Our Orkney, Our Health
NHS Orkney’s Integrated
Corporate Strategy for
Delivering Healthcare and
Health Improvement
CHAIRMAN & CHIEF EXECUTIVE’S FOREWORD
We are delighted to be able to present this Strategy which has been formulated to set the context, direction and framework for health and healthcare services in Orkney. It focuses on the delivery of clinically safe, sustainable and affordable services to treat ill health as well as to improve health and reduce health inequalities. The different sections of the document set out the important principles and actions required to deliver high quality services for the future; it acknowledges the unique challenges and opportunities of providing healthcare services in Orkney.
The people of Orkney need an efficient and effective healthcare service that is continually improving and responding to its changing environment. NHS Orkney and its joint partners, especially Orkney Islands Council and NHS Grampian, are determined to work together in order to secure that better service for local people. This paper sets out a shared vision of how we will achieve that goal.
We are committed to ongoing meaningful engagement with all parts of the Community and we urge as many people as possible to get involved in the ongoing consultation programme on the specific service changes.
John Ross Scott David Pigott
EXECUTIVE SUMMARY
The aim of Our Orkney, Our Healthis to set out an integrated strategy that describes how NHS Orkney will improve health, reduce health inequalities and treat ill health over the next five years. It brings together a Clinical Strategy that will underpin the development of our services, a Service Redesign Plan which states how we will achieve the Clinical Strategy and a Financial Strategy that sets out how we will achieve financial balance. This is a dynamic document and over the coming months we will be developing further strands including a Workforce Strategy and Health Improvement Strategy.
The vision for the future of healthcare and health improvement services in Orkney will need to be persuasive to all stakeholders. A whole systems approach to thinking through the changing shape of healthcare services is required. The first section of this document sets out the vision, values and overall strategic planning framework for NHS Orkney. It also sets out the national and local context which describes why the Board needs to redesign its services now.
The second section of the document sets out a revised Clinical Strategy. The concepts and initiatives presented in the strategy are drawn from national direction presented in „Better Health Better Care‟ and „Delivering for Remote and Rural Healthcare‟ in 2008. These have been distilled to create five key themes that will underpin clinical services in Orkney. This section identifies the service improvements that the Board wishes to make.
In order to deliver the improvements we will need to redesign and reconfigure services in Orkney in partnership with Orkney Islands Council, the voluntary sector and other NHS organisations. The third section of the document outlines how our services will change within the Service Redesign Plan that will deliver the changes. The Service Redesign Plan responds to some important issues such as the role of social care, the increased importance that we will place on reducing unplanned hospital admissions and the work required to establish fit for purpose healthcare facilities.
The role of social care is essential and needs to operate effectively at all levels of service delivery. Already there is effective engagement between the NHS and Orkney Islands Council but further enhancement of partnership working will be required to deliver the improved outcomes set out in this document. The establishment of the shadow Community Health and Social Care Partnership (CHSCP) will facilitate this.
Individuals will be provided with the opportunity to be supported in their own homes where this is possible thereby preventing unnecessary admission to hospital. The ability to do this will be enhanced by a new Intermediate Care Service and a new joint health and social care facility in Kirkwall which will allow patients who do not require medical intervention within an acute hospital setting, but who require additional support within a continuing care setting, to be cared for appropriately. NHS Orkney will continue to engage with staff, local communities and its joint partners to finalise the future shape of Balfour Hospital. This will include the option to develop plans within the first year of the Strategy for the reprovision of Balfour Hospital services.
The Service Redesign Plan recognises that Primary Care services are critical to healthcare provision and health improvement. NHS Orkney will continue to engage with local communities and its joint partners to finalise the future shape of primary and community care services on the Islands and the Mainland. It is recognised that a significant amount of consultation and engagement has already taken place with local communities and this will provide a clear direction on the future shape of primary and community care services over the next five years. The next stage in the development of these proposals will be the preparation of detailed project plans. In order for services to be sustainable and to facilitate the service improvements set out in the Clinical Strategy and Service Redesign Plan it is critical that the Board ensures its services are affordable and deliver value for money in all areas. The Financial Strategy shows how this will be achieved, recognising the challenging economic climate in which all public sector organisations will have to operate during the next few years.
The five-year financial plan forecasts a breakeven position in each year, but is dependant on Scottish Government Health Directorate brokerage of £2.8 million over the first two years and a £9.4 million reduction in expenditure over the five years. The expenditure reduction over the five years of £9.4 million includes:
£3.2 million recurring reduction which is supported with firm service redesign proposals
£0.8 million recurring reduction secured through the 2008/09 Budget Review exercise
£2.8 million currently non-specific recurring cash releasing targets which the Board must focus on developing further service redesign plans to deliver, there are significant risks with this target
£2.6 million non-recurring schemes, the reliance on which reduces significantly year on year from 2010/11
The financial plan was commented on formally by the Board‟s External Auditors (KPMG) as part of the 2008-09 Annual Accounts process. Their view was positive to the extent that the plan clearly demonstrates that the focus has moved to achieving a recurring financial balance rather than short-term achievement of in-year targets. The Board will face significant challenges in achieving the Clinical Strategy and financial plan over the next five years and will be required to ensure there is evidence of robust implementation and monitoring of the service change and associated financial results.
NHS Orkney and its partners are fully committed to working together to deliver safe and sustainable healthcare services. The time is now right to deliver and implement key changes to achieve the improvements set out in this document.
