nhsscotland shared services health portfolio laboratories ... · (dsg) and the various diagnostic...

NHSScotland Shared Services

Health Portfolio

Laboratories Programme Strategy Paper

Authors: Heather Bryceland, Janice Archer, Dr Bill Bartlett Contact: [email protected] [email protected]

Date issued: 18th July 2017 Version: 0.28

mailto:[email protected]


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Programme Title Health Portfolio - Labs Programme Strategy Paper

Project Managers Heather Bryceland, Janice Archer

Programme Manager Kim Walker

Subject Matter Expert Dr Bill Bartlett

Programme Director Dr Brian Montgomery

Contact [email protected] 0131 314 1533

DOCUMENT HISTORY

Revision History

Version Number

Revision Date Contributors

v0.1-v0.4 04/04/17 Janice Archer

V0.5 05/04/17 Janice Archer

V0.6-16 03/05/17-23/06/17 Janice Archer / Heather Bryceland

V0.17 25/06/17 Kim Walker/Janice Archer/Heather Bryceland

V0.18IR 26/06/17 Heather Bryceland / Janice Archer

V0.18kw 29/06/17 Kim Walker

V0.19hb 03/07/17 Heather Bryceland / Bill Bartlett / Brian Montgomery

V0.20hb 05/07/17 Heather Bryceland / Bill Bartlett

V0.21-V0.25

07/07/17- 11/07/17 Heather Bryceland

V0.26 12/07/2017 Linda Kerr/Emma Smith

V0.27 17/07/17 Heather Bryceland / Bill Bartlett / Emma Smith

V0.28 18/07/17 Heather Bryceland/ Brian Montgomery

Strategy Paper

I confirm that this Strategy Paper has been approved.

Signed by:

Brian Montgomery

Date: 18 July 2017


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Table of Contents

1 Executive Summary .................................................................................................................. 4

What we are asking of the CEs ................................................................................................... 7

2 The Strategic Case .................................................................................................................... 8

The case for change .................................................................................................................... 8

Current arrangements and challenges ....................................................................................... 11

Investment objectives and guiding principles ............................................................................. 15

A future service model for the delivery of laboratory services.....................................................16

Enablers .................................................................................................................................... 20

Main benefits criteria ................................................................................................................. 21

Risks ....................................................................................................................................... 22

Constraints ................................................................................................................................ 23

Dependencies ........................................................................................................................... 23

3 Economic Case ....................................................................................................................... 24

4 Commercial Case .................................................................................................................... 29

5 Financial Case ......................................................................................................................... 30

6 Management Case .................................................................................................................. 31

7 Readiness to Proceed ............................................................................................................. 32

What we are asking of the CEs ................................................................................................. 33

Appendix 1 – SWOT analysis ..................................................................................................... 34

Appendix 2 – PESTLE analysis .................................................................................................. 39

Appendix 3 – Workshop outputs ............................................................................................... 42

Appendix 4 – Laboratories in Scotland 2015 ............................................................................ 47

Appendix 5 – Baseline data ........................................................................................................ 48

Appendix 6 – Investment objectives and benefits .................................................................... 56

Appendix 7 – Stakeholders ........................................................................................................ 61

Appendix 8 – Shared Services and Laboratories – Background ............................................. 65

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1 Executive Summary The current model of laboratory services delivery across Scotland is not equitable nor is it sustainable in light of the challenges it faces. This paper proposes developing a business case to deliver a future service model for laboratories in NHSScotland.

This strategy paper will describe the case for change and provide a high level description of the proposed model emerging through extensive stakeholder engagement. The contention, that there is an opportunity to use the significant resources - workforce, facilities, equipment and finance - available to Health Boards to deliver laboratory services in a way that is more efficient, effective, equitable, resilient and affordable, has been confirmed by stakeholders. Stakeholder consensus has formed around a Distributed Service Model (DSM). The DSM provides the correct volume, range and repertoire of tests reported within an appropriate timescale to support local delivery of front line services. The DSM will deliver an optimal distribution of laboratory services across Scotland with concentration of workloads and sharing of expertise across wider geographical areas. Delivery of the DSM will depend upon coordination across and between laboratories and standardisation of operating procedures across services. In planning terms this will equate to a single virtual service functioning to consistent standards across Scotland while different aspects of service can be delivered by the relevant operational unit at the most appropriate level whether national, regional, Health Board level, individual hospital or community. In many respects this replicates the approach adopted by Scottish National Blood Transfusion Service (SNBTS) in recent years. Guiding principles for a distributed service model have been developed and endorsed by the stakeholder group, and are listed on page 16. The DSM contrasts with the current situation that sees Health Boards providing services that exhibit a high degree of unplanned variation in form, function and capacity. As a consequence the existing model results in unnecessary duplication of services nationally which impacts upon the cost effectiveness and resilience. The existing model also fails to deliver a critical mass in relation to service planning, delivery, workforce and procurement. It is the view of stakeholders that the DSM offers greater sustainability and resilience and will enable us to meet the future needs of NHSScotland. The details including quantified costs and benefits of the DSM now need to be developed through a business case for laboratories. This will not be through a single all-encompassing business case but through a suite of linked cases covering delivery of the identified enablers and redesigned services. The cases will address pressures, priorities and opportunities agreed with stakeholders while being constructed as deliverables of manageable scale and complexity. The net effect will to be incremental delivery of a DSM covering all aspects of laboratory services falling within the programme’s remit.

Current Situation and Drivers for Change

Stakeholders have endorsed the SWOT analysis Appendix 1 and PESTLE analysis, Appendix 2, of the present service model undertaken during workshops following stakeholder engagement (see Appendix 3). These demonstrate inherent weaknesses with the current system and highlight significant drivers for change. These analyses confirm the need for a new service delivery model for laboratories services in NHSScotland: The DSM. Table 1 summarises at a high level drivers for change identified by stakeholders.

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Drivers for Change

Multiple factors challenging the sustainability of the current model (see SWOT Appendix 1)

Increasing demand on health care service as a consequence of ageing populations and increasing prevalence of long term conditions delivering increased demand for laboratory services.

Need to support evolving models of care as a consequence of the NHSScotland National Clinical strategy and in response to the Health and Social Care Delivery Plan.

New and emerging technologies that will enable service transformation and increased clinical effectiveness and efficiencies.

Emergence of personalised medicine and need to deliver companion diagnostics

Need to address intrinsic variation in service delivery and extrinsic variation service utilisation across the current model for laboratory services.

Challenges in delivery of a sustainable and competent work force appropriately structured to meet the current and evolving requirements of NHSScotland

Need to address inequity of service delivery across NHSScotland

Need to deliver affordable laboratory services to NHSScotland that are optimally configured to deliver maximum whole system benefit by enabling access of the right test, in the right place at the right time.

Table 1: High Level Drivers for Change Addressing the drivers is hampered by current arrangements where Health Board level accountability has created a number of barriers which will have to be surmounted to realise the full potential of the DSM. Much of this relates to intrinsic variation, that is, variation within and between laboratories where there is no standard approach across Health Boards to operating procedures covering planning, delivery, IT systems, procurement or employment. This results in:

Inequitable access to testing across boards;

No NHSScotland standard approach to data;

Standalone IT systems which are expensive to maintain and which do not connect with other clinical systems. Nor do they connect with systems in other laboratories within and between Health Boards;

Failure by several Health Boards to achieve critical mass in relation to laboratory services;

Service duplication;

Unutilised or underutilised capacity within laboratory facilities – buildings and equipment;

High risk of single points of failure, both within specialist analytical areas and within discipline specific IT staff;

Workforce planning not linked to national requirements;

Difficulties providing opportunities for training and career progression;

Difficulties in succession planning;

Difficulty in workforce recruitment and retention;

Board level capital plans to maintain and develop facilities and capacity within laboratories;

in the face of ageing real estate and ageing IT infrastructure;

Different local priorities; and,

Variation in the achievement of accreditation standards between Health Boards.

A further challenge for the current configuration of laboratories is meeting the required standards for accreditation and regulation. This is costly and complex in terms of both time and resource. However there is the potential for some rationalisation by moving from accreditation of individual laboratories to accreditation of Health Boards. This could potentially be taken further once the DSM has been established and there is greater clarity around regional delivery and accountability. This is dependent upon what constitutes the legal entity responsible for the facility being accredited. The significant work that has been done since the Laboratories Positioning Paper was submitted to the Chief Executives (CEs) in November 2016 has allowed greater understanding and

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quantification of the issues outlined in that paper1. The paper identified four enabling projects necessary to ensure that maximum benefit is derived from the DSM

1. Benchmarking The development of robust and consistent benchmarking data to enable service planning and improvement. This work is being taken forward by all Boards in partnership with Keele University.

2. IT

Definition of the IT specification required to support delivery of the DSM. An initial workshop has been held and a shared understanding of the future requirements for an IT connected DSM have been agreed by stakeholders.

3. Standardisation

Alignment of laboratory practices and procedures to reduce unwarranted variation of laboratories service provision and promote consistency and connectivity between Board level services.

4. Innovation

Exploring innovative solutions to support the efficient and effective delivery of laboratory services through the DSM. Digital Pathology is being progressed as an initial pilot supported by funding secured from Scottish Government.

Table 2: Enabling Projects As with other service areas covered by the Shared Services Health Portfolio, realising the full potential of the solution proposed in the business case will depend upon addressing extrinsic variation; the variation in the practice of clinicians and others who access the testing services provided by laboratory disciplines. There is significant variation in demand for certain tests between Health Boards which needs to be understood and, where appropriate, addressed. This will require further engagement with the wider clinical community through Medical and Nurse Directors, the Diagnostic Steering Group (DSG) and the various Diagnostic and Clinical Networks. The approach must also link to the ethos of Realistic Medicine and the Demand Optimisation Group.

Anticipated Benefits

A number of anticipated benefits have been identified by stakeholders and now require to be developed further as part of the business case.

Anticipated benefits of the DSM

A laboratories model capable of supporting emergent front line clinical models

Service model that is focussed on delivery of Triple Aim benefits

Greater adherence to the concept of delivery of the right test, right place, right time

Equity of provision

Greater sustainability and resilience

More efficient and effective use of resources – facilities, equipment and finance

Reduced requirement for capital to refurbish and develop facilities

Greater critical mass with benefits in areas such as the application of clinical expertise and in procurement

Improvements for workforce including improved workforce planning with delivery of training opportunities, better career structure and improved recruitment and retention

Consistent application of new technology to improve efficiency and effectiveness

IT connectivity with the ability to match demand and capacity through remote working

Streamlined more efficient approach to accreditation

Table 3: Anticipated benefits

1 The Shared Services Laboratories Position Paper was presented to the Chief Execs when they met on 8th November 2016

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The work on laboratories has also identified several examples where investment in new investigations could significantly alter care pathways with benefits to patient experience and efficiencies which can be realised as savings or capacity and performance gains. An example would be the introduction and consistent application of B-type natriuretic peptide (BNP) testing, (table 19 refers) which would provide patients with faster, more accurate diagnosis of heart failure and reduce demands on cardiac imaging and cardiology outpatient appointments. Such initiatives will be most effective if introduced as part of standardised national clinical management pathways in line with the National Clinical Strategy, Demand Optimisation and Realistic Medicine. There is the opportunity to improve efficiency, effectiveness, equity, resilience and affordability of laboratories services pan Scotland. Stakeholders overwhelmingly agreed that progression to the DSM for laboratories in Scotland is the most appropriate way to achieve this and to support future development.

What we are asking of the CEs

The CEs are asked to: a) Give authority for the laboratories programme to develop a business case(s) outlining options

for a distributed service model with key components for Scotland in accordance with the guiding principles; and,

b) Ensure support from the NHS Boards to assist with enabler projects / pilots; and,

c) Ensure that any future capital investment and re-procurement plans considered necessary to sustain business as usual are aligned with the work of the Laboratories Programme and comply with the guiding principles for a distributed service model (as listed on page 17)

d) Support the next steps of the Laboratories Programme.

