviewed on a regular basis to ensure it is highlighting the right patients to go to the right hospitals. Although triage will be protocol-based, it is acknowledged that provider judgement (“up-triage”, when a provider feels that the protocol underestimates the degree of injury; and “down-triage” when a provider feels that the protocol overestimates the degree of injury) adds to the performance of triage. This information will be recorded and it will therefore be possible to assess the performance of the triage trauma tool as well as provider judgement. This will provide useful data for the further development and refinement of the triage tool in Scotland, with a view to optimising under and over triage rates.

1.2 Pre-alert

Description Patients who are triaged as requiring Major Trauma Centre (MTC) care are notified to the receiving hospital (pre-alert).

Rationale Pre-alerts allow trauma teams to be assembled prior to arrival of the patient, improving the care they receive in the initial stages of their hospital journey (6,

14). Numerator Number of patients triaged as requiring MTC care for whom a pre alert is

recorded.

Denominator Number of patients triaged as requiring MTC care.

Data source Numerator = Standby = Y

Denominator = MTCCareRequired = Y

Note Await confirmation of SAS data and implementation of triage tool.

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1.3 Diversion to lower level of care

Description Patients who are triaged as requiring MTC care are taken directly to a MTC if they are within 45 minutes travel time.

Rationale The aim of the trauma system is to deliver patients to definitive care, whenever possible; to provide safer care, decrease mortality and improve functional outcome (2, 15 – 17)

.

Numerator Number of patients triaged to MTC care that are within 45 minutes travel time of a MTC and are taken directly to a MTC.

Denominator Number of patients triaged to MTC care that are within 45 minutes travel time of a MTC.

Data source Numerator = FirstHospType = MTC. Denominator = Triage decision = MTC and MTC achievable within 45 minutes = Y.

Notes Await the implementation of triage tool. Further analysis must include number out with range and provider judgement decision.

Section 2: Early hospital Care Early hospital care includes initial reception of the patient in the ED through to the patient being discharged to a rehabilitation service or home.

2.1.1 Consultant led reception for patients triaged and taken to

MTC care

Description Patients who are triaged as requiring MTC care and are taken to a MTC are received by a Consultant led trauma team.

Rationale A Consultant will have the necessary expertise and experience to effectively coordinate the initial assessment and treatment of a major trauma patient (7,

18).

Numerator Number of patients who are triaged and taken to a MTC and are received by a Consultant led trauma team.

Denominator Number of patients who are triaged and taken to a MTC.

Paediatrics Paediatric Emergency Medicine Consultant: 1. Same definition as adult from 8.00-23.59. 2. Seen by a consultant within 30mins from 00.00 to 7.59 (19).

Paediatric

numerator

1. Number of patients who are triaged and taken to PMTC care and time of admission is between 08.00 and 23.59 and are received by a consultant led trauma team.

2. Number of patients who are triaged and taken to PMTC care and time of admission is between 00.00 and 7.59 and are seen by a consultant within 30 minutes of arrival.

Paediatric

denominator 1. Number of patients who are triaged and taken to PMTC care and

time of admission is between 08.00 and 23.59. 2. Number of patients who are triaged and taken to PMTC care and

time of admission is between 00.00 and 7.59. Data source Numerator = ConsultLed = Y

Denominator = Triage decision= MTC care and FirstHospType = MTC. Paeds option 1 – Add EnterTime Paeds option 2 - GradeSenior, EnterDT, ArriveDTSenior to calculate ConsultArrivedWithin30mins.

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Note

2.1.2 Consultant review for patients triaged to MTC care and taken

to a TU

Description Patients who are triaged to MTC care and are taken to a TU should be seen by a Consultant within 60 minutes of arrival.

Rationale A Consultant will have the necessary expertise and experience to effectively coordinate the initial assessment and treatment of a major trauma patient (7,

18).

Numerator Number of patients who are triaged to MTC care and taken to a TU and are seen by a Consultant within 60 minutes of arrival.

Denominator Number of patients who are triaged to MTC care and taken to a TU.

Data source Numerator = ConsultLed OR GradeSenior, EnterDT, ArriveDTSenior Denominator = Triage decision = MTC care and FirstHospType = TU.

Notes STAG will need confirmation of hospitals that are designated as a TU in order to report this KPI.

2.2 Time to Major Trauma Centre care

Description Major trauma patients who are not taken directly to a MTC and are later transferred to a MTC are transferred within 24 hours.

Rationale Some patients with major trauma will not be taken directly to a MTC due to a number of reasons including prolonged distance to a MTC, unstable clinical condition, under triage and patients having being taken to hospital by private transport. It is essential that these patients are transferred to definitive care (MTC) as soon as possible, improving the patient experience and outcome(2).

Numerator Number of major trauma patients, who are admitted to a MTC within 24 hours of arrival in the first ED.

Denominator Number of major trauma patients who are transferred from an LEH or TU to a MTC.

Data source Numerator = ISS > 15, FirstHospType = LEH or TU, TransHospType = MTC, EnterDT, TransHospDT. Denominator = ISS > 15, FirstHospType = LEH or TU, TransHospType = MTC.

2.3 Time to secondary transfer

Description Time to secondary transfer to a MTC for patients who have suffered major trauma (ISS > 15) is minimised to ≤ four hours from time of call (to arrange

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transfer) to SAS to departure.

Rationale Major trauma patients who are not taken directly to a MTC should be transferred without delay to definitive care after initial assessment and optimisation in the receiving hospital (2).

Numerator Number of major trauma patients who depart their receiving hospital to a MTC in ≤ four hours from call to SAS.

Denominator Number of major trauma patients who are transferred from a non-MTC to a MTC.

Data source - Transfer by SAS

Numerator = ISS > 15, FirstHospType = LEH or TU, TransReason = MTC care, call start DT, resource left scene DT Denominator = ISS > 15, FirstHospType = LEH or TU, TransReason = MTC care

Paediatrics patients transfer by ScotSTAR Paediatric Retrieval Service)

1. Decision to mobilisation time <60 minutes. 2. Decision to team arrival with patient <3 hours (road/mainland). 3. Decision to team arrival with patient <4 hours (island/air)

Note – these are standards set by ScotSTAR Paediatric Retrieval Service20.

Paediatric numerator

1. Number of patients where time from decision to mobilisation is less than 60 minutes.

2. Number of patients where time from decision to team arrival with patient is less than 3 hours (road/mainland)

3. Number of patients where time from decision to team arrival is less than four hours (island/air)

Paediatric denominator

1. Number of major trauma patients who are transferred from a non-MTC to a MTC (by ScotSTAR) and age on admission in first hospital ≤ 16.

2. Number of major trauma patients who are transferred from a non-MTC to a MTC (by ScotSTAR) and age on admission in first hospital ≤ 16, AND team arrived by road/mainland.

3. Number of major trauma patients who are transferred from a non-MTC to a MTC (by ScotSTAR) and age on admission in first hospital ≤ 16, AND team arrived by air.

Data source - Transfer by ScotSTAR

Referral DT, mobilisation DT, arrival with patient DT, type of transport – road/mainland or island/air.

Notes Paediatric transfer data will be sent to STAG by ScotSTAR monthly as this is held within a different dataset from SAS data.

2.4.1 Time to CT head

Description Patients with a severe head injury have a CT scan within 60 minutes of arrival in first hospital with an ED.

Rationale Severe head injury is defined as a patient with a Glasgow Coma Scale (GCS) ≤ 8 or an Abbreviated Injury Scale (AIS) (head) ≥ 3. All patients with a severe head injury (GCS ≤ 8) following trauma should have a CT scan as soon as possible to determine treatment required in order to reduce mortality and improve functional outcome 21.

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Numerator Number of patients with a severe head injury who undergo a CT head within

60 minutes of arrival in ED.

Denominator Number of patients with a severe head injury.

Data source Numerator = GCS ≤ 8, AIS head codes, CTBodArea = head, EnterDT, CTScanDT Denominator = GCS ≤ 8, AIS head codes, CTBodArea = head

Notes Discussion around cohort (NICE and SIGN guidelines GCS<13). Start GCS 8 as there is clinician support for this and review once we have compliance data.

2.4.2 Time to CT head written report

Description Patients with a severe head injury have a CT scan written report available within one hour of the CT scan.

Rationale Severe head injury is defined as a patient with a (Glasgow Coma Scale (GCS) ≤ 8 or an AIS (head) ≥ 3 All patients with a severe head injury following trauma to the head should have a CT scan as soon as possible to determine treatment required in order to reduce mortality and improve functional outcome. 21.

Numerator Number of patients with a severe head injury where a CT head written report by a radiologist is available within one hour of the time the CT scan was performed.

Denominator Number of patients with a severe head injury.

Data source Numerator = GCS ≤ 8, AIS (head) ≥ 3, CTBodArea = head, CTScanDT, CTScanWrittenDT Denominator = GCS ≤ 8, AIS (head) ≥ 3, CTBodArea = head

2.5 Major Trauma Centre care for patients with a severe head injury

Description Patients who have suffered a severe head injury are managed in a MTC.

Rationale Severe head injury is defined as a patient with an AIS (Head) ≥3. Patients who have suffered severe head injury should be managed in a MTC with specialist facilities to reduce mortality and improve functional outcome (2,

16).

Numerator Number of patients who have suffered a severe head injury and are managed in a MTC.

Denominator Number of patients with who have suffered a severe head injury.

Data source Numerator = AIS (Head) ≥3, FirstHospType or TransHospType = MTC Denominator = AIS (Head) ≥3

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2.6 Management of open long bone fractures

Description Patients with an open long bone fracture will receive intravenous (IV) antibiotics within three hours of first contact with Emergency Services.

Rationale Evidence recommends that IV antibiotics are given to patients with open long bone fractures as soon as possible (ideally within three hours) (22). As injury time data is poorly collected, STAG will use “first contact with emergency services” as a surrogate. This will be the first applicable option from - date/time SAS were called, date/time the patient enters a Minor Injury Unit or the date/time the patient enters an Emergency Department.

Numerator Number of patients with a severe open long bone fracture who received IV antibiotics within three hours.

Denominator Number of patients with a severe open long bone fracture.

Data source Numerator = IVAbxDT; First contact DT Denominator = AIS codes = open long bone fracture

2.7 Administration of Tranexamic Acid in patients with severe

haemorrhage

Description Trauma patients with severe haemorrhage should be given Tranexamic Acid (TXA) within three hours of first contact with Emergency services.

Rationale Trauma patients with severe haemorrhage are defined as having received at least one unit of blood products within six hours of injury for the purpose of this indicator. Blood products include: fresh frozen plasma, red blood cells, cryoprecipitate and platelets. TXA has been shown to reduce death by bleeding if given within three hours of injury to bleeding trauma patients (23.24). As injury time data is poorly collected, STAG will use “first contact with emergency services” as a surrogate. This will be the first applicable option from - date/time SAS were called, date/time the patient enters a Minor Injury Unit or the date/time the patient enters an Emergency Department.

Numerator Number of trauma patients with severe haemorrhage that start the administration of TXA within three hours of first contact with emergency services.

Denominator Number of trauma patients with severe haemorrhage.

Data source Numerator = TXA Date/Time; First contact Date/Time Denominator = Blood product = Y

Notes

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____________________________________________________________________________________________________________ 2.8 Specialist care

Description Patients who have suffered major trauma and are taken to a MTC, are admitted under the care of a Major Trauma Service.

Rationale The Major Trauma Service would coordinate care from the acute phase through to rehabilitation ensuring patients receive all necessary care in a timely manner (2).

Numerator Number of major trauma patients who are admitted to a MTC (primarily or secondarily) and are under the care of a Major Trauma Service.

Denominator Number of major trauma patients who are admitted to a MTC (primarily or secondarily).