CONTENTS
A. OVERVIEW AND CONTEXT
A1 Introduction
A2 NHS Orkney‟s Strategic Planning Framework A3 Mission, Vision and Values
A4 2009/10 Corporate Objectives
A5 Local and National Context
A6 The Story so Far
A7 Workforce
A8 Moving Forward
B. CLINICAL STRATEGY
B1 Introduction
B2 The Local Context
B2.1 - Meeting the Changing Needs of Our Population
B3 The National and Regional Context
B4 Key Themes of Orkney‟s Clinical Strategy B5 Taking the Strategy Forward
B6 Working with Our Partners
B7 Conclusion
C. OUTLINE SERVICE REDESIGN PLAN
C1 Introduction
C2 Service Model
C2.1 - Self Care and the Important Role of Carers
C2.2 - Primary Care and Community Services
C2.3 - Social Care and Partnership Working
C2.4 - Shifting the Balance of Care through Partnership Working
C2.5 - Balfour Hospital
C2.6 - Acute Services outwith Orkney
C2.7 - Public Health
C2.8 - Mental Health Services
C2.9 - Children‟s Services C2.10 - Maternity Services C2.11 - Dental Services C2.12 - Pharmacy Services C2.13 - Optometry Services C3 Conclusion
CONTENTS
D. FINANCIAL STRATEGY FOR 2009 – 2015
D1 Introduction - Revenue
D2 National Financial Context
D3 Local Financial Context
D4 Key Criteria for Securing Recurring Financial Balance
D5 High Level Financial Plan
D5.1 - Annual Resource Limit Performance
D5.2 - Brokerage Requirement and Repayment Assumptions
D5.3 - Sensitivity Analysis
D6 Changing the Financial Profile/Progressing the Service Redesign
D7 Recurring Savings Plans
D7.1 - Primary Care Service Redesign
D7.2 - Acute Services Redesign/Shifting the Balance of Care
D7.3 - Pharmacy Service Redesign
D8 Financial Planning Assumptions
D8.1 - CRES & General Schemes
D9 Non-recurring Savings Plans
D10 Impact of National Economic Climate on Anticipated Levels of SGHD Uplift
D11 Inflation
D12 Cost Pressures
D13 Carry Forwards from 2008/09
D14 Introduction – Capital D15 Service Redesign Plan
D16 Intermediate Health and Social Care Facility
D17 Specific Capital Schemes
D18 Conclusion
E. COMMUNICATIONS STRATEGY
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Document to be incorporated at a later date>F. CONCLUSION AND NEXT STEPS
F1 Conclusion
F1.1 - Governance and Accountability
F1.2 - Summary
G APPENDICES
G1 Action Plan
Our Orkney, Our Health
A1. INTRODUCTION
This section sets out the strategic overview and context for the Corporate Strategy. It presents NHS Orkney‟s Mission, Vision and Values, articulates the wider strategic planning framework and sets out the national and local context in which the Strategy has been developed.
A2. NHS ORKNEY’S STRATEGIC PLANNING FRAMEWORK
The Board set out a strategic planning framework to help staff and stakeholders understand how the different aspects of the Strategy connected together. This is summarised in the diagram below:
Year 5 Corporate Action Plan Year 2 Corporate
Action Plan
NHS Orkney Strategic Planning Framework
Our Mission
The fundamental purpose of the organisation
Our Vision
A picture of how the organisation will look at a point
in the future when we have delivered. A lucid description of
what people will see, hear and feel.
Our Strategic Aims
The key areas of action that need to be addressed in order to deliver the vision. Usually no more than 5 – 8 areas which provide the framework in which strategy is developed
National Policy and Direction
Local Policy and Needs
Our Values
The behaviours and ways of working that support achievement
of the vision
Our Values
The behaviours and ways of working that support achievement of the vision C lin ic al Str ate g y T he s tra te gy th at se ts o ut w ha t s er vice s w e w ill pro vid e a nd h o w w ill pro vid e t he m F in an cia l Str ate g y T he s tra te gy th at se ts o ut th e ov era ll i nco m e a nd e xp en dit ure an tic ip ate d i n t he fu tu re , in clu din g ch an ge s i n t he a llo ca tio n o f fu nd in g be tw ee n se rv ice s t o d eli ve r o ur C lin ica l St ra te gy Se rv ic e R ed es ig n Str ate g y T he s tra te gy th at se ts o ut ho w w e w ill ch an ge o ur s er vice s t o de liv er ou r C lin ica l & F in an cia l St ra te gie s W o rk fo rc e Str ate g y T he s tra te gy th at se ts o ut ho w w e ch an ge th e pro file a nd s ki lls m ix of th e w ork fo rce to s up po rt d eli ve ry o f t he v is io n, C lin ica l a nd F in an cia l an d S tra te gie s H ea lth Im p ro ve m en t Str ate g y T he s tra te gy th at se ts o ut ho w w e w ill im pro ve th e h ea lth o f o ur co mmu nit y an d re du ce h ea lth in eq ua liti es O rg an is at io n D ev elo p m en t Str ate g y T he s tra te gy th at se ts o ut ho w w e su pp ort th e d eli ve ry o f t he v is io n by ch an gin g o ur cu ltu re , s tru ct ure , ma na ge m en t p ra ct ic es a nd sy ste m s Year 1 Corporate Action Plan •Recovery plan
•Operational Delivery Plan
Year 3 Corporate Action Plan Year 4 Corporate
A3. MISSION, VISION AND VALUES
In order to guide the development of this Strategy the Board agreed its Mission, Vision and Values in April 2009. This work has underpinned the development of all aspects of the Strategy.
Mission We are here to improve the health of the people of Orkney by working in partnership. We will provide quality assured, appropriate health services that are accessible and responsive to local need. We will work within the framework and resources provided by the Scottish Government Health Directorate.
Vision To be the best provider of remote and rural healthcare in the UK.
Values Making patient safety our number 1 priority.
Having patient needs and interests at the heart of what we do.
Living within our means and driving efficiency, productivity and sustainability in all we do.
Working with and listening to the Community.
Working in multi disciplinary teams where everyone‟s skills are valued.
Creating healthcare facilities that are fit for purpose for patients and staff.
Creating an environment where people enjoy working and can give their best.
Constantly improving by aiming high, using evidence and best challenge to improve, encouraging innovation and driving out waste wherever we find it.
Strategic Aims Delivering safe, effective and appropriate care
Improving Orkney‟s health and reducing health inequalities
Living within our means and demonstrating best value
Working mutually by involving patients, partners and the wider community
Developing our workforce to deliver our services
Creating a culture of excellence and continuous improvement
A4. 2009/10 CORPORATE OBJECTIVES
From the above the Board also confirmed its corporate objectives for 2009/10. In future years the Board‟s corporate objectives will be determined to secure delivery of the proposals set out in the Strategy.