Next steps To enable the ongoing process of a successful design of the DSM, a programme delivery group will be established. This will include multidisciplinary representation from:

1. Territorial Health Boards; 2. Relevant Special Health Boards; 3. Managed Diagnostic Networks; 4. Diagnostic Steering Group; and, 5. Partnership.

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1. The Strategic Case

The Case for Change

In 2015 a Shared Services visioning exercise facilitated by Deloitte identified the advantages of delivering Shared Services within NHSScotland. Laboratory services were recognised as one of the elements of the emerging programmes for diagnostic services which is now embedded within the Health Portfolio. This section of the Strategic Paper sets out a compelling case for change to design the DMS for Laboratory Service delivery to NHSScotland. The DSM is required to enable delivery of an efficient, effective, resilient and affordable service to meet future national and local requirements.

National Drivers for Change

Drivers for change, in terms of relevant policies, strategies and reports are summarised in table 4 below.

Policy / Driver Requirements

Health and Social Care Delivery Plan (January 2017)2

Delivering Value: Services should be organised and delivered at the level where they can provide the best, most effective service for individuals. Regional, and in some case, national, centres of expertise and planning should develop for some acute services to improve patient care.

Health and Social Care integration: Delivering the right test and the right place and the right time.

Primary and Community Care: “...to enable those waiting for routine check-up or test results to be seen closer to home by a team of community health care professionals” “enable GPs to have more access to hospital-based tests so that people can be referred to the right clinician first time.”

Realistic Medicine: “reduce unwarranted variation ... [to] ... support a workforce that can find more effective and valued ways of delivering medicine”

NHS Board reform: Review the functions of existing national NHS Boards to explore the scope for more effective and consistent delivery of national services and the support provided to local health and social care system for service delivery at regional level. Ensure that NHS Boards expand the ‘Once for Scotland’ approach to support functions

2 http://www.gov.scot/Resource/0051/00511950.pdf

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National Health and Social Care Workforce Plan (NHSCWP) : The NHSCWP will take forward the commitment to a sustainable workforce

Research and development, innovation and digital health: Digital technology. The time is right to develop a fresh, broad vision of how health and social care service processes in Scotland should be further transformed making better use of digital technology and data.

The Christie Commission Report 3

A future Laboratories Service model will be tackling fragmentation and complexity in the design and delivery of the service.

National Clinical Strategy 4

Laboratory Services to be planned and delivered nationally and regionally, based on evidence supporting best outcomes for the populations those services will serve.

Healthcare Quality Strategy5

Effective collaboration between clinicians, patients and others. Continuity of Care.

7 day working

NHSScotland faces a challenge with regard to sustaining a suitably trained workforce over the next five to ten years. The Scottish Government Seven Day Working Taskforce has been asked to identify the optimal service models and consider what is needed to deliver them.

Ageing population and increase in long term conditions

The resulting increase in workload cannot be supported within the current laboratories structure.

Financial pressures/shrinking budgets across the health care system

A future service model for Laboratories will increase efficiency, reduce waste through identifying unwarranted variation and demonstrate whole system benefit.

Scottish Healthcare Science National Delivery Plan (2015-2020)6

Demand Optimisation: This is defined as the process by which diagnostic test use is optimised to maximise appropriate testing which in turn optimises clinical care and drives more efficient use of scarce resource. The process needs to consider:

Minimising over-requesting and under-requesting, both of which can be damaging to optimal patient care.

Reducing unnecessary repeat requesting.

Ensuring appropriate and useful test repertoires are universally available across all healthcare outlets.

The development of a future service model is driven by the desire for

3 http://www.gov.scot/resource/doc/352649/0118638.pdf 4 http://www.gov.scot/Resource/0049/00494144.pdf 5 http://www.gov.scot/Resource/Doc/311667/0098354.pdf 6 http://www.gov.scot/Resource/0047/00476785.pdf

http://www.gov.scot/Resource/0047/00476785.pdf

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demand optimisation.

The Future of Pathology Services (Nuffield Trust, June 2016)7

IT: There is widespread agreement on the need for better supported IT that is interoperable so patients and other institutions can easily access data. The National Laboratory Medicine Catalogue is an important foundation for this work. Effective laboratory information management systems are also critical for the delivery of high-quality, safe pathology services. As the quantity of digital information increases, the ability to store, retrieve and analyse data will become increasingly important. Workforce: The Royal College of Pathologists identified that 40% of pathologists are over 55 and most are expected to retire in the next five years. Training pathways will not generate sufficient people to replace them, which pose a significant risk to service delivery.

Table 4: National Drivers for Change

Local Drivers for Change The PESTLE analysis was completed: Appendix 2. The key points from this analysis are summarised in table 5 below.

Policy/Driver Themes relevant to Labs

Increasing demand and new models of care

Laboratory Services existing configuration will be unable to respond to either due to ageing IT, other existing infrastructure and continued working in silos.

Industry regulation Evidencing compliance with ISO 15189 through UKAS accreditation visits is more challenging for clinical and scientific staff in smaller NHS Boards. MHRA and other bodies place a regulatory framework around elements of service delivery that are challenging to deliver and maintain.

Workforce sustainability Due to the current silo environment, role development and skills mix are becoming increasingly challenging to manage. New technologies are challenging existing role boundaries. Increasing the focus on the data information, information and knowledge management is also identifying the need for new roles.

Increasing need for big data analysis

Current disparity between both laboratory software and data means that meaningful cross border analysis is not currently possible.

There is a wide variation in form and function of services across Health Boards

This forms a barrier to cross border collaboration and lab to lab communication.

Table 5 Local drivers for change

7 https://www.nuffieldtrust.org.uk/files/2017-01/future-of-pathology-services-web-final.pdf

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Current Arrangements and Challenges

At this time, laboratory services in Scotland appear to be unbroken to users. Historically service providers across the Health Boards have evolved largely to meet their local Health Board requirements. This has led to high degrees of intrinsic and extrinsic variation in form and utilisation of service. The development of local services has been tempered by competition / demand for resource. Therefore, variation in service form and function arise as a consequence of competing local priorities for investment across the wider system at Health Board level. This is a major cause of intrinsic variation across the country which needs to be managed in order to deliver sustainable and equitable services in the future.

Laboratory Services in Scotland Laboratory services in Scotland are complex, varied and wide reaching. This map in Appendix 4, is indicative of the location of laboratories in NHSScotland in 2015.

Current situation In order to verify and qualify data obtained from Scottish Health Service Costs8 (Cost Book) the following baseline data was gathered in April 2017 from laboratory services across Scotland in the form of a questionnaire. This involved input from Shared Services leads and designated laboratory representatives from the Health Boards. This data demonstrates significant variation and range of services provided in each locality. The following figures demonstrate the extent of variation in laboratory services by location and by service configuration. Thus blood sciences departments are made up of three disciplines in some Health Boards and two in others. There is further variation at hospital level within services delivered across Health Boards which is shown in Appendix 5: Table A1: Baseline data - Service Component delivered by location.

Figure 1: Laboratory services by location, West of Scotland (NHS Greater Glasgow & Clyde, Golden Jubilee, NHS Ayrshire & Arran, NHS Lanarkshire, NHS Dumfries & Galloway, NHS Western Isles, NHS Forth Valley)

8 http://www.isdscotland.org/Health-Topics/Finance/Costs/

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1

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Monklands Hairmyres Wishaw GJNH Vale of Leven

Gartnavel General

Glasgow RI Queen Elizabeth

Stobhill Ambulatory

Care

Victoria Ambulatory

Care

Inverclyde Royal

Royal Alexandra

FV Royal Ayr University

Crosshouse DGRI Galloway Community

Western Isles

Airdrie East Kilbride

Wishaw Clydebank Alexandria Glasgow Greenock Paisley Larbert Ayr Kilmarnock Dumfries Stranraer Stornoway

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Site and Location

Blood Sciences Chemical Pathology Genetics Haematology Histocompatibility and Immunogenetics Histopathology Immunology Medical Microbiology Neuroimmunology Andrology

http://www.isdscotland.org/Health-Topics/Finance/Costs/

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Note: Genetics service at NHS Highland Raigmore Hospital is reported under NHS Tayside

Figure 2: Laboratory services by location, East of Scotland (NHS Borders, NHS Tayside, NHS Lothian, NHS Grampian, NHS Fife, NHS Highland, NHS Orkney, NHS Shetland) There are also examples where some Health Boards are providing laboratory services for other Health Boards: Appendix 5, Table A2 Tests provided and received for the period April – December 2016 (within Scotland). Based on Cost Book data 2015/16 the current laboratories situation is detailed within Appendix 5, Tables A5 and A6:

27 laboratory sites

Containing 87 laboratories

Covering 16 Boards (14 territorial and 2 special)

Approximately 3759 FTE staff

Annual Costs estimated at £251.6 million

£178.9 million staffing costs

£72.7 million non-staffing costs These services may be provided under Service Level Agreements (SLAs) following historical arrangements. There is variation in the level of cross charging for these transferred workloads. These arrangements have often been ad-hoc reflecting local specialist interests or more structured when commissioned as national services. Ad–hoc arrangements by their very nature are unplanned in the context of NHSScotland as a whole. They can be expensive and raise issues in terms of equitable access to specialist testing. The current laboratory service in NHSScotland is therefore challenging in its complexity and variability in its various aspects of form and function across the Health Boards.

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Gilbert Bain Balfour Aberdeen RI Aberdeen Sexual

Health Clinic

Dr Gray's Belford Raigmore Caithness General

Lorn and Islands

Ninewells Perth RI Victoria Edinburgh RI RHSC Western General

St John's Borders General

Lerwick Kirkwall, Orkney

Aberdeen Elgin Fort William Inverness Wick Oban Dundee Perth Kirkcaldy Edinburgh Livingston Melrose

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Site and Location

Blood Sciences Chemical Pathology Genetics Haematology Histocompatibility and Immunogenetics Histopathology Immunology Medical Microbiology Neuroimmunology Andrology

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IT Systems The IT infrastructure in place to support the delivery of laboratory services in NHSScotland displays an unacceptable level of variation. In most cases there is limited standardisation within the IT systems employed in the laboratories. This is reflected in the systems used and the way that the systems are configured. See table 6 below. The detailed breakdown of this is found in Appendix 5, within Table A3: LIMS systems by Board and Discipline and A4: Order Communication System.

Variation of IT Systems (15 Boards -not including SNBTS)

Laboratory Information Management System (LIMS)

Electronic Ordering (Order Comms)

Eleven different LIMS

Supplied by nine different system providers

Three Health Boards using multiple systems

Where Health Boards are using the same systems they are using different software versions

Eight different systems

Only five offer between Health Board communication

Most Health Boards use different systems for primary and secondary care.

The IT system employed by SNBTS has not been universally adopted by all boards delivering a degree of complexity around the management of blood products.

Table 6: Variation of IT Systems

The challenge within IT systems in the laboratories in NHSScotland is due to the high degree of variation they do not facilitate cross border working and lab to lab communication. This variation carries significant overhead in terms of management and delivery of critical systems and delivers complex interface with laboratories. It will also impact on the ability of services to respond nimbly to national initiatives dependent upon IT configuration.

Workforce Many of the workforce issues identified in the DSG Workforce Report of 2013 are still prevalent

and evolving. The stakeholder workshops identified a consensus that the current workforce

configuration does not provide the resilience required for the future. More information relating to workforce will be gathered through completion of the Keele questionnaires data from 2016/17. There was significant consultation and constructive discussion around the form of these questionnaires with stakeholders within the data / benchmarking enabler project. At this stage major workforce challenges were identified as follows:

Ageing workforce with poor succession plans;

Workforce model is expertise heavy;

Recruitment and retention issues; and,

Sustainability of specialist disciplines. The DSM for service delivery and technological developments will have a major impact on workforce planning.

