20:20 route map local delivery plan - aspen people ltd · 2014. 12. 4. · • 2014-15, 2018-19...

20:20 Route Map

Local Delivery Plan 2014 - 2015

1 Contents 2 Executive Summary 6

3 Person Centred Care 8

3.1 Information and support to enable people at home and during times of transition 8

3.2 Person-centred Health and Care Collaborative Implementation 12

4 Safe Care 16

5 Primary Care 21

5.1 Developing a Coherent Strategic Vision for the Development of Primary Care in Ayrshire & Arran 21

5.2 Creating the Capacity to Support Innovation and Development 23

5.3 Maximising the opportunities offered by the new Contractual Arrangements 25

6 Deep End GP Practices Approach 27

7 Unscheduled and Emergency Care 29

8 Integrated Care 36

8.1 New Bill 36

8.2 Health and Social Care Partnerships 36

8.3 Implementation of Health and Social Care Partnerships – High Level Programme Plan 39

9 Care for Multiple and Chronic Illnesses 41

9.1 Key pressure points in the entire pathway for the most common illnesses will be identified and actions agreed. 41

9.2 Through more detailed analysis of existing data, people will be identified as at risk and anticipatory care plans will be agreed. 44

10 NHS Ayrshire & Arran Service Improvement Group for Chronic Pain 46

10.1 Pathways / Referral Criteria 46

10.2 Data Collection / Measurement 47

10.3 Multidisciplinary Team (MDT) working / shift to community based activity 47

10.4 Information / Education for Health Care Practitioners 47

10.5 Supporting Self Management 48

10.6 Service Sustainability 48

11 Early Years 49

11.1 Work stream 1: 52

11.2 Work stream 2: 52

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12 Health Inequalities 55

12.1 Introduction 55

12.2 Keys to Life 55

12.3 Welfare Reform – Mitigating the health impacts in NHS Ayrshire & Arran 56

12.4 Ayrshire and Arran 57

12.5 North Ayrshire Locality Team Action Plan 58

12.6 South Ayrshire Locality Team Action Plan 60

12.7 East Ayrshire Community Planning Partnership: 63

13 Cancer Prevention 67

13.1 Early Detection of Cancer 68

14 Workforce 71

14.1 Context 71

14.2 Overarching approach to workforce 71

14.3 Stock-take summary of 2020 Workforce Vision actions 71

14.4 Use of the Nursing Workforce & Workload Planning Tools 77

14.5 Workforce Risks 77

15 Employability 79

15.1 Community Planning Partnership Areas of North, South and East Ayrshire 79

15.2 Youth Contract (placements offered in locations throughout Ayrshire) 82

15.3 Employability Fund 82

15.4 Transitional Employment 82

15.5 Modern Apprenticeships 82

15.6 Schools Work Experience Placements 83

15.7 College Work Experience Placements 83

15.8 Skills for Work 83

15.9 Project Search 83

16 Innovation 86

17 Efficiency and Productivity – recommendations to increase shared services 88

17.1 Finance 88

17.2 Human Resources (HR) 89

17.3 Facilities and Estates 90

17.4 Capital and Hard Facilities Management (Hard FM) 91

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17.5 Private Public Partnership (PPP)/ Private Financial Initiative (PFI)/ Non Profit Distributing (NPD) Contract Management 91

17.6 Sterile Services 92

17.7 Transport and Vehicle Fleet 92

17.8 Waste 93

18 Strategic Assessment of Primary Care in NHS Ayrshire & Arran 94

19 Heat Risk Management Plans and Delivery Trajectories 105

19.1 Introduction 105

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Appendices • 2014-15, 2018-19 Financial narrative V2 • NHS A&A Financial Plan – Local Delivery Plan (LDP) 2014-15-LDP

Financial Plan – template – 2014-15 V3 • Route Map with Designated Directors • Stroke Bundle trajectory 2014-2015 • Local Services and Strategies Aligned to 2020 vision

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2 Executive Summary

In the compilation of this 2014 / 2015 Local Delivery Plan (LDP), NHS Ayrshire &

Arran acknowledges that Health and Social Care is undergoing transformation during

this year whilst we move towards the new Integrated Health and Social Care

Partnerships.

To provide coherent structure to the plan we have selected to integrate ‘A Route

Map to the 2020 Vision for Health and Social Care’1 and have clearly linked local

programmes of work and their performance to the priority areas set out in the 2020

Route Map. NHS Ayrshire & Arran is using the 2020 Route Map as a framework to

contextualise strategic priorities for the organisation. It is our intention to develop a

performance framework from this to support the delivery of the 2020 Vision. In

addition, NHS Ayrshire & Arran has approved a local health and wellbeing

framework which is at Appendix 1. The title “Our Health 2020” emphasises co-

production and embodies the Board’s agreed purpose, commitments and values

which are being embedded throughout the organisation through a programme of

structured support. The Board has also undertaken a local services and strategies

stocktake comprising 70 plans which have been aligned to the national 2020 vision

and this is included as an appendix to our LDP.

We are making the shift to a strategic 5 year plan that will be reviewed annually and

recognise that this year will mark a transition towards a comprehensive 5 year plan.

Monitoring of associated action plans will be carried out on a quarterly basis.

We do not expect our level of Independent Sector usage to change in 2014-15, in

that we would only use this service for a specific pressure and only for a very limited

number of cases. We are not currently planning any use into the new financial year.