A5. LOCAL AND NATIONAL CONTEXT A5.1 National Context
This Strategy is being produced at a time of significant economic uncertainty for Orkney along with the rest of the UK and the world. It is anticipated that this will continue to put pressure on all parts of the public sector over the next few years. This Strategy has been delivered in response to Scottish Government policy in respect of improving health, reducing health inequalities and treating ill health. The main driver is Better Health, Better Care published in 2007. Delivering for Remote and Rural Healthcare also sets out the framework for the delivery of sustainable healthcare in remote and rural Scotland. More details on the national context as it relates to the component parts of the Strategy are provided in each section.
A5.2 Local Context
Orkney is located six miles north of the mainland of Scotland, and is an archipelago of 54 islands of which 18 are inhabited. Orkney covers an area of 974 square kilometers, with more than half being taken up by the mainland of Orkney. The main island is known as the Mainland, with the south isles of Burray and South Ronaldsay joined by the Churchill Barriers. The outer islands to the north of the Mainland are Shapinsay, Rousay, Egilsay, Wyre, Westray, Eday, Sanday, Stronsay, Papa Westray, North Ronaldsay and to the south of the Mainland Hoy, Graemsay and Flotta.
The total population of Orkney is approximately 20,000 with 80% living on the Mainland of Orkney and linked islands. Kirkwall, with a population of approximately 7,600, is the administrative centre of Orkney. The smaller town of Stromness, with a population of 2,100, is situated in the West Mainland.
There is clear evidence that the North and South islands are tending to depopulate and also have an aging population (Biggar Economics 2007). Population mid-year estimates for 2001-2005, show Orkney overall is aging at a faster rate than Scotland. By 2016, it is estimated that 23% of the Orkney population will be 65+, and that by 2024 30% will be 65+ (compared to 23% nationally).
Agriculture is the main source of economic activity followed closely by tourism. Other industries include oil, fishing, salmon farming, craft industries and food and drink processing.
In February 2009 the claimant count unemployment rate in Orkney was 1.3% which is lower than Scotland as a whole which had a rate of 3.7%. However, these figures mask other issues such as low pay and lack of access to full time rather than part time employment.
Although Orkney is geographically isolated, the islands are well served by transport links to mainland Scotland. This facilitates the provision of specialist services in partnership with other NHS Boards in particular Grampian.
A6. THE STORY SO FAR
NHS Orkney, like all other Scottish Health Boards, is facing a challenging future. We are dealing with significant increases in demands for healthcare services as the number of older people in the population and the level of chronic ill health increases. Patients and service users are now better informed and rightly expect faster, more personalised care which is delivered closer to home. Not only are the demands on services increasing but we are trying to deal with these demands at a time when the working age population is shrinking and healthcare funding is reducing.
For nearly a decade NHS Orkney has been experiencing financial pressure that has led to under investment in core clinical services such as Mental Health and Children‟s Services. In 2006 NHS Orkney recognised that it could not rise to this challenge by simply doing more of what it had done in the past. Since August 2006 the Board has been on a journey to create clinically appropriate, safe and sustainable services whilst also balancing its budget.
In August 2006 the Board recognised that a structured strategic review was required to achieve clinical, service and financial recovery. The Board established the Creating Sustainable Services Programme as the mechanism for starting this process. The Creating Sustainable Services team spent 12 months reviewing all areas of NHS Orkney. They identified a wide range of service improvement initiatives that would both directly improve the standard of care for some patients and deliver an estimated £2.1m of cost savings. The team was influenced by „Delivering for Health‟, „Better Health, Better Care‟ and the National Remote and Rural Health Care report. These documents set a clear direction for the development of some services. Initially some aspects of these national strategies did not seem to fit well with service models in Orkney. However through discussion and visiting other healthcare systems we were able to get a better understanding of what would work in Orkney. This clarity is still emerging as we begin to understand what terms such as anticipatory care, self care, preventative care and shifting the balance of care really mean in practice. The team presented their proposals the Board in December 2007. The proposals included:
A fundamental redesign of the hospital to modernise service and improve the patient experience. The redesign included increasing the level of day surgery, developing an innovative rehabilitation approach in fit for purpose facilities, creating stronger resource sharing between the acute wards and implementing a multi disciplinary receiving area to act as a „one stop shop‟ for Primary Care out of hours, casualty and minor injury / minor ailments.
Options for creating a more sustainable and cost effective approach to delivering Primary Care in the Orkney islands which took account of the wider social and economic needs of these communities.
Initiatives to reduce medicine costs by changing prescribing habits and making use of collective buying power to negotiate better prices.
Proposals to reduce staff numbers in non clinical support areas by creating joint services with Orkney Islands Council.
The team urged the Board to refocus on its core business of providing healthcare. It should aim to drive out more cost by further reducing the number of people that it employs and by creating a culture where improving service and removing waste becomes a day to day way of thinking for everyone. The Board accepted all of the recommendations made by the Creating Sustainable Services Programme Team.
In winter 2008 a Shaping Up Team was put together to take forward the Creating Sustainable Services recommendations. Over the next 12 months the Shaping Up team refined the proposals and started to turn the plans into reality. The team undertook the detailed redesign of the rehabilitation services and worked with Orkney Islands Council to design a new integrated care team and scope out the NHS elements of an integrated health and social care facility.
A7. WORKFORCE
Changing population trends, coupled with the infrastructure challenges in Orkney, will result in challenges for workforce planning. Furthermore, there are significant concerns about the availability of key clinical staff to meet predicted future clinical demands. This challenge is potentially confounded by the requirement to comply with the relevant working time directives.
Workforce Plans need to respond proactively to the way we will be delivering clinical services in the future. There is a need for change related to changing demography, medical technology, the future availability of key professional staff and clinical practice. This makes it even more important that NHS staff and joint partners work together on the basis of a set of shared values.
The future capacity required to meet these outcomes and deliver priorities should be based on the multi-professional teams which NHS Orkney, Orkney Islands Council and other joint partners envisage will be needed to provide sustainable services through a redesigned workforce.
The Workforce Strategy for NHS Orkney will be published in due course to support the delivery of this Strategy.