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Specialities The map in Appendix 4 highlights the Health Board distribution of the five main laboratory services in NHSScotland and displays a breakdown of a range of specialties (as identified by the Cost Book). The Royal College of Pathologists9 identifies on their website that they oversee training of pathologists and scientists working in 19 specialities which include cellular pathology, haematology, clinical biochemistry and medical microbiology. As demonstrated in Figures 1 and 2, there is variation in the distribution of specialities. Laboratory services need to make provision to enable sustainable delivery of these 19 specialities across NHSScotland. This delivers concerns regarding sustainability of the current model due to challenges highlighted under workforce and general issues identified in the SWOT analysis: Appendix 1. The emerging challenge for laboratory services is delivery of a resilient infrastructure that will enable supply of the required laboratory outputs from the 19 specialties that meets evolving user requirements.

Technology and Innovation Technology and innovation will shape future laboratory service delivery. Within the current model adoption and deployment of new technology, innovation and best evidence is challenging. Coordinated responses across Health Boards, in the main, can only be achieved at this point in time through consensus and/or compromise where funding streams are locally based. Local interests and strategies may deliver ad-hoc and piecemeal adoption of new approaches to service delivery. This limits the potential benefits realisation, to the population of Scotland that may be achievable through a more coordinated delivery. An example of new technology that will clearly enable a new approach to service delivery is provided by Digital Pathology. A pilot project is in an advanced stage of development delivered by collaborative working between NHS Greater Glasgow & Clyde and NHS Lothian, with wider involvement of the Cellular Pathology Networks and Shared services. This was identified under the innovation enabler project as a key development in this speciality. The challenge following a successful delivery of this project will be national deployment of the technologies across all Health Boards faced with competing priorities for pressurised resource. Digital Pathology highlights the feasibility of a “Once for Scotland” approach involving multiple stakeholders in its delivery and at the same time identifies the need to develop a service model that will enable sharing. Other examples which could be considered important at this point in time and potentially game changing includes (not exhaustive):

Molecular testing in infectious diseases;

Robotics (delivery of multidisciplinary workloads in high volumes);

Emergence of techniques to support the delivery of personalised medicine;

Development in mobile technologies and Point of Care Testing (POCT); and,

Information, data and knowledge management.

9 https://www.rcpath.org/

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Summary It has been highlighted that the current service model faces many challenges that will impact on its long term sustainability. These challenges have been recognised and validated by multiple stakeholders who proposed the delivery of a future service model that would be best placed to meet these. The proposal is that a distributed service model (DSM) would deliver a framework to respond to current challenges and meet future service need. The stakeholder consensus is that the DSM approach is best suited to delivering services that are efficient, effective, equitable, resilient and affordable.

Investment Objectives and Guiding Principles

The investment objectives identify what is needed to be achieved to overcome the problems with the existing arrangements. The key investment objectives for this proposal are listed in table 7 and were developed using outputs from stakeholder workshop 1 (the visioning workshop) which was held on the 15 September 2016. The investment objectives were accepted by stakeholders at workshop 2, held on 14 December 2016. They have been widely circulated with no objections received in response. Each investment objective has been selected in response to the need for change outlined above and to align with stakeholder ambitions for what we could achieve through applying the DSM to laboratory services.

Effect of the cause on the organisation What needs to be achieved to overcome this need? (Investment objectives)

Existing configuration is currently unable to respond to increasing demand and new models of care, mainly due to ageing IT systems and the fact that both disciplines and Boards work in their own silos

To put in place a flexible, scalable configuration of facilities that can meet future demand

Risk of failure as the current service model is not resilient

To enhance service resilience through minimising variation and enabling cross border working

There is an imminent risk to service sustainability due to the workforce

To provide a sustainable, resilient, adaptable workforce linked to a credible workforce plan

Change is required to support the delivery of the NHSScotland Clinical Strategy, by refreshing outdated technology/ageing infrastructure and spreading the good practice which is currently happening in silos

To provide improved and equitable outcomes for patients (2020Vision) by reconfiguring to support NHS transformation

Due to shrinking budgets and competing demand for revenue and capital, we need to make savings to meet CRES targets at a time when investment is needed

Deliver demonstrable value for money, reduce/avoid expenditure to enable appropriate investment in effectiveness

Table 7: Investment Objectives Alongside the investment objectives a series of guiding principles for laboratory service improvement/transformation were developed and endorsed by stakeholders in workshop 2. These have also been subject to widespread circulation without objections received in response. The

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Access Directorate of NHS Tayside has already adopted these as a point of reference to be considered in any imminent laboratory developments. The guiding principles that underpin the development of the DSM are listed in table 8. A table of how the investment objectives and guiding principles are mapped can be found in Appendix 6.

1 Enables national planning of services while enabling a focus on local needs (right testing, right place, and right time).

2 Is aligned with the National Clinical Strategy, supporting health care improvement with a Triple Aim focus.

3 Employs a Once for Scotland approach through an appropriate governance structure.

4 Enables national workforce planning.

5 Allows the free flow of materials, information, data, knowledge and skills across organisations.

6 Enables optimised demand on services locally and nationally via appropriate interfaces with users and planners.

7 Supports local education and training of laboratory, other NHS personnel and students to ensure optimal delivery and usage of laboratory resource.

8

Ensures a sustainable Laboratory Service provision configured to deliver what is required locally to deliver equitable patient access and outcomes across NHSScotland (right testing, right place, right time frame; support delivery of optimal patient flow and capacity).

9 Delivers services designed upon Lean principles.

10 Enables appropriate standardisation of systems and processes, and sharing of resources and best practice (simplify, standardise and share).

11 Has an infrastructure that enables maximisation of return on investment in laboratory services (e.g. optimal use of distributed capacity).

12 Focussed on delivery of efficient, effective, resilient, and affordablelaboratory services that address waste, harm and variation in terms of both service provision and clinical application of their outputs (deliver efficiencies and invest in effectiveness).

13 Enables appropriate distribution of services to deliver economies of scale and to enable investment in new or complex technologies.

14 Is able to innovate and has developed mechanisms to enable rapid translation of best practice/guidance and the benefits of new technologies uniformly into national approaches.

15 Supports delivery of POCT in primary and secondary care.

16 Supports clinical research and other forms of research and development within NHSScotland.

Table 8: Guiding Principles

A Future Service Model for the Delivery of laboratory services The proposal is that a future laboratories service model should enable equitable access to services to patients and meet the future needs of NHSScotland through a DSM complying with the guiding principles listed in table 8. The DSM would result in the development of a network of laboratories across Scotland configured to meet local and national requirements. The DSM will provide opportunities for the consolidation of ‘colder’, low volume and technologically challenging workloads, into a smaller number of centres. The goal is to deliver appropriate consolidation of workloads not centralisation. This is about delivering efficient, effective, equitable, resilient and affordable laboratory services. A visual representation of the DSM is presented in figure 3. This model will deliver the investment objectives which have been agreed with stakeholders and are presented in table 7, by enabling laboratory services to be configured to meet both national and local needs. This new configuration will meet the requirements of the service users and providers.

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Figure 3: Distributed Service Model The DSM enables delivery of the right testing repertoire in the right place at the right time to enable optimal patient care locally and nationally. There is a notional workload of varying degrees of complexity and volume described as the “national pie” in the figure 3. The DSM will deliver laboratory services through a distributed network of laboratories of varying size and complexity. (pielets). They will be configured to deliver immediate local requirements with opportunities for the consolidation of ‘colder’, low volume and technologically challenging workloads, into a smaller number of centres. Each of these laboratories will have different compositions with each requiring a critical mass of resource to enable tailored delivery of local services. This will be delivered against the backdrop of a national standard with residual capacity within the critical mass of resource to deliver value added service to the network. Under the DSM specialist services need not be restricted to largest centres. The DSM delivers a focus on functional consolidation not centralisation: Form should follow function.

Key Attributes of a Distributed Service Model

Laboratories at different geographical locations will have differing configurations not necessarily include all disciplines.

A critical mass of resource to enable tailored delivery of local services providing opportunities for local and national service development.

Delivery of services against the backdrop of the national clinical strategy utilising residual local capacity to deliver a value added service with a national focus.

Specialist services delivery not necessarily restricted to larger centres.

Reduced intrinsic and extrinsic variation (demand optimisation).

Reduced waste and improved patient safety.

Right test, right place, right time.

Efficiency, effectiveness, equitability, resilience and affordability.

Table 9: Key Attributes of the DSM

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Benefits of a Distributed Service Model The clinical and financial benefits of the application of the DSM on a macro level Scotland wide are difficult to quantify specifically at this stage. Individual Health Boards have undertaken reorganisation that is consistent with this approach. Below in table 10 is an example of how this was achieved at Health Board level within NHS Tayside highlighting the benefits to one Board that has undertaken a review of services and delivered a distributed model with a Triple Aim focus.

Efficiency Saving at NHS Tayside Innovative Solutions deliver efficiencies and enable investment

What Optimisation of laboratory services.

How An integrated management model for laboratory services was introduced which featured state of the art automation, data management and order communications software. The transformation delivered:

An integrated management model for laboratory services;

Merging of the Biochemical Medicine, Haematology and

Immunology departments into the 1st fully UKAS accredited

integrated Blood Sciences Department in Scotland;

Consolidation of 4 disciplines into a single automated track;

Consolidation of GP workloads on to a single site; and,

Transfer of medical microbiology from Perth Royal Infirmary (PRI) to

Ninewells Hospital with introduction of paperless working.

Benefit Enabled Ninewells Hospital to take on 73% of PRI workload

avoiding a £5M lab rebuild cost in PRI;

97% of core blood sciences workload is now released in just over 2

hours, previously 4 hours;

Consolidation to Ninewells Hospital has increased efficiency in

Blood Sciences by 62%;

Move to MSC transferred risk and generated 500k /annum revenue

saving in year 1 with a projected financial saving of £4.59M

over the course of the contract and £100K recurrent reduction

in management costs. Novel application of advanced robotics

combined with high functionality order communications is delivering

a turnaround time to diagnosis of liver disease of 2.5 hours through

the innovative iLFT programme developed with support from the

CSO; and,

Redefinition of roles and role extension to enable more effective use

of staff.

Table 10: Efficiency savings at NHS Tayside

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Whole system thinking and cross disciplinary working enables the delivery of significant service developments and benefits. It is difficult to extrapolate the potential benefits into a national arena without further investigation, but experience tell us that these are likely to be significant and will be considered as part of scoping benefits in the proposed business case.

Options for the DSM In all three of the workshops held to date, the overwhelming consensus has been that laboratories in Scotland should adopt the DSM. Therefore this paper does not present a long list of options. The concept of the DSM could be delivered in a number of ways to address the guiding principles and deliver the business objectives. (Tables 7 and 8). A common requirement of any DSM would be national consistency which would include the following:

Delivery and ownership of the national vision for the DSM;

Ownership of a national strategy;

Enabling alignment of service delivery to national priorities;

Enabling assessment of adoption of new technology and facilitation of innovation;

Specification and oversight of a national governance structure;

Delivery on national standards; and

Aspects of governance to ensure that the DSM is:

o Person centred; o Safe; o Effective; o Efficient; o Equitable; and o Timely

At this point there are two emerging options which would be appraised moving forward to a business case. These are:

1. National Governance; Regional Delivery (table 11) 2. National Governance; National Delivery (table 12)

Option 1. National Governance; Regional Delivery

Current laboratory services within Boards are distributed to best fit regional priorities and infrastructures effectively delivering 3 regionally distributed services.