Data source Numerator = ISS > 15, FirstHospType OR TransHospType = MTC, AdmitSpec or TransAdmitSpec = Major Trauma Service Denominator = ISS > 15, FirstHospType OR TransHospType = MTC

Notes Clear definition of major trauma service required by STN Steering Group. Single organ injuries may still go to specialty e.g. isolated head will go to Neuro, update when decision final.

Section 3: Ongoing hospital care Ongoing hospital care includes rehabilitation of the patient within a hospital setting or/and within the community.

3.1.1 Assessment of rehabilitation needs

Description Major trauma patients admitted to a MTC have a rehabilitation plan written.

Rationale Rehabilitation should start as soon as appropriate to enable patients to achieve their functional potential (25, 26).

Numerator Number of major trauma patients admitted to a MTC, with a length of stay of more than three days who have a rehabilitation plan.

Denominator Number of major trauma patients whose length of stay is more than three days.

Data source Numerator = ISS > 15, FirstHospType OR TransHospType = MTC, RehabPlan = Y Denominator = ISS > 15, FirstHospType OR TransHospType = MTC

Note Await implementation of Rehabilitation Plan.

3.1.2 Time to assessment of rehabilitation needs

Description Major trauma patients admitted to a MTC, who have a rehabilitation plan, have it written within three days of admission.

Rationale Rehabilitation should start as soon as appropriate to enable patients to achieve their functional potential (25, 26).

Numerator Number of major trauma patients admitted to a MTC who have a rehabilitation plan that is written within three days of admission to a hospital.

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Denominator Number of major trauma patients admitted to a MTC (on day one, two or three) who have a rehabilitation plan.

Data source Numerator = ISS > 15, FirstHospType OR TransHospType = MTC, EnterED, RehabPlanDate.

Denominator = ISS > 15, FirstHospType OR TransHospType = MTC

Note Await implementation of Rehabilitation Plan.

3.2 Functional outcome

Description Patients who have survived major trauma have their functional outcomes assessed at specified timelines.

Rationale Trauma systems have been shown to reduce mortality and reduce disability. This will provide information on the functional outcome of patients with moderate or major trauma to ensure that the Major Trauma Service is effective (16, 27).

Numerator Number of major trauma patients who survive to discharge who are approached about inclusion in the Patient Recorded Outcomes Measure (PROMS) Trauma Programme.

Denominator Number of major trauma patients who survive to discharge.

Data source Numerator = ISS > 15, outcome = alive, FirstHospType OR TransHospType = MTC, Proms = yes Denominator = ISS > 15, outcome = alive, FirstHospType OR TransHospType = MTC.

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Appendix 3 - Unit staffing

Option B: Level 2 Trauma Unit (1 RN to 3 Patients) 6 beds

PROFESSIONAL JUDGEMENT: Senior Nurse WFP

Table 1 Calculating working hours required: Registered Nurses

Healthcare Support Workers

Shift Length of shift (hrs) times No. of

staff x No. of days

Total Hours

Required Shift

Length of shift (hrs)

times No. of staff x No. of

days

Total Hours

Required Early 7.5 x 2 x 7 105 Early 7.5 x 1 x 7 52.5 Late 7.5 x 2 x 7 105 Late 7.5 x 1 x 7 52.5 Night 10 x 2 x 7 140 Night 10 x 1 x 7 70 TOTAL 350 TOTAL 175 Table 2 Time out Allowance

Total hours required Divide by

Baseline Hours (100%)

Times Time Out Allowance (22.5%)

Total Time Out

Hours

Total hours required

Divide by

Baseline Hours

(100%) Times

Time Out Allowance (22.5%)

Total Time Out

Hours

350 \ 100 x 22.5 78.75 175 \ 100 x 22.5 39.38 Table 3 Staffing Establishments WTE Calculated

Hrs

WTE (hrs / 37.5)

Calculated Hrs

WTE (hrs / 37.5)

Baseline Establishment 350 9.33 Baseline Establishment 175 4.67 Time Out Allowance 78.75 2.10 Time Out Allowance 39.38 1.05

Total Establishment 428.75 11.43 Total Establishment 214.375 5.72

5.72 11.43 1wte SCN 0 1wte WA 0 17.15

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Appendix 4 - Minimum Requirements for a Regional Trauma Network

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Appendix 5 - Summary Programme to implement a Major Trauma Centre - Based on November funding decision

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Appendix 6 - Implementation Group members Surname

Forename Designation Location/Address Email Contact Tel. / Extension

Anderson Karen Director of Allied Health Professions

AHP Directorate Kings Cross Hospital Clepington Road, Dundee DD3 8EA

[email protected] PA Wendy Meldrum

Ext. 71194 Tel. 01382-424194

Ballantyne Eric Consultant Neurosurgeon

Neurosurgery, Ninewells Hospital NHS Tayside

[email protected] Ext. 36052 Ext. 35224 Bleep 3076

Beattie Jill Project Manager Ninewells Hospital NHS Tayside

[email protected] Ext. 40733

Carroll Hazel CSM Orthopaedics Ninewells Hospital NHS Tayside

[email protected] PA Vanessa McCafferty

Ext. 36389, 36342

Chakraverty Sam Consultant Radiologist Radiology Dept. Ninewells Hospital NHS Tayside Leaving Jan. 2018 Ian Zealley taking over Radiology part of project.

[email protected] Ext. 32651 Bleep 4832

Dickie Sarah Associate Nurse Director

Nursing & Midwifery Directorate Ninewells Hospital NHS Tayside


Donald Colin Consultant A&E A & E, Ninewells Hospital Dundee


Donald Michael, Dr Consultant A&E A & E, Ninewells Hospital Dundee


Dunstan Edward Director of Surgery Orthopaedic Consultant, Queen Margaret Hospital, Whitefield Road, Dunfermline KY12 0SU, NHS Fife

[email protected] Not known

Fraser Lorraine HR Business Lead HR Directorate Ninewells Hospital NHS Tayside

[email protected] Ext. 33469 or 36532

Freeburn Ken Head of A&E Services Scottish Ambulance Service Glencairn Medical Centre, 76 West School Road, Dundee, DD3 8PQ

[email protected] Mob. 07786703222

Gentleman Douglas Consultant CBIR, Royal Victoria Hospital Dundee


Greig Louise Management Accountant (Revenue)

Finance Department Ninewells Hospital NHS Tayside


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Henderson Susan Clinical Audit Facilitator

A & E, Ninewells Hospital NHS Tayside


Johnston Mike, Dr Consultant in Emergency Medicine

A&E Department, Ninewells Hospital NHS Tayside


Kendall Matthew Interim Head of AHP’s Dundee Health & Social Care Partnership Claverhouse Offices, Dundee

[email protected] PA - Jane Ogilvie

Tel.. 01382 436315 Mob. 07807077955

Love Gavin Orthopaedic Consultant

Orthopaedics, Wards 16-19 Ninewells Hospital, Dundee, NHS Tayside

[email protected] Ext. Not on LDAP Bleep 4858

Mason Wilma Capital Management Accountant

Maryfield House Dundee NHS Tayside

[email protected] Ext. 70251 Tel: 01382 424472

McGuire Barry, Dr Consultant Anaesthetist

Anaesthetics Dept., Ninewells Hosp., NHS Tayside


McLean Ann Head of Nursing, Surgery

Ward 16 Corridor, Ninewells Hospital NHS Tayside

[email protected] PA Vanessa McCafferty

Ext. 40739

Payne Christopher Consultant General & Colorectal Surgeon

General Surgery, Ninewells Hospital NHS Tayside


Scott Lorraine Programme Manager (Service Planning Lead)

Summerfield House,2 Eday Road, Aberdeen AB15 6RE, NHS Grampian

[email protected] Tel. 012245 558431

Shaw David, Dr GP, Clinical Lead for IJB

Erskine Practice, Arthurstone M.C., 39 Arthurstone Terrace, Dundee, DD4 6QY, NHS Tayside

[email protected] Tel. 01382 458333

Wiggin Lorna Chief Operating Officer C10 046, Board Headquarters Level 10, Ninewells Hospital NHS Tayside


Wilson Eddie, Dr Consultant Anaesthetics Dept., Ninewells Hosp., NHS Tayside

[email protected] Ext. 32175 Bleep 4013

Wood Arlene General Manager, Surgery

Ward 9/10 Corridor, Level 6 Ninewells Hospital NHS Tayside


Zealley Ian, Dr Consultant Radiologist Radiology Dept Ninewells Hospital NHS Tayside


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Appendix 7 - Equipment List - v4 (Included in STN funding bids)

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Appendix 8 - Capital works The list below was included within the STN funding bids and includes high level cost estimates based on the available information at that time. Accurate costings will be known once surveys of the existing infrastructure and detailed designs have been completed.

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Appendix 9 - Issue Log

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Appendix 10 - Risk Log

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PROJECT INITIATION DOCUMENT

EASTERN REGION - MAJOR TRAUMA CENTRE The Project Initiation Document regarding the above development scheme has, following discussion, been accepted by the key local stakeholders – as detailed hereunder. Signature & date Lorna Wiggin, Chief Operating Officer, NHST

Michael Johnston, Consultant in Emergency Medicine, NHST

Edward Dunstan, Director of Surgery, NHS Fife

Arlene Wood, General Manager, Surgery, NHST

Carol Goodman, General Manager, Medicine, NHST

Lindsay Bedford, Director of Finance, NHST

Karen Anderson, Director of Allied Health Professions

Comments: Signed: Jill Beattie Project Manager Date……………………… … … … … .

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Item Number 5b

TPB60/2017 Transformation Programme Board

29 November 2017 NHS TAYSIDE ELECTIVE CARE CENTRE

1. SITUATION AND BACKGROUND

The Scottish Government, through its 20:20 Vision for Health and Social Care, set out a vision for a stronger NHS in Scotland and one of the key deliverables is to ensure effective use of NHS capacity to deliver a better service for patients. This policy agenda is committed to population based planning, which is explicit in the 20:20 Workforce Vision and Route Map. The demand for surgical procedures has been steadily increasing in recent years due to changing demographics, epidemiology, and advancing technology which enable more conditions to be surgically treated. National trends reflect an increasing demand over the previous 10 years for common elective procedures, in particular orthopaedic and ophthalmology. Application of this growth rate to the current population and age profile projections reflects that further activity increases should be anticipated. The Scottish Government has recognised the challenges faced by NHS Boards with addressing the healthcare demand associated with the projected increase in population, particularly within the over 65 age group. In October 2015 The Scottish Government announced that an additional £200m would be invested in elective care facilities across Scotland with new facilities to be considered in Tayside, Grampian, Highland, Lothian and Glasgow. The National Programme Board for Elective Care confirmed the approach to planning for the Elective Care Centres should be at a Regional level in the context of a regional strategy for elective care which will subsequently be reflected in the Regional Transformation and Investment Plans.

2. ASSESSMENT

Within this national context, NHS Tayside are developing strategic plans to sustainably provide the required elective care capacity to meet the anticipated increasing demand for elective surgery in the north region over the next 5 to 20 years. This work is aligned to the National programme of work, collaboratively working with the North Boards, North of Scotland Planning Group and SEAT to ensure effective regional planning and optimal use of available resource. The planned Elective Care Centre for Tayside will provide maximum benefit and value by delivering three distinct yet co-dependent proposals:

• Elective Care Centre a dedicated facility within the Ninewells campus to meet the projected activity needs for additional elective surgical capacity for NHS Tayside and the North of Scotland region.

• Rolling Ward Block Refurbishment create capacity for a decant facility to underpin the Ninewells hospital environmental improvement plan. By providing additional bed capacity co-located in the new facility this will support a phased programme of capital refurbishment and infrastructure upgrade for the ageing Ninewells estate.

Please note any items relating to Committee business are embargoed and should not be made public until after the meeting

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• Academic Health Science Partnership provide an opportunity to link with our Academic Health Science Partnership colleagues to co-locate the new Cuschieri Skills Centre, facilitating world-class combined environment for healthcare delivery and education.