A8. MOVING FORWARD
The remainder of this strategy document sets out the Clinical Strategy and the associated Service Redesign Plan. Decisions about the redesign and reconfiguration of services often require difficult judgements to be made. The following principles have also been identified to guide this decision making process;
Judgements should be evidence-based. This means that they will be informed by the best available evidence on what is the most appropriate clinical treatment and on what is the most effective management practice informed by patient, carer and public views.
Decisions should be systems minded. That is they will consider the impact on all aspects of the healthcare system of any proposed set of changes, rather than taking issues in isolation from each other.
Decisions should be preventive in nature. That is they will attempt to organise healthcare delivery systems that prevent problems occurring rather than dealing with their consequences.
Decisions taken must also be affordable. This is why the financial strategy is critical to the delivery of change.
Finally judgements should be patient-centred. This means that NHS Orkney and its joint partners are committed to a genuine and increasing level of patient, carer and public involvement in the planning and delivery of healthcare services.
Our Orkney, Our Health
B1. INTRODUCTION
NHS Orkney is committed to providing high standards of healthcare, investing in and supporting health improvement and understanding the changing health needs of the population. This will enable us to target our health promotion activity and healthcare to areas of greatest need and clinical priority. This strategy sets the context, direction and framework for the delivery of clinical services to the people of Orkney. It is complimented by the Service Redesign Plan which sets out how the direction and framework will be achieved. The Strategy is influenced by national policy and developments and regional initiatives but acknowledges the unique challenge of providing services in Orkney.
The Strategy provides an overview of the local health needs of the people of Orkney and draws conclusions about how these health needs will inform priorities and resource allocation over the next five years. It sets out the national strategic drivers which NHS Orkney must comply with in a way that is appropriate to our local context. It identifies five strategic themes and associated high level intentions that will underpin the development of clinical services in the future and maps proposed initiatives against these themes. Finally the Strategy sets out the key partners that NHS Orkney must work with in order to deliver the challenging programme of clinical work that is required over the next five years.
B2. THE LOCAL CONTEXT
Our Clinical Strategy must respond to the health needs of our population. In 2007 NHS Orkney carried out Health Needs Assessments to help the Board understand the main priorities for healthcare and health improvement in Orkney. The Health Needs Assessments enabled NHS Orkney to start building up a picture of how demands for services might change not just over the next five years but also over the next ten to twenty years.
B2.1 Meeting the changing needs of our population
The overall population of Orkney declined in the decade up to 2001 but subsequently there has been an increase to 19,770 (2006) due to the number of people migrating to Orkney slightly outweighing a falling birth rate and outward migration.
The age profile has also been changing. Compared to the rest of Scotland the population in Orkney comprises of more older people, with the percentage of the total population who are of working age significantly below the Scottish average. The age profiles vary across the islands. A recent housing needs survey shows a high proportion of elderly households living in the Outer Isles; particularly Eday, Sanday, Stronsay and North Ronaldsay. There is also a longer term trend of younger more economically active households moving towards the greater Kirkwall area.
Considering the Health and Well-being profiles prepared by the Scottish Public Health Observatory in general the health profile of the people living on Orkney compares favourably with the rest of Scotland. Male and female life expectancies are better than the Scottish average, with Orkney female life expectancy highest of all Community Health Partnerships in Scotland. All
average. Premature (under 75s) death rates from heart disease, cancer and stroke are better than the Scottish average but not significantly so.
Orkney has a significantly higher percentage of lone pensioner households, but a lower percentage of unpaid care for over 20 hours a week, than Scotland as a whole (2001 Census).
There is a significantly higher than average percentage of older people with intensive care needs cared for at home, rather than in care homes/geriatric long-stay beds (42% compared to 29.2% Scotland wide). Emphasising the importance of working closely with our social care colleagues to ensure an integrated care management approach.
However there are areas that we need to pay particular focus to:
Alcohol Misuse: There have been 23 alcohol related deaths in the last five years, and the proportion of the population hospitalised for alcohol related and attributable causes is significantly worse (higher) that the Scottish average.
Safety: The road traffic accident casualty rate, and the rate of unintentional injuries among older people in the home are both significantly worse than average.
Inequalities in Health: the remote and rural nature of the population of Orkney presents challenges for identification of inequalities and ensuring access to and providing effective and efficient care particularly for hard to reach/deprived groups and to improve the health of the population.
An estimated 13% of households are experiencing extreme fuel poverty (Scotland 5.9%). With being a largely rural island area not surprisingly over half the population (59%) live in the 15% „most access deprived‟ areas in Scotland (Scotland 15%).
Health Needs Assessment
During 2006 as part of the Creating Sustainable Services Programme a rapid health needs assessment was carried out by NHS Orkney on the top disease areas contributing to 80% of current service activity. The aim of these reviews was to look at current disease profiles and to predict future changes.
The service areas reviewed and the high level observations identified were:-
Service Area High Level Observation
Cardiovascular disease
Cardiovascular disease – current prevalence in Orkney is lower in Orkney than the rest of Scotland, especially for women. However, there was a marked rise in the incidence of disease in older age groups compared to the national picture. Looking ahead to 2016 a 24% rise in cases was expected compared to 2006.
Cancers Cancer – the rate of diagnosis of new cases is likely to rise due to the aging population from 102 new cases a year in Orkney in 2006 to 128 new cases in 2020.
Diabetes Diabetes – The prevalence of diabetes in
Orkney in 2006 was generally higher in Orkney than the rest of Scotland, particularly in type 1 diabetes. In 2006 the prevalence of diabetes was expected to rise by 15% over the next ten years.
Mental Health Mental health – Although there is poor national epidemiology data collection dementia was predicted to rise from 2006 levels by 11% by 2015. The age profile and dependency/co-morbidity of dementia sufferers was also expected to rise
Musculo-skeletal Musculo-skeletal – There was expected to be a significant rise in the number of new cases of back pain and osteo-arthritis between 2006 and 2016
Neurology Respiratory
Neurology – the raw prevalence in Orkney in 2006 was less than the Scottish rate
Gastro and digestive n/a
The outcome of these assessments were reviewed for the Clinical Strategy and the overall conclusions were considered to remain valid and were used in planning the service redesign changes set out in Section C. The outcomes will be kept under review as the work is updated for the Health Improvement Strategy and the detailed service redesign project plans are prepared
B3. THE NATIONAL AND REGIONAL CONTEXT
The national context for Orkney‟s Clinical Strategy is set out in „Better Health, Better Care‟ which was published by the Scottish Government in 2007. „Better Health, Better Care‟ set three priority areas for healthcare in Scotland.
