additional material - nhs highland · 2019-08-20 · clinics and specialty pathway changes such as...

$: Additional material - NHS Highland · 2019-08-20 · Clinics and specialty pathway changes such as the establishment of virtual fracture liaison clinics in Argyll & Bute • Reduce$
1 | P a g e A n n u a l O p e r a t i o n a l P l a n F i n a l D r a f t 3 0 J u l y 2 0 1 9

Annual Operational Plan Appendices

No. Title Page

Appendix 1 Key Performance Indicators 2

Appendix 2 Waiting List by Speciality 3

Appendix 3 Cancer Waiting Times Improvement Plan 9

Appendix 4 NHS Highland Unscheduled Care Improvement Plans 2019 - 2020 Board Wide Priorities 10

Appendix 5 Child and Adolescent Mental Health Services 17

Appendix 6 Psychological Therapies and Waiting Times in A&E 20

Appendix 7 Improvement Plan for Psychological Services AMH 22

Appendix 8 HAI QEUH Report 26

Appendix 9 List of Contributors to the Plan 31

Appendix 10 AOP 2019-20 Letter 32

Appendix 11 Implications for Sustainability 38

Appendix 12 Elective Care Centre 40

Appendix 13 Annual Operational Plan (AOP) Action Tracker 42

Additional material

Slide Deck Supplied Separately


Appendix 1 – KPIs by type

NHS Highland Operational Plan 2019 - 2020 - Key Performance Indicators by type

Patients & Performance People Pounds and Pence

Primary Care Digital Health Regional Planning Integrated Care Elective Care Healthcare Associated Infection Mental Health Unscheduled Care

New GP GMS Contract - by 2022, completion of the primary care modernisation programme

During 2019/20, increase the number of users of the Electronic Patient Record (EPR) from the current 500 to 2000 active users. Extend the dataset available to clinical staff to include access to the primary care dataset.

Cardiac Service Review – establishing a NoS & WoS TAVI services in 2019; ensure equity of access for population to Catheter Lab services; implement NoS & WoS Cardiothoracic Surgery Sustainability Plans

40% of people receiving enablement interventions will not require ongoing care interventions after an initial 6 weeks

• To deliver improved access times for patients based on the Scenario that is funded for Cancer, Outpatients, TTG and Diagnostic pathways

• Reduce incidence and achieve CDI Heat target for NHSH by achieving an annual performance rate of 32.0 per 100,000 occupied bed days or less

• Delivering 18 weeks referral to treatment. No patient will wait longer than 12 weeks from referral to a first outpatient appointment. This will be done by establishing an average baseline for the last 3 years and in the introduction of a drug and alcohol screening service based on standardised tools

• 95% of all patients attending accident and emergency should be seen, treated, admitted or discharged within 4 hours, ultimately aiming for 98% of all patients.

SPSP Primary Care – by 2021 • 95% reliability of Warfarin Bundle across NHSH

During 2019/20, extend the deployment of digital solutions in the community so that all operational areas are accessing and recording clinical activity in all healthcare settings.

Trauma Network – developing enhanced major trauma services across the region to improve clinical outcomes and quality of life. The NoS the first of the national trauma networks which commenced on 1 October 2018 with WoS service to follow in 2019

90% of completed rehabilitation courses, for clients with sensory impairment who are self-management will have achieved independence or achieved independence above expectation.

• To deliver a Digital Programme for Outpatients during 2019/20 and beyond, including the introduction of Clinical Dialogue, the continued roll out of electronic triage, NHS Near Me, Phone Consultations and use of established VC Clinics and specialty pathway changes such as the establishment of virtual fracture liaison clinics in Argyll & Bute

• Reduce incidence and achieve SAB HEAT target for NHSH by achieving an annual performance rate of 24.0 per 100,000 acute occupied bed days or less

• Drugs and Alcohol Rehabilitation will achieve an annual decrease in the number of people waiting more than 18 weeks from referral to accessing a service

• Reduce unplanned (Emergency) admissions – by increasing anticipatory care activity in the community and in primary care

SPSP Primary Care – by 2021 • 100% roll out of the Sepsis Template to Vision Practices within NHSH during 2019/20

During 2019/20, progress the deployment of the ‘digital ward’ initiative including evaluation within an integrated team and implementation within the admission wards, general wards and community wards with a realtime dashboard reflecting activity in these areas.

Digital Transformation – The single regional Care Portal became live in January 2019 and work will continue to link with the NHS GG&C Portal with NHS Tayside joining the portal in 2019

Achieve the premature mortality rate (per 100,000 population) of 370 or less.

• In 2019/20 redesign pathways for post-surgery patients by introducing Patient Initiated Return Appointments and implement Patient Focussed Booking for Return Patients.

• Meet the mandatory requirements of the Clinical Risk Assessment by ensuring that MRSA Screening Compliance of 90% is achieved in Raigmore and the Rural General Hospitals

• Perinatal and parental mental health - focus developing pathway for perinatal mental health, this will include additional work on parental mental health and an interagency training plan for HSCP staff implemented in 2019

• Reduce unnecessary attendance

SPSP Primary Care – by 2021 • 95% of patients (aged 16 or over) with suspected sepsis are escalated by Primary Care and their National Early Warning Score (NEWS) communicated to the hospital, out of hours service or the Scottish Ambulance Service (SAS)

During 2019/20, upgrade all user devices to Windows 10. Start the migration to Office 365 which will provide enhanced tools that support agile working. Implement national solutions that will enable NHS Highland to comply with the Cyber Essential (+) standard.

Secondary and Tertiary Flows - Priority Pathway work to address key challenges and opportunities to deliver sustainable service

To meet the target of 90% of people will access drug or alcohol treatment services within 18 weeks.

• To publish a Cancer Strategy for NHS Highland by the end of the first quarter of 2019/20.

• Reduce the incidence of SSI infection and maintain a rate of under 2% for C-Section and Orthopaedic and 10% Colorectal

• HSCP Health and Wellbeing focus upon staff mental health and wellbeing as part of our OD and iMatter development in 2019

• Delayed discharges – reduce the amount of time (occupied bed days) patients are delayed in hospital

GP Near Me – by 2021 • Completion of phase 2 trial to 10 practices with a mixture of demographic and geographic challenges

During 2019/20, deploy ‘tap on – tap off’ technology & a Virtual Desktop Infrastructure (VDI) environment that will enable rapid access to devices in clinical settings across the four main acute hospitals.

Ophthalmology – improve standardisation of service across the NoS and WoS e.g. deliver an on-call shared rota for eye care services; develop optometry service provision; reduction of variation

Less than 90 per 1,000 patients are readmitted to hospital within 28 days

• To develop an Action Plan to allow for the recommendations within the Cancer Management Framework to be taken forward through 2019/20.

• Meet the national antimicrobial prescribing targets as defined by Scottish Government and supported by Scottish Antimicrobial Prescribing Group by meeting national targets

• Finalising in 3rd Quarter of 2019/20 our mental health workforce plan for next 3 years, incorporating the outcome of Community Mental Health Service review, to enhance and strengthen community teams operating presence, skills and capacity in 2019

• Reduction in occupied bed days for unscheduled care (emergency)

Scottish Rural Medicine Collaborative (SRMC) by 2021 • Embed the six initial projects (rural GP recruitment good practice, rural GP recruitment yearly wheel, rural GP marketing resources, valuing rural GPs, rural GP recruitment and retention toolkit and rural GP recruitment support.

During 2019/20, implement and evaluate the introduction of ‘clinical floor walkers’ and ‘Acute Facilitators’ with a view to improving the access and use of digital technology in the clinical environment.

Radiology – delivery of national intents within NoS; develop sustainable service; phase 2 implementation of single IT connectivity

Achieve the target of people spending 90% of the last 6 months of life spent at home or in a community setting.

• To develop the workforce to allow activity to transfer to AHP roles, Audiologists, Neuropsychologist, Optometrists and Clinical Nurse Specialists

• Receive assurance from Estates of completion of HAI-Scribes for all new builds / refurbishments throughout 2019. Documentary evidence to be maintained

• Ensuring alignment with our emerging Primary care mental health professionals (PCIP) implementation plan, further development and embedding of mental health practitioners within primary care 2019/2020

Scottish Rural Medicine Collaborative (SRMC) by 2021 • Progression of the phase two projects making rural practice attractive, enablers to rural practice and multi-disciplinary working.

During 2019/20 the eHealth Department will develop the following business case that will transform clinical and non-clinical services and will (if approved) enable financial savings to be generated: • EPR – Hospital Record Scanning

Reduce the number of days people spend in hospital when they are ready to be discharged, per 1,000 population (75+) to 900 days or less.

• Transfer of Work to the Community Setting including the purchase of ECG recorders for GP Practices to reduce the number of referrals to Cardiology

• Receive assurance from the Operational Units that Nursing and midwifery staff have undertaken Healthcare associated infection training as per Mandatory training requirements. Demonstrate a 20% increase in compliance figures by March 2020 (compared to 2018/19 data)

• Continuing to strengthen our service User and Carer engagement within service development/service change in our service review and redesign areas of dementia, acute services and learning disability

ITR by 2021 established investigation and treatment rooms in the North and West Division urban centres.

During 2019/20 the eHealth Department will develop the following business case that will transform clinical and non-clinical services and will (if approved) enable financial savings to be generated: • Order Communications – Primary Care

Average age to be 78 or older o admission to long-term residential and nursing care (All Adults).