The indicative capital requirement for the elective care centre was initially assessed as £39m based on high level footprint on the Ninewells site at 2016 prices. An Elective Care Centre Programme has been established to support the development of the Elective Centre and its objectives are:

• To provide efficient, effective and resilient elective care services which are timely, accessible and enhance patient experience

• To deliver increased productivity & efficiency through review, redesign and improvement of current pathways, adopting the productive opportunities of the national collaborative programmes and the ‘best in class’ service delivery model

• Reduce cancellation of elective surgery through streaming of scheduled and unscheduled patient flows

• Optimise collaborative working through co-location of University, NHS Staff and the elective care centre on the Ninewells Campus, enhancing teaching and research opportunities as well as ability to recruit and retain required workforce

• To engage with all relevant stakeholders including our health and social care partners to ensure our business case proposal is fully understood and agreed

The Programme is supported by a core project team, established to review our approach to the delivery of elective care taking cognisance of the need for regional collaboration and planning aligned to the integration of outputs from our local improvement programmes of work including ‘Shaping Surgical Services’ and ‘IHO Theatre Optimisation’. The Project Team will report to the Elective Care Centre Programme Board (chaired by Stephen Hay, Non-Executive Board member) and will:

• Monitor the progress of the overall programme • Monitor the risk log and support mitigation where necessary • Authorise financial commitments within existing financial instructions • Ensure the required resources are available to deliver the programme

The Project Team will also be required to provide regular updates to the regional and national Elective Care Programme Boards. The Programme governance arrangements and Core Project Team membership are outlined in Appendix 1.

Key Programme Milestones

Initial Agreement (IA) Completed January 2018 Outline Business Case (OBC) Completed August 2018 Full Business Case (FBC) Completed May 2019 Construction Commencement July 2019 Construction Completion and Handover Begins January 2021 Occupancy Begins April 2021

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Current Priorities for Programme

• Establish Programme office & adopt Agile’ approach to project documentation/management

• Establish weekly huddle of core project team • Provide a draft outline of Initial Agreement • Recruitment of Clinical Pathway and Design Leads • Completion of Stakeholder Analysis • Progress with defining Target Operating Model for key specialities– regional data

modelling & pathway development • Engagement with key clinical services

Regional Planning & Collaboration A key component of the development of the Elective Care Centre proposals is the development of a regional strategy for elective care. A regional strategic case and assessment was prepared and submitted to the National Programme Board in May 2017 (attached Appendix 2). The case outlines the requirement for a multi-faceted approach involving workforce development; culture change and infrastructure improvement as well as an existing common sense of purpose to improve all services in the North, including the development of children’s services, cancer services and unscheduled care. Strategic effort and collaboration will be part of the continuous improvement of services to create a model which is tailored to the geography and population distribution in the region, taking cognisance of the region’s workforce and financial constraints. In shaping a vision for elective care services across the North of Scotland the following strategic aims have been agreed:

- Equity of access based on clinical urgency - Shared culture and drive to provide value added care for NoS residents - Regionally planned services reflecting critical mass and low volume activity, as locally as

possible and as specialist as necessary - Progressive and innovative workforce models to support service sustainability - Mobile communications and network technologies to enhance co-ordination of care and

local service delivery - Optimising physical and workforce capacity across all North of Scotland elective sites - Best value from collective resources and assets to achieve consistent standards and “best

in class” performance - Commitment to collaborative working with Integrated Joints Boards to manage demand

To support the development of regional elective planning, short life working groups reviewing patient pathways have been established within Ophthalmology and Orthopaedics in the first instance. The Information Support Teams across the North Region are working collaboratively with the support of ISD to develop a NoS data modelling tool that will provide short and long term projections of demand and capacity at speciality level. The tool utilises national data with local validation and facilitates scenario testing for specialities around managing waiting list size, long waiters and anticipated recurring capacity gaps. Initial speciality workshops to further validate and develop the data modelling tool are planned for December and January. An early example of the output from the tool is attached in Appendix 3.

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3. RECOMMENDATIONS The Transformation Programme Board is asked to note the progress to date of the Elective Care Centre Programme and the associated timeline for submission of the Initial Agreement, Outline Business Case and Full Business Case.

4. REPORT SIGN OFF

Ms Lorna Wiggin Ms L McLay

Chief Operating Officer Chief Executive Mrs Lynn Smith General Manager, Access

November 2017

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NHS Tayside Elective Care Centre

Appendix 1

Programme Governance

Core Project Team Membership

Project Role Name SRO & Programme Lead

Lorna Wiggin

Programme Manager

Darren Burgess (NSS)

Managerial Lead

Lynn Smith

Clinical Leads for Pathways & Design

Advert circulated

Finance Lead

Louise Greig

Health Intelligence Analyst

Kenny Scott

Public Involvement manager

Allyson Angus

Capital Planning Lead

Jonathan Milne

Project Support

Julie Gowans Carol Mayo (NOSPG)

Regional Elective Care

Strategic Case

June 2017

Document Control Information Version Number 12 (June 2017) Author(s) Jaime Lyon, NOSPG

Iain Buchan, Buchan + Associates Karen Pirrie, Buchan + Associates Graeme Smith, NHS Grampian Neil Strachan, NHS Grampian Jillian Evans, NHS Grampian Deb Jones, NHS Highland Donna Smith, NHS Highland Lorna Wiggin, NHS Tayside Lynn Smith, NHS Tayside

NORTH OF SCOTLAND

PLANNING GROUP

Appendix 2

0

Table of Contents

1 Executive Summary ........................................................................................................................ 2

2.1 Introduction & Context ......................................................................................................... 5

2.2 Current Arrangements .......................................................................................................... 6

2.3 Need for Change ................................................................................................................. 24

2.4 Investment Objectives ........................................................................................................ 31

2.5 Benefits, Risks, Constraints & Dependencies ................................................................. 32

3 Conclusion ........................................................................................................................... 34

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1 EXECUTIVE SUMMARY The challenges we face in meeting the health care needs of the North of Scotland population are fundamental and significant. Almost all Boards in Scotland are affected by an ageing population; financial pressures and waiting time targets - problems which are magnified in the North because of our particular demographics and geography. Without change in the way care is provided, performance, standards of care and ultimately health outcomes will worsen. Rural inequalities will also persist in the North of Scotland if we do not tackle issues concerning access to care for dispersed populations.

The decision by Scottish Government to invest in capital infrastructure to cope with the need for increased care is welcome. By enhancing the physical infrastructure in Boards across the North of Scotland we will increase the efficiency and consistency of care for our 1.3 million population and provide a positive experience for patients, staff and visitors.

Strategic planning for elective care in the North of Scotland involves a range of specialties and diagnostic services. Ophthalmology and Orthopaedics are the initial focus of this strategic case, firstly because they are particularly affected by the growing care needs of an ageing population in Scotland and as such they are considered ‘driver’ specialties for the purposes of regional planning. Secondly, these two specialties are the primary focus of NHS Highland’s elective care centre proposal and as such, a regional viewpoint approach has been taken at the request of Scottish Government. We anticipate the scope of regional elective care planning to evolve as individual Board plans develop. The issues uncovered in this strategic case illustrate that transforming health care delivery to meet future health care needs requires a multi-faceted approach involving workforce development; culture change and infrastructure improvement. A common sense of purpose to improve all services already exists in the North, including the development of children’s services, cancer services and unscheduled care. This specific case outlines the strategic aims of the North of Scotland in developing elective care and the endeavours that are necessary to achieve these. This strategic effort and collaboration will be part of our continuous improvement of services to create a model which is tailored to the geography and population distribution in the region, taking cognisance of the region’s workforce and financial constraints.

The following strategic case provides a detailed overview of the services of Ophthalmology and Orthopaedics: from how services are structured and population they serve, the activity they undertake; the performance against key national indicators as well as the challenges currently being faced in the short, medium and long-term by each Board, as well as collectively as a region.

In shaping a vision for elective care services across the North of Scotland the following strategic aims were agreed:

- Equity of access based on clinical urgency - Shared culture and drive to provide value added care for NoS residents - Regionally planned services reflecting critical mass and low volume activity, as

locally as possible and as specialist as necessary - Progressive and innovative workforce models to support service sustainability - Mobile communications and network technologies to enhance co-ordination of care

and local service delivery

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- Optimising physical and workforce capacity across all North of Scotland elective sites - Best value from collective resources and assets to achieve consistent standards and

“best in class” performance - Ensure there is a high level of collaborative working between NHS Boards and

Health and Social Care Partnerships to assess need and manage demand effectively

The need for change from a strategic perspective was set out in the Health and Social Care Delivery Plan published in December 2016, which included a commitment to strengthen population-based planning arrangements for hospital services, as part of the range of commitments to deliver the National Clinical Strategy. The proposal to review and consider reconfiguration of patient pathways is consistent with a central tenet of the Delivery Plan – that we should plan and deliver all services in a way that allows for the “triple aims” of Better Health, Better Care and Better Value to be met. For the purpose of the NoS strategic case the need for change focuses on the following areas:

• Addressing the demographic impact of an ageing population and the impact on projected procedures

• Balancing the demands for elective and unscheduled care • Current infrastructure unable to deliver the agreed “Best in Class” blueprint • Development of consistent care standards and processes across the North

Boards are already redesigning clinical roles and developing non-medical staff to sustain current and future service provision. This needs to be matched with physical infrastructure which is fit for purpose, future proofed and available for the entire North of Scotland population. Investment in permanent operating capacity; diagnostics infrastructure; one-stop and short stay facilities is important, particularly given the geography and dispersed population of the North. In all Boards, the need to re-organise and enhance physical infrastructure to improve co-ordination of care is crucial.

The following investment objectives have been agreed as common to the three mainland boards within the north of Scotland:

• Safe, timely & effective patient care provided locally with repatriation of patients from out of area

• Capacity to meet demand through improved pathways & facilities • Recruitment & retention of staff • Partnership and collaborative working across the North of Scotland ensuring

efficiency and effective pathways • Achievement of “best in class” blueprints consistently across the North of Scotland • Services delivered as locally as possible and as specialist as necessary

Capital and infrastructure investment is part of the solution to meet the future needs for elective care. This will be underpinned by a progressive and adaptive workforce in the North, and a service delivery model that enables consistent levels of practice and quality for patients. The NoS Boards have developed a common set of benefits, risks, constraints and dependencies. These will inform individual board proposals. In summary, this strategic case supports the development of the initial agreement for the investment in new facilities in Inverness as part of the emerging elective care strategy for the North of Scotland. Consequently, the regional case concentrates on Orthopaedics and Ophthalmology, as this is the specific focus of the Inverness development. However this will

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evolve in the coming months to include a broader range of services to support the proposed developments in Grampian and Tayside. The case presented demonstrates the common purpose of the Boards in the north region in relation to elective care, including the commitment to harmonise policies and pathways, and to integrate services as far as possible to assure optimal access and quality for the population of the north. The information provided highlights key issues in relation to activity and productivity, confirms the challenges in relation to population growth, and the future health care burden likely to be experienced by services and facilities. The information also sets out the challenges associated with the facilities used to deliver elective care services to patients both in terms of capacity i.e. physical size, and functional suitability i.e. their ability to support the delivery of efficient, modern and person centred care for patients. The strategic case for the development for new facilities and the modernisation of existing infrastructure is clear. The North of Scotland Boards are committed to co-ordinating efforts which maximise the collective benefits and efficiencies which can be gained from capital investment.

This strategic case for change is also a dynamic tool, grounded in a co-production approach which will be influenced as each board strategically appraises the future need for elective care based on a thorough examination of current service configuration and patient pathways. Individual initial agreements will be developed taking this into account.

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2.1 INTRODUCTION & CONTEXT

The Scottish Government has recognised the challenges faced by NHS Boards with addressing the healthcare demand associated with the projected increase in population, particularly within the over 65 age group. In response to this the Government announced, in October 2015, that an additional £200m would be invested in elective care facilities across Scotland with new facilities to be considered in Tayside, Grampian, Highland, Lothian and Glasgow.