The first priority area is „towards a mutual NHS‟. This priority sets out the requirement to move to more inclusive relationship with patients where they become partners in care delivery rather than recipients. Implicit within this is the need for NHS Boards and local communities to feel a joint sense of ownership and accountability for the clinical services that are delivered. In order to deliver this priority NHS Orkney needs to continue to develop robust mechanisms for involving the public and patients in the design and delivery of services and focus on increasing transparency in decision making and resource allocation.
The second priority area is „improving Scotland‟s health‟. This priority sets out the goal of increasing life expectancy in Scotland, breaking the link between early life adversity and adult disease, reducing health inequalities and tackling the most common causes of risk to a healthier life.
The third priority is „ensuring better, local and faster access to health care‟. This priority focuses on improving the quality of services, putting patients at the centre of care delivery, significantly improving patient safety, moving care provision from hospitals to community and home based facilities, improving efficiency, delivering equity of access to services and reducing the time taken from referral to treatment. „Better Health, Better Care‟ sets out an emerging model of care in Scotland, which is summarised in the table below:
Current View Evolving Model of Care
Geared towards acute conditions Hospital centred
Doctor dependent Episodic care Disjointed care Reactive care
Patient as passive recipient Self care infrequent
Carers undervalued Low tech
Geared towards long term conditions Embedded in communities Team based Continuous care Integrated care Preventive care Patient as partner
Self care encouraged and facilitated Carers supported as partners High tech
The proposed evolving model of care will be familiar to many healthcare practitioners in Orkney as it describes the way many services are already provided. The challenge moving forward will be to ensure that all services are delivered in this way.
„Better Health, Better Care‟ recognised that the challenges of clinical service delivery in remote and rural Scotland were substantially different from the challenges in urban Scotland. „Better Health, Better Care‟ was supplemented with „Delivering for Remote and Rural Healthcare‟ which sets out the national strategy for healthcare delivery in remote and rural Scotland. The report sets out the concept of a continuum of care, with self care and preventative care (which takes place in the home often supported by community services) at one end of the continuum, through to care in local community facilities (such as the Balfour Hospital) and where appropriate care in major specialist centres (such as Aberdeen Royal Infirmary).
The diagram below summarises this integrated approach to clinical care delivery for remote and rural communities.
The Remote and Rural report identified that in communities such as Orkney there are a limited number of health and social care professionals, whose skills and expertise need to be shared if we are to have local access to the widest possible spectrum of care. The report recommended that Health Boards develop Extended Community Care Teams (ECCT) to ensure that a robust system of local services is both available and sustainable.
The report designated Balfour Hospital as a Rural General Hospital (RGH) and identified the key services that such hospitals are expected to deliver. These requirements are reflected in this Strategy and the associated Service Redesign Plan. The report recognised the requirement for Rural General Hospitals to develop close working relations with large tertiary teaching hospitals such as Aberdeen Royal Infirmary and Raigmore Hospital in Inverness. These links enable the Rural General Hospitals to access a wider range of skills and specialism‟s which in turn help them provide the best possible care for all patients.
The report recognises the interrelated nature of service delivery in remote and rural communities. There are certain services that will be provided in Orkney, with highly specialised hospitals concentrating on providing services or procedures for patients who require specialist skills or services. The report recommended the formalisation of networks to ensure that larger centres are obligated to support and sustain healthcare services in remote and rural areas. These formalised networks are referred to as obligate networks.
B4. KEY THEMES OF ORKNEY’S CLINICAL STRATEGY
This section sets out five key themes which underpin NHS Orkney‟s Clinical Strategy. Under each theme we have set out high level intentions that will guide the development and delivery of clinical services in Orkney.
Key Theme 1: We will build our services around patients needs
Our clinical services must be responsive to the needs of our communities, our patients, their families and their carers.
We will develop and implement strategies which ensure that all patients have access to services regardless of the age, gender, disability, ethnic background, sexual or spiritual orientation.
We will involve service users, their families and carers in the development and design of our services.
Key Theme 2: Safeguarding and improving patient safety
Patient safety is central to what NHS Orkney does. Reducing and minimising the risk of harming a patient as a result of a health care intervention is the number one priority and underpins all clinical activity and services that NHS Orkney is responsible for.
We will focus on clinical effectiveness.
We will set standards for clinical care that are based on best practice guidelines - such as from the “Scottish Intercollegiate Guidelines network (SIGN) guidelines and the Quality Improvement Scotland (QIS) standards).
We will implement systematic clinical governance and risk management systems.
We will put in place clinical governance procedures which will underpin our ability to provide safe care and inform continuous improvement. These will include clinical audit, participation in benchmarking, structured monitoring and evaluation of outcomes and demonstrating that we are incorporating evidence based practice into our service. This will include a reduction in rates of Healthcare Acquired Infections.
We will create effective Board level governance and risk management frameworks that will deliver assurance and accountability.
We will create effective Board level governance and risk management by creating a system of internal control which gives the Board and ultimately the public assurance that our services are safe and that we are minimising risk.
We will train and develop staff to enable them to provide safe care.
We recognise that appraisal, education, training and continuous learning is key to the provision of high quality, safe services. We will invest in learning and education to ensure that all practitioners have access to mandatory training and the specialist training required to keep their skills up to date. We recognise that it is essential for staff to participate in clinical networks in order to remain up to date and conversant with changes in healthcare.
Key Theme 3: Partnership and whole systems working
We recognise that when it comes to delivering healthcare and improving health we do not work in isolation. We must work in partnership with staff and other agencies to take a whole systems approach to planning and delivering service.
We will develop partnerships which enable us to deliver the best possible care and improve health.
The key partnerships are outlined in section B6 of this strategy.
We will participate in regional and national networks to improve patient outcomes.