• To undertake a breach analysis of all urology patients on the Cancer pathway to improve understanding of where the delays are occurring and develop plans for improvement.

Enabler – effective infection control enables savings to be made elsewhere in the organisation

• Enhancing the use of technology to support psychological interventions/treatment, increasing our CBT take-up, utilising “Near Me” remote consultations and access to psychological therapies group work over 2019

• Reduce GP and GP Practice workload through the introduction of roles described in the new GP GMS Contract memorandum of understanding. Remove secondary care continuation work from practices via the ITR development.

During 2019/20 the eHealth Department will develop the following business case that will transform clinical and non-clinical services and will (if approved) enable financial savings to be generated: • Order Communications – Secondary Care

Average age of admission to long-term residential and nursing care (Older People) to be 81 or older.

• To review benchmarked information to identify productive opportunities and key projects identified including a Theatre Efficiency Programme including maximising operating at Caithness General Hospital and Belford Hospital

• SPSP - wider in-patient services development in 2019 includes the implementation of Improving Observation in Practice within In-Patient Services

• Ensure continuation of quality improvement resource via SPSP team and by influencing the development of GP clusters.

During 2019/20 the eHealth Department will develop the following business case that will transform clinical and non-clinical services and will (if approved) enable financial savings to be generated: • The digitisation of the paper record

Percentage of referrals for technology enabled care received per quarter with reason given 'to enable to remain at/return home' & 'to enable independence' to increase. Target - 35% of referrals.

• To develop sustainable services (cross referenced with Quality Improvement and Collaborative Working) through a number of formal Redesign Workshops with clinical leads

• Continue to embed principles of recovery within our practice and service redesign through 2019

• Continue innovation and promotion of new ways of working via the SRMC and GP Near Me projects.

During 2019/20 the eHealth Department will develop the following business case that will transform clinical and non-clinical services and will (if approved) enable financial savings to be generated: • Full implementation of a voice recognition system to support clinical and non-clinical staff

Emergency bed day rate (per 100,000 population). Target – 100,000

• Aligned with our Carers strategy and action plan, enhance our support to carers within mental health

• Enhance GP practice resilience via the new GMS contract work streams and the SRMC phased projects, thus avoiding further practices requiring NHS support and management.

During 2019/20 the eHealth Department will develop the following business case that will transform clinical and non-clinical services and will (if approved) enable financial savings to be generated: • Implementation of hospital based self-service check-in facilities

• Deliver agreed improved efficiencies for first outpatient attendance DNA, non-routine inpatient average length of stay, review to new outpatient attendance ratio and day case rate by March 2020

• By enabling first contact physiotherapy and mental health input within practices referral patterns will improve lessening secondary care burden.

• To establish the future need for Learning Disability Services in Inner Moray Firth Operational Unit. A strategy will be developed by Nov 2019 to modernise services and redesign of the day centre

• Avoid harm via SPSP focus on warfarin safety, medicine reconciliation and sepsis management thus avoiding hospital admission and reduced morbidity.

• Ensure that all commissioned services are reviewed and comply with regulations, using the Contracts and Commissioning Programme (set until 2021)

• Utilise GP Near Me to avoid patient travel and enhance practice resilience by enabling distal working.

• Explore commissioning continuing care beds for adults with dementia. This will be done by identifying the need for the number of continuing care beds and to secure senior management backing to tender for provision of services

• Prevent patient travel and ensure

quality continuation of secondary care

workload closer to the patient via the

ITR project


APPENDIX 2 – WAITING LIST BY SPECIALITY

OUTPATIENTS

Specialty Detail Volume Funding Jun-19 Sep-19 Dec-19 Mar-20 Jun-19 Sep-19 Dec-19 Mar-20 Jun-19 Sep-19 Dec-19 Mar-20 TOTAL LOCUM IN-HOUSE IS GG&C OTHERENT Locum consultant 2WTE and additional clinics 1,620 260,200£ 100 87 76 68 150 113 74 82 250 200 150 150 260,200£ 200,000£ - - 60,200£ -

General Surgery Additional clinics 80 25,100£ 0 0 0 0 150 130 120 100 150 130 120 100 25,100£ - 25,100£ - -

Gynaecology Additional clinics 488 71,040£ 0 0 0 0 15 15 15 15 15 15 15 15 71,040£ - 30,840£ - 40,200£ -

Neurosurgery Additional clinics 94 14,006£ 0 0 0 0 5 5 5 5 5 5 5 5 14,006£ - - - - 14,006£ NHS Grampian

OMFS Additional clinics 1,937 134,601£ 15 13 10 7 80 62 45 30 95 75 55 37 134,601£ 127,601£ - - 7,000£ -

Ophthalmology Additional clinics 156 66,700£ 75 86 100 114 85 54 20 -4 160 140 120 110 66,700£ - - - 66,700£ -

Orthodontics Additional clinics 404 56,000£ 5 5 5 0 0 0 0 5 5 5 5 5 56,000£ - - 56,000£ - -

Orthopaedics Hand therapist role extension, additional clinics, see & treat package via IS 530 230,900£ 55 50 48 40 305 270 252 260 360 320 300 300 230,900£ - 11,900£ 120,000£ 74,000£ 25,000£ Hand therapist extension

Plastic Surgery No funding - - 0 0 0 0 5 5 5 5 5 5 5 5 - - - - - -

Surgical Paediatrics No funding - - 0 0 0 0 5 5 5 5 5 5 5 5 - - - - - -

Urology Locum consultant 1WTE, admin manager, see & treat package via IS 476 668,200£ 0 0 0 0 40 20 0 0 40 20 0 0 668,200£ 188,520£ - 442,180£ - 37,500£ Admin manager extension

Cardiology No funding - - 0 0 0 0 56 60 70 80 56 60 70 80 - - - - - -

Clinical Genetics No funding - - 0 0 0 0 54 54 54 54 54 54 54 54 - - - - - -

Dermatology Additional clinics via IS national tender 1,146 164,950£ 130 110 87 50 35 20 13 50 165 130 100 100 164,950£ - - 63,650£ 21,300£ 80,000£ Recruitment of GPwSI

Gastroenterology Additional clinics 419 98,000£ 0 0 0 0 50 50 0 0 50 50 0 0 98,000£ - 18,000£ 80,000£ - -

General Medicine Additional clinics 92 28,900£ 20 20 16 14 35 25 24 21 55 45 40 35 28,900£ - - 28,900£ -

Haematology Locum post 1WTE 300 150,000£ 0 0 0 0 15 15 15 15 15 15 15 15 150,000£ 150,000£ - - - -

Neurology Additional clinics and recruitment 921 146,746£ 0 0 0 0 5 5 5 5 5 5 5 5 146,746£ - - 96,746£ - 50,000£ Neuropsychology recruitment

Pain Management Additional clinics 16 2,000£ 45 40 40 40 15 15 5 0 60 55 45 40 2,000£ - 2,000£ - - -

Paediatric Medicine Additional clinics 188 33,088£ 0 0 0 0 35 35 30 30 35 35 30 30 33,088£ - 7,888£ 25,200£ - -

Rehabilitation Medicine No funding - - 0 0 0 0 5 5 5 5 5 5 5 5 - - - - - -

Respiratory Medicine No funding - - 0 0 0 0 72 110 148 185 72 110 148 185 - - - - - -

Rheumatology No funding - - 0 0 0 0 53 74 95 117 53 74 95 117 - - - - - -

TOTAL 8,867 2,150,431£ 445 411 382 333 1,270 1,147 1,005 1,065 1,715 1,558 1,387 1,398 2,150,431£ 666,121£ 95,728£ 883,776£ 298,300£ 206,506£

TTG

Specialty Detail Volume Funding Jun-19 Sep-19 Dec-19 Mar-20 Jun-19 Sep-19 Dec-19 Mar-20 Jun-19 Sep-19 Dec-19 Mar-20 TOTAL LOCUM IN-HOUSE IS GG&C OTHERBreast Surgery Additional sessions 48 35,000£ 0 0 0 0 10 10 10 10 10 10 10 10 35,000£ - 35,000£ - - -

Community Dental Additional sessions 15 10,750£ 0 0 0 0 80 80 80 80 80 80 80 80 10,750£ - 10,750£ - - -

ENT Funding through locums (see outpatient section) - - 0 0 0 0 276 209 142 75 276 209 142 75 - - - - - -

General Surgery Additional sessions and treat package via IS 273 690,252£ 8 6 6 4 292 244 194 150 300 250 200 154 690,252£ - 90,000£ 600,252£ - -

Gynaecology Additional sessions 38 84,470£ 0 0 0 0 100 110 110 120 100 110 110 120 84,470£ - 84,470£ - - -

OMFS Additional sessions and treat package via IS 76 118,332£ 8 10 4 4 92 90 86 76 100 100 90 80 118,332£ 118,332£ - - - -

Ophthalmology Additional sessions via IS national tender 675 388,125£ 0 0 0 0 240 200 160 135 240 200 160 135 388,125£ - - 388,125£ - -

Orthopaedics Vanguard 1 including staffing costs 1,052 2,670,444£ 0 0 0 0 727 654 581 510 727 654 581 510 2,670,444£ 431,500£ 956,500£ 532,444£ - 750,000£ Consumables

Pain Management No funding - - 0 0 0 0 50 50 50 50 50 50 50 50 - - - - - -

Plastic Surgery Additional sessions 10 12,180£ 0 0 0 0 17 17 17 17 17 17 17 17 12,180£ - - - - 12,180£ NHS Lothian