The National Programme Board for Elective Care confirmed the approach to planning for the Elective Care Centres should be at a Regional level in the context of a regional strategy for elective care which will subsequently be reflected in the Regional Transformation and Investment Plans. The planning for Elective Centres has been taken forward on the basis of previous regional planning arrangements, with a regional approach commencing in October 2016 with the establishment of the regional project board.

Underpinning each individual Health Board’s elective care centre proposals is the Scottish Government’s mandate that all individual Health Board’s Initial Agreements include a Strategic Case which has a regional focus and has been prepared collaboratively with regional partners.

This document presents the Strategic Case for the North of Scotland and has been developed collaboratively with the mainland Boards of Tayside, Grampian and Highland with consultation from the Island Boards of Orkney, Shetland and the Western Isles. A common list of strategic aims has been agreed with the above mentioned Boards to assist with shaping the North of Scotland’s vision for the future. These are outlined below: Figure 1: Strategic Aims

- Equity of Access based on clinical urgency

- Shared culture and drive to provide value added care for NoS residents

- Regionally planned services reflecting critical mass and low volume activity as locally as possible, as specialist as necessary

- Progressive and innovative workforce models to support service sustainability

- Mobile communications and network technologies to enhance co-ordination of care and local service delivery

- Optimising of physical and workforce capacity across all North of Scotland elective sites

- Best value from collective resources and assets to achieve consistent standards and “best in class” performance

- Ensure there is a high level of collaborative working between NHS Boards and Health and Social Care Partnerships to assess need and manage demand effectively

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The regional strategic case will be used by each of the mainland boards in the development of their initials agreements. The strategic case for change identifies common investment objectives.

2.2 CURRENT ARRANGEMENTS Scope of Services in this Proposal The strategic case will continue to be developed as the initial agreements for the elective care centres in Grampian and Tayside are formulated with the aim of creating the regional strategic context for dealing with challenges at a more local system level. A brief summary of the approach being taken by NHS Highland, Grampian and Tayside is set out below. Figure 2: Scope of services by Board

Board Scope

NHS Highland

Part of a collaborative partnership with University of Highlands and Islands and Highlands & Islands Enterprise. This new elective care centre will contribute to the provision of regional healthcare, research and enterprise, as well as creating new teaching, training and employment opportunities - specifically concentrating on the specialties of Ophthalmology & Orthopaedics.

NHS Grampian

Whole scale development of elective care aiming to drive maximum benefit from existing capacity and resources and ensuring capital investment can be applied effectively across a review of 19 Medical & Surgical specialties. Orthopaedics and Ophthalmology are two of these specialties.

NHS Tayside

An Elective Care Centre to facilitate a reduction on the reliance of mobile theatres as well as creating capacity for a decant facility to underpin the Ninewells hospital environmental improvement plan. Two of the specialties included in Tayside’s scope are Ophthalmology & Orthopaedics although the final decision on services in scope has still to be determined. This will also provide an opportunity to link with our Academic Health Science Partnership colleagues to co-locate the new Cuschieri Skills Centre, facilitating world-class combined environment for healthcare delivery and education.

Each of the mainland boards across the North of Scotland has identified capacity and functional suitability issues related to their elective care facilities. This includes current and future capacity constraints in two service areas; Orthopaedics and Ophthalmology, where demographic changes and the need to optimise assets and resources beyond the current configuration is required to deliver ‘better health, better care, better value’. The regional strategic case will continue to evolve as each board identifies how services across the elective care spectrum will be delivered, as reviews are completed and productivity and efficiency gains are identified across the whole of the north of Scotland. The redesign opportunities will provide scope to improve access to services, maximising resources in line with national best practice. It should be recognised that as Grampian and Tayside move through their individual programmes of elective care work, the regional strategic case will evolve to ensure the regional components are covered for any other capital investment.

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It is anticipated that most, if not all, elective care pathways across the region may be affected by either the re-design of existing facilities or the relocation of some specialties into new builds.

Location & Catchment population of Current Services

The specialties are provided in the following locations in the North of Scotland :

Figure 3: Current catchment areas by Board:

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Note: The above map shows formal administrative boundaries but it is worth noting that patient flows will be determined by the development of logical pathways for services regardless of Health board boundaries.

Grampian Current Service Delivery Summary – Ophthalmology & Orthopaedics The NHS Grampian Ophthalmology service currently consists of 8.5wte Consultants, (with another Consultant due to take up post in July 2017 and one further vacancy) and 2wte Associate Specialists. They are supported by a team of Registrars, FY2s, Optometrists, Orthoptists, and nursing staff (including Specialist Nurses and Nurse Injectors).

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The service is predominantly delivered from Ward 203 and the Eye Outpatient Department at Aberdeen Royal Infirmary (ARI) with visiting services to Dr Grays, Elgin, and peripheral clinics across Aberdeenshire and Shetland. A paediatric service is also delivered from Royal Aberdeen Children’s Hospital (RACH). The secondary care team liaise closely with General Practice and in particular Community Optometry through the Eye Health Network which allows for shared services to be delivered across a range of sub-specialties. Regular meetings of the Eye Health Network board allow for governance of this process as well as discussion of new proposals and organisation of opportunities for professional development of optometrists involved in the network. The service provides a wide range of outpatient and inpatient elective ophthalmology with specialist clinicians in the areas of medical retina, surgical retina, glaucoma, occuloplastics, cornea and paediatrics. Out of hours, the service operate a comprehensive on-call involving FY2s, Registrars and Consultants. The elective inpatient and day case Orthopaedic services are delivered at Woodend Hospital in Aberdeen, Dr Gray’s Hospital in Elgin and at the Royal Aberdeen Children’s Hospital. At the Woodend site there are 6 dedicated theatres, 5 of which have laminar flow. Emergency Trauma surgery is delivered at ARI, though at times there is a requirement to move some trauma activity to Woodend. At Dr Gray’s there is both trauma and elective theatre activity mainly delivered through one theatre; similarly that is the case at RACH. Outpatient clinics are conducted at a number of locations, including on Orkney, and an arrangement exists between Golden Jubilee National Hospital and NHS Shetland to deliver non-complex procedures and outpatient clinics. Complex cases continue to be referred to the team at Woodend. Highland Current Service Delivery Summary – Ophthalmology and Orthopaedics The Ophthalmology service is consultant-led with a workforce of 8 WTE who currently work from several peripheral units including rural areas within NHS Highland, Orkney and The Western Isles, with the workforce spread over a wide geographical area. Adult inpatient beds are all within Raigmore Hospital. Operating is undertaken on a visiting basis within Caithness, Orkney and the Western Isles. Approximately 30% of the department workload is delivered out with Raigmore Hospital. Approximately 30,591 outpatient appointments occur in a year which represents 16% of NHS Highland’s total outpatient appointments. This includes Orthoptics and Optometry. Work is closely aligned with Community Optometrists who undertake all cataract reviews following surgery in addition to their routine activity. Out of hours activity is provided by the Raigmore consultant team who are first on-call and see patients within the inpatient facility at Raigmore Hospital. The operating theatre and day-case facility at Raigmore is a rented modular theatre with limited lifespan. The facilities within Raigmore Hospital are now inadequate for the provision of a high quality, modern service within the North of Scotland. With an increasing demand for Ophthalmology services and requirement to change practice in the future to deliver care in a different way including increasing the number of Virtual Clinics incorporating enhanced imagery is essential. The Orthopaedic service is consultant-led with a workforce of 13 WTE who provide inpatient and outpatient services within NHS Highland and The Falklands. Elective and Trauma surgery is only delivered at Raigmore Hospital and The Falklands, whilst clinics take place at Raigmore Hospital and 6 peripheral locations, plus The Falklands. Within Raigmore there is currently 1 elective theatre and 1 trauma theatre supplemented at the moment with a temporary Vanguard Theatre.

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Allied Health Professionals (AHP) work closely with the Orthopaedic team and work is ongoing to develop and progress pathways which allow further development of AHP roles. There is also a Nurse-led fracture clinic and arthroplasty service. A full consultant-led on-call service is presently provided within Raigmore Hospital. Both Ophthalmology and Orthopaedic services undertake Paediatric surgery within Raigmore Hospital and clinics throughout NHS Highland. Tayside Current Service Delivery Summary – Ophthalmology & Orthopaedics The Department of Ophthalmology is predominantly based at Ninewells Hospital, with peripheral clinics based at a number of other hospital sites across the Tayside region including Stracathro Hospital, Perth Royal Infirmary, Arbroath Infirmary and Montrose Cottage Hospital. Orthoptics, Optometry and Ophthalmic Imaging form part of the service and these services also deliver community based clinics and the school screening services across the region in a number of local health care facilities. The Ophthalmology Service has well established partnerships with Community Based Optometry Services across Tayside and North East Fife with direct referral pathways and post operative care for cataract pathways. The Ophthalmology Service reflects a range of general Ophthalmology and sub specialty Ophthalmology including Macular Retinal Services, Vitro Retinal Services, Stabsismus, Ocular Motility and OcculoPlastic. As the Ophthalmology Service is part of a large regional centre this offers many opportunities to develop areas of interest with other specialities in a multidisciplinary context including ENT and Neurosurgery. The Medical team currently consists of 10.3wte Consultants who work across a number of locations in Tayside. They are supported by Associate Specialists and Registrars. Out of hours the service provide a comprehensive on-call involving Registrars and Consultants. Junior staff have opportunities for experience across the consultant body for training and service commitment, assisting in clinics and theatres. The medical staff are supported by team of extremely experienced and dedicated nursing, optometry, orthoptics, ophthalmic imaging and administration staff and the Department has a very proactive approach to multidisciplinary skill mix development with nursing, orthoptics and optometry staff specialist roles for example nurse-led IVT injections, nurse led clinics and YAG Lasers. The Department at Ninewells Hospital has a dedicated 10 bedded Ophthalmology ward, and a 24 Day Case Treatment facility, emergency treatment room, outpatient clinic suite, ophthalmology imaging facility and IVT treatment room based in Ninewells Hospital with additional clinic facilities in Stracathro Hospital, Arbroath Hospital, Montrose Hospital and Perth Royal Infirmary. Development work is underway to explore extending the range of facilities available within Stracathro Hospital to include an IVT treatment room and ophthalmology imaging resource. There are 2 operating theatres entirely dedicated to Ophthalmology, and session resource for occuloplastic surgery at Stracathro Hospital. There is also a dedicated paediatric theatre attached to the paediatric surgical ward. The Department of Orthopaedic and Trauma Surgery provides services to people from Tayside and NE Fife comprising of an Orthopaedic Trauma service at Ninewells Hospital and PRI, an Orthopaedic Elective Surgical Service at Ninewells Hospital, PRI and Stracathro, and the Tayside Orthopaedic and Rehabilitation Technology Services and Tayside Rehabilitation Engineering Service from the Ninewells site. A 3 year SLA with Golden Jubilee is currently in place to support some foot and ankle activity. The service is consultant-led with x wte. There is a multi-disciplinary approach to development and management of patient pathways, optimising available resource.

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Functional Size

Figure 4: Key Points relating to Functional size – By Board

- Dispersed services across 11 sites in the North of Scotland reflecting local provision across vast geographical area – (70% of Scotland’s land mass)

- Regional and local sites have ring-fenced elective bed capacity (Woodend, Raigmore, Ninewells & Stracathro)

- Workforce constraints in Grampian can restrict physical theatre capacity

- Rural sites across Highland, Grampian and Tayside include shared Theatres with other specialties

The functional size of each site across the North is detailed below:

Figure 5: Ophthalmology Physical Beds and Day-Case Capacity – By Board

Ophthalmology Orthopaedics

Board Number of

Beds

Number of Day Case Spaces

Number of Beds

Number of Day Case Spaces

Highland 4 24 52 n/a

Grampian 7 6 137 6

Tayside 10* 30 108 10

Total 21 60 297 16 *Tayside beds open Monday – Friday 9am – 5pm

Ophthalmology is predominantly a day-case service with only a small element of activity categorised as in-patients, this is reflected in the number of beds available for this specialty.