There is irrefutable evidence that patients‟ experiences of health care and clinical outcomes are improved by formalising collaborative working. The developments of technology (such as video conferencing, tele-health, electronic transfer of images, and shared clinical databases) enable Orkney clinicians to participate in clinical networks in a way that has not been possible in the past. Much of the specialist care in Orkney is dependent on the relationships with secondary care services on the Scottish mainland. For this reason it is important to engage and build opportunities to ensure that cross boundary care and communication is as integrated as possible. NHS Orkney robustly supports the concept of Obligate Networks, and will work closely with partner NHS Boards to implement these networks for the benefit of the population in Orkney, as well as to ensure specialist support and advice is available to clinical staff.
Clinical services will be supported by a responsive and flexible infrastructure.
Health care delivery in Orkney is highly dependent on an infrastructure that takes into account the challenges of its rurality and remoteness. This infrastructure includes:-
An on island, inter island and off island transport system that supports the delivery of services.
IT and communications systems that are robust and make the most of new technologies and opportunities, such as tele-health and remote clinical monitoring.
Organisational links with national and regional systems that support our local services such as the emergency retrieval services and NHS 24.
Primary care and secondary care services should, where possible, be integrated to ensure a seamless service and best use of local resources.
Orkney is served well by a close integration of community based Primary Care services with hospital based Acute services. Moving forward it will be increasingly important to strengthen this integration so that patients experience a seamless service and resources are used in the most effective way. In practice this will mean investing in systems and tools that contribute to making the patient experience seamless such as electronic referral systems.
Key Theme 4: Data, Evidence And Best Practice Will Drive Our Decision Making
Service planning must be based on robust health and epidemiological data.
NHS Orkney must make choices about what services it will provide and how it delivers these services. Service planning decisions will be based on evidence of effectiveness and accurate data about the changing health needs of the population. In addition NHS Orkney must build capacity and access service usage data to help it plan its services.
Additionally, all clinical services must participate with clinical audit procedures to encourage reflective practice and ensure that services are attaining the relevant clinical standards.
National strategies and best practice will be used to inform local service development and delivery.
Orkney must redesign services to ensure that resources are targeted to the health needs of our population. In undertaking service redesign we must build on national and regional best practice to ensure that patients in Orkney can receive the best possible care. In order to achieve this we must continue to be open to learning from the experiences of other health services outside of Orkney. National clinical strategies must be interpreted in the context of our knowledge of the specific challenges that face Orkney. There is not a „one size fits all‟ model and therefore services must be designed and delivered according to specific local circumstances. In order to successfully translate national strategies in a local context we must work with communities and patients to understand the specific needs of service users in Orkney.
Key Theme 5: Providing services that are responsive, accessible and accountable
Clinical services need to be available and easy to access. NHS Orkney is accountable to the local community for how it spends healthcare funding and how it performs.
Service user and carer feedback will be central to service development and improvement.
We will use information from patients, service users and carers to refine and develop our clinical services. We will continually seek to improve the quality of information about clinical services and treatments for the public
We will work with GPs, NHS Grampian and NHS Highland to reduce patient waiting times from initial referral to treatment.
We recognise that unnecessary delays in accessing health care are a source of anxiety for patients. Therefore, we will ensure that the referral pathways into the Orkney services and the NHS Grampian specialist services are clear and designed to minimise unnecessary waiting. We will also move to electronic referrals based on the national “SCI gateway” system. We will involve service users, carers and staff in decisions affecting services we are unable to provide locally.
B5. TAKING THE STRATEGY FORWARD
This section identifies the high level initiatives that NHS Orkney intends to deliver during the next five years. These build on the local health needs assessments, the national direction set out in „Better Health, Better Care‟ and the „Delivering Remote and Rural Healthcare‟ report and the key themes set out in the section above. The detail of how these initiatives will be implemented is covered in the Service Redesign Plan and in addition an action plan in appendix 1 summarises how these initiatives will be progressed.
Key Themes Projects and Initiatives
Building our services around patients needs
Increasing our ability to involve the community in the design and delivery of healthcare services by creating a local approach to Public Partnership Forums.
Participating in Better Together, NHS Scotland’s Patient
Experience programme.
Implementing the Patients Rights Bill which will provide a legal framework that sets out what patients can expect from NHS Orkney.
Implementing the National Participation Standards that are being developed by NHS Quality Improvement Scotland and the Scottish Health Council.
Building capacity to enable supported self management
for patients with Long Term Conditions by addressing
the ways in which we provide support, advice and information to patients.
Safeguarding and improving patient safety
Implementing the Scottish Patient Safety Programme.
Reducing Healthcare Acquired Infection.
Implementing Clinical Staff Revalidation as described in
the white paper Trust, Assurance and Safety: The Regulation of Health Professionals February 2007.
Revising NHS Orkney’s Clinical Governance and Risk Management Arrangements to create a system of internal
control which gives the Board, and ultimately the public, assurance that our services are safe.
Key Themes Projects and Initiatives Partnership and whole
systems working
Implement a Community Health and Social Care
Partnership to enable NHS Orkney and its partners to
provide better integration of services and to work together to tackle health inequalities, enhance anticipatory care, preventative care and shift resources to community settings.
Further strengthening Managed Clinical Networks as a means of linking groups of professionals and organisations to deliver high quality services.
Implementing revised models of community nursing that
can deliver effective nursing support to individuals against a backdrop of greatly increased demand, and changing health and service needs.
Implement the actions in the National palliative care action plan “Living and Dying well” to further strengthen
existing services and improve access and communication for all patients requiring end of life care.
Implementing Anticipatory Care systems to allow better management of patients with long terms conditions as they are vulnerable to relapse. As a result this will reduce urgent and unplanned admissions to hospital care.
Implementing more joined up unscheduled care services. We will work with Primary Care providers, Out of
Hours services, hospital services, the Scottish Ambulance service and NHS 24 to ensure that our unscheduled care services deliver equity of clinical outcome for all patients requiring emergency and urgent care in Orkney.
Where appropriate and clinically safe we will “Shift the
Balance of Care” from the in patient hospital setting to the
community, especially for rehabilitation patients and those with Long Term Conditions. NHS Continuing Care will be provided in partnership with community social services rather than in hospital based facilities.