Surgical Paediatrics No funding - - 0 0 0 0 15 15 15 15 15 15 15 15 - - - - - -

Urology Funding through outpatient section 236 - 0 0 0 0 129 106 83 60 129 106 83 60 - - - - - -

Multiple specialties Theatre equipment to allow for operating at RGHs - 52,122£ - - - - - - - - - - - - 52,122£ - - - - 52,122£ Theatre equipment at RGH

Multiple specialties Minor procedure room conversion (capital) - 100,000£ - - - - - - - - - - - - 100,000£ - - - - 100,000£ Minor procedure room conversion

Multiple specialties Vanguard 2 theatre extension (22 weeks until Jan 2020) - 400,000£ - - - - - - - - - - - - 400,000£ - - 400,000£ - -

TOTAL 2,423 4,561,675£ 16 16 10 8 2,028 1,785 1,528 1,298 2,044 1,801 1,538 1,306 4,561,675£ 549,832£ 1,176,720£ 1,920,821£ -£ 914,302£

DIAGNOSTICS & OTHER

Specialty Detail Volume Funding Jun-19 Sep-19 Dec-19 Mar-20 Jun-19 Sep-19 Dec-19 Mar-20 Jun-19 Sep-19 Dec-19 Mar-20 TOTAL LOCUM IN-HOUSE IS GG&C OTHER

Endoscopy Additional sessions 136 4,100£ 119 110 105 98 318 361 400 440 437 471 505 538 4,100£ - 4,100£ - - -

Clinical Physiology NCT, ECG test support - 40,000£ - - - - - - - - - - - - 40,000£ - 40,000£ - - -

Radiology Centralised booking across Northern Highland - 75,000£ - - - - - - - - - - - - 75,000£ - 75,000£ - - -

Radiology Reporting of scans 88 48,300£ - - - - - - - - - - - - 48,300£ - 48,300£ - - -

CT scans No funding - - - - - - - - - - - - - - - - - - - -

MRI scans Continuation of MRI van for 9 weeks 2,556 174,564£ - - - - - - - - - - - - 174,564£ - - 174,564£ - -

Ultrasound No funding - - - - - - - - - - - - - - - - - - - -

Waiting times Service Manager post - 50,000£ - - - - - - - - - - - - 50,000£ - 50,000£ - - -

TOTAL 2,780 391,964£ 119 110 105 98 318 361 400 440 437 471 505 538 391,964£ -£ 217,400£ 174,564£ -£ -£

TOTAL LOCUM IN-HOUSE IS GG&C OTHER

7,104,070£ 1,215,953£ 1,489,848£ 2,979,161£ 298,300£ 1,120,808£

Northern - Breaching position



A&B - Breaching position



IF OTHER (more detal)



FUNDING SPLIT

TOTAL - Breaching position



FUNDING SPLIT

FUNDING SPLIT

FUNDING SPLIT


Waiting List Breakdown by Speciality – ARGYLL & BUTE

A&B Outreach waiting times - Current Pressures & Demand Modelling – NEW and RETURN PATIENTS ONLY -March 2020 & March 2021 Analysis of New & Return Activity ENT- Projected Requirements As per the 64 sessions as recorded on PMS, across the past 12 months there were on average 85 slots per month for ENT and the DCAQ projections based on the actual referral demand indicate an extra 19 sessions annually will be required 2019/20 to meet average demand and an extra 38 sessions to meet the optimum level 2020/21 Table 37: PMS Analytics as at 4th March 2019

DCAQ Projections Mar18 - Feb19 *

Average Required Slots per

Month

Minimum Slots per

Month

Maximum Slots per

Month

Optimum Capacity

Number of

Clinics in

period

Required Yearly Clinics

Based on Average

(variance)


Based on Optimum (variance)

110 86 147 135 64 83 (19) 102 (38)

* Based on return demand % ratios of

ENT 30%

Oral Surgery- Projected Requirements As per the 90 sessions as recorded on PMS, across the past 12 months there were on average 83 slots per month for Oral Surgery and the DCAQ projections based on the actual referral demand indicate we require an extra 1 session annually 2019/20 to meet average demand and an extra 15 sessions to meet the optimum level 2020/21. This is reflective of the fact that demand and capacity are quite closely matched across this specialty and breaching patients tend to occur after periods of consultant absence (sole consultant) causing backlogs Table 38: PMS Analytics as at 4th March 2019


Average Required Slots

per Month

Minimum Slots per Month

Maximum Slots per Month

Optimum Capacity

Number of Clinics in period


Based on Average

(variance)



84 63 105 97 90 91 (1) 105 (15)


Oral Surgery 40%

Dermatology- Projected Requirements As per the 74 sessions as recorded on PMS, across the past 12 months there were on average 146 slots per month for Dermatology and the DCAQ projections based on the actual referral demand indicate we require an extra 18 sessions annually 2019/20 to meet average demand and an extra 32 sessions to meet the optimum level 2020/21.


Table 39: PMS Analytics as at 4th March 2019



Month

Minimum Slots per

Month

Maximum Slots per

Month

Optimum Capacity

Number of

Clinics in

period


Based on Average

(variance)



182 127 230 209 74 92 (18) 106 (32)


Dermatology 56%

Pain- Projected Requirements As per the 107 sessions as recorded on PMS, across the past 12 months there were on average 52 slots per month for Pain Management and the DCAQ projections based on the actual referral demand indicate we require an extra 27 sessions annually 2019/20 to meet average demand and an extra 95 sessions to meet the optimum level 2020/21. Table 40: PMS Analytics as at 4th March 2019



Month

Minimum Slots per

Month

Maximum Slots per

Month

Optimum Capacity

Number of

Clinics in

period


Based on Average

(variance)



65 25 117 98 107 134 (27) 202 (95)


Pain Management 88%

Orthopaedics- Projected Requirements As per the 120 sessions as recorded on PMS, across the past 12 months there were on average 195 slots per month for Orthopaedics and the DCAQ projections based on the actual referral demand indicate we require an extra 23 sessions annually to meet average demand 2019/20 and

an extra 44 sessions to meet the optimum level 2020/21. Table 41: PMS Analytics as at 4th March 2019



Month

Minimum Slots per

Month

Maximum Slots per

Month

Optimum Capacity

Number of

Clinics in

period


Based on Average

(variance)



232 176 290 267 120 143 (23) 164 (44)


Orthopaedics 50%


Ophthalmology- Projected Requirements

As per the 218 sessions as recorded on PMS, across the past 12 months there were on average 341 slots per month for Ophthalmology and the DCAQ projections based on the actual referral demand indicate we require an extra 42 sessions annually 2019/20 to meet average demand and an extra 82 sessions to meet the optimum level 2020/21. Table 41: PMS Analytics as at 4th March 2019


Average Required Slots

per Month

Minimum Slots per

Month

Maximum Slots per

Month

Optimum Capacity

Number of

Clinics in

period


Based on Average

(variance)



406 267 519 469 218 260 (42) 300 (82)


Ophthalmology 79%

General Medicine- Projected Requirements

As per the 436 sessions as recorded on PMS, across the past 12 months there were on average 358 slots per month for General Medicine and the DCAQ projections based on the actual referral demand indicate we require an extra 39 sessions annually 2019/20 to meet average demand and an extra 173 sessions 2020/21 to meet the optimum level. Table 42: PMS Analytics as at 4th March 2019



Month

Minimum Slots per

Month

Maximum Slots per

Month

Optimum Capacity

Number of

Clinics in

period


Based on Average

(variance)



390 307 548 500 436 475 (39) 609 (173)


General Medicine 73%


Speciality Medical Nursing AHP Admin

Non-pay

costs Total Captial

ENT - 19 additional sessions 20,756 1,000 21,756

1.0 Band 5 Audiologist Support 38,335 38,335

Oral Surgery - 15 additional sessions 16,461 500 16,961

Dermatology - 32 additional sessions 34,354 1,500 35,854

Pain - 27 additional sessions 19,324 19,324

0.5 Band 7 Nurse 28,126 28,126

Additional Drug Costs 10,000 10,000

Orthopaedics - 23 additional sessions 25,050 1,200 26,250

2.0 Band 6 MSK Physiotherapy Support 95,449 95,449

Ophthalmology - 42 additional sessions 88,412 2,000 90,412

Orthoptics - 10 additional days 2,568 2,568

OCT x 2 60,000

Medicine - 39 additional sessions 27,913 1000 28,913

Radiology 1.0 band 6 47,725 47,725

Support for evening & weekend clinics 8,524 8,524 17,048

Respiratory Medicine Stethoscope x3 -

Development of Near Me Clinics 18,000

Centralised Booking Office - IT & Project Work 50,000 50,000

Medical Records/Waiting Times Lead 1.0 Band

6 47,725 1000 48,725

Electronic Patient Records Scanner x3 -

Enhance Clinical Portal 180,000

3.0 Band 3 Medical Records Admin 81,009 81,009

E-health Support - Clinical Portal 0.2 Band 5 7,667 7,667

Performance Support Analyst 0.5 Band 5 19,167 19,167

Inflow to GGC clinics per clinical pathways -

estimate based on 18/19 GGC formula of

NRAC share 2,360,000

Total 232,270 36,650 184,076 214,092 18,200 3,045,288 258,000

Total Capital and Revenue Bid 3,303,288

Notes:

Costing includes AfC payaward 19/20.