Appendix 1 provides a more detailed analysis of bed, theatre and day case complement by site as well as by Board. Service Theatre Capacity & Utilisation

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The existing elective theatre availability is shown below: Figure 6: Elective Weekly Theatre Capacity – By Board

Ophthalmology Orthopaedics

Board No. of

theatres No. of

sessions No. of

theatres No. of

sessions

Highland 1^ 10 2 20

Grampian 6* 19 9 71

Tayside 2 20 4 42

Total 9 49 15 133 *Theatres not solely used for Ophthalmology ^Raigmore Theatre only, in addition NHS Highland Consultants operate in General Theatres in Wick, Western Isles and Orkney which equates to 2 sessions per week. Figure 6 highlights the dedicated Orthopaedic and Ophthalmology sessions at board level but does not take into account theatre sessions delivered within other locations within Highland, Tayside and Grampian that are shared sessions. It should be noted at the time of writing 20 of the 71 theatre sessions in Grampian are currently unavailable due to staffing shortages. Theatre Utilisation NSS Discovery has developed a national theatre efficiency dashboard with four indicators measured against planned sessions at a specialty level. The two bar charts below illustrate where Tayside, Grampian and Highland have performed against these measures as well as bench-marking this against the average for all Health Boards in Scotland. Figure 7: Orthopaedic Theatre Efficiency November 2016 – February 2017

The information in the above chart can be summarised into a “Total Unproductive %” with each Board ranging from 23% to 26% for Orthopaedics. Figure 8: Ophthalmology Theatre Efficiency November 2016 – February 2017

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The information in the above chart can be summarised into a “Total Unproductive %” with each Board ranging from 31% to 36% for Ophthalmology. The four month period of November 2016 – February 2017 has been selected as this was the most accurate data period consistent for all three Boards that would provide the most complete data collection period. It should be noted that the utilisation shown in the above time period for NHS Tayside is lower than normal average due to service and workforce pressures that required a prioritisation of IVT delivery over surgical procedures. NHS Tayside’s annual utilisation for the period April 2016 – March 2017 was 83.3% and is a more accurate reflection of this Boards performance. Current Activity Figure 9: Key Points relating to Orthopaedic & Ophthalmology Elective IP/DC and Out-Patient Activity

- 78.6% of total Ophthalmology IP/DC activity can be attributed to cataract surgery ranging from 72% to 85% across all Boards

- Over one third of Orthopaedic IP/DC activity in the NoS relates to hip and knee surgery.

- New to return ratio for Ophthalmology outpatients in the NoS is 3.36, ranging from 3.3 to 3.5 between the Boards. This compares to 2.2 on average across Scotland.

- New to return ratio for Orthopaedic outpatients in the NoS is 1.75, ranging from 1.4 to 2.02 between the Boards. This compares to 1.5 on average across Scotland.

Figure 10: Ophthalmology Cataract & Other IP/DC Activity (April 2016 – March 2017)

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Figure 11: Orthopaedics – Total IP/DC Elective Activity (April 2016 – March 2017)

Figure 12: Ophthalmology – Total New & Return OP Activity (April 2016 – March 2017)

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Figure 13: Orthopaedics – Total New & Return OP Activity (April 2016 – March 2017)

Activity undertaken out-with the North of Scotland

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Figure 14: Key Points relating to Out-sourced Elective IP/DC Activity – April 2016 – March 2017

- An average of 11% of Ophthalmology activity has been out-sourced across the North in 2016/17, ranging from 2.2% to 26% across the mainland Boards.

- The above equates to 1,037 procedures of which 91% related to cataract activity

- An average of 4.6% of Orthopaedic activity in Grampian, Highland and Tayside was outsourced in 2016/17(545 procedures). 58% related to hips and knees with 42% relating to other Orthopaedic procedures. (61% of the “other” is for foot and ankle surgery relating to Tayside residents)

A significant number of patients currently travel out-with the North of Scotland for their elective procedures. In planning for future elective care service delivery, it is anticipated that activity will be repatriated to NoS Boards. Further discussion with relevant Boards will be required, specifically regarding potential revenue consequences; however this project will provide the physical capacity for such work. For Ophthalmology, only Grampian and Highland used external providers in 2016/17. 8% of outsourced activity was provided by the Golden Jubilee National Hospital. 92% was provided by independent sector and/or delivered on NHS sites. In particular, 106 cataract procedures were carried out on the Raigmore site with 750 cataracts on the ARI site and by a private provider. For Orthopaedics, Grampian and Highland used external providers for hips and knees whereas Tayside have only out-sourced activity for foot and ankle surgery. Outsourced activity was provided by the independent sector (77%) and Golden Jubilee (23%). Not all capacity available through external contract with the Independent Sector or Golden Jubilee has been utilised by NoS Boards. This is mainly due to patients being unwilling to travel out-with their host Board area for treatment. Figure 15: Ophthalmology: Total Elective IP/DC Activity Out-sourced (April 2016 – March 2017)

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Figure 16: Orthopaedics: Total Elective IP/DC Activity Out-sourced (April 2016 – February 2017)

Current Performance The following tables set out some key metrics for the two specialities covering the period April 2016 – March 2017: Figure 17: BADS rate by Board

Board Ophthalmology Orthopaedics Tayside 91.50% 93.90% Highland 99.00% 90.70% Grampian 87.2% 84.4%

Figure 18: Elective Average Length of Stay by Board

Board Ophthalmology Orthopaedics Tayside 1.6 3.8 Highland 1.4 3.8 Grampian 1.9 3.9 Best in Class Blueprint n/a 4 National Average n/a 3.2

Figure 19: Pre-Operative Stay by Board

Board Ophthalmology Orthopaedics Tayside 0.14 0.07 Highland 0.00 0.09 Grampian 0.09 0.61 National Average 0.09 0.24

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Figure 20: Current Number of Cataracts and Hip/Knee Joints per 3.5 Hour Theatre Session – By Board

Board Cataracts per 3.5 hour session

Joints per 3.5 hour session

Tayside 5 3 (for all-day lists) Highland 6 1.7 hips /1.6 knees

Grampian 6 2 (for AM list) 1 for

PM list Best in Class 7 2

Note: Information for average length of stay and pre-op stay have been extracted from a Discovery dashboard prepared by the Discovery wrap-around service for the specialties of Ophthalmology and Orthopaedics, all other information in the performance section has been provided by Boards Demand The number of patients waiting longer than 12 weeks for a first OP consultation is one indication of a demand/capacity gap (Figure 21). Waiting time performance is affected by increased demand, service capacity and organisation.

Outpatient performance fluctuates, but it is generally understood to be deteriorating and acknowledged to be unsustainable. In addition, delays in outpatient care with its subsequent impact on IP/DC masks the actual demand for treatment, evident through the reducing additions to the IP/DC waiting list.

The graphs below illustrate this point for both the specialties of Ophthalmology and Orthopaedics. Figure 21: Ophthalmology & Orthopaedics – Patients waiting > 12 weeks for 1st OP Appointment

39% of all outpatients waiting over 12 weeks relate to Ophthalmology and Orthopaedics.

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The graphs that follow look at demand for IP/DC in both specialties. As mentioned earlier however, the demand and capacity gap for outpatients masks the real demand for IP/DC. The gap between the additions and removals to the waiting list is shown for the calendar years of 2013 - 2016 (net additions) which gives an indication of the size of the IP/DC gap. Figure 22: Net Additions to the Waiting List – Ophthalmology (2013 – 2016)

Figure 23: Net Additions to the Waiting List – Orthopaedics (2013 – 2016)

Another indication of the demand and capacity gap is waiting time performance. Figures 24 to 26 illustrate how performance has worsened in the past year.

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Figure 24: Ophthalmology – 12 week TTG Position (April 2016 – February 2017) – % Patients Treated within 12 weeks

Figure 25: Orthopaedics – 12 week TTG Position (April 2016 – February 2017) – % Patients Treated within 12 weeks

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Figure 26: Ophthalmology & Orthopaedics – TTG Position – Patients Waiting > 12 Weeks for IP/DC

Workforce Challenges (Short, Medium and Long-Term) This section summarises the challenges faced across the mainland NoS Boards with regard to the multi-disciplinary workforce for the specialties of Ophthalmology and Orthopaedics. Ophthalmology Common short-term challenges faced by Highland, Tayside and Grampian include:

• Sick leave, particularly in vulnerable sub specialties (paediatric) • Consultant recruitment difficulties and resultant pressure on business continuity

including on call

Particularly in Highland, the geographical coverage of service means significant travelling for clinical staff impacting negatively on productivity and staff experience. In Grampian, the difficulty of securing recurring funding to redesign and enhance nursing roles to manage increased demand for care (e.g. Age Macular Degeneration (AMD) has impacted on consultant time. Shortages of staff, including theatre nursing and consultant staff has impacted significantly on productivity and the ability to use physical capacity in ARI and Dr Grays effectively. Medium term challenges faced by Highland, Tayside and Grampian include:

• Recruitment of clinical staff, and on-going workload pressures whilst vacancies remain unfilled

• Redesign of advanced nursing roles to allow surgical assistance with cataract surgery

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Tayside are experiencing particular challenges with providing an out-of-hours service for their VR service (Vitreoretinal) whilst in the process of recruiting to a vacant post

Challenges which Boards are expecting to be longer-term and will require carefully managed include:

• Consultant recruitment within Highland • Optometrist recruitment within both Tayside and Highland • Availability of Theatre staffing within Grampian • Significant demand on the AMD service across the North requiring additional

investment to ensure nurse practitioners are suitably trained to carry out injections • Provision of a robust and safe out-of-hours VR service

Orthopaedics Recent challenges faced by Highland, Grampian and Tayside include:

• Service vulnerability due to sickness absence in sub specialties • Recruitment and retention of middle grade clinical staff • Recruitment and retention of theatre teams (anaesthetics and nursing) • Redesign of non medical roles to cope with increasing demand for care • High cost of providing care, particularly through the use of expensive locums and

independent sector.

In Grampian there are particular challenges associated with the availability of post-op HDU level care as well as junior doctor cover at Woodend Hospital. Similar problems are likely to endure in the medium and longer term for Boards with the key themes including:

• Redesign of non-medical roles eg. Nurse practitioner • Recruitment and retention of middle grade clinical staff • Significant high cost of medical locums

The redesign of non-medical roles and recurring solutions for recruitment of dedicated theatre teams are crucial to maximise efficiency and quality. Service Providers

Within the North of Scotland, NHS Highland, NHS Tayside and NHS Grampian are the service providers. All clinical and non-clinical workforce and support services including domestics, decontamination (SSD) and patient transport services are managed by the North of Scotland Health Boards.

Associated Buildings and Assets

Each of the Boards within the North of Scotland’s Property Strategy Management Groups seek to ensure that the asset portfolio of each Board is both utilised as effectively as possible and is planned and developed in line with the need to improve accommodation and reduce waste and duplication. The Group seeks to ensure that all property in the NoS Boards support the goals of achieving an acceptable asset management categorisation level, and facilitates the maximisation of occupancy and utilisation of assets.

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NHS Highland

The main estate for Orthopaedics is the theatre block with one ward and an outpatient clinic. These are being currently refurbished and as such they are condition B with the outpatient clinic as condition D. The ophthalmology estate is condition D with the exception of the modular theatre which is condition C. The backlog maintenance associated with The Orthopaedic service is limited to the outpatient clinic, as this is one part of a larger facility. As to functional suitability, the theatre is condition B, ward area is condition C with the outpatient clinics being condition D. For space utilisation, theatre area is condition B, the ward area condition C and out patients is condition D for both specialties. NHS Tayside Ninewells Hospital is split into 38 blocks and all are assessed as a condition B, however, the Physical Condition facet is subdivided into Building and Engineering elements and one or some of these 19 individual elements could be in a poor or unacceptable condition and therefore have backlog maintenance costs associated with them. Tayside therefore, have buildings in a satisfactory condition but investment is required for certain elements of the building to ensure it remains in a B condition, for example electrical infrastructure.