National services (supra-regional) identified through a national planning process would also be delivered through regional boards.

A framework would be established to ensure that services are delivered within a shared vision for NHSScotland. Regional delivery is consistent with the guiding principles for the DSM to enable national consistency.

Regional structures are developed to ensure and assure that services meet local needs, regional needs and support national approaches.

Delivery of a regional infrastructure to ensure / assure compliance of the distributed service with all legal, statutory, regulatory and accreditation requirements.

Structured to support delivery of the Triple Aim and support/enable the delivery of the National Clinical Strategy.

Table 11: National Governance; Regional Delivery

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Option 2. National Governance; National Delivery

Single laboratory service provided as the DSM to NHSScotland.

A national delivery of the DSM consistent with the guiding principles that also enables delivery of the right test, right time, right place to the population of NHSScotland.

Delivery of a national infrastructure to ensure / assure compliance of the distributed service with all legal, statutory, regulatory and accreditation requirements.

Delivery of a nationally consistent service within a unified distributed service.

Delivery of a national DSM assuring nationally consistency.

Structured to support delivery of the Triple Aim and support/enable the delivery of the National Clinical Strategy.

Table 12: National Governance - National Delivery

Laboratory services are highly complex. The optimal design for the DSM will deliver many challenges as the process progresses to define the optimum delivery model. The next steps would be to progress a detailed design process with options appraisal. An objective would be to deliver a development route map for implementation of the preferred model that enables incremental change and benefit. Development of the options and business case will require continuation of existing enabler projects and may deliver requirements for additional projects.

Enablers The development of the DSM is underpinned by a number of enablers which were identified by stakeholder at the Visioning Workshop on the 15 September 2016. These are detailed in the table 13 below.

Enabler Why it is important for this proposal

A robust management and governance structure

Ensures that local needs are effectively served but with the efficiencies of a nationally coordinated distributed service.

Joined up IT systems / Robust interoperability

A move towards a consistent and joined up IT strategy in laboratory services throughout Scotland, is an essential pre-requisite to the move towards the DSM.

Robust and consistent benchmarking data

This will enable service planning, improvement and standardisation of information across Scotland.

Innovation in practice

Technological, scientific and clinical innovation provides opportunities for increasing the impact of investment in diagnostics. Innovation delivers opportunities of new ways of working that challenge existing models of service delivery impacting on effectiveness and resilience.

A resilient workforce

This is important to enable delivery of service sustainability and value. A highly trained and flexible workforce is needed to deliver complex clinical, scientific and technologically driven service. Technology will deliver new opportunities for transformation of laboratory services to meet the need of NHSScotland, but this cannot be achieved without an appropriately configured and trained sustainable workforce. Cross discipline, cross border working will facilitate the DSM, and gives us the potential to

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manage workloads evolving in workload and range of repertoire. Delivery of an effective 24/7/365 service requires a critical mass of trained staff.

Standardisation of systems, processes and approaches

This is a fundamental requirement to enable convergence of services, sharing of outputs, to enable service optimisation enabling cross border working, facilitating best practice adoption of best practice, easing the burden of accreditation. Enables future specification and procurement of diagnostic and IT systems.

Logistics

An appropriate logistics approach will enable timely and safe transport of samples between centres supported by lab to lab communications to enable associated and required data flows.

Table 13: Enablers

Main Benefits Criteria The main benefits for the DSM are identified in the following table. These are not exhaustive and further benefits will be identified as the models are developed and appraised by stakeholders.

Outputs Outcomes Benefits

Lean systems for delivery of service locally and nationally

Better use of existing infrastructure ‘Just in Time’ philosophy NHSScotland focus to ensure maximum benefit from targeted investment to the whole system

Better value for money

Improved flow and capacity

Better use of existing analytical capacity

Reduction of excess capacity

Full exploitation of capacity 24/7

Shared Infrastructure

Efficiency, economies of scale, better use of capacity including facilities, knowledge and skills.

Shared Quality Systems

Shared HR/Finance/H&S/Procurement

Reduction of risk

Reduction of variation

Equitability

Affordability.

Scotland wide focus on delivery of accreditation with flexible scope delivery of accreditation across larger and more diverse functional units.

National focus for investment of existing and in new resource.

Innovation Centre/s to enable co-working with commercial partners

Support of national international clinical trials Provision of services for

Once for Scotland approaches enabling/facilitating rapid adoption of emerging technologies.

Income generation

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other UK Health care systems Provision of consultancy work to 3rd parties Provision of education and training

Table 14: Main Benefits Criteria The benefit criteria for each of the enablers can be found in Appendix 6.

Risks

Broadly the risks to delivery of the investment objectives relate to reduction of variation and stakeholder engagement. The highest scoring risks for the programme are summarised in the table 15 below. These risks were identified by the programme team and stakeholders.

Risk description Impact Risk score Mitigation

Health Boards continue with capital plans/ service development for laboratory services

Reduced benefit and minimal impact on service improvement. 16 – high

Recommend that Health Boards use the guiding principles as a standard for procurement / service design.

Clinical engagement

We are unable to define a robust service model as part of the business case.

16 – high

Engage with professional groups and networks e.g. SPAN, SMVN, SCBMN and Haematology SLWG.

Health Boards do not support proposals if they are not seen as positive for their Board

Reduced benefit and minimal impact on service improvement. 12 – medium

Establish a technical working group which involves stakeholders from all Health Boards.

We will not be able to source the baseline data we need to support the development of the business case

Inaccurate data collated and therefore unable to baseline appropriately.

12 - medium

Establish a data working group which involves stakeholders from all disciplines, Health Boards and Networks. Engage with the DSG.

Table 15: Risks

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Constraints Initial assessment identified the following constraints. These are not exhaustive and further benefits will be identified as the DSM is developed and appraised by stakeholders:

1. The design of the DSM will need to be compliant with guidelines from the professional bodies associated with all of the laboratory disciplines, and compliant with all applicable legal, statutory and regulatory frameworks.

2. The development of the DSM needs to continue to support existing academic partnerships to include teaching, clinical research and research and development priorities both within the NHS Boards and nationally.

3. The DSM will need to be designed to ensure that the required support of all relevant public and private sector users continues. Services which are obtained out with Scotland may still need to be supported in the new model.

Dependencies

Laboratory Services are highly complex and variable in form, delivering outputs from as many as 19 disciplines across the Boards. Design and eventual establishment of the DSM to enable optimal delivery of high impact laboratory outputs will have multiple dependencies. These will be further characterised as the design process progresses. Design of the DSM and delivery of a business case will be dependent upon: 1. Delivery of a focused and co-ordinated multidisciplinary approach to the design of the DSM for

NHSScotland with continued committed engagement of multiple stakeholders.

2. Continuing investment within the Laboratories Programme to support the delivery of the next steps and existing enabler projects.

3. Successful delivery of the desired outputs of the current enabler projects with coordination with the diagnostic networks to avoid duplication.

4. A clear mandate to progress the design and business case development, with commitment

from the Boards to ensure local staff are prioritising the initiative. Redesign/transformation of laboratory services is already occurring to greater or lesser extent within Health Boards. In addition there is a now also a superimposed regional perspective emerging on service delivery/development as a consequence of the Health and Social Care Delivery Plan. Dependencies arise as a consequence of these to collate and understand Health Board/Regional developments in order assess their potential impact upon future design and delivery of the DSM. New localised or regional initiatives in underpinning infrastructure such as IT, communications, or commitment to long term contracts for new analytical technology, may deliver impediments to standardisation and lock in variation across the wider system with impact on the DSM business case.

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3. Economic Case

Introduction Stakeholders have agreed that the current model of laboratory services in NHSScotland is not sustainable and improvements could be made in service delivery to support future service demands in the form of a DSM. The investment objectives in table 7 outlines what is needed to be achieved to overcome the problems with the existing arrangements to move towards the DSM. This is about delivering efficient, effective, equitable, resilient and affordable laboratory services for NHSScotland.

Financial Costs The estimated annual cost of running laboratory services across NHSScotland in 2015/16 was estimated at £251.6million per annum. This is made up of:

£178.9m staffing costs; and

£72.7m non staffing costs. Table 16 below is a breakdown of the total spends per discipline per Board.

Table 16: Direct costs of labs For breakdown between pay and non-pay, see Appendix 5, table A7: NHSScotland capital expenditure in laboratories services This is the most reliable financial data available to date, however it is acknowledged that the quality of the information within the Cost Book is not fit for purpose moving forward. It is important that any financial data is accurate to enable the design of the DSM, therefore a coordinated approach to data gathering and analysis is integral to the future planning.

2015-16 Direct Costs for Labs by speciality

Board Name

Clinical

Chemistry

£m

Clinical genetics

£m

Haematology

£m

Microbiology

£m

Other

£m

Pathology

£m

Total

£m

NHS Ayrshire & Arran 3.7 0.0 3.1 3.3 0.0 3.0 13.1

NHS Borders 0.0 0.0 0.0 0.9 2.6 0.0 3.5

NHS Dumfries &

Galloway 1.3 0.0 1.8 2.2 0.0 1.4 6.7

NHS Fife 2.7 0.0 2.3 3.5 0.0 2.3 10.8

NHS Forth Valley 2.0 0.0 3.2 2.7 0.0 2.4 10.2

NHS Grampian 9.4 2.9 3.1 5.0 0.0 2.3 22.7

NHS Greater Glasgow

& Clyde 22.4 5.2 18.3 19.1 1.9 18.5 85.4

NHS Highland 1.6 0.2 1.5 3.2 0.0 1.3 7.8

NHS Lanarkshire 8.3 0.0 5.5 4.5 0.0 4.9 23.1

NHS Lothian 8.8 4.1 5.3 10.8 3.0 10.1 42.1

NHS Orkney 0.2 0.0 0.1 0.1 0.4 0.0 0.8

NHS Shetland 0.5 0.0 0.3 0.2 0.0 0.0 1.1

NHS Tayside 3.6 2.6 4.8 5.3 2.9 5.3 24.5

Total 64.5 14.9 49.3 60.7 10.8 51.4 251.6

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In order to gather accurate and specific financial data for the laboratories in NHSScotland it is intended that the programme:

Identify the gaps and inaccuracies in the current cost book data;

Define what additional data is required to support service design;

Format a questionnaire to capture these gaps and inaccuracies; and

Approach the individual Directors of Finance in each health board to gather the data.

Willingness and ability to contribute will have a significant effect on the quality of the data gathered. Once a national financial picture is developed, it will be easier to identify variation that may lead to inefficiency and waste.

Staffing There are approximately 3,759 full time equivalent (FTE) staff currently in laboratory services in NHSScotland with a combined direct cost of £178.9m per annum. See table 17 for a breakdown by Board.

Table 17 Laboratories WTE * NHS Grampian WTE in 2015/16 has been manually adjusted as the value returned in the Cost Book was 1186 WTE due an increase in 835 WTE for Support Service staff. ** NHS Highland attributed too many Administrative Services staff to labs in 2014/15 & 2015/16. The 2015/16 value was updated in the Cost Book and the updated value is presented above. The 2014/15 value has been manually adjusted here by taking the average of the previous & subsequent years WTE. The unadjusted 2014/15 WTE was 1108 WTE. Zero WTE indicates lack of return for that year.

Table 17 shows that despite factors which would increase workload (e.g. ageing population, long term conditions, 7 day working), the actual WTE has remained the same over the last five years, which indicates that the workforce has overall become more productive, and has met the challenges presented. As a programme, these success stories within laboratories need to be identified; to present an opportunity to learn from past situations.