Any paid travel time is included within the pays costs.

Any travel and subsistence costs are within non-pay.

No data from GGC detailing 19/20 waiting times charge for patients following the agreed clinical pathways.

2019/20 Waiting Times Estimated Costs of Additional Sessions


Speciality Medical Nursing AHP Admin

Non-pay

costs Total Captial

ENT - 38 additional sessions 41,996 1,000 42,996

1.0 Band 5 Audiologist Support 39,567 39,567

Oral Surgery - 15 additional sessions 16,946 500 17,446

Dermatology - 32 additional sessions 35,365 1,500 36,865

Pain - 95 additional sessions 69,993 69,993

0.5 Band 7 Nurse 29,030 29,030

Additional Drug Costs 10,000 10,000

Orthopaedics - 44 additional sessions 48,626 1,200 49,826

2.0 Band 6 MSK Physiotherapy Support 98,516 98,516

Ophthalmology - 82 additional sessions 90,622 2,000 92,622

Orthoptics - 10 additional days 2,650 2,650

Medicine - 173 additional sessions 127,460 1000 128,460

Radiology 1.0 band 6 49,258 49,258

Support for evening & weekend clinics 14,840 14,840

-

Medical Records/Waiting Times Lead 1.0 Band 6 49,258 1,000 50,258

3.0 Band 3 Medical Records Admin 83,612 83,612

Inflow to GGC clinics per clinical pathways -

estimate based on 18/19 GGC formula of NRAC

share 1,450,000

Total 431,007 43,870 189,991 147,710 18,200 2,251,098 -

Total Capital and Revenue Bid 2,251,098

Notes:

Costing includes AfC payaward 20/21.

Any paid travel time is included within the pays costs.

Any travel and subsistence costs are within non-pay.

No data from GGC detailing 20/21 waiting times charge for patients following the agreed clinical pathways.

2020/21 Waiting Times Estimated Costs of Additional Sessions


APPENDIX 3 – CANCER WAITING TIMES IMPROVEMENT PLAN

ANNUAL COST (£)

YEAR 1 Year 2 Year 3 Year 1 Year 2 Year 3 Comments

ACTIVITY ACTIVITY ACTIVITY COST COST COST

Number Action Plan Specialty

Recurring/ Non-

Recurring Year 1 Year 2 Year 3 Year 1 Year 2 Year 3 Cancer

Cancer.1

Additional Renal Operating Sessions Urology Recurring 36 38 40 £ 25,200.00 £ 26,460.00 £ 27,720.00

Additional incidence and capacity from single handed Consultant

Cancer.2

Additional Melanoma Operating Melanoma Recurring 24 32 40 £ 16,800.00 £ 22,400.00 £ 28,000.00

As Per Melanoma Nursing service as above

Cancer.3

Additional Urology Consultants Urology Recurring 0 0 0 £ - £ - £ - Included in TTG/OP Proposal

Cancer.4

Additional Haematology Consultant PAs Lymphoma Recurring 0 0 0 £ - £ - £ - Included in TTG/OP Proposal

Cancer.5

Melanoma NS and Admin support Melanoma Recurring 0 0 0 £ 56,200.00 £ 55,000.00 £ 55,000.00

Increasing demand and to support and manage patients throughout pathway, maximising time for surgery before 62 Days

Cancer.6

Breast & Immunotherapy - Clinical Oncology Breast Recurring 0 0 0 £ 44,000.00 £ 44,000.00 £ 44,000.00

Increasing likelihood of appointment to Oncology post providing full time presence ( rather than part time locum as at present

Cancer.7

Additional Haematology Nurse Specialist Lymphoma Recurring 0 0 0 £ 56,200.00 £ 55,000.00 £ 55,000.00

Freeing up Consultant capacity for new patients from Lymphoma and H&N pathway ( the latter often being referred late into 62 Day pathway

Cancer.8

Cancer GI Nurse Specialists ( 1.6 wte Bd7) Upper GI Recurring 0 0 0 £ 90,400.00 £ 88,000.00 £ 88,000.00

In order support the development of the Regional Surgical Service

Cancer.9

Assistant Service Manager – Cancer All Cancer Recurring 0 0 0 £ 49,000.00 £ 49,000.00 £ 49,000.00

As Per Effective Cancer Management Framework Review


APPENDIX 4 - NHS HIGHLAND UNSCHEDULED CARE IMPROVEMENT PLANS 2019 - 2020 Board Wide Priorities

Focus Area Essential Action Actions Indicators Date Progress

N.

Highland

Progress Argyll & Bute

The risk of noro virus outbreaks and transmission is minimised

1 Clinically focussed and empowered hospital management

Annual norovirus prevention plan in place across the board area.

HPS Annual Guidance distributed to all primary and acute care clinicians and managers

Increased vigilance of GP referrals and presentations to A&E

Number of wards closed due to norovirus Monthly compliance in all wards and care homes

Complete In place In place

Business continuity plans in place and fit for purpose


All areas have robust BC plans which are continually updated based on desk top and live testing.

Ability to sustain services

Complete In place In place

Joint working with partners to reduce delays

4 - Pathways arranged for optimum care

Review of paediatric emergency service pathways and support for RGHs

Review of mental health pathways and access to specialist MH support

↓in waits for transfer / retrieval

October 2019

LIH – Paeds pathway currently under review. Pathway to GG&C. Mental Health crisis also under review. Additional resource allocated to support community mental health teams to support crisis intervention.

Reducing

attendance at ED

6. People cared for at

home

Summary of services available from

Pharmacies being developed

Roll out of Pharmacy First initiative.

Promotion of self-care and sources of

advice and information available

Increase awareness of ‘Know Who to

Turn to’.

↓in unnecessary

OOH/A&E attendances

October

2019


DRAFT - Unscheduled Care Improvement Plans 2019 - 2020 Inner Moray Firth Division

Focus Area Essential Action

Actions Indicators Date Progress

Continued development and improvement of safety huddle


Continued development and improvement of system wide huddles

Continued improvement and embedding of escalation processes and arrangements

System wide responses to pressure in the system

Ongoing Caithness and MH now joining the huddle daily

Review and evaluate ED processes

2 Capacity and patient flow alignment

Review current data to identify key focus areas

Review pathways and processes for management of minors

Appointment of additional speciality doctor cover in evening period in ED

Robust implementation of Capacity Escalation protocol for AMU

↑ED performance against 4 hour access standard

April19

1 of 4 appointed starting April 20 –recruitment ongoing

Reducing LOS for post-acute Patients in Raigmore

3 Patient not bed management

Review current processes and data

Test of new admission information document for community teams

Recruitment of Care at Home Liaison Officer

Recruitment of Care Home Liaison Officer

Focus on proactive consistent approach to discharge planning across the division

Review of Home First Initiative

↓ in OBDs by people no longer requiring acute hospital care ↓LOS ↓ Numbers of in patients not meeting DoCA criteria ↓numbers of people waiting experiencing delayed transfers of care

April 19

Evaluating the impact of short stay beds in Assessment Unit on flow & Discharges


Re launch and extension of GA short stay trial.

Development of increased workforce for year 2019/20

Streamline flow out of AMU and ensure safe handover of patients

ED 4 hour performance Numbers of boarders LOS for Medicine

April 19


DRAFT - Unscheduled Care Improvement Plans 2019 - 2020 Inner Moray Firth Division (cont.)



Evaluating the impact of PAW on LOS and Delayed Discharge


Review factors leading to delay in discharge on PAW

Standardise PAW assessment and set up shared drive for PAW waiting list

Evaluate the impact of the ‘30, 60, 90 day reviews on LOS & DD

↓numbers of people waiting experiencing delayed transfers of care

May 2019

Reducing LOS 5 7 day services

Review Ambulatory Care - increase availability 7/7

Enhance medical receiving rotas - 7/7 senior decision making

Weekend admission and discharge rates

June 2019

Reduce readmissions rates

6 - People cared for at home

Implement robust discharge processes and enhanced discharge support

Develop bespoke admission avoidance strategies for all patients re-admitted more than once through an MDT approach

↓ in OBDs by people no longer requiring acute hospital care ↓LOS ↓ Numbers of in patients not meeting DoCA criteria ↓numbers of people waiting experiencing delayed transfers of care

Sept 2019

Alternatives to hospital care/ increase rates of discharge

6 - People cared for at home

Continued development and support of the virtual ward

Additional overnight care at home hours

Step up / step down beds

Implement discharge to assess

Implement discharge scorecards on all wards

June 2019

Improving pathways for Flow Group 4 patients


Enhancing pathways for Trauma and Surgical patients ED performance for Flow Group 4 patients

May 19

Reducing numbers of admissions


Review of medical receiving model to assess to admit ED performance July 2019


DRAFT Unscheduled Care Improvement Plans 2019 -2020 Caithness & Sutherland



Continued development of safety huddle - locally and participation in system wide huddle


Development of robust escalation processes and arrangements Improved ED performance

June

2019

Create capacity to manage surge in demand locally and improve flow through ED


Identification of additional capacity locally for surges in demand

Review of capacity of community hospitals in Caithness and Sutherland

4 hour ED target Numbers of breaches ‘waiting for beds’ People delayed waiting C@H and Community Hospital Transfer

June

2019

Reduce numbers of people experiencing protracted hospital stays.