We will work with Orkney Islands Council to create more effective intermediate care facilities and services. This will be provided in a combination of intermediate care beds; in continuing care beds; in rehabilitation beds; or in the patient‟s home and community facilities. There will be a reduction in the number of beds in Balfour Hospital, which at present provides a service to patients with long-term conditions, either on an ongoing basis or an intermittent basis, with an increase in community facilities.
Key Themes Projects and Initiatives
We will develop the Extended Primary Care Team in line with the recommendations in the Delivering for Remote and Rural Healthcare Report.
We will continue to develop shared care services with NHS Grampian.
Data, Evidence and Best Practice Driving Decision Making
We will create an acute receiving area in the Balfour Hospital to improve the patient pathway for unplanned hospital admissions.
We will increase day case activity in Balfour Hospital to reduce demand on beds, and improve the patient experience.
Providing Services that are responsive, accessible and accountable
We will work towards the development of new Dental
Health facilities which will allow greater access to dental
services.
We will work in partnership with the Scottish Ambulance Service to continue to improve access to emergency
services in line with the emerging models of emergency
care provision in Remote and Rural areas.
We will continue to have a system to manage
unplanned activity so that patients requiring specialist
services in other parts of the UK can be referred for treatment.
We will redesign our services to achieve the 18 week
referral to treatment standard.
We will support staff and the regional cancer network (NOSCAN) to ensure we continue to meet the 62 day standard for patients referred urgently with a suspicion of cancer. In addition to this we will work with all services to implement the new “31 day” cancer diagnosis to treatment standard.
We will strengthen our adult and children mental health
service to ensure equality of access to services.
We will finalise the review of Primary Care services in the islands and consult with the community on the preferred options.
We will work with the community pharmacy service
providers to implement the new elements of the new pharmacy contract which will in turn deliver benefits to
B6. WORKING WITH OUR PARTNERS
We recognise that we cannot deliver better services alone. Increasingly we need to work within partnerships to provide health improvement and healthcare. This section outlines the key partners that we will work with in order to deliver better health outcomes for the people of Orkney.
B6.1 Orkney Island Council
Orkney Islands Council is a key partner in improving health and providing healthcare within Orkney. The mechanism that we will use to drive forward this partnership is the Community Health and Social Care Partnership (CHSCP). The development of the CHSCP will support the development of effective joint working arrangements to achieve improved outcomes for people who use our services and their carers. The CHSCP will drive delivery of the jointly owned HEAT targets, Single Outcome Agreement targets and community care outcomes which are designed to focus resources on improving health outcomes for the population. We will also seek to deliver non-clinical support services with the Council in a more integrated cost effective way to maximise efficiency and best value.
B6.2 Scottish Ambulance Service
We will continue to work closely with the Scottish Ambulance Service (SAS) to continuously improve the emergency response in all areas of Orkney. We will deliver new and innovative ways of delivering services with SAS for both unscheduled and planned care, making best use of both organisations‟ resources.
B6.3 Carers
Carers play a major role in supporting people with health problems to remain in their own homes. This subsequently supports the NHS in Orkney. Carers will therefore be recognised as playing an important part in the planning and development of services in the future. NHS Orkney will ensure that carers are identified and, in partnership with Orkney Islands Council, fully supported to continue to provide this essential role.
B6.4 NHS 24
We will continue to work with NHS24 to ensure that the people of Orkney receive effective and appropriate Primary Care services outside GPs normal working hours. As the role of NHS24 is widened to include other services, such as supporting patients with long term conditions, we will seek to integrate these developments with local services so that we can collectively make best use of resources.
B6.5 NHS Grampian
NHS Grampian is a key partner in the delivery of health care services in Orkney and the provision of off island services to Orkney patients. We will work with NHS Grampian on three levels. The first level is in the development of clinical networks that will enable Orkney based staff to connect into a wider range of knowledge, resources and skills. The second level is the provision of visiting clinical services from NHS Grampian to Orkney and the third level is the provision of off island services, primarily through Aberdeen Royal Infirmary, to the people living in Orkney. In addition we will work closely with NHS Grampian to develop our Public Health, Infection Control and Laboratory services.
B6.6 NHS Highland
We will work with NHS Highland to continue to develop the ophthalmic service and ensure that it meets the requirements of the patients in Orkney. We will work with NHS Highland to continue to develop its potential in supporting our Primary Care out of hours services and the deployment of bank nursing staff.
B6.7 The Third Sector
The Third Sector (voluntary agencies) provides an important resource in supporting the delivery of care to patients and carers. They also provide an independent voice in shaping service development. NHS Orkney has always worked well with the Third Sector, and will continue to develop that relationship for the benefit of patients, where ever the opportunity arises.
B7. CONCLUSION
This Strategy sets out the „what‟ for the development of clinical services in Orkney. NHS Orkney is determined to make this Strategy a reality by improving the services that are provided to the people of Orkney. In order to implement this Strategy we will need to continue to engage with our patients, our staff and independent service providers.
The next section of this document is the Service Redesign Plan which sets out how the proposed developments in clinical services are to be delivered over the next five years.
Our Orkney, Our Health
Section C: Service Redesign
Plan
C1. INTRODUCTION
The Service Redesign Plan has been designed in response to the Clinical Strategy and to facilitate its delivery. At this stage the programme presents a framework for future service planning and further refinement of the detailed service changes will be required in due course.
The Redesign Plan has been prepared in conjunction with service leads and has been the subject of discussions with the Board‟s Clinical Advisory Committees and stake-holder groups. This section of the strategy document takes the care services in Orkney, identifies the key planning assumptions that NHS Orkney is making and the impacts / outcomes that we wish to achieve.
C2. SERVICE MODEL
Delivering continuous improvement will require the redesign and reconfiguration of services in Orkney and its external service providers.
Primary and Community based services are being reviewed in partnership with local communities including the evaluation of pilot projects. Recommendations will help to shape the way clinical services are delivered in the future. We will continue to work in partnership with staff, local communities, Orkney Islands Council, NHS24, the Scottish Ambulance Service, voluntary sector, carers and other joint partners to review existing service configuration.