WTE for NHS Scotland Laboratory Departments

Board 2011/12 2012/13 2013/14 2014/15 2015/16

NHS Ayrshire & Arran 226 219 219 233 229

NHS Borders 61 63 0 0 0

NHS Dumfries & Galloway 96 98 99 100 101

NHS Fife 157 141 141 144 146

NHS Forth Valley 134 133 143 151 149

NHS Grampian* 374 386 381 351 351

NHS Greater Glasgow & Clyde 656 1,267 1,278 1,181 1,288

NHS Highland** 167 156 310 266 223

NHS Lanarkshire 321 333 334 331 346

NHS Lothian 561 534 556 528 505

NHS Orkney 7 6 7 7 7

NHS Shetland 7 7 9 10 10

NHS Tayside 1,128 372 378 398 405

NHS Western Isles 17 14 0 0 0

Total 3,912 3,727 3,855 3,701 3,759

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The SWOT analysis, Appendix 1, however highlights that we have a workforce demographic who are nearing retirement age. If nothing is done to address this, the current workforce framework could very soon become unsustainable.

Investment in Diagnostics There will be many individual case studies across Scotland that demonstrates improvements in efficiency and effectiveness through transformation. This has resulted in pockets of best practice that may deliver greater benefits to NHSScotland through a “Once for Scotland” approach. Work on the Laboratories Program has identified several examples where investment in new investigations could significantly alter care pathways with benefits to patient experience and efficiencies which can be realised as savings or capacity (performance) gains. The following are examples of this. At this stage it difficult to estimate these gains on a national level, however moving forward to a business case these will be evaluated.

Triple Aim win The impact of diagnostics is whole system however it is frequently viewed as a cost to the service rather than an investment. Design and investment in service consistent with delivery of the Triple Aim identified by the Institute for Healthcare Improvement and adopted by NHSScotland would enable the value of diagnostics to be realised and recognised. A good example of this is the development of the use of Quantitative Faecal Immune Testing (qFIT) for detection of bleeding in the faeces of patients with symptoms consistent with bowel cancer. This is a low cost test that can rule out the need for gastrointestinal referral reducing the demand for colonoscopy. Therefore, a comparatively small investment in laboratories is delivering a significant reduction in demand for pressurised expensive downstream services. The results are better quality of care, cost of care and experience of care. Other Health Boards are now are now seeking to develop a relationship with NHS Tayside with the intention of delivering a distributed service in this area: table 19 refers.

Investment in Diagnostics at NHS Tayside Investment in diagnostics delivers Triple Aim win

What Optimise the pathway for investigation in patients in primary care with symptoms consistent with bowel cancer.

How New stool test (qFIT) which measures blood in faeces and predicts likelihood of serious bowel disease was used at the point of assessment in the GP Practice

Benefit • Negative qFIT result rules out the need for a colonoscopy;

• 70% of patients did the test at the point of assessment (GP);

• 14% reduction in referrals to outpatients; and

• Reduced demand of services in secondary care.

Table 18: qFIT Testing

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Whole System Benefits Under existing funding and organisational arrangements, it is extremely difficult to introduce new diagnostics across Scotland to translate proven benefit into practice. This is often because the investment required is new and the main beneficiaries are down steam services with non linked budgets. B-type natriuretic peptide (BNP) testing is one such example highlighted in the Chief Medical Officer’s Annual Report. A letter from CEs has clearly identified the benefits of this investigation in terms of both impact on cardiology resources and drug spends, however there is still a requirement for 15 separate business cases to enable its introduction. The DSM could enable a more nimble approach to this type of scenario. Individual Health Boards have been attempting for 10 years or more to enable this.

NHS GGC - Investment in Diagnostics in BNP Testing Investment in diagnostics delivers impact on waiting times, patient pathway and need for waiting time initiatives and also delivers prescribing cost avoidance

What Increased waiting time for echocardiography, delaying treatment for priority patients. Expensive drug prescribed routinely for heart failure is only effective in some patients

How BNP testing was used to triage patients to either eliminate heart failure as a diagnosis or to refer to a one stop clinic where management of the condition can be initiated.

Benefit 10-20% reduction in use of echo cardiograms;

Reduction in waiting times for an echo from 12 to 6 weeks;

Reduction in waiting times for cardiology clinic from 19 to 6 weeks;

Test enabled urgent cases to be expedited;

Renfrewshire pilot over 10 months sees £12k savings; and

Prioritises high risk patients.

Business case put to the Chief Executives in March 2017

Table 19: BNP Testing

Once for Scotland Approach Laboratories are often judged against sets of Key Performance Indicators (KPI) that focus on efficiency (cost per test, number of test performed per WTE, etc.) rather than clinical impact (impact on bed stays, impact on drug bills, antibiotic stewardship, etc.). The introduction of procalcitonin assays on NHS Tayside is an example of how the correct whole system focus can justify investment in diagnostic services with measurable outcomes that are of importance to users.

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Improving Patient Management & Outcomes at NHS Tayside Improving patient management through effective antibiotic stewardship

What Antibiotic stewardship in acute settings

How Procalcitonin (PCT) analysis - biomarker used for the identification and management of sepsis - used to guide antibiotic treatment

Benefit 30 day pilot in ICU yielded

£753 saving in costs

Reduction in antibiotic days by 38 days

Reduction in staff time and cost of administering

Reduction in bed days easing patient flow & capacity

Reducing risk of antibiotic side effects

Reducing risk of antibiotic resistant strains of bacteria

This is now a routine test in ICU, MHDU and SHDU on Tayside

Table 20: Antibiotic Stewardship

These are all good examples of practice that are transportable, a “Once for Scotland” approach. The technologies involved are not new, but with an organised delivery structure (DSM) they are more effective. It would require appropriate infrastructure to enable translation. The above case studies demonstrate the potential economic benefits that could be achieved within the DSM. There will be many other examples to be drawn from other disciplines and Health Boards. The benefits of extending the type of thinking and practical examples illustrated above across an NHSScotland DSM will be substantial, but difficult to quantify at this point in time. Moving towards business case this will be developed.

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4 Commercial Case A commercial case for establishing the DSM for laboratories has not yet been established. This will be developed as we move to business case. Where relevant, it will contain:

Procurement viability;

Procurement strategy;

Service requirements;

Charging mechanism;

Risk transfer;

Sources of budget funding;

Key contractual arrangements;

Personnel, i.e. Transfer of Undertakings (Protection of Employment) Regulations (TUPE) implications;

Accountancy treatment; and

Discussion of the affordability of the proposal.

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5 Financial Case A financial case for establishing the DSM will be developed as we move to business case. It is anticipated that establishing the DSM for laboratories will provide a platform for more cost effective utilisation of resources. This will be explored in parallel with the development of the DSM along with any additional costs and funding required in the next business case presented. It is likely this will involve working with Health Boards to provide more detailed financial information due to the limitations of working with currently published information such as the Cost Book.

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6 Management Case The arrangements required to successfully manage and deliver the project will be defined when developing the business case. The areas covered will include:

Project management strategy and methodology;

The project framework;

Project roles and responsibilities;

The project plan, including the high level timeline for the project; and

Project communication and reporting arrangements.

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7 Readiness to Proceed Shared Services Laboratories is a programme of significant scale and complexity. It faces the challenge of delivering transformation change while maintaining current service provision and causing no disruption to patient care. In the interests of making things manageable, the approach adopted will have to be iterative and incremental, in a way that does not miss or preclude opportunities. Laboratories encompass a number of disciplines currently delivered as discrete entities. Each deliver a spectrum of activity ranging from less complex high volume activity to small volume but highly, and increasingly, specialist activity. At the less complex end of the spectrum new and anticipated technologies provide an opportunity to have a common generic core in relation to activity and necessary skills. In recent years this has already been seen in blood sciences across clinical biochemistry and haematology and could be explored further across multiple disciplines. This is important because, while there is an attraction in managing the challenge of scale by taking a discipline-by-discipline approach to redesign there is a significant risk that such an approach misses the opportunity for economies of scale and commonality across the disciplines. Health Boards are currently at various stages in taking forward initiatives in relation to laboratories whether (re)procurement of information systems, (re)procurement of analysers, local reconfiguration of laboratories or exploration of regional opportunities. It is important that the strategic direction set by Shared Services complements this activity while ensuring that it aligns and synchronises in a way that achieves consistency and convergence at a national level. In this way the gains from a “Once for Scotland” approach are optimised. This is in keeping with the principles agreed earlier in the process and will be a key consideration as the business case is developed. There are real opportunities for the Shared Services team to work with Health Boards to align and coordinate these established activities. This ensures the benefits of consistency and economies of scale whether they are multi-Board, regional or national, are realised while enabling Health Boards to pursue local operational imperatives. Figure 4: Illustrates how a potential pilot could be run between boards going out to procurement of IT systems. This approach makes no assumptions about specific software solutions, but rather pilots a model of working which can be replicated out to the regions as appropriate.

Figure 4: Potential Pilot

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Through engagement with Health Boards, the intention is to acknowledge and address local priorities while pursuing and delivering whole system benefits. It is anticipated that this approach will establish a new way of working which will lead to continuing successful delivery of transformational change. To enable the ongoing process of a successful design, a programme delivery group will be established. This will include multidisciplinary representation from:

1. Territorial Health Boards; 2. Appropriate Special Health Boards; 3. Managed Diagnostic Networks; 4. Diagnostic Steering Group; and 5. Partnership Working.

Conclusion

There is the opportunity to improve efficiency, effectiveness, equity, resilience and affordability of the Laboratories Services in NHSScotland. Stakeholders overwhelmingly agreed that progression to a distributed services model for laboratories in Scotland is the most appropriate way to achieve this and to support the future development of NHSScotland. What we are asking of the CEs

The CEs are asked to: a) Give authority for the laboratories programme to develop a business case(s) outlining options

for a distributed service model with key components for Scotland in accordance with the guiding principles; and,

b) Ensure support from the NHS Boards to assist with enabler projects / pilots; and,

c) Ensure that any future capital investment and re-procurement plans considered necessary to

sustain business as usual are aligned with the work of the Laboratories Programme and comply with the guiding principles for a distributed service model (as listed on page 17)

d) Support the next steps of the Laboratories Programme.