The present electrical infrastructure including emergency power generators, switchgear, primary and secondary distribution cabling and distribution boards date back to the original electrical installation and as such are now some 40 plus years old and components are obsolete. Following the original electrical installation the Ninewells site has expanded beyond its original footprint by approx 50%. There have also been advancements in clinical technology resulting in capacity pressures on the existing (normal and emergency) electrical installations. The current electrical systems are non- compliant with current technical standards (SHTM06). Due to the impact on clinical activity and the existence of many single points of failure within the primary electrical systems, planned maintenance and testing is prevented from being carried out. This increases the risk of outages within the Hospital. The lack of available electrical capacity severely constrains any additional electrical load required for improvement to clinical care. Therefore, clinical projects are unable to proceed resulting in clinical risks not being addressed. As identified by the 2013 Energy Survey the condition of the current electrical systems; the lack of normal and emergency power supplies and non-compliance with current NHS Scotland Technical Standards demonstrate the need for change. NHS Grampian ARI Eye Out Patient department – This service will move to the Phase 1 yellow zone once it has been re-furbished to B condition and made functionally suitable for the services provided.

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The ARI short stay surgery wards 301/2 used for multiple specialties - is generally in a B condition although functional suitability is a C condition due to current bed spacing standards. ARI short stay theatre 3 used for ophthalmology – is generally in a B condition although the theatre ventilation is in requirement of upgrading works. ARI ophthalmology ward 203 - is generally in a B condition although functional suitability is a C condition due to current bed spacing standards. ARI main theatre suite G10, used by ophthalmology - is generally in a B condition although the theatre ventilation is in requirement of upgrading works. Dr Gray’s outpatient department – is in a B Condition and is a B Functional Suitability. Dr Gray’s theatre’s - in C condition requiring some upgrading works but is functionally suitable (B). Woodend Hospital Out Patient Department – is generally in a B condition however additional Consulting space is required to improve the functional suitability from C to B condition. Woodend Hospital Orthopaedic wards 7, 8, 9 & 10 – are in a B Condition although functional suitability is a C condition due to current bed spacing standards.Woodend Orthopaedics theatres 1-6 - generally in a B condition although the theatre ultra clean ventilation is in requirement of upgrading works. Impact of DO Nothing It is clear that existing pressures will magnify without change in the way services are delivered. Endeavours to improve efficiency and achieve consistent standards of care are ongoing, including national programmes such as the collaborative programmes for Orthopaedics and Ophthalmology.

However the challenges for healthcare in the future are more fundamental, significant and enduring. Many affect all Boards in Scotland - an ageing population; financial pressures and waiting time targets. However these are intensified in the North because of our particular demographics and geography. Without change in the way care is provided, performance, standards of care and ultimately health outcomes will deteriorate.

Rural inequalities will persist if we do not tackle the issues concerning access to care for dispersed populations. This challenge is unique to the North of Scotland which has 70% of Scotland’s land mass and is reflected in the dispersed nature of sites and services.

Similarly our approach to tackling our workforce issues require to be tailored to the unique challenges of the North of Scotland. In order to attract and retain a high calibre workforce which meets increasing demand for care, we need a conducive and progressive environment which allows innovation and high standards of care to flourish. Any successful recruitment efforts will be short lived if we do not enhance our physical capacity and create the right cultural conditions to optimise our collective resources and assets for effective, progressive and co-ordinated working across the North of Scotland.

The Boards recognise that significant improvement programmes are required to ensure the minimisation of waste and variation from the overall healthcare systems. Across the NoS boards are implementing a number of national and locally designed improvement programmes including the national Orthopaedic and Ophthalmic collaborative, theatre efficiency and improving flow across the health and care interfaces. Although these programmes are creating momentum; these alone will not achieve the projected additional capacity requirements to meet future demand

The regional planning work will support the programme of work to ensure there are consistent assumptions made within Boards, regionally and nationally to plan the Elective Centre developments. This will include projections of patient flows.

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2.3 NEED FOR CHANGE Figure 27: Key Points relating to the Need for Change This section sets out the need for change which is based on the following areas:

- Addressing the demographic impact of an ageing population and the impact on projected procedures

- Balancing the demands for elective and unscheduled care

- Current infrastructure unable to deliver the agreed “Best in Class” blueprint

- Development of consistent care standards and processes across the North

Impact of demographic challenge

As outlined in the current arrangements each board is facing a considerable challenge to meet out-patient waiting time targets and treatment time guarantees.

Furthermore, population projections estimate that within the North of Scotland, the population will increase from 1.378 million to 1.540 million between 2015 and 2037, with the greatest increase in the over 65 age group. This will undoubtedly add to the considerable pressure within elective care.

The line graph below illustrates this growth. Growth to 2027 is anticipated to be 35.7% and to 2037 56.7% from 2012.

Figure 28: 65+ Population Projections by Health Board – North of Scotland

To quantify the impact of the population projections, Scottish Government’s Access Support team recommended and agreed national planning assumptions related to growth for cataract, hip and knee procedures. These assumptions are tabled below:

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Figure 29: Scottish Government National Planning Assumptions

Scottish Government National Planning Assumptions

Procedure Projections

Min % Growth to

2015

Max % Growth to

2025

Cataracts 20% 50%

Hips 40% 80%

Knees 30% 60%

It is recognised that any capacity modelling undertaken to determine future capacity requirements should allow and factor in the impact of any known programmes of work that relate to either Ophthalmology or Orthopaedics.

There are some opportunities for improvement specifically for Orthopaedics with the on-going progress from Boards regarding the Trauma & Orthopaedic ACCESS review final report titled “Addressing Core Capacity Everywhere in Scotland Sustainably”. For Ophthalmology the recently concluded National Review of Ophthalmology: Hospital Eye Services which also outlines improvements that Boards are required to undertake.

The table below lays out for the North of Scotland the projections anticipated for specific high-volume procedures within Orthopaedics (hips & knees) and Ophthalmology (cataracts).

Figure 30: Projected Increase in Procedures

North Region - Anticipated Growth (based on SG National Planning Assumptions)

Procedure Projections

2015 Elective Activity

NoS

Min % Growth to 2025

Max % Growth to 2025

Min Additional growth to

2025

Max Additional growth to

2025

Cataracts 6,736 8,083 10,104 1,347 3,368

Hips 1,502 2,103 2,704 601 1,202

Knees 1,431 1,860 2,290 429 859 Balance demands for elective and unscheduled care

The relationship between staff, theatres and beds is fundamental to the successful delivery of quality patient care. In a number of cases there is a lack of separation between elective and emergency inpatient accommodation within the majority of board areas. This in turn impacts adversely on elective care procedures which can be cancelled at short notice due to increased unscheduled care workload.

26

This can be reflected in the number of elective surgery cancellations, however when pressures are anticipated, planning and booking of elective patients is often reduced (as in the case of Grampian and Highland during winter 2017). The use of stand-alone metrics therefore masks the fundamental pressures and ways of working. A better demonstration of patient and organisational effects is best done by combining metrics such as Boarders, waiting times for unscheduled and scheduled procedures and elective throughput. Although we have not included an assessment of Boarders within this strategic case due to the availability of data, the other metrics throughout the case indicate the pressures and inter-related nature of unscheduled and elective care. The National Clinical Strategy for Scotland also outlines the benefits and improved outcomes felt when there is a separation of elective and unscheduled activity on the health of the population.

Facilities and infrastructure to deliver to agreed “Best in Class” Blueprints

The current plans for the Elective Centres projects will have a significant focus on Orthopaedics and Ophthalmology as a national theme (although these are not the only specialties planned as part of the regional approach). This provides an ideal context and impetus for pursuing and implementing service model blueprints for Ophthalmology and Orthopaedics. Supported by Boards, Chief Medical Officer and Chief Nursing Officer, the concept of a “best in class” blueprint will build on the clinically led national collaborative work already in progress and help to create consistent pathways of care. Work on variation and realistic healthcare will also be part of this national work programme. In addition, the national “peer reviews” for Ophthalmology and Orthopaedics have led to Board specific improvement plans to reduce variation, which will be supported and implemented regionally. It is intended that the “best in class service blueprint” will be framed in plain English and will clarify at each stage why achieving this is important to the public in delivering safe, effective and truly person centred care. The March National Programme Board approved the setting up of a sub group to support the development of this work stream.

The system is under strain with increasing pressure for services and growing waiting times for treatment. The current pressures we have will be magnified as our population ages. Without significant elective care service redesign and investment in additional supporting infrastructure, there will be inadequate capacity to deliver the additional workload associated with meeting national access targets and increasing demand linked to population growth. (eg. Inadequate pre-operative assessment area within Grampian)

There are also deficits in operating theatre capacity across the region (size, configuration and technology infrastructure), particularly with regard to the incorporation of enhanced intra-operative imaging techniques. (eg. Mobile theatres have been a feature within Highland and Tayside for a number of years)

The need for the redevelopment is also based on the limitations and age of the current estate and buildings across the North. The condition of buildings and the infrastructure that supports them is deteriorating and many now require investment and refurbishment to meet current Scottish Health Planning Note guidance. In many cases, clinical adjacencies do not support current models of care resulting in significant inefficiencies and a sub-optimal care environment for patients, staff and visitors. (eg, Ninewells Hospital requires a significant amount of infrastructure works)

27

Development of consistent processes across the North reducing variation

The National work which has been progressed collaboratively between Boards, the Regional team and Scottish Government, concerning the specialties of Orthopaedics’ and Ophthalmology referenced earlier in the strategic case, has resulted in Board focussed improvement plans following peer review visits. Each mainland Board within the North has adopted improvement methodologies aimed at transforming the quality of care through the reduction of harm waste and variation. In defining the strategic case boards have acknowledged the need to establish standard work in those areas where cross boundary flows are required to maximise the asset base. Other drivers for change

There are a number of national, regional and local strategies and policies which are other drivers for change. These are summarised below:

Figure 31: Other Drivers for Change

Level Policy Impact

National

National Clinical Strategy Consideration of Regional planning of services where the evidence base is strong in this area

2020 Vision for Health & Social Care:

Explicitly the need for effective use of NHS capacity (eg.when hospital treatment is required, and cannot be provided in a community setting, day case treatment will be the norm)

Health & Social Care Delivery Plan:

Population based planning (National, Regional, Local) to be strengthened

20:20 Workforce Vision & Route Map - 12 Priority Areas for Action, Pan Scotland Workforce Planning Report and the Public Bodies (Joint Working) (Scotland) Act 2014

Specifically around creating a sustainable workforce

Regional Regional Clinical Strategy

Adopting a regional approach to addressing service sustainability challenges

Local

Tayside Clinical Strategy & Tayside Transformation Programme

Radical Programme of redesign and reform to improve the sustainability of services and enhance quality of care

Grampian Clinical Strategy

Strategic plan for prevention; self-management; elective and unscheduled care. It focuses on enabling strategies which will manage future needs for care; increasing system wide capacity and improving efficiency in all endeavours.

Highland Quality Approach

Framework for creating an improvement culture, which seeks to put quality first to deliver better health, better care and better value

Western Isles

Orkney

28

Shetland All of the above address the delivery and adequacy of health care services and emphasise the requirement to have a person-centred health care system.

Summary of the need for change

A detailed summary of the causes and need for change, the effect this is having on current service delivery as well as explanation on why action is required can be found in the table below with each area linked to one of the four summary areas identified at the beginning of this section of the case.

Addressing the demographic impact of an ageing population and the impact on projected procedures

What is the need for change?