Hospital services (Balfour Hospital and off island providers, particularly NHS Grampian), mental health services, optometry services, dental services, children‟s services, maternity services and allied health profession services to name but a few will need to develop, define and in some cases redefine, their roles in order to deliver our overall vision.
The following sections show the detail of how services will change.
C2.1 SELF CARE AND THE IMPORTANT ROLE OF CARERS
It is important to recognise that care and treatment can be informal and either self administered or provided by unpaid carers.
C2.1.1 Key Planning Assumption
C2.1.2 Impact / Outcome
A more pro-active role for patients and carers as the leading partners in their own care will be a strong feature at every level in this new service model.
The provision of well-targeted information and advice.
Multidisciplinary involvement in reviewing pathways of care such as preventative, self care and anticipatory care.
The provision of a reliable home care service.
The provision of flexible respite care.
C2.2 PRIMARY CARE AND COMMUNITY SERVICES
NHS Orkney will continue to engage with local communities and its joint partners to finalise the future shape of primary and community care services on the Islands and the Mainland. It is recognised that a significant amount of pre-consultation and engagement has already taken place with local communities on the Isles gathering their views and opinions, and this will provide a clearer direction on the future shape of primary and community care services over the next five years.
This will include working with local communities to consider some pilot projects where the concept of extended networks of health and social care staff working together flexibly can be evaluated (as per Delivering for Remote and Rural Healthcare 2007). This will avoid changes being put in place which are reactive and unforeseen. It will also avoid ongoing uncertainty with key timelines being agreed with local communities.
Most of the proposed changes have already been subject to extensive consultation and engagement with local communities. This work needs to continue and is part of a service change process that was previously agreed by the Cabinet Secretary.
C.2.1.1 Key Planning Assumption
The shape of Primary and Community based services will change over the next five years, being delivered through a range of Community and Primary Care networks.
C2.1.2 Impact / Outcome
The evaluation of pilot projects with local communities will help to shape the way clinical services are delivered in the future. The pilot project in Eday and Stronsay, where the GP provides a visiting service to Eday from Stronsay, supported by a Practice Nurse and an Advanced Nurse Practitioner on Eday, has provided encouraging feedback from the local communities. This pilot is currently being formally evaluated and will help to shape the way clinical services are delivered on these two islands in the future.
Each community, its culture, its size and its proximity to other communities and the Mainland are unique. However, it is recognised that in order to provide safe and sustainable clinical services, steps will need to be taken to tackle the potential problems of isolated practices (particularly single handed practitioners) and to „network‟ services together more effectively. Primary and Community care practitioners will be encouraged to operate as members of extended multidisciplinary Primary Care teams working with back up and support from local communities, other islands, the Mainland, the Scottish Ambulance Service, social care, NHS24 and other joint planning partners.
Extended Primary Care teams will be adapted to meet local circumstances on islands and the Mainland. An evaluation of these pilots will help to shape the way future primary and community services are delivered. This will be done on a planned and phased basis in full consultation with clinical staff and in partnership with local communities
By working together more effectively, individuals, teams and services in primary and community care we will continue to provide safe and sustainable clinical services to local communities.
Case Study – Family Living on an Inner Island in Orkney
Family of 4 living on an inner island in Orkney. All fit and well and just requiring routine services. Mum and Dad work in Kirkwall and the 2 teenage children live at home but travel to school on the mainland.
Traditionally, all family members have to get back to the island for any GP appointments. This means that they have to leave work / school early to get back in time. Mum would like to see a female GP for ‘women’s health’ issues but the regular and locum GP’s are males. The 17 year old teenage daughter would like advice on stopping smoking.
In the new system all family members will have the choice of receiving health services on their island or at the practice on the Mainland that is linked with their island practice. This means that Mum will have the choice of getting her cervical smear taken by the practice nurse at the Mainland practice or when the practice nurse has a visiting service on the island. The daughter will have a choice of receiving smoking cessation advice from the Mainland practice.
In the new system Dad will have access to a 'well man' clinic and will be actively encouraged to attend by his employer during the working day and his teenage son has access to information and life style choices at the school and Youth Cafe
As a consequence of these developments that will enhance choice and clinical care, we will respond proactively to workforce issues, such asimpending retirements, which could affect sustainable service delivery on the Mainland and the Isles.
It is anticipated that as staffing models change due to workforce issues there may be a reduction in the number of single handed GP Practices. This will help to inform the future shape of extended multidisciplinary Primary Care teams who will continue to provide safe and sustainable services to communities on the Mainland and the Isles through a networked model of care.
This will be a phased approach and timelines will need to be agreed along with the required resources to support any changes.
Transport links are a crucial factor in delivering safe and sustainable clinical services. It is recognised that work has been undertaken, however the transport strategy needs to be updated in light of the key planning assumptions set out in this document.
The use of new technology such as telehealth, web-based and digital communications media will support the delivery of self care, anticipatory care and primary care from remote and rural areas. Their role in enhancing clinical and service delivery will be evaluated and consulted on prior to implementation.
Establishment of an enhanced and flexible Primary Care team. This team would provide flexible cover for the Out of Hours Service and Locum Cover In Hours and out of hours. It is recognised, for example, that a rotation of a male and female GP would be well received by local communities who currently only have access to one GP.
A review of the Community Nursing Service is ongoing and this will link into the work outlined above.
Robust plans are to be put in place for delivering a whole journey waiting time target of 18 weeks from general practitioner referral to treatment… by December 2011, including the development of diagnostic services to deliver this vision
C2.3 SOCIAL CARE AND PARTNERSHIP WORKING
The role of social care is essential and needs to operate effectively at all levels of service delivery. There is effective engagement across the NHS and Orkney Islands Council both at strategic and operational levels. The establishment of the shadow Community Health and Social Care Partnership (CHSCP) will provide a robust framework for partnership working. A detailed work plan will be developed and will be supported with robust monitoring and effective leadership from NHS Orkney and Orkney Islands Council.
C2.3.1 Key Planning Assumption
To support and further develop effective joint working arrangements to achieve a seamless service and improved outcomes for people who use services and their carers.