Appendix 1 – SWOT analysis SWOT

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Appendix 2 – PESTLE analysis

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Appendix 3 – Workshop Outputs

Workshop 1 – Flash report

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Workshop 2 – Flash Report

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Workshop 3 – Flash Report

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Appendix 4 – Laboratory services in Scotland 2015

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Appendix 5 – Baseline data

The information in tables A1-4 was gathered using a questionnaire issued from shared services directly to the laboratories on 16th February 2017. The information in tables A5 & A6 comes from cost book data. The information in table A7 was gathered using a questionnaire issued from shared services directly to the directors of Finance in April 2017

Table A1: Baseline data - Service Component delivered by location

Health Board Site Name

An

dro

log

y

Au

top

sy

Ba

cte

riolo

gy

Blo

od

Tra

ns

fus

ion

Clin

ica

l Bio

ch

em

istry

Cy

to-g

en

etic

s

Cy

tolo

gy

-Ce

rvic

al

Cy

tolo

gy

-Dia

gn

os

tic

Ha

em

ato

log

y

His

toc

om

pa

tibility

an

d Im

mu

no

ge

ne

tics

His

top

ath

olo

gy

Imm

un

olo

gy

Mo

lec

ula

r Ge

ne

tics

Mo

lec

ula

r Pa

tho

log

y

Ne

uro

-imm

un

olo

gy

Ne

uro

pa

tho

log

y

Pa

ed

iatric

an

d M

eta

bo

lic B

ioc

he

mis

try

Viro

log

y

<B

lan

k-N

o d

eta

il>

NHS Ayrshire & Arran University Hospital Ayr ● ● ●

University Hospital Crosshouse ● ● ● ● ●

NHS Borders Borders General ● 4

NHS Dumfries and Galloway DGRI ● ● ● ● ●

Galloway Community Hospital ● ● ●

NHS Fife Victoria Hospital ● ● ● ● ● ● ● ● ●

NHS Forth Valley Forth Valley Royal Hospital ● ● ● ● ● ●

Golden Jubilee National Hospital Golden Jubilee National Hospital ● ● ● ●

NHS Grampian Aberdeen Royal Infirmary ● ● ● ● ● ● ● ● ● ● ● ●

Aberdeen Sexual Health Clinic ●

Dr Gray's ● ●

NHS Greater Glasgow & Clyde Vale of Leven Hospital ● ● ●

Gartnavel General Hospital ● ● ●

Glasgow Royal Infirmary ● ● ● ● ● 2

Queen Elizabeth University Hospital ● ● ● ● ● ● ● ● ● 1

Stobhill Ambulatory Care Hospital ● ●

Victoria Ambulatory Care Hospital ● ●

Inverclyde Royal Hospital ● ● ●

Royal Alexandra Hospital ● ● ● ● 1

NHS Highland Belford Hospital ● ● ●

Raigmore Hospital ● ● ● ● ●

Lorn and Islands Hospital ● ● ● ● ●

Caithness General Hospital ● ● ●

NHS Lanarkshire Monklands Hospital ● ● ● ●

Hairmyres Hospital ● ● ●

Wishaw Hospital ● ● ● ●

NHS Lothian Royal Hospital for Sick Children ● ●

Royal Infirmary of Edinburgh ● ● ● ● ● ● ● ● ●

Western General Hospital ● ● ● ● ● ● ●

St John's Hospital ● ● ● ●

NHS Orkney Balfour Hospital ● ● ● ●

NHS Shetland Gilbert Bain Hospital ● ● ● ●

NHS Tayside Ninewells Hospital ● ● ● ● ● ● ● ● ● ● ● ● ●

Perth Royal Infirmary ● ● ●

Raigmore Hospital ●

NHS Western Isles Western Isles Hospital ● ● ● ●

Note: Cyto-genetics service at NHS Highland Raigmore Hospital is reported under NHS Tayside

Table A2 Tests provided and received for the period April – December 2016 (within Scotland)

Note: FV received tests from Lothian is per annum figure not adjusted for period Apr-Dec 16

The above table demonstrates the high level of cross board traffic between laboratories, which would be financed through Service Level Agreement. It also shows a huge disparity between the numbers of tests providing boards are reporting as providing, compared to what is reported by the receiving boards.

Health Board - Providing Health Board - Receiving Tests Received Tests Provided

NHS Ayrshire & Arran NHS Borders 1 1

NHS Dumfries & Galloway 1 1

NHS Fife 1

NHS Forth Valley 1

NHS Grampian 70 1

NHS Greater Glasgow & Clyde 731

NHS Highland 1

NHS Lanarkshire Unknown

NHS Lothian 46 1

NHS Shetland 1

NHS Borders NHS Greater Glasgow & Clyde 55

NHS Tayside 108

NHS Dumfries & Galloway NHS Grampian 1



NHS Fife NHS Greater Glasgow & Clyde 132

NHS Tayside 214,977

NHS Forth Valley NHS Greater Glasgow & Clyde 353

NHS Tayside 693

Golden Jubilee National Hospital NHS Greater Glasgow & Clyde 5

NHS Grampian NHS Ayrshire & Arran 1


NHS Highland 13,500 19,102

NHS Lothian 720

NHS Orkney Unknown 9,739

NHS Shetland 9,782 16,841

NHS Tayside 2,897

NHS Western Isles Unknown

NHS Greater Glasgow & Clyde Golden Jubilee National Hospital 9,761 7,217

NHS Ayrshire & Arran 153 55,382

NHS Borders 2,141 1,523

NHS Dumfries & Galloway 6,088 19,314

NHS Fife 4,617

NHS Forth Valley 145 55,374

NHS Grampian 11,492 11,812

NHS Highland 282,633

NHS Lanarkshire 7,745 121,303

NHS Lothian 20,334 20,425

NHS Orkney Unknown 225

NHS Shetland 176 323

NHS Tayside 2,707 9,717

NHS Western Isles Unknown 2,186

NHS Highland NHS Ayrshire & Arran 2

NHS Borders 123

NHS Dumfries & Galloway 41

NHS Grampian 90


NHS Lanarkshire 346

NHS Tayside 978


NHS Lanarkshire NHS Ayrshire & Arran 4 Unknown

NHS Dumfries & Galloway 4 10,000

NHS Greater Glasgow & Clyde 475 Unknown

NHS Tayside 399

NHS Lothian NHS Ayrshire & Arran 25 1,116

NHS Borders 18,627 48,637

NHS Dumfries & Galloway 693 1,757

NHS Fife 34,403 26,437

NHS Forth Valley 1,000 3,787

NHS Grampian 1,599 10,787

NHS Greater Glasgow & Clyde 704 12,465

NHS Highland 2,384

NHS Lanarkshire 185 3,081

NHS Orkney Unknown 523

NHS Tayside 11,854 7,267

NHS Western Isles Unknown 142

NHS Shetland NHS Greater Glasgow & Clyde 1

NHS Tayside NHS Ayrshire & Arran 7

NHS Borders 73

NHS Dumfries & Galloway 8

NHS Fife 1,093

NHS Grampian 157 33

NHS Greater Glasgow & Clyde 132 7,300

NHS Highland 500


NHS Lothian 1,305 402


NHS Western Isles NHS Greater Glasgow & Clyde 2

Table A3 LIMS systems by Board and Discipline

Health Board System Name System Provider Version Blood SciencesChemical

PathologyGenetics Haematology

Histocompatibility

and

Immunogenetics

Histopathology ImmunologyMedical

Microbiology

Neuroimmunolog

yAndrology

Clinical

Biochemistry

NHS Ayrshire & Arran

NHS Borders LABCENTRE CLINISYS ● ● ● ●

NHS Dumfries and Galloway ILAB APEX CSC 5.8.10022.363 ● ● ●

NHS Fife LABCENTRE CLINISYS 1.13 ● ● ●

NHS Forth Valley ILAB APEX CSC 5.8 ● ●

Golden Jubilee National HospitalLABCENTRE CLINISYS 1.11 ● ●

NHS Grampian ILAB APEX CSC V6.0 P1 B6 ● ● ● ● ●

NHS Greater Glasgow & Clyde ILAB TP CSC 1.9 ● ● ● ● ●

ILAB TP + SOME LOCALLY DEVELOPED ACCESS DBSCSC 1.9 ●

MANZEN TISSUE TYPING SYSTEMS 2.7.2 ●

NHS Highland CIRDAN ULTRA CIRDAN 4.5 ●

LRS MEDIPATH LRS 1.4 ● ● ●

TELEPATH ISOFT 7.1 ● ●

NHS Lanarkshire TRAK CARE LAB INTERSYSTEMS 20 11 16 ● ● ● ●

NHS Lothian GENETICS DIALOGIC APPLICATION DIALOGIC 150917 ●

ILAB APEX CSC 5.8 ● ● ● ●

NHS Orkney CLINISYS MASTERLAB CLINISYS 1.10 ● ●

NHS Shetland CLINISYS MASTERLAB CLINISYS 1.10 ● ●

NHS Tayside LABCENTRE CLINISYS 1.12 ● ● ●

NHS Western Isles MEDIPATH LAST RESORT SOLUTIONS ● ● ●

No details given

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Table A4 Order Communications Systems

Health Board System Name Primary Care Secondary Care

Between board

electronic ordering

(Yes/No) ?

Services


NHS Borders INTERSYSTEMS TRAKCARE ● Blood Sciences; Haematology; Immunology; Medical Microbiology

NHS Dumfries and Galloway PLUMTREE ● No Bacteriology; Clinical Biochemistry; Haematology

NHS Fife OTHER-CLINISYS CYBERLAB ● ● NoAndrology; Bacteriology; Clinical Biochemistry; Cytology-Diagnostic;

Haematology; Histopathology; Virology

OTHER-CLINISYS CYBERLAB ● No Blood Transfusion

OTHER-CLINISYS CYBERLAB ● No Cytology-Cervical

NHS Forth Valley PLUMTREE ● ● No Andrology; Bacteriology; Cytology-Diagnostic; Histopathology; Virology

OTHER-"NATIONAL SYSTEM" ● ● No Cytology-Cervical

Golden Jubilee National Hospital OTHER-ORION HEALTH ● No Clinical Biochemistry; Haematology

NHS Grampian INTERSYSTEMS TRAKCARE ● NoBacteriology; Cytology-Diagnostic; Forensic Pathology; Haematology;

Histopathology; Immunology; Neuropathology; Virology

OTHER-SCCRS ● ● No Cytology-Cervical

SUNQUEST ICE ● NoBacteriology; Cytology-Diagnostic; Forensic Pathology; Haematology;

Histopathology; Immunology; Neuropathology; Virology

INTERSYSTEMS TRAKCARE ● Yes Clinical Biochemistry

NPEX ● ● Yes Clinical Biochemistry

SUNQUEST ICE ● Yes Clinical Biochemistry

NHS Greater Glasgow & Clyde INTERSYSTEMS TRAKCARE ● No Bacteriology

SUNQUEST ICE ● No Bacteriology

INTERSYSTEMS TRAKCARE ● Clinical Biochemistry; Haematology; Immunology

SUNQUEST ICE ● Clinical Biochemistry; Haematology; Immunology

NHS Highland

NHS Lanarkshire

NHS Lothian INTERSYSTEMS TRAKCARE ● YesClinical Biochemistry; Haematology; Paediatric and Metabolic Biochemistry;

Toxicology; Virology

SUNQUEST ICE ● YesClinical Biochemistry; Haematology; Paediatric and Metabolic Biochemistry;

Virology

INTERSYSTEMS TRAKCARE ● No Bacteriology; Histopathology

SUNQUEST ICE ● No Bacteriology; Histopathology

NHS Orkney

NHS Shetland

NHS Tayside SUNQUEST ICE ● ● NoBacteriology; Blood Transfusion; Clinical Biochemistry; Haematology;

Immunology; Virology

NHS Western Isles

Not implemented OCRR






Table A5

Table A6

2015-16 Direct Pay Costs for Labs by speciality

Board Name

Clinical

Chemistry

£m

Clinical

genetics

£m

Haematology

£m

Microbiology

£m

Other

£m

Pathology

£m

Total

£m


NHS Borders 0.0 0.0 0.0 0.6 2.0 0.0 2.6

NHS Dumfries &

Galloway 1.1 0.0 1.5 1.5 0.0 1.1 5.2

NHS Fife 1.5 0.0 1.8 2.3 0.0 2.0 7.6

NHS Forth Valley 1.2 0.0 2.1 1.9 0.0 2.1 7.2

NHS Grampian 6.6 2.1 2.7 3.4 0.0 1.8 16.5

NHS Greater Glasgow

& Clyde 15.0 3.5 13.6 12.9 1.5 14.0 60.6

NHS Highland 1.4 0.1 1.3 1.9 0.0 0.8 5.6

NHS Lanarkshire 5.2 0.0 3.9 3.1 0.0 4.1 16.4

NHS Lothian 5.0 3.0 3.4 7.2 1.0 8.5 28.1

NHS Orkney 0.1 0.0 0.0 0.1 0.3 0.0 0.5

NHS Shetland 0.2 0.0 0.1 0.2 0.0 0.0 0.5

NHS Tayside 2.6 2.4 3.9 3.8 1.4 4.8 19.0

Total 42.0 11.1 36.6 41.2 6.3 41.7 178.9

2015-16 Direct Non Pay Costs for Labs by speciality

Board Name

Clinical

Chemistry

£m

Clinical

genetics

£m

Haematology

£m

Microbiology

£m

Other

£m

Pathology

£m

Total

£m


NHS Borders 0.0 0.0 0.0 0.3 0.6 0.0 0.9

NHS Dumfries &

Galloway 0.2 0.0 0.3 0.7 0.0 0.3 1.4

NHS Fife 1.2 0.0 0.5 1.1 0.0 0.3 3.2

NHS Forth Valley 0.8 0.0 1.1 0.8 0.0 0.3 3.0

NHS Grampian 2.8 0.8 0.4 1.6 0.0 0.5 6.1

NHS Greater Glasgow

& Clyde 7.3 1.7 4.7 6.2 0.3 4.5 24.7

NHS Highland 0.2 0.0 0.2 1.2 0.0 0.5 2.1

NHS Lanarkshire 3.0 0.0 1.6 1.4 0.0 0.8 6.8

NHS Lothian 3.9 1.1 1.9 3.6 1.9 1.6 14.0

NHS Orkney 0.2 0.0 0.0 0.0 0.1 0.0 0.3

NHS Shetland 0.3 0.0 0.2 0.1 0.0 0.0 0.6

NHS Tayside 1.0 0.2 0.9 1.4 1.5 0.5 5.5

Total 22.5 3.8 12.7 19.5 4.5 9.8 72.7

Table A7 - NHSScotland capital expenditure in laboratories services

Board Y1 15/16

Y2 16/17

Y3 17/18

Y4 18/19

Y5 19/20

Comments


Total £325k

The only capital investment identified is for the works for refurbishment required once the Managed Lab Service has been finalised in the Biochemistry Lab which is £285k.