What effect is it having, or likely to have, on the

organisation? Why action now? Reliably and consistently meeting waiting time targets (current & future).

Faster, appropriate access to care leading to better outcomes

Performance is worsening and unsustainable

Rural access inequalities where centralisation of services does not promote care closer to home;

Persistent and enduring inequalities in health and poorer outcomes for patients

Unacceptable situation which cuts across strategic aim of reducing inequality

Common agreement and assumptions about future need for care required – and the value added activities for health improvement and outcomes

Pursuit of triple aim “population health; effective care and best value”

Pursuit of national, regional and local strategies on realistic health care

Balancing the demand for elective and unscheduled care



organisation? Why action now? Separation of elective and unscheduled care to improve patient experience, outcomes and workforce effectiveness

Effective care, reliable and safe processes and greater productivity

Pursuit of greater efficiency, effectiveness and patient experience

29

Current infrastructure unable to deliver the agreed “best in class” blueprint model



organisation? Why action now?

Provision of "one stop" services

"One Stop" treatment will be implemented as the norm (where appropriate) with diagnostic services and facilities re-organised in support.

Poor patient experience particularly for rural populations.

Fragmentation of services and poor co-ordination of care

Creates an efficient environment to deliver high quality elective care services. Improved processes and minimisation of 'hand-offs'. Reduces waste and non-value adding interactions. Ensures consistency of quality.

Lack of co-located services in appropriate environment leads to inefficient working and difficulty in co-ordinating care

Current facilities are unsuitable to deliver optimal model of care.

Creates an efficient environment to deliver high quality elective care services. Improved processes and minimisation of 'hand-offs'. Reduces waste and non-value adding interactions. Ensures consistency of quality.

The environment for patients will deteriorate if action is not taken now to improve condition of buildings and current infrastructure

IT infrastructure to support radically different approaches to care e.g.inter-regional communication, tele-medicine clinics.

Increased self management and shared decision making with patients Virtual consultations Better co-ordination of secondary and primary care within local and regional systems Changing culture and adaptability

Pursuit of national, regional and local strategies for realistic and co-ordinated care

Development of consistent care pathways and processes across the North



organisation? Why action now?

Improved efficiency and productivity of theatres

Productivity, throughput and value for money

Increase in efficiency to deliver current waiting times and standards

Travel times to diagnostic and treatment facilities within rural context

Improved access to diagnostic and treatment facilities. Services as local as possible.

Across the North access to services is currently not equitable when compared to the rest of Scotland

Over reliance on elective care delivered by Independent Hospitals due to a lack of capacity within NHS Scotand.

Reinvest independent sector spending into local and regional NHS services and develop local capacity

Financial sustainability and development of local services

30

Inadequate sharing of infrastructure (facilities) and resources (workforce) across the North of Scotland.

Population based planning. Potential to use the North of Scotland 'global' resource.

Current structure of services are not set up to cope with current demand without considering the increase in population anticipated in the next ten years

Improved inter and intra regional working to create more sustainable and efficient service solutions (workforce and infrastructure).

An improved multi-centre approach to smooth peaks of demand across regional boundaries. Whole system collaboration.

Current structure of services are not set up to cope with current demand without considering the increase in population anticipated in the next ten years

31

3 INVESTMENT OBJECTIVES Using the agreed principles set out, the North of Scotland boards have developed the following Investment Objectives: Figure 34: Investment Objectives

Effect of the need for change on the organisation:

What has to be achieved to deliver the necessary change (Investment Objectives)

Equity of access across the North of Scotland based on clinical priority

Shared capacity and access agreements across NoS Boards, including repatriation of services provided out of area

Optimisation of physical and workforce capacity across all North of Scotland elective sites

Improved facilities in place underpinned by a standard “best in class blueprints” to ensure consistent levels of practice, quality and efficiency

Progressive and innovative workforce models to support service sustainability

Improved recruitment and retention of staff, through reinvestment of outsourced spending into NoS economy

Mobile communications and network technologies to enhance co-ordination of care and local service delivery

Vision for and implementation of information communication technologies that transform service delivery

Shared culture and drive to provide value added care for NoS residents

Partnership and collaborative working across the North of Scotland ensuring efficiency and effective services

Best value from collective resources and assets to achieve consistent standards and “best in class” performance

Agreement and implementation of “Best in Class” blueprints across the North of Scotland for consistent standards and quality of care

Regionally planned services reflecting critical mass and low volume activity

Services delivered as locally as possible as specialist as necessary

Each of the identified investment objectives will be elaborated on further in each individual Boards initial agreement’s as they move through their own elective care programmes of work.

32

3.1 Benefits, Risks, Constraints & Dependencies This NoS Boards have developed a common set of benefits, risks, constraints and dependencies. Each individual project will include any at specific board level. Benefits The benefits have been identified in line with the three dimensions of the Quality Strategy – Safe, Person Centred and Efficient and are outlined below; Figure 35: Benefits

Quality Dimension Identified Benefit

Person Centred

Seperation of planned surgical services from unscheduled services

Improve equity of access to a wide range of secondary and tertiary services associated with modern acute surgical practice

The redevelopment of facilities will markedly improve the quality of the service provided and a much improved environment for both patients Enhance patient experience by providing care tailored to individual needs of the patient Improve patient choice by optimising patient pathways

Compliance with legislation providing a modern, purpose-built facility to enhance privacy, dignity and patient experience

Safe

Improve efficiency of the surgical service across the North of Scotland and to develop safe predictable elective services

Improved ability to support the HAI agenda for the inpatient surgical population Consistently deliver high quality care in a safe environment Allowing the development of specialist services locally where volume, outcomes and evidence permits Improved staff experience

Efficient

Develop partnership arrangements within the North of Scotland to promote and deliver a comprehensive range of value for money integrated services

Reduction in bed shortages assisting achievement of key performance targets and reducing cancellations for elective surgery

Opportunity for re-engineering the clinical models and patient pathways in order to improve utilisation

Patient care will be improved as service co-location and adjacencies support improved efficiency, productivity and patient experience

Providing a flexible working environment from an estates, facilities and service perspective

33

A Benefits Register will be developed for each project to record all the main benefits that are expected to flow from addressing the need for change and establish who is responsible for realising them and the means by which to monitor progress.

Risks

The risks have been identified within the following areas and are outlined below; Figure 36: Risks Risk Heading Identified Risk

Demand & Capacity

The population projections and the consequent population demand exceeds or over estimates current estimates

Organisation

System Wide Approach: securing system wide ownership and engagement i.e. from HSCPs and primary care to ensure that upstream solutions can be implemented e.g. in relation to the development of primary care capacity, self care etc.

Coordination of all elective care redesign activity to ensure maximum impact

Reputation

Public acceptability: patients and the public may not accept alternative ways of working e.g. delivery of care by different professionals, application of digital health initiatives etc

Funding

Hidden Capacity: the programme does not reveal significant hidden capacity to contribute to the efficient application of capital

Deliver services within identified revenue budget, currently no revenue consequence funding identified by Scottish Government

Timescale Converting the outcomes of the clinical engagement into viable plans for capital expenditure

Staffing Clinical Engagement: achieving a high level of clinical engagement to gain ownership of more efficient ways of working

A risk register will be developed for each individual Board elective care project and each risk scored and a mitigation / management action set out.

Constraints

The following areas have been identified as limitations on the investment proposal:

• Physical site for the construction works eg. for Tayside due to this being located within the boundary of the existing Ninewells Hospital

• The availability of capital for all the projects • Facilities available from 2020/21 • Availability of revenue funding (both short and long-term)

Dependencies

The following areas have been identified as actions which are required from others to ensure the success of proposal:

34

• Reaching a consistent agreement on the model on a national and regional basis • Clinical consensus to the agreed target operating model • Scottish Ambulance Service provides a solution with meets the need of the

identified model • Data sharing and national portal available • Funding currently top sliced for Golden Jubilee Hospital is returned to North of

Scotland boards to support delivery of services within the north • Agreed planning assumptions between projects

4 CONCLUSION Elective care strategic planning in the North of Scotland involves a range of specialties and diagnostic services. Ophthalmology and Orthopaedics are the focus of this strategic case because they are most affected by the growing care needs of an ageing population in Scotland as well as being the primary focus for NHS Highland’s Elective Care Centre proposal. As such they can be considered ‘driver’ specialties for the purposes of regional planning whilst individual Boards develop specific plans to address unique challenges. We anticipate the scope of regional strategic planning to evolve as individual Board plans develop. It is clear that transforming health care delivery to meet future health care needs requires a multi-faceted approach involving workforce development; culture change and infrastructure improvement. This case outlines the strategic aims of the North of Scotland in developing elective care and the endeavours that are necessary to achieve these. The challenges for improving elective care in Scotland are intensified in the North because of our particular demographics and geography. Without change in the way care is provided, performance, standards of care and ultimately health outcomes will deteriorate and rural inequalities will persist if we do not tackle the issues concerning access to care for dispersed populations. Capital and infrastructure investment is part of the solution to meet the future needs for elective care. This will be underpinned by a progressive and adaptive workforce in the North, and a service delivery model that enables consistent levels of practice and quality for patients.

35

Appendix 1 – Functional Size of Ophthalmology and Orthopaedics – By Site/Board

Board Hospital Number of Beds Number of Theatres

Number of Day case spaces (Dedicated day case & ward bed complement

Highland

Raigmore

Ophthalmology 4 (E)

Orthopaedics 22 (E)

Orthopaedics 30 (Trauma)

Ophthalmology 1 modular

Orthopaedics 1 E, 1 trauma & 1

Vanguard

Ophthalmology 6 chairs

Orthopaedics 1 multi specialty ward

Caithness General Hospital, Wick

Ophthalmology 1 shared theatre

with other specialties


Kirkwall Hospital, Orkney




Stornoway




Tayside

Ninewells

92* (82 Orthopaedic,

10 Ophthalmology)

Ophthalmology: 2 (Ths 14 & 15

5days)

Orthopaedics: 1.2 (Th 1 5

days, & Th 16 1 day)

12 – DSU shared resource with general

surgery

30 - Ophthalmology DBU

PRI 18**

(18 Orthopaedics)


days, Th 5 4 days, Th 2 2x ½ days, DSU 2 1

day)

6 – Shared resource Orthopaedics and General Surgery

Stracathro 8**

(8 Orthopaedics)


days, Th 2 3 days)

10

(10 Orthopaedics)

Grampian

ARI Ophthalmology 7

Orthopaedics 45

Ophthalmology 2

36

(Ortho should all be for non-electives)

Dr.Grays Orthopaedics 20

Ophthalmology 2

Orthopaedics 1

Royal Aberdeen Children’s Hospital

Orthopaedics 4 Ophthalmology 2

Orthopaedics 2

Woodend Orthopaedics 68 (primarily elective) Orthopaedics 6

Wd 7 - 10 beds and 6 chairs (primarily day

case)

37

Appendix 2 – Detailed Physical Elective Theatre Capacity – By Site/Board

Board Hospital Site Theatre availability

Orthopaedic Ophthalmology

Tayside

Theatre 1 (NWS)

2 sessions per day, 5 days per week

Theatre 16 (NWS)

2 sessions per every Tuesday

Main Suite (PRI)

3 theatres having, 10 sessions per week x 3 = 30

sessions - 5 trauma sessions = 25, there are 3 unfunded

orthopaedic sessions / week where no activity takes place as it's not resourced so that

brings funded sessions down to 22 / week average.