Review reasons for delay to understand barriers to timely discharge

Proactive management and planning for all patients in post-acute phase to ensure safe early discharge from hospital

Robust and equitable application of the HOME bundle to reduce the numbers of people delayed waiting in hospital for care home placement

↓ in OBDs by people no longer requiring acute hospital care ↓LOS ↓ Numbers of in patients not meeting DoCA criteria ED 4 hour performance

Sept

2019



Explore reasons for attendance at ED - establish alternative pathways to reduce demand

RE establish Ambulatory Care

Sept

2019

Increase discharges

5- 7 day services

Explore opportunities for increasing access to services and decision makers 7/7

Sept

2019

Reduce attendances and admissions

6. People cared for at home

Creation of innovative community based solutions to support early safe discharge

Sept

2019


DRAFT Unscheduled Care Improvement Plans 2019 - 2020 Lochaber





Continued development and improvement of escalation processes and arrangements

Exploration of options to enable participation in Highland wide huddle

May 2019




4 hour ED target Numbers of breaches ‘waiting for beds’ People delayed waiting C@H

June 2019





Robust and equitable application of the HOME bundle to reduce the numbers of people delayed waiting in hospital for care home placement

↓ in OBDs by people no longer requiring acute hospital care ↓LOS ↓ Numbers of in patients not meeting DoCA criteria ED 4 hour performance

Sept 2019




Oct 2019

Increase discharges rates at weekends

5- 7 day services

Explore opportunities for increasing access to services and decision makers 7/7

↓LOS

Nov 2019



Creation of innovative community based solutions to support early safe discharge

↓LOS

Aug 2019


DRAFT Unscheduled Care Improvement Plans 2019 -2020 Lorn & Islands Hospital Oban




Continued development and improvement of system wide huddles

Continued improvement and embedding of escalation processes and arrangements.

HSCP winter huddle across A&B HSCP as part of winter planning

Improved ED performance

System wide response to pressure in system

Increased communication between primary and secondary care

On

going

Hospital safety Huddle daily in place and well

established.

Community Huddle established.




Winter huddle established across Argyll & Bute HSCP daily

Ensure performance against 4 hour target maintained

Ensure patient flow within Hospital maintained.

On

going

Daily winter huddle by teleconference,

established across HSCP.





Stop boarding of patients, to ensure patients are in the right bed at the right time

Carers support on discharge project pilot

PJ Paralysis project to be launched across A&B HSCP

Reduce Occupied Bed days

Reduce length of stay

Reduction in the number of boarders

Improved Carers support

On

going

Daily review of patients delayed and process for

escalation.

Accountability wall with community manager to

monitor in place.

Carers project to support discharge in place with

very positive results.


DRAFT Unscheduled Care Improvement Plans 2019 -2020 Lorn & Islands Hospital Oban (cont.)





Increase awareness of ‘Know who to turn to’

Promotion of self-care and sources of advice and information

Increase available information using social media

Reduce number of inappropriate presentations to A/E.

On

going

New leaflet developed for Lorn & Islands. Audit to

take place around effectiveness. HSCP social

media provides useful information for members of

the community.

Increase discharges 5- 7 day services Explore opportunities for increasing access to services and decision makers 7/7

Improved handovers within the Medical team, ensuring clear management plans for patients

Reduction in length of stay. 7 day discharge increased.

On

going

Implementation of new ward round improvement

work within the medical department.



Creation of innovative community based solutions to support early safe discharge.

Frailty project implementation at Lorn medical centre.

Reduction in admission for frail elderly. Improved communication to inform the community huddle.

On

going

Frailty project at GP practice going well,

looking to roll out to other GP practices.

Medical consultant attends once per week,

this improves communication between 1o and

2o care and prevention of admission.


APPENDIX 5 - CHILD AND ADOLESCENT MENTAL HEALTH SERVICES

1. The LDP Standard for specialist Child and Adolescent Mental Health Services is for at least 90% of young people to start treatment within 18 weeks of referral. Please complete the table with your trajectory for meeting the standard by, or before, December 2020. Quarter ending Mar 2019 Jun 2019 Sep 2019 Dec 2019 Mar 2020 Jun 2020 Sep 2020 Dec 2020

Performance against

the LDP standard(%)

80 81 82 83 85 87 88 90

2. Please describe the actions that will be taken each quarter to deliver the above trajectory, the expected impact of these actions on progress towards the standard, and any associated dependencies and risks. Actions might include for e.g.: recruitment of specific staff; waiting list initiatives; improvement work to improve processes; wider system change; etc. An example is included in the table below. Quarter

ending

Action(s) Forecast

impact on

standard

Funding – source

and amount

(confirmed in

2019-20)

Interdependencies (i.e.

between performance,

funding, workforce,

partners)

Risks and steps to mitigate

December

2020

Maintain Access funded posts Minimal £218,000 Post holders do not

leave

Maintain staff morale and

wellbeing

Manage sickness and absence

Sep 2019 NES funding proposals agreed

and moving to recruit (HIG

Taskforce funds)

1%

uplift/month

in people

seen within

18 weeks.

£256,324 Posts are prioritised by

PMO Grip and Control

/Vacancy Management

/financial measures

Posts can be recruited to

Time limited posts are proving

difficult to recruit to

Ongoing dialogue over securing

permanent funding


March

2020

Work with the MHAIST team

continues to better understand

demand and capacity re consultation

and treatment and related

consideration of best use of time

across the H and A+B teams

As above Additional admin and

management in the

NES allocation

£40,380

Data on consultation to

treatment will inform

discussion over

prioritisation of 1:1 work

and consultation and the

interface between Tier 2

and 3 interventions

Influence across the HHSCP and

Care and Learning Teams to ensure

seamless experience of care

Risks from disinvestment in Local

Authority support for additional

needs

Additional need and referrals from

the Neuro-Developmental

Assessment Service in the North

Highland Partnership

In the A+B service a small team is

vulnerable to reduced performance

when there is staff sickness and

absence so maintaining staff morale

and wellbeing and

managing sickness and absence is

key

Fixed term funding coming to an end

will impact on performance: ongoing

discussion re mainstreaming funding

key

*March

2020

Seek consolidation of temporary

posts

Chances of meeting trajectory

reduced if NES resource lost

Is not continued and will impact

on trajectory being achieved


Figure 5.1 - Trajectory for CAMHS


APPENDIX 6 - PSYCHOLOGICAL THERAPIES & WAITING TIMES IN A&E

1. The LDP Standard for Psychological Therapies is for at least 90% of people to start treatment within 18 weeks of referral. Please complete the table with your trajectory for meeting the standard by, or before, December 2020. Quarter ending Mar 2019 Jun 2019 Sep 2019 Dec 2019 Mar 2020 Jun 2020 Sep 2020 Dec 2020

Performance against the

LDP standard (%)

78% 80% 82% 84% 86%* 88% 90% 90%

2. Please describe the actions that will be taken each quarter to deliver the above trajectory, the expected impact of these actions on progress towards the standard, and any associated dependencies and risks. Actions might include for e.g.: recruitment of specific staff; waiting list initiatives; improvement work to improve processes; wider system change; etc. An example is included in the table below. Quarter

ending

Action Forecast impact

on standard

Funding – source

and amount

Interdependencies

(i.e. between

performance, funding,

workforce, partners)


Dec 2019 Telephone screening

replacing face to face

assessments to save

clinician time.

10% uplift in people

seen within 18

weeks.

No additional cost. Support required from

MHAIST.

Risk of delay between screening and starting

treatment due to people being accepted for

treatment faster. Mitigated by signposting those

screened as needing low tier services to low

intensity group based interventions as opposed to

one to one interventions and rollout of “Near Me”

in Highland. Implementation of the NHS Highland

Clinical Psychology improvement plan.

*Mar

2020

Seek consolidation of

funding for current

temporary posts

Maintain trajectory £0.5M per annum

from NHS Education

Scotland

Chances of meeting trajectory reduced if NES

resource lost

which currently covers circa

500 patients, which would

increase the length of the

waiting list.


Mental Health Waiting Times in Emergency Departments 1. The LDP Standard for Waiting Times for all presentations at ED is 4 Hours. Please complete the table with your trajectory for

meeting the standard, specifically for Mental health presentations by, or before, December 2020.

Quarter ending Mar 2019 Jun 2019 Sep 2019 Dec 2019 Mar 2020 Jun 2020 Sep 2020 Dec 2020

Performance against the

LDP standard (%)

88% 89% 90% 91% 92% 93% 94% 95%

2. Please describe the actions that will be taken each quarter to deliver the above trajectory, the expected impact of these actions on progress towards the standard, and any associated dependencies and risks. Actions might include for e.g.: recruitment of

specific staff; waiting list initiatives; improvement work to improve processes; wider system change; etc. An example is included in the table below.

Quarter

ending

Action Forecast

impact on

standard

Funding – source

and amount

Interdependencies

(i.e. between

performance, funding,

workforce, partners)


Sep 19 Partnership working with A&E

to increase speed of refferals of

patients requiring mental health

liaison assessments.