There is an additional sum of £20k set aside for minor alterations to Haematology/Microbiology, giving an overall total in 17/18 of £325k. No other projects for Lab alterations have been identified.

It should also be noted that the provision of the equipment is part of the overall managed lab service.

NHS Borders Nil return

NHS D&G Do have investment in laboratories within their LDP

Laboratory services are currently going through a new build with blood sciences and cell sciences labs moving to the new site. The building is an NPD project so not paying directly through capital for the building but through a unitary charge. As part of the move there is equipment being bought and also, through renewal of managed service contracts, equipment being provided through revenue funded contract.

Plans to extend the managed service contract to take in more kit over the next 5 years if financially beneficial, therefore no capital spend planned but the service funded through a different route.

NHS Fife Equipment £88750

Building Investment £6,666,667

NHS Forth Valley

Nothing returned from NHS Forth Valley

NHS Grampian

Laboratory services have a rolling replacement programme for all equipment which outlines when equipment needs to be replaced. However, the replacement programme for laboratories forms part of the annual prioritisation exercise that is carried out for all medical equipment across Grampian where equipment requirements are prioritised against available capital funding. This is done on an annual basis and the process for 17/18 is just commencing. Therefore, just because an item appears on the Labs replacement programme does not give any guarantee that funding can be made available. To put this into context, we have £22m of medical equipment bids for the 17/18 year and less than £0.5m of capital funding to prioritise them against.

Currently tendering for a new Managed Service Contract for our Labs service. Although the funding for the MSC will come through revenue and not capital, the specification for the MSC does include funding for a number of items of equipment.

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NHS GG&C Nil return for Labs in the Capital Plan.

NHS Highland

eHealth lab replacement programme £182k



There may be a requirement for building works / equipment to support the new lab system but there is nothing specific in plans as yet for those aspects.

NHS Lanarkshire

Have a managed service contract with Roche for the laboratories. This contract includes the replacement of equipment.

Building work has been carried out to centralise some of the Lab functions.

No provision in our Capital Plan for the Laboratories.

NHS Lothian Microbiology Automation £2,400K Ventilated Pathology Dissection £35K Track & Trace ( to include Pathology) £640K

(Equipment) Shared Laboratories Mortuary £1200K (Buildings) Shared Laboratories Mortuary £400K

(Equipment) Shared Laboratories Mortuary £1200K (Buildings) Shared Laboratories Mortuary £400K

NHS Orkney No plans for any capital expenditure on Labs in the LDP as a new shared contract with NHS Shetland was set up in 16/17 which has already involved replacing equipment.

SNBTS £7,266 Equipment

£21K Equipment

£72,714 Equipment

£60,385 Equipment

NHS Shetland

Entered in to a managed services Labs contract with Abbot in 2016-17 so no equipment purchases expected in this time frame.

NHS Tayside Nothing returned from NHS Tayside

NHS Waiting Times GJH

£240K Equipment Bloodbank

£32,196 Equipment Pathology & Microbiology

NHS Western Isles

£30K Equipment £146K Other

Appendix 6 – Investment Objectives and Benefits

Table A1 Maps the investment objectives

Effect of the cause on the organisation What needs to be achieved to overcome this need?

(Investment objectives)

Guiding Principles

Existing configuration is currently unable to respond to increasing demand and new models of care, mainly due to ageing IT systems and the fact that both disciplines and Boards work in their own silos

To put in place a flexible, scalable configuration of facilities that can meet future demand

1, 4, 5, 9, 10, 11, 12, 13, 14, 15

Risk of failure as the current service model is not resilient

To enhance service resilience through minimising variation and enabling cross border working

1, 3 ,4, 5, 9, 10, 11, 12, 13, 15

There is an imminent risk to service sustainability due to the workforce

To provide a sustainable, resilient, adaptable workforce linked to a credible workforce plan

3, 4, 7, 11, 13, 14, 15

Change is required to support the delivery of the NHSScotland Clinical Strategy, by refreshing outdated technology/ageing infrastructure and spreading the good practice which is currently happening in silos

To provide improved and equitable outcomes for patients (2020Vision) by reconfiguring to support NHS transformation

1, 2, 3, 4, 6, 7, 8, 10, 11, 12, 13, 14, 15, 16

Due to shrinking budgets and competing demand for revenue and capital, we need to make savings to meet CRES targets at a time when investment is needed

Deliver demonstrable value for money, reduce/avoid expenditure to enable appropriate investment in effectiveness

1, 2, 3, 4, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16

Tables A2 to A7 list the benefit criteria from each of the enabler projects

Table A2 – IT Project


A strategy for delivering a joined up IT system which supports the development of a distributed service model. .

Delivery of a joined up IT system which will support the distributed service model

Cross border working Ability to work in a distributed service model Ability to show trends in results over time Ability to add assistance to clinician in the request/reporting cycle Will deliver a national approach to service delivery. Will enable harmonisation of approaches to delivery and reporting of diagnostic testing across all NHS Boards. Will enable lab to lab communication, delivering benefits in terms of efficiency of processes, with improved information and data flow, including real time performance and dashboards, identification of variation and CQI. Will facilitate the reporting of real time information to the centre (e.g. prompt reporting of data on antimicrobial resistance to Health Protection Scotland or cancer stats to ISD and Screening Audit). This would lead to savings out with the diagnostic networks by removing double manual entry.

An overarching platform that would standardise on access to supporting IT systems, for example

Convergence of labs IT across Scotland

All of the above benefits

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order communications, reporting, auditing and clinical systems access

A definition of the minimum deliverable for the IT enabler project

Set expectations for the project in the context in the overall programme

Delivery focused on the most important aspects of joined up IT. Value for money

Improved information, data and knowledge management systems

Will demonstrate value of investment in diagnostics Ability to provide cross board Business Intelligence and Health Intelligence, as well as supporting clinical research

User interface the hides organisation complexity

Enables correct action to be taken on behalf of the patient

Common user interface Provider complexity hidden from users Supports users of varying expertise

Enables correct choices of repertoire to be made more easily. Enables informed and appropriate access to efficient and effective lab services

Resilience Standardised approach to enabling backup

Larger scale makes resilience more affordable Bigger critical mass of knowledge and skills shared by a wider organisation reduces risk

Table A3 – Data Project


Consistent, complete and accurate laboratories data across Scotland

Completed baseline data returns for all disciplines for all boards.

Will provide a baseline for distributed service model development Will improve data collection and reporting for laboratories in Scotland Will deliver a robust and sustainable system to produce data with quality and integrity to meet the needs of the business Will enable constructive challenge of services across Scotland Will enable benchmarking with other services within the UK

Table A4 – Workforce Project


Identification of future workforce needs and requirements for training & education programmes. Identification of approaches for the development of requirements for Training and competency frameworks to support future workforce plans.

A workforce plan tailored to the emerging model of service delivery. Flexible and robust and competent workforce appropriately qualified in specialities to deliver the needs of NHSScotland

A review of current service configuration allows us to develop a credible workforce plan to build future sustainability of labs of all sizes by:

Understanding training requirements

Proviision of a workforce able to sustainably deliver for evolving and emerging f specialties

Providing potential for role extension in mitigating future medical workforce issues

Potential to improve skills mix across labs through economies of scale Enables better succession planning Defined career pathways Encourages a multi disciplinary approach

Shared workforce Staff working across organisational and

Service resilience across wider systems of work. Cross discipline working facilitates consolidation

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speciality borders Common Terms & Conditions Appropriate skill mix


Standardised Training & Education programmes

Flexible and robust workforce who are competent specialised, highly qualified and trained Common Terms & Conditions Appropriate skill mix

A review of current service configuration allows us to build future sustainability of labs of all sizes by:

Understanding training requirements

Providing for an ever-growing range of specialties

Providing potential for role extension in mitigating future medical workforce issues

Potential to improve skills mix across labs through economies of scale Enables better succession planning Defined career pathways Encourages a multi disciplinary approach

Table A5 – Standardisation Project


Identification of processes to enable reduction of intrinsic variation in services. Identify processes and opportunities to optimise extrinsic (user based) variation. Delivery of common standard operating procedures. Adoption of common methodological approaches. Alignment of references intervals, test s and test profile definitions. Common terminology, codings and taxonomies

Remove variation in processes between boards Convergence of service processes towards an optimal configuration.

Preparation for delivery of common IT approaches Enablement of cross system working Improved lab to lab communications to support flow of work between laboratories Improvement in patient safety Equitability of access to testing across boards Demand optimisation Industry accreditation will be obtained at a national level yielding cost savings. Enabling development of a service model that is demonstrably, efficient, effective, equitable, resilient and affordable. Enables progression of delivery of an optimised form follows function design for services.