Theatre 14 (NWS)

2 sessions per day, 5 days per week

Theatre 15 (NWS) 2 sessions per day, 5 days

per week

Highland

Theatre 9 (Raigmore)

2 sessions per day, 5 days per week (mixed case mix

including paediatric, shoulder and back surgery)

Vanguard (Raigmore)

2 sessions per day, 5 days per week (joint surgery)

Theatre 1 (Raigmore)

9 session per month (minor non-laminar flow surgery)

shared with other specialties

Modular Theatre

(Raigmore)

5 Days a Week 2 Sessions a Day, 10 Sessions Per

Week

Caithness General

20 Days Per Year, 40 Sessions Per Year -

shared with other

38

Hospital, Wick specialties

Kirkwall Hospital, Orkney



Stornoway



Grampian

Theatres 1-6 at Woodend

Up to 10 x 6 theatres sessions per week subject to staffing and ward bed availability, which is are routine pressures which limit throughput

(NB. currently 2 out of 6 theatres closed most days linked to theatre staffing

availability)

ARI Theatre 10 9 sessions available per week

ARI short-stay theatre 3 8 sessions available per

week

Dr Gray’s 1 theatre – 9 sessions per wk 2 sessions available per week

Stracathro RTC 4 all-day theatre lists per month

39

Appendix 3 – Ophthalmology Activity Detail (April 2016 – March 2017)

Board Activity Type Total Activity Carried out at Host Board Activity %

Tayside

Total IP/DC Activity (inc Non-Elec) 3499(598+2901) 3425(582+2843) 97.88%

IP/DC Elective Activity 3286(385+2901) 3215(372+2843) 97.84%

IP/DC Cataract Activity (OPCS4 C75.1)

2463 2420 98.25%

OP New 9477 9205 97.13% OP return 31324 30613 97.73%

Highland

Total IP/DC Activity (inc Non-Elec) 2420 2,333 96.4%

IP/DC Elective Activity 495 492 (incl uncoded

spells 60) 99.3%


1,925 1,841 95.6%

OP New - 4,012 100% OP return 14,222 14,222 100%

Grampian

Total IP/DC Activity (inc Non-Elec) 3244 3160 97.4%

IP/DC Elective Activity 896 890 (172 not yet

coded) 99.3%


2348 2270 96.7%

OP New 9620 9620 100% OP return 32078 32078 100%

40

Appendix 4 – Activity undertaken within the Independent Sector or Golden Jubilee (April 2016 – March 2017)

Board Specialty Procedure Independent Sector activity

Golden Jubilee Activity

Tayside

Orthopaedic

Hips only 0 13 Knees only 0 20 Other 5 109 Total 5 142

Ophthalmology Cataract 0 0 Other 0 0 Total 0 0

Highland

Orthopaedic


Ophthalmology Cataract 106 – Synaptik at

Raigmore site 84

Other - 3 Total 106 87

Grampian

Orthopaedic


Ophthalmology Cataract 78 0 Other 6 0 Total 84 0

41

Appendix 5 – Total Orthopaedic Activity April 2016 – March 2017 – By Board

Board Activity Type Total Activity Carried out at Host Board Activity %

Tayside

Total Activity 6393 5977 93.81%

Elective Activity 3904 3583 91.78% Hips* 589 570 96.77% Knees* 429 407 94.82% Hips – Revisions^ 41 37 90.24% Knees – Revisions^ 27 25 92.60%

Spine 57 39 68.42% OP – New 11889 11130 93.62% OP – Return 20480 19514 95.62%

Highland

Total Activity 2,616 2,361 90.2%

Elective Activity 1,735 1,646 (inc.

uncoded spells 399)

94.9%

Hips* 471 331 70.3% Knees* 334 308 92.2% Hips – Revisions^ 9 9 100% Knees – Revisions^ 17 17 100%

Spine 50 50 100% OP – New 9,988 9,988 100% OP – Return 13,938 13,938 100%

Grampian

Total Activity 5857 5714 97.6%

Elective Activity 4354 4338 (389 not yet coded) 99.6%

Hips* 672 604 89.9% Knees* 585 538 92.0% Hips – Revisions^ 39 39 100% Knees – Revisions^ 39 39 100%

Spine 168 156 92.8% OP – New 15079 15079 100%

42

OP – Return 30407 30407 100% * Used procedure codes: Hip Procedures W371, W381, W391, W931, W941, W951 Knee Procedures W401, W411, W421 ^ Used procedure codes: Hip Revisions W37.3, W37.4, W38.3, W38.4, W39.3, W39.5, W93.3, W94.3, W95.3, W46.3, W47.3 and W48.3 Knee Revisions W40.3, W40.4, W41.3, W41.4, W42.3, W42.5 Appendix 6 – Workforce Challenges Specific to each Board Highland

Challenges experienced in the last 12 months

Challenges experienced currently and expected to be short term

Challenges experienced currently and expected to be long term

Ort

hopa

edic

Period of planned sick leave for solo hand consultant surgeon

Recruitment and retention of middle-grade staff and high cost of locums



Development of dedicated theatre teams to maximise efficiency, quality and throughput to facilitate 4 joint days as the ‘norm’

Requirement to increase skill capacity for non-medical roles e.g. nurse practitioners to ensure a sustainable and safe workforce

Junior Doctors’ experience &skills



Implementing alternative AHP and nurse-led roles

Recruitment and retention of theatre and anaesthetic staffing

Funding of WLI payments to maximise output

Oph

thal

mol

ogy Unable to recruit to a vacant

Consultant post

1.0 WTE Consultant post out to advert with closing date of 29th May, we know of one applicant who will apply for a 0.5 WTE post

1.0 WTE Consultant post out to advert with closing date of 29th May, we know of one applicant who will apply for a 0.5 WTE post

43

1 WTE Paediatric Consultant on long term sick leave now for 1 year

2 x 1 WTE Band 6 Optometry posts out to advert – second advert has gone out with only one applicant interviewed and appointed on the Bank from the first advert equating to 6 sessions per month

2 x 1 WTE Band 6 Optometry posts out to advert – second advert has gone out with only one applicant interviewed and appointed on the Bank from the first advert equating to 6 sessions per month

Vacant administrator support for long periods of time

Increased nurse injector capacity is required to meet demand with an additional 4 sessions agreed to be financed and recruitment to these hours is now taking place

Increased nurse injector capacity is required to meet demand with an additional 4 sessions agreed to be financed and recruitment to these hours is now taking place

Geographical area that we have to cover is vast and with that comes a significant number of nights away from home for Consultant, Orthoptic and Optometry staff as well as significant time spent travelling, all of which is part of the job planned activity

Time to be found to plan ahead for the future when faced with significant challenges on a daily basis across the service

Time to be found to plan ahead for the future when faced with significant challenges on a daily basis across the service

Consultants are 1st on-call for NHS Highland and covering a vacancy adds to this already onerous rota

Grampian

Ort

hopa

edic

Prolonged absence of Consultants affecting subspecialty flows

Availability of post-op HDU level care for cohort of patients

Funding shortfall to support MSK advanced scope AHP pathway

Consistent challenge in FY level post cover for Woodend Hospital

Increasing budgetary pressure

Availability of theatre staffing


Availability of post-op HDU level care for cohort of patients

Sustained recurring capacity gap

Cessation in use of independent sector

Cessation in use of WLIs

Oph

thal

mol

ogy

Vacant Post Vacant post to recruit to


Ability to utilise Dr Gray’s capacity

Redesign of advanced nursing roles to assist in cataract procedure

Growing AMD workload

44

room medium term

AMD workload increase and limitations placed on advanced nurse injectors – impacting on Consultant time

AMD workload increase and limitations placed on advanced nurse injectors – impacting on Consultant time

Sustained recurring capacity gap


Cessation in use of WLIs

Tayside

45

Challenges experienced in the last 12 months

Challenges experienced currently and expected to be short term

Challenges experienced currently and expected to be long term

Ort

hopa

edic

Challenges to achievement of the Treatment Time Guarantee



Significant unexpected Consultant absence over the course of 16-17 further impacting the elective patient pathway as emergency trauma required to be prioritised

Consultant retirements Consultant retirements

Oph

thal

mol

ogy

Recruitment challenges in Optometry, Ophthalmology Ward Nursing, and Ophthalmology Theatre Nursing

Two Consultant Ophthalmologist vacancies

Optometry vacancies vacant for 6 months or more

Challenges in providing an out of hours VR emergency service until new Consultants start later this year.

Ongoing increase in IVT Injection demand requires continual increase in investment in Nurse staffing.

One Consultant Ophthalmologist maternity leave

Small local pool of Ophthalmology Nursing staff – challenging to expand this pool to provide for service growth

Impending retiral of two Ophthalmology Senior Charge Nurses

Ongoing increase in IVT Injection demand requires continual increase in investment in Nurse staffing.

Providing a robust out of hours Vitreo Retinal Surgery Emergency service - small pool of surgeons nationally

46

Appendix 3

NoS Data Modelling Tool – Example Output of Long Term Projections

The data modelling tool pulls together national historical data across 10 key specialities utilising this

to then forecast for the next 12 months to 10 years. Initial local validation of the data has

progressed with the Information Support teams.

Aggregating this data into a NoS trajectory starts to highlight a significant elective gap.

All Specialties

Activity gap ~27,900 outpatients p/a~ 7,620 inpatients p/a

Next steps for the modelling tool is to run speciality level clinical workshops to further validate and

test the principles of the tool. Incorporating agreed national and regional pathways of care and

recognised productive opportunities across the region.

Ophthalmology – % Improvement Required

NoS = 18% improvement required for the waiting list to achieve max manageable

NoS = 33% improvement required for the waiting list to achieve max manageable

Daycase

T

he service level outputs from this work will then inform the recurring elective gap that will be

supported through the development of the new Elective Care Centres aligned to the regional

elective care strategy.

NHS Tayside Item 6 Record of Attendance Transformation Programme Board 1 April 2017 – 31 March 2018

Members 6 April 17 3 May 17 1 June 17 6 July 17 3 Aug 17 7 Sept 17 5 Oct 17 11 Oct 17 1 Nov 17 29 Nov 17 20 Dec 17 1 Feb 18 1 Mar 18 Mr L Bedford Director of Finance Present Apologies Present Present Present Present Present Present Present

Mr J Connaghan NHSScotland Chief Operating Officer

Apologies Apologies Apologies

Prof J Connell Chairman Present Present Present Present Present Present Present Present Present

Mrs G Costello Nurse Director Present Apologies Present Present Present Present Present Apologies Present

Dr A Cowie Non-Exec Member Present Apologies Present Present Apologies Apologies Present Apologies Present

Mr D Cross Vice Chair Present Present Present Present Present Present Present Present Present

Mr G Doherty Director of HR & Organisational Development

Present Apologies Present Apologies Present Present Present Present

Mrs J Golden Employee Director Present Apologies Present Present Present Present Present Present Present

Mr S Hay Non-Exec Member Present Present Present Present Present Present Present Present Present

Mrs V Irons Chief Officer, Angus HSCP

Present Present Present Apologies Present Present Apologies Apologies

Mr D Lynch Chief Officer, Dundee HSCP

Present Present Apologies Present Present Apologies Present Present

Ms L McLay Chief Executive Present Present Present Present Present Present Present Present Present

Mr B Nicoll Director of Strategic Change

Present Apologies Present Present Present Present Present Present Apologies

Mr R Packham Chief Officer, Perth & Kinross HSCP

Present Present Present Apologies Apologies Apologies Present Apologies

Mr H Robertson Non-Exec Member Present Present Present Apologies Present Present Present Apologies Present

Prof A Russell Medical Director Present Present Present Present Present Present Present Apologies Present

Dr D Walker Director of Public Health

Present Apologies Apologies Present Apologies Apologies Apologies

Ms L Wiggin Chief Operating Officer

Present Present Present Apologies Present Present Present Apologies Present

In Attendance

Mrs J Duncan Head of Corporate Communications

Present Present Present Apologies Present Present Present Present Present

Ms M Dunning Board Secretary Apologies Present Present Apologies Present Present Apologies Present Present

Mr A Gall Interim Director of Performance

Apologies Present Present

Mr A Pattinson Transformation Programme Lead

Present Present Present Apologies Present Present Present Present Present

1

Documents

Transformation Programme Board