Maintain

trajectory

No additional funding

Jun 19

Utilise Action 15 fund to

increase MH staff time to rural

general hospital A&E

departments

Maintain

trajectory

No additional funding Additional posts from Action 15 money are: 3 x Band 7 WTE for Supporting A&E and GPs in Ft William, Skye and Caithness. (under recruitment) 1 x Band 4WTE Assistant Psychologist for implementing Computerised CBT (under recruitment) 1 x Band 8A WTE Mental Health Pharmacist – in post 10 sessions Consultant Psychiatrist for Adult Services to introduce in-patient Consultant model releasing current sessions to increase community psychiatry and support to primary care 8 sessions Consultant sessions for OAMH to provide Liaison Psychiatry/ Younger people with dementia sessions 2 x Band 6 WTE for Personality Disorder Service 0.6 Band 5 WTE for Personality Disorder Service


APPENDIX 7 - THE IMPROVEMENT PLAN FOR PSYCHOLOGICAL SERVICES AMH

Issue to address Improvement Plan Progress Reduce and remove current waiting list (required to begin implementation of redesign 2019-2020)

An audit of clinical activity has been completed and areas for improvement identified.

A minimum level of clinical activity each working day has been agreed and implemented consistent with professional Standards. An on-line booking system for consulting rooms has been adopted in order to share the resource more efficiently amongst clinicians for clinical activity to increase. A departmental supervision rota has been developed to ensure that adequate managerial and professional supervision is provided regularly, by an appropriately qualified and experienced colleague for every member of the team.

A method of recording outcomes has been implemented in order to ensure that accurate data is entered and therefore useful data retrieved from the patient management system online. Data collected is now appropriate and sufficient to inform a demand/capacity audit. The waiting list has been organised and recorded accurately electronically.

The third phase of the waiting list initiative will begin formally on 3rd July 2019 now that administrative support and supervision is in place to help clinicians with the referrals that will be allocated to them. All patients will be treated according to a formal contract which will be agreed and signed at their first therapy session. Twelve sessions will be offered in the first instance with further sessions agreed in the clinician’s supervision if necessary.

May-June 2019 complete

June 2019 June 2019 June 2019

June 2019; this is ongoing as electronic systems will be explored with the wider Mental Health Services

July 2019 ongoing - December

June 2019 July-December 2019 Commenced early 2019


Until the implementation of the recommendations of the redesign commences the waiting lists will be divided according to whether the referral is for CBT or Clinical Psychology intervention. All but referrals received within the last six months will be allocated to therapists pro rata for the weekly hours that they work. As current cases are closed gaps in caseloads will be filled with patients from the allocated section of the waiting list. The patient contract will ensure that timescales are recognised as important. It will be the responsibility of individual therapists to decide on the most appropriate ways of addressing the cases allocated to them – for example by running groups. It is planned to have made a significant reduction to the waiting list six months from starting this – 12 weeks maximum to finish with every current open case and further 12 weeks to finish with at least 50 patients per therapist from the list. Afterwards the remaining cases will be triaged and will start covering geographical areas on a six month rotational basis. The current waiting list will be addressed by having a full complement of qualified therapists who will be prioritising this initiative. Starting with a variety of group interventions thus increasing the throughput of patients. Once the current list is significantly reduced in numbers any remaining clients will be assessed, triaged and offered an appropriate intervention according to a matched care model. This will enable us then to implement fully the recommendations from the service mapping and begin to assess every referral at point of entry.

Ongoing July to December 2019/January 2020

Ensure all geographical areas have equal access to service

As a result of the service mapping it was decided to move away from geographical patch working where individual clinicians worked in one area not covering or moving into another to cover leave or vacancies. All referrals and clinicians will be centralised rather than attached to a geographical area. This is to ensure equity of access for patients where ever they live and for staff to begin covering remote areas. A rota for all clinics covering the wide spread geographical areas of NHS Highland will be introduced. This will ensure a more equitable service is provided and consistency irrespective of leave.

August 2018 Referrals centralised late 2018 Rota due to commence July 2019


Ensure all geographical areas have equal access to expertise required for each client need

When the recommendations of redesign are fully implemented all referrals will receive a comprehensive Clinical Psychological Assessment where need and treatment will be determined. Referrals will then be triaged to the professional with the appropriate expertise for the referral.

January/February 2020 approximately

Ensure appropriateness of referral accepted into service

Development of the inclusion criteria for psychological therapies within an overall secondary mental health service. Further clarification of the inclusion criteria and more stringent adherence to these to ensure that referrals are appropriate for the service and that patient care is “matched” with the presenting problems.

September 2018 July 2019 ongoing

Ensure pathways of care are active and not stuck due to bottle necks

Introduction of treatment contract discussed with, agreed, and signed by patient at first therapy session. This outlines goals and plan for therapy with a clear end point. It also includes clinical outcome measures at the start, mid-way and end point of therapy to give objective data. The treatment contract enables a review point to determine if therapy is beneficial, if not why not; it allows the monitoring of patient compliance and engagement through progress as well as DNA and CNAs. This contract enables the client to end therapy after 12 sessions and it also enables the clinician to end sessions if the patient is not actively engaging in treatments. If the patient DNA’s or CNAs regularly it enables the sessions to be stopped and the patient need and commitment to treatment to be reviewed. If after 12 sessions the clinician and patient feel there is a need for further sessions then another contract for up to 12 sessions can be agreed. If at the end of this contract the client is not ready for discharge the clinician will need to undertake a case file review with the Service Head to understand why and the benefit of further sessions

Commenced April 2019 ongoing

Increase Clinician efficacy A minimum level of clinical activity each working day has been agreed and implemented consistent with professional Standards. An on-line booking system for consulting rooms has been adopted in order to share the resource more efficiently amongst clinicians for clinical activity to increase.

June 2019 June 2019 June 2019


A departmental supervision rota has been developed to ensure that adequate managerial and professional supervision is provided regularly, by an appropriately qualified and experienced colleague for every member of the team. The introduction of treatment contracts to prevent bottle necks and reduce DNA/CNAs Active referral and performance management.

April 2019 ongoing May 2019 ongoing

Active referral/waiting list management

Through the measures outlined above referrals and waiting lists will be actively managed by the Service Head.

May 2019 ongoing

Reduce DNA & CNAs As a result of the treatment contract patients will be made aware that the number of DNAs and CNAs are limited to each contract which prevents ongoing repeated sessions being booked with no benefits to the patient’s treatment. The treatment contract also enables a clinician to review a patient’s treatment and its beneficial impact in the context of other psychosocial factors which may prevent treatment being viable at a given time.

April 2019 ongoing

Improve recruitment and retention

All team members have participated in an initial, individual appraisal. These will continue on a yearly basis in order to support professional development/training which is in line with the development of the department as a whole. The recommendation from the Service Mapping was that during staff appraisals each staff member is asked to identify an area of expertise or special interest that they would like to develop further and which would be of value and benefit to the wider service. Once identified this interest should be supported through continued professional development activities. In return for this support the clinician becomes a source of expertise over time for specialist service provision, consultancy, supervision, and training in the chosen area to other members of the Psychological Therapies Service and to the wider service overall, ensuring this expertise is available across all of Highlands and ultimately benefiting all the clients in all areas.

May – June 2019

April 2019 ongoing

This improvement plan is focused upon AMH but once fully operating, monitored, and evaluated it will be adjusted generalised across other specialities within the Psychological Services to ensure consistency.


APPENDIX 8 – HAI QEUH REPORT

Assessment of Position against Recommendations and Requirements Contained in the Healthcare Improvement Scotland, Unannounced

Inspection Report – Safety & Cleanliness of Hospitals, Queen Elizabeth University Hospital, NHSGG&C January 2019

Report compiled on behalf of NHS Highland, Executive Nurse Director and Board Lead for Infection Prevention and Control by Catherine

Stokoe, NHSH IPC Manager, Eric Green, NHSH Head of Estates, Kate Patience – Quate, Lead Nurse 14.03.19

Requirement NHS Highland Position Requirement 1 NHS Greater Glasgow and Clyde must improve the governance arrangements in both estates and infection prevention control teams to assure themselves of safe patient care in line with Scottish Government’s guidance, NHS Scotland Health Boards and Special Health Boards – Blueprint for Good Governance (2019) (see page 10).

The Board Nurse Director is the Executive Lead for Infection Prevention and Control and both the Infection Control Manager and Head of Estates are members of both the Health & Safety Committee and Control of Infection Committee. These report directly to the Board. This dual representation is reflected in the operational sub structures across NHS Highland. NHS Highland is reviewing its governance structure taking into account the recently published Blueprint for Good Governance.

Requirement 2 Boards must ensure functioning negative pressure isolation rooms are available in the hospital in line with Healthcare Facilities Scotland, Scottish Health Planning Note 04. (a) Where these are not available, staff are provided with clear guidance on how to manage a situation where a patient would require this type of isolation. 8.1 and 6.5 priority 1 (b) Staff in ID will be reminded of facilities available for admission of patients with infectious diseases of high consequence

NHS Highland does not have an Infectious Diseases unit. Raigmore Hospital as the Boards only District General Hospital has working negative pressure isolation rooms available in the intensive care unit (2) and the respiratory ward (2)

Requirement 3 NHS Greater Glasgow and Clyde must ensure all staff involved in the running of water are clearly informed of their roles and responsibilities in this and a clear and accurate record is kept to allow early identification of any water outlets that are not being run

A standard operating procedure developed by the Water Safety group clearly outlines the process for water flushing and roles and responsibilities of staff. All domestic staff are trained to flush the water system in line with the standard operating procedure, and receive training on induction.


Domestic Supervisors provide ongoing support to the staff through the delivery of training and monitoring of compliance. Compliance with water flushing is monitored regularly through the HAI walk round assurance tool, and water results through the Water Safety group.