Reduction in waste and variation Improves safety

Table A6 – Innovation Project


Pilot digital pathology across NHS GG&C and NHS Lothian Develop recommendations for wider adoption

Digital Pathology adopted nationally

Reduced turnaround time to diagnosis. Improved accuracy of diagnosis

Enable innovation New technologies become affordable

Reinvestment into value added specialist services are now possible Supports new models of care

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Supports stratified medicine

Table A7 – Logistics Project


Integrated efficient and responsive transport system

National integrated approach

Tracking & traceability Enables cross board working

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Appendix 7 – List of stakeholders

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First Name Last Name Job title Organisation

Karen Aitchison Laboratories and Out Patients Service

Manager NHS Lanarkshire

James Allison Service Clinical Director - Biochemistry NHS Grampian

Julia Anderson Scientific Manager for Biochemistry network NHS Dumfries & Galloway

David Ashburn Microbiology Department Manager NHS Highland

Mark Ashton Consultant Histopathologist NHS Highland

Lynn Ayton Head of Operations NHS Golden Jubilee

Bill Bartlett Consultant Clinical Scientist Joint Clinical Director Diagnostics (Laboratory Services)

NHS Tayside

Paul Batstone Deputy Head of Cytogenetics NHS Grampian

David Baty Head of Laboratory Genetics NHS Tayside

Christine Bell Geneticist, NHS Grampian NHS Grampian

Liz Blackman Senior Programme Manager NHS National Services Scotland

Gareth Bryson Head of Service for Pathology NHS Greater Glasgow & Clyde

Susan Buchanan Associate Director Patient Service NHS NSS

Mike Burns Interim Laboratory Service Manager NHS Dumfries and Galloway

Chris Anne Campbell Nurse Director NHS Western Isles

Karen Carolan General/Service Manager NHS Shetland

Tejinder Chima Clinical Service Manager, Diagnostics Group

NHS Tayside

Martin Connor Consultant Microbiologist NHS Dumfries and Galloway

Bernie Croal Clinical Director for Laboratories Chair of the Royal College of Pathologists Scottish Council

NHS Grampian

Peter Croan Head of Finance & Operations National Services Scotland

Anne Cruickshank Clinical Director for Laboratories NHS Greater Glasgow and Clyde

Kevin Deans Consultant Chemical Pathologist NHS Grampian

Linda Delgado Chair of Scottish Health Committee Partnership

Scottish Health Committee

Elaine Dick Assistant General manager NHS Ayrshire & Arran

Euan Dickson Regional Lead for the HPB MCN NHS Greater Glasgow & Clyde

Roger Diggle Medical Director NHS Shetland

Ellie Dow Consultant in Biochemical Science NHS Tayside

Sinclair Dundas Sarcoma Cancer Network Rep NHS Grampian

Fraser Duthie Lead Pathology for the Scottish HepatoPancreatoBiliary Network

NHS Greater Glasgow & Clyde

Robert Farley NES Healthcare Science Director Scottish Government

Frank Findlay Consultant Clinical Scientist NHS Greater Glasgow & Clyde

Adele Foster Cell Science Service Manager NHS Dumfries & Galloway

Liz Furrie Lead Clinical Scientist NHS Tayside

Donna Galloway Laboratory Services Manager NHS Fife

Fiona Gardner Associate Medical Director Diagnostics NHS Lanarkshire

Ian Gilbert Laboratory Manager NHS Western Isles

Ian Godber Clinical Lead (Biochemistry) NHS Lanarkshire

Mike Gray Service Manager for Laboratory Medicine NHS Lothian

Rachel Green Associate Medical Director / Chief of Medicine


Nicole Hamlet General Manager, Acute and Diagnostics NHS Dumfries and Galloway

David Harrison John Reid Chair of Pathology, Director of Research

University of St Andrews

Chris Hind Clinical Laboratory Manager- Haematology NHS Tayside

Alex Javed Laboratory Services Manager NHS Highland

Ingolfur Johannessen Clinical Director, Laboratory Medicine NHS Lothian

Peter Johnston Consultant Pathologist / Associate Postgraduate Dean

NHS Tayside

Lee Jordan Consultant Cellular Pathologist NHS Tayside

Kathy Kenmuir Practice Nurse Support and Development team manager


Ian King Clinical Manager Labs - Pathology NHS Lothian

Sheila Kowalczyk Lab Service Manager NHS Forth Valley

Betty Kyle Lead Biomedical Scientist NHS Lanarkshire

Joyce Lang Clinical Directorlaboratory services NHS Ayrshire and Arran

Claire Lawrie Programme Manager – Information National Services Scotland

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Management Service, NNMS

Alistair Leanord Consultant Medical Microbiologist NHS Greater Glasgow and Clyde

Michael Lockhart Consultant Microbiologist AMR Team NHS NSS

Fiona MacKenzie Scottish Microbiology & Virology Network (SMVN) Manager / Clinical Scientist

Aberdeen Royal Infirmary/ University

Suzanne MacKenzie Consultant Clinical Biochemist NHS Ayrshire & Arran

Aileen MacLennan Director of the Diagnostics Directorate NHS Greater Glasgow and Clyde

Lachlan Macpherson Acute Services Manager NHS Western Isles

Elizabeth Mallon Consultant Pathologist NHS Greater Glasgow & Clyde

Marion Mathie Deputy Laboratory Manager NHS NSS

Cameron Matthew Divisional General Manager NHS Grampian

Debbi McEwan Pathology Manager NHS Ayrshire & Arran

Angus McKellar Medical Director NHS Western Isles

Bruce Michie Consultant Pathologist NHS Forth Valley

Dale Moore Laboratory Manager; Chief Biomedical Scientist

NHS Grampian

Mary Morgan Director Scottish National Blood Transfusion Services

Karen Munro General Manager NHS Ayrshire and Arran

Isobel Neil General Manager for Lab Medicine NHS Greater Glasgow and Clyde

John O'Donnell Consultant Biochemist NHS Borders

Gillian Orange Consultant Clinical Microbiologist NHS Tayside

Judith Park General Manager, Surgical and Critical Care

NHS Lanarkshire

Norman Pratt Head of Department NHS Tayside

Stephen Rogers Consultant Haematologist / CMO Speciality Advisor for Haematology

NHS Fife

Annabel Ross GP - Aberlour Medical Practice NHS Grampian

Ann Ross Head of Performance and Quality Improvement

NHS Grampian

Colin Smith Professor of Neuropathology University of Edinburgh

Lynn Smith Interim General Manager NHS Tayside

Damien Snedden Project Accountant, Business Services NHS National Services Scotland

Judy Stein Service Manager NHS Forth Valley

Karen Stewart Healthcare Science Officer Scottish Government

David Stirling Director of Healthcare Science NHS National Services Scotland

Jeremy Thomas Consultant Pathologist Labs - Pathology NHS Lothian

Moira Thomas Consultant Immunologist NHS Greater Glasgow & Clyde

Aris Tyrothoulakis Service Director pan-Lothian Services NHS Lothian

Jackie Wales Head of Laboratories NHS Golden Jubilee

Jackie Walker Head of Technical Services NHS Greater Glasgow & Clyde

Robert Wardrop Laboratory Manager Western Isles

Michelle Watts Associate Medical Director NHS Tayside

Philip Wenham Consultant Clinical Scientist NHS Fife

Paul Westwood Consultant Clinical Scientist, Deputy Head of Laboratory Genetics


Nicola Williams Consultant Clinical Scientist, Head of Laboratory Genetics


Allan Wilson Lead Biomedical Scientist & SPAN manager

NHS Lanarkshire

Andrea Wilson General Manager, Laboratories NHS Fife

Brian Wilson Microbiology Lab Manager NHS Ayrshire & Arran

Arlene Wood General Manager NHS Tayside

Event / Group

Date / Annual

No. Type Outputs

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frequency WS1 Visioning 15/09/16 95

stakeholdersengaged over a period of 3 workshops

Representation from every Territorial Boards

Senior consultant & clinicians

Lab managers

Service managers

Clinical Directors

Scottish government

NSS – ISD & NSD

Clinical Networks

Staff side / union

Scottish Government

Higher Education / NES

SNBTS

Golden Jubilee

Stakeholder feedback has been extremely positive over the course of the workshops. Highlighting that this is the only opportunity they have to network nationally across disciplines and roles.

They have a strong sense of engagement in the laboratories programme and feel they are fully contributing to the development of the programme.

They feel they have an improved understanding of the role of shared services in relation to their clinical areas.

To date we have achieved workshop objectives and have obtained the necessary content for our strategic paper to be delivered to the CE’s in Aug’17

Outputs are fully analysed and quickly turned around for follow up communication via flash reports, newsletter and website content.

WS2 Agreed Way forward

14/12/16

WS3 Service design

14/03/17

Data Project Group

Monthly meetings

20 As above Group oversees the national benchmarking project (enabler of the Labs programme)

Digital Pathology Group

Monthly Meetings

20 NHS GG&C

NHS Lothian

NHS NSS - Procurement

Senior Pathologists and histo-pathology

Clinical directors Diagnostics

Service managers

Steering group for the Digital Pathology Pilot (innovation enabler of the Labs Programme)

Scottish Pathology Network (SPAN)

Quarterly, however currently meeting up monthly TC with SS

27 All territorial HB

NSS – NSD (Networks and IMS)

Senior Pathologists and histo-pathology leads

Working with network to align national data collection to Labs programme benchmarking

Supporting each other regarding overlap in SPAN work plans and Labs programme enablers

Scottish Clinical Biochemistry Diagnostic Network (SCBMDN)

Quarterly 35 All territorial HB


Senior Clinical Biochemistry and Haematology leads

SNBTS

Working with network to align their data collection requirements to Labs programme benchmarking

Supporting each other regarding overlap in SCBMDN work plans and Labs programme

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enablers

Scottish Microbiology & Virology Network (SMVN)

Quarterly 36 All territorial HB


Senior Clinical Microbiologists and Virology leads


Supporting each other regarding overlap in SMVN work plans and Labs programme enablers

Haematology Working Group

Inaugural Meeting May 2017

20 All territorial HB


Senior Clinical Microbiologists and Virology leads

SNBTS


Supporting each other regarding overlap in haematology work plans and Labs programme enablers

IT working group

First workshop 21 June 2017

12 Cross board representation

Technical representation

Steering group for the IT enabler project to produce the design for a joined up labs IT system

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Appendix 8 – Shared Services and Laboratories – Background

Overview of Shared Services In January 2015, the National Health Service (NHS) National Services Scotland (NSS) Programme Management Services (PgMS) was commissioned by the Guiding Coalition (now Senior Leaders Forum), made up of Board Chairs and Chief Executives, to take forward the NHSScotland Shared Services: to deliver sustainable, efficient services which will ultimately improve service user experience. One such work stream is the Health Portfolio, set up to consider a “Best for Scotland” approach for a number of clinical services including laboratory services. Initially this included a review of existing Shared Services programmes and work streams, scoping emerging programmes and the development of a vision and roadmap. The key messages that emerged included the need for further input from the leadership of NHSScotland and from the Scottish Government. Shared Services must be driven from the top by Chief Executives and any changes must be future-proofed to make the most of the hard work involved in driving improvements. Process The Shared Services Portfolio is following best practice guidelines from existing and pilot Scottish Capital Investment Manual (SCIM)10 Guidance where appropriate, to support the development ofBusiness Cases. This involves two documents, namely an Initial Agreement (IA) (now called “Strategy Paper”), and FullBusiness Case (FBC). These documents together make five cases for change, detailed as follows: The strategic case section. This sets out the strategic context and the case for change, together with the supporting investment objectives for the scheme.

The economic case section. This demonstrates that the organisation has selected a preferred way forward, which best meets the existing and future needs of the service and is likely to optimise value for money (VFM).

The commercial case section. This outlines what any potential deal might look like.

The financial case section. This highlights likely funding and affordability issues and the potential balance sheet treatment of the scheme.

The management case section. This demonstrates that the scheme is achievable and can be delivered successfully in accordance with accepted best practice.

Business Case development is an iterative process and at each key stage further detail is added to each of the five dimensions. The level of detail and the completeness of each of the five dimensions of the case are built up at different rates during the process. The Strategy Paper’s primary purpose is to establish the strategic case for change and fit with other programmes. It must also identify a preferred way forward, detailing a full appraisal of a ‘long list’ of options to achieve this, in what is categorised as part 1 of the economic case. What it does not do is outline every detail of the proposed change – rather, it takes a strategic overview of the status quo and proposes a way forward to meet the business needs of NHSScotland. Engagement In execution of the process for delivery of a composite business case, NSS Project teams have undertaken engagement with NHSScotland professionals working in the relevant environment. This has been achieved through workshops and open discussions, leading to documented outcomes which inform the business case elements. As and when required, prior to appointment of a Subject Matter Expert (SME), expert guidance was sought from other sources from within NHSScotland. The IA (now “Strategy Paper”) and FBC will ultimately comprise outputs from the workshops and other engagement. Therefore, a wide range of professional views have been taken into account in the process of identifying a preferred way forward.

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Further Information For further information about this Strategy Paper please contact the business case owner, Brian Montgomery, Health Portfolio Director on [email protected], or the Laboratories Programme Manager, Kim Walker [email protected].



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