Requirement 4 NHS Greater Glasgow and Clyde must ensure all clinical areas across comply with the current national guidance in relation to the use of bladeless fans

Guidance was issued across NHS Highland following the alert from Health Protection Scotland to remove bladeless fans from all clinical areas and at the same time of the alert, procurement was also advised that the ordering of these fans was prohibited in the Board for clinical areas. In response to the Healthcare Environment Inspectorate report for NHS Dumfries and Galloway, and NHS Greater Glasgow and Clyde highlighting this issue in other Boards, this information was reissued in NHSH.

Requirement 5 NHS Greater Glasgow and Clyde must ensure that information on the expressed breast milk recording charts is in line with national guidance. This will ensure that the storage of expressed breast milk is managed in a way that reduces the risk to patients.

NHS Highland has a policy for the Expression, Storage and Administration of Expressed Breast Milk Guidelines for hospital which outlines the correct management and storage.

Requirement 6 Is there a strategy that ensures the environment in the emergency department is clean and patient equipment is clean and ready for use to ensure infection prevention and control can be maintained?

A previous inspection highlighted to NHS Highland the need to ensure a system was in place to allow nursing and domestic staff time to clean between patients in our busy Emergency department areas. In response to this feedback, a risk assessment was developed and implemented in these clinical areas which allows staff to identify the necessary level of cleaning for the environment which is proportionate to the patients presentation and level of identified risk to ensure that staff have the necessary time to complete cleaning regimes in accordance with National Cleaning specifications. Additionally, Domestic staff are part of the safety brief, which ensures clinical and domestic teams communicate effectively are able to co-ordinate work more effectively. The nurse in charge


and domestic supervisors also perform regular checks to ensure standards are maintained and any actions are fed back to the staff, rectified or escalated as necessary.

Requirement 7 NHS Greater Glasgow and Clyde must ensure the patient environment, and patient equipment, is clean and ready for use to reduce the risk of cross infection

NHS Highland has a number of assurance systems in place to monitor the cleanliness of equipment and the environment. Cleaning schedules are in place and monitored, and spot checks occur. The facilities management tool, alongside regular HAI walk round assurance tool performed by multi-professional groups including Infection prevention & Control, health & safety and estates staff. An annual Peer Review Inspection of sites also provides further assurance.

Specifically, within Raigmore Hospital a ‘Bed busting team’ is in place which provides additional support and capacity to areas to react rapidly in the cleaning of areas and equipment. – this initiative has been positively received by both clinical, managerial and domestic staff and the team have received an award for their success with this initiative.

Requirement 8 The board must ensure that domestic cleaning schedules are signed as complete by domestic supervisors with evidence and satisfaction that the domestic cleaning has been completed as detailed within the cleaning schedule

Cleaning schedules are in place in all areas. Cleaning schedules are signed by domestics for every task completed. The Domestic supervisor’s sign the completed cleaning schedules daily and the Senior Charge Nurse or their nominated deputy reviews and signs the form. Cleaning schedules are also reviewed as part of Nurse Manager and / or Lead Nurse reviews.

Requirement 9 The board must ensure domestic staff have the necessary equipment to perform their cleaning duties, to keep the environment clean and safe

Domestic staff regularly meets with the Domestic supervisor, and are aware to raise any concerns with equipment as and when necessary. All areas have a daily huddle where any issues or concerns are able to be shared and dealt with in a timely manner and this is


seen as an effective route for the multi professional team to raise issues.

Requirement 10 NHS Greater Glasgow and Clyde must provide staff with suitable and functioning domestic services rooms to minimise the risk of cross contamination from the disposal of soiled water after cleaning regime

All Domestic Service rooms are deemed fit for purpose, within the scope of the facility. These areas are reviewed regularly as part of the HAI Quality Monitoring reviews and independent peer review. The importance of Domestic Services rooms is recognised and within all redesign plans and new builds, the space is protected and designed in accordance with SHTN guidance.

Requirement 11 The board senior management must ensure all staff are aware of the correct cleaning method for cleaning hand wash basins and that the correct cleaning products are used to clean all sanitary fittings in line with current national guidance

NHS Highland follows the guidance within the National Cleaning Specification manual and the National Infection Prevention and Control manual.

Requirement 12 The board must ensure that the built environment is effectively monitored to ensure it is maintained to allow effective cleaning to ensure effective infection prevention and control.

The facilities management tool, alongside the regular HAI walk round assurance tool conducted by multi –professional team provides assurance. An annual Peer Review Inspection of sites also provides further assurance.

Requirement 13 The Board must ensure the estates reporting system is reliable and effective and acted on. Staff should also be informed of timescales for completion.

All estate faults are reported through the Maximo system, which allows progress to be seen. On a monthly basis the Estates department issue outstanding work order information to various staff groups including hospital managers, infection control staff and Senior Charge Nurses. This process allows oversight and escalation as and when necessary. The Maximo reports allow the Head of Estates to monitor estates performance. Further monitoring occurs during HAI walk round assurance tool completion. Any estates issues which are noted are reported on to the Maximo system, any defects which have not progressed can be scrutinised and escalated.


Requirement 14 The board must ensure that ventilation panels are cleaned

Reactive work is actioned. The status of work orders is reported monthly as described above, should any escalation be required. As part of the cleanliness review process performed via the Facilities Management tool, and the HAI walk round assurance tool completion these areas would be assessed and actioned as appropriate.

Recommendation a NHS Greater Glasgow and Clyde should ensure that access to audit information is not person dependent to ensure the continuity of the audit programme

The introduction of a ‘HEI folder’ into all ward areas has ensured that audit reports are available to all staff in order to address the challenge of a person dependant system which focuses on the role of the SCN. The Board is also in the process of developing an electronic system to aid the visualisation and accessibility of such reports and it is anticipated that this will form part of the Excellence in Care dashboard for clinical areas.


APPENDIX 9 – LIST OF CONTRIBUTORS TO THE PLAN

Scottish Patient Safety Programme – Maria Anderson, Stewart Lambie

Mental Health – Michael Perera, Stephen Whiston

Unscheduled care- Hazel Smith, Lorraine Paterson

Scottsh Access Collaborative – Donna Smith

Regional Planning – Paul Nairn, Stephen Whiston

Performance – Amie Westwater, Andrew Ward, Stephen Whiston, Derick MacRae, Donna Smith, Hazel Smith

Integration for Health & Community Care – Simon Steer

Primary care – Paul Davidson, Stewart Macpherson, Stephen Whiston

Health care infection – Catherine Stokoe


APPENDIX 10 – AOP 19-20


APPENDIX 11

Implications for Sustainability

Services in the Acute Sector can be categorised into 4 groups in terms of sustainability:

1. Sustainable with the transformation that is underway including, e-triage, NHS Near

Me, Active Clinical Referral Triage, Management of DNAs and improvements to the

Booking System, plans to implement a Procedure Room to move activity from Main

Theatres to increase capacity

Table One – Sustainable Services at Risk because of pressures

Dermatology General Medicine

Neurology

The above specialties have had issues with data recording where non recurrent activity has

not been accurately recorded, and has therefore been included erroneously within the

recurrent activity model.

In 19/20 NHS Highland terminated the contract for Dermatology services delivered by GPs

and the effect this will have has yet to be determined.

It should be noted that General Medicine have insufficient capacity to run the rotas for

medical receiving and a business case is being developed for additional consultants

2. Sustainable Services – assuming a steady workforce and recruitment underway is

successful

Table Two – Sustainable Services

Neurosurgery *Paediatric Medicine

Plastic Surgery

Rehabilitation Medicine

Respiratory Medicine

Rheumatology

Surgical Paediatrics

Dependant on recruitment of 2 consultant vacancies currently out to advertisement plus any

future changes of the management of neonatal activity within Raigmore Hospital

3. Sustainable as a result of implementing developed plans

Table Three – Plans in place for sustainable Services

Specialty Plans Funding Implication

Colorectal Redesign of service with zero patients waiting over 12 weeks as at March 2021

Funded

Ophthalmology Elective Care Centre to open Sept 2021

Business Case developed

Orthodontics To reinstate local service in Caithness and Belford and work with the General Dental

Business Case being developed


Practitioners to develop expertise to manage Category 1 patients

Orthopaedics Elective Care Centre to open Sept 2021

Business Case developed

4. Non-sustainable as a result of Workforce issues e.g. Long Term Consultant

Vacancies with a requirement to develop plans working differently within NHS

Highland and across the North of Scotland. The Clinical and Care Strategy will work

on developing the models of care in the next 6 to 12 months.

Table Four – Unsustainable Services due to workforce Issues

Specialty Issue Funding Implication

Cardiology

Lack of a 7 day service results in inefficiencies in the patient pathway

Develop a 24/7 Cath Lab in Raigmore

ENT

Long term consultant vacancies. Highly complex patients utilise a significant amount of resource and are small volume

Decision around the future of Head and Neck Cancer and redesigning patient pathways across the Region

Gastroenterology

Consultant vacancies resulted in a change to workforce model moving patients to Nursing, but this hasn’t achieved a sustainable position.

To be determined based on the care strategy being developed.

General Surgery (Upper GI and RGH activity)

Difficulty in recruitment for Consultant vacancies and high spend areas in the RGHs


Gynaecology

Delivery of a hub & spoke model is challenging the workforce model


Haematology Consultant recruitment difficulty To be determined based on the care strategy being developed.

OMFS Long term consultant vacancies in NHS Highland

Provide an Oral Surgery Service in NHS Highland and a Regional Maxillo-facial surgery service in the North of Scotland – costs to be determined

Oncology Consultant recruitment difficulty combined with sub-specialisation


Urology Long term consultant vacancies in NHS Highland

Develop a Regional Model for Urology services.

Elective Care Centre

NHS H has developed a full business case which is planned to open in September 2021. The

activity projections included in Appendix 1 assumes that the activity planned in the Full

Business Case is delivered. This development will free up clinical space within Raigmore

Hospital. The planning for how NHSH will utilise this freed up space to support new models of

care for the non-sustainable services is being considered and will be outlined in detail in the

20/21 Annual Operational Plan.


APPENDIX 12 – Elective Care Centre

Ophthalmology

For ophthalmology in 2018/19 a total of 3060 elective cases, of which 66% were Cataract

surgery This activity, based on a theatre utilisation target rate of 92%, would require a minimum

of 1.32 Operating Theatres to meet the activity moving forward.

At the end of 2018/19, the amount of patients still breaching waiting time targets was 325 which

would require an additional 0.14 of an operating theatre. Applying a 4% population growth

assumption would increase the requirement by a further 0.06 of an Operating Theatre.

Therefore the recent analysis suggests that Ophthalmology require 1.52 elective Operating

Theatres to meet their demand rounded to 1.60. This takes no account of training requirements

but is consistent with what was submitted in the initial agreement submitted at the outset of the

capital planning process.

The chart below sets out the projected cataract plan but assumes no additional WLI monies

for 2019/20 v9 assumes 2 operating tables and v8 assumes 3 operating tables

From the ophthalmology forecast is can been seen that TTG sustainability will either be

achieved in April 2013 assuming the ophthalmic department has the planned 3 tables (v8)

rather than the 2 tables identified as v9 when TTG sustainability will be delivered in February

2024

Orthopaedics

In 2018/19, Orthopaedics undertook a total of 2425 cases This activity, based on a theatre

utilisation target rate of 92%, would require a minimum of 2.58 Operating Theatres to meet the

activity moving forward.

At the end of 2018/19, the amount of patients still breaching waiting time targets was 784 which

would require an additional 0.79 of an Operating Theatre. If a population growth figure of 4%

is added this would increase the requirement by 0.13 of an Operating Theatre. In total

Orthopaedics require 3.51 again broadly consistent with the additional theatres identified within

the ECC business case

0

500

1000

1500

2000

2500

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3500

Jun

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Au

g-1

9

Oct

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De

c-1

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Feb

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Ap

r-2

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Jun

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g-2

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Feb

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r-2

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c-2

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Feb

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r-2

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g-2

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c-2

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Feb

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r-2

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Jun

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g-2

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c-2

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Feb

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Ap

r-2

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Jun

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g-2

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Oct

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c-2

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Feb

-25

Ap

r-2

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Jun

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g-2

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Oct

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c-2

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Feb

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r-2

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Jun

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Feb

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Ap

r-2

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Jun

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g-2

7

Year 1 & 2 Plan Year 3 & 4 Plan Year 5 Plan Year 5+ Plan

Ophthalmology Cataract Forecast

V9 WL Size - End of Month V8 WL Size - End of Month


The following charts set out the projections for hips and knees based on the May waiting list

position and include assumed activity historically received from Moray.

It is anticipated that TTG compliance will be achieved on April 2022 for hips and September

2022 for knees

-20

0

20

40

60

80

100

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g-2

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c-2

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Feb

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r-2

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c-2

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Feb

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r-2

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g-2

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Feb

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r-2

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Jun

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g-2

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Oct

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c-2

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Feb

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ECC Plan

Orthopaedics Hips Forecasting

WL Size - End of Month Excess Capacity Averaged expected Waiting Time (weeks)

-20

0

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40

60

80

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120

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-100

0

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Feb

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r-2

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Jun

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Au

g-2

0

Oct

-20

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c-2

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Feb

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Ap

r-2

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Jun

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g-2

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Oct

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c-2

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Feb

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r-2

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Jun

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g-2

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c-2

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Feb

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Ap

r-2

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Jun

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g-2

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Oct

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c-2

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Feb

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ECC Plan

Orthopaedics Knees Forecasting

WL Size - End of Month Excess Capacity Averaged expected Waiting Time (weeks)


APPENDIX 13 – AOP Action Tracker

ID Action Description Owner Priority Timescale Comments

1 Introduction

2 Approach

3 Activity

3.1

3.2 A summary of the latest 3 year activity forecast by specialty / service to be

prepared and used in all performance monitoring reporting

DS/ DJ End August

An extensive piece of work has been undertaken to better understand

the likely effects of demand on the future activity that will be expected

of all our services. This has multiple applications re informing RTT

(see later), Finance and our clinical strategy. It needs to be signed of

3.3

3.4

4 Elective Waitng Times

Work needs to be concluded comparing the resource and actions required to

deliver sustainable WL position by the end of 19/20 with the current plan to

deliver acceptable waiting list numbers on a non recurrent basis. The different

approaches need to be reconciled and a plan developed to address any

material differences.

DP / DS / KS Very High End Julythere is currently a lack of clarity around the apparent differences

between the two different approaches described. This needs to be

urgently addressed given the very high risk to delivering our agreed

and funded Wl numbers.

It is not currently clear what the cost of delivering sustainable WL services is

likely to be across all relevant services. This is a critical planning requirement

for both Scottish Govt. and the HB.

DP / DS/ KS Very High End July

Moving forward we need to better understand the relationship between

demand, capacity and cost. At the moment this topic isbeing

addressed as referenced above on a N/R basis. This represent a

considerable risk to the HB and the wider service and needs to be

The impact of potential service improvement and productivity work needs to be

considered in developing our future plans to deliver sustainable services. This

will require a dialogue with Scottish Govt to clarify how this can be incentivised

across the system

At the moment the impact of any productivity gains are deemed to be

non recurring and hence relatively low value. The eviodence suggests

however that there could be copnsiderbale gains delivered were we

able to agree a way of making these benefits financially recurrant.

Elective Care Centre (ECC)

When the ECC opens Ortho and Optho will vacate the existing clinical capacity

therby freeing it up for alternative use. Work is required to establish what this

might be, the impact on RTT and any additional costs.

DJ / DP High End July

At the moment there is no clarity about how the freed up clinical

capacity will be used to assist in delivering sustained RTT compliant

services nor is there clarity around how much of the available physical

capacity is staffed and therefore available.

Remodel the impact that any additional waiting Times activity completed in the 3

years of this AOP will have on both the capacity available for additional external

RTT work and on the costs of running the new service.

DJ High End of July The modelling needs to be refined as it currently assumes little or no

reduction in the WL position for the two named specialties ahead of

thnew facility coming on stream. This is unlikely to be the case.

5 Cancer Waiting Times

Develop an action plan in response to the national 'Effective Cancer

Management Framework' issued in Feb 2019

KS High End August Developing and implimenting this action plan is a priority particularly

given our poor performance in this area.

Develop and agree a Concer Strategy to deliver more consistent and

performance compliant performance in the future

KS Medium October This needs to be incorporated into and be consistent with the

organisations clinical strategy currently under developemnt

Recognising the ongoing difficulties associated with recruiting to a number of

critical clinicl posts intiate work develop alternative clinical modesl and to stream

work to other health professionals.

This recognises that there are a number of posts we are unlikely to fill

and therefore we need to dveleop alternative models or divert our

patient to alternative centres.

Initiate discussions with regional colleagues to develop improvements to clinical

pathways

KS High Septemberessential to address longer term capacity and subspecialisation issues

6 Unscheduled Care Waiting Times

Focus attention on the inability to place patients in suitable onward setting due

to the lack of suitable alternative service availability.Develop a BC to capture

the detail, explore the options and highlight any related investment / savings

DP/KS The scale of both the problem and the potential benefit have been

hinted at through the recent National Day of Care survey which

highlighted the high volume of patients retained in ED who could and

should be more appropriately cared for elsewhere, were there any


7 Integration

The plan to develop care in home in the N&W sector to be ona par with S& mid

to be formailes, quantified and signed off as soon as possible, including key

delivery milestones

DP High End August Work already underway on this however there has previouisly been

resistance and it probably benefit from greater exposure to SLT and

the formailsation of any local plans.

8 Mental Health

9 Community Services

Given the lack of any digital informatione.g. activity / performance etc for

Community Services it is an essential proiority that this is addressed at pace to

allow the service to be more effectively managed. Hence the BC for Morse

needs to be expedited.

DP High September

This is a major service where we struggle to understand, in detail what

is happening.

10 Primary Care

Progress against implimenting the agreed GMS contract plans to be reported to

SLT / Board

This is a major issue in context of the national Medium Term Plan and

we need to be sighted at regular intervals on progress.

11 HCAI

12 Finance

Need to formalise the additional funding that the HB will receive from Scottish

Govt. in support of the Community and Hospital Services in Skye, Lochalsh&

South West Ross including a bid for full support funding of the SLR

recommendations.

Need to recruit a permanent PMO Director CEO High December Interim PMO director will leave at end of March 2020 latest

13 Risk and Mitigation

Agree and impliment a clear approach to ensure that there is a Dof or TD or

both in post asap to provide clear focus, drive and leadership to the whole

financial improvement agenda

14 Conclusions

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