NHS Ayrshire & Arran is committed to achieving the Government’s Scheduled Care

Standards and Treatment Time Guarantee in 2014-15 in accordance with guidance.

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Much of the work that we do is achieved through strong alliance with our Local

Authority and Community Planning partners and we have woven details of the

ongoing work to achieve the Community Planning Outcomes throughout this Local

Delivery Plan.

John Burns

Chief Executive

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3 Person Centred Care

3.1 Information and support to enable people at home and during times of transition

NHS Ayrshire & Arran is committed to realising the national and local strategic

objective of working in partnership to ensure people are empowered to live at home

or in a homely environment. Support from health and other partners is especially

important at times of transition where it is crucial that people make informed

decisions and receive integrated support that enables them to live full and positive

lives within their own communities.

In recent years, NHS Ayrshire & Arran has embarked on an inclusive process of

whole system change to community services, working with partners (patients, public,

local authorities, third sector organisations) to support wellbeing and independence

as the norm. This will ensure that all services from early years right through to end of

life care are person centred, outcome focused, supporting prevention and community

resilience. This focus is ensuring that the health contribution to community planning

outcomes is significant across a number of areas including employability, reducing

health inequalities, enabling children to get the best start in life and that older people

are supported to longer healthier lives. A number of strategies and programmes

support the aspiration of providing information and supporting people at home and

during times of transition, which will provide a strong platform for further joint

strategic commissioning as health and social integration develops. This includes:

Delivery of the early years collaborative programme locally

Implementation Self-management framework for NHS Ayrshire & Arran

Delivery of the New Horizons: Reshaping Learning Disability Services in NHS

Ayrshire & Arran strategy

Mental Health Strategy – Mind Your Health

NHS Ayrshire & Arran Telehealth and Telecare programme

Reshaping Care for Older People – Ten Year Vision for Joint Services

Equality Outcomes for NHS Ayrshire & Arran

Living and Dying well action plan for NHS Ayrshire & Arran

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1. Key deliverable Ensuring that every baby, child, mother, father and family in Scotland has access to the best supports available.

Activity: Delivery of the four workstreams (together with a fifth leadership workstream): to ensure that women experience positive pregnancies all children within each CPP have reached all of the expected developmental

milestones at the time the child starts primary school all children within each CPP have reached all of the expected developmental

milestones at the time of the child’s 27-30 month child health Ensure the timely delivery of workstreams “stretch aims”.

Monitoring: This will be evidenced by a reduction of 15% in the rates of: stillbirths (from 4.9 per 1000 births in 2010 to 4.3 per 1000 births in 2015) and infant mortality (from 3.7 per 1000 live births in 2010 to 3.1 per 1000 live births in 2015).

85% of all children within each CPP have reached all of the expected developmental milestones at the time of the child’s 27-30 month child health review by end-2016.

90% of all children within each CPP have reached all of the expected developmental milestones at the time the child starts primary school, by end-2017. 2. Key deliverable Self-management approaches are embedded as the norm in all services. Activity: Delivery of the self-management framework for 2014-18. Monitoring: 95% of people have a positive Self reported outcomes 95% of people report a positive measure of enablement.

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3. Key deliverable Delivery of the Mind Your Health Mental Health Strategy Activity: A range of actions to enable and support people in their own homes including locality teams, liaison services to support transitions, improved access to services, recovery focus. Monitoring: Delivery of KPI’s including: HEAT Targets/standards e.g. all people newly diagnosed with dementia will have a minimum of a year’s worth of post-diagnostic support coordinated by a link worker, including the building of a person-centred support plan Achievement of SOA outcomes 4. Key deliverable Delivery of the New Horizons Action Plan for learning disability services Activity: A range of actions to enable and support people in their own homes including locality teams, liaison services to support transitions, improved access to services, asset based approaches. Monitoring: This will be carried out against a number of locally agreed key performance indicators 5. Key deliverable Delivery of the reshaping Care for Older People Strategy Activity: A range of actions in partnership to ensure Older people in Ayrshire enjoy full and positive lives within their own communities. Monitoring: Delivery of Key Performance Indicators including: Emergency inpatient day rates for people aged 75+ (HEAT target) Patients whose discharge from hospital is delayed more than 28 days (HEAT) target Percentage of time in the last 6 months of life spent at home or in a community setting.

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6. Key deliverable Delivery of NHS Ayrshire & Arran Equality Outcomes (2013-17) Activity: Deliver a range of activities to:

Further on or more of the needs of the public sector equality duties Reduce inequalities and improve access and service Involve people who share a relevant protected characteristic

Monitoring: Delivery of KPI’s including: Gender Based Violence – number of people using support resources Older people supported in the community - % of users satisfied with their opportunities for social interaction People are supported to gain psychological / spiritual strength to allow them to continue to live independently in their community - Results of Patient Reported Outcome Measure 7. Key deliverable People are supported to receive palliative and end of life care in their place of choice. Activity: A range of actions in partnership to ensure people achieve their preferred place of care and final care Monitoring: Number of people with an ACP in place Number of people who achieve their preferred place of care and final care

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3.2 Person-centred Health and Care Collaborative Implementation The Person-centred Health and Care Collaborative is a three year programme

(December 2012 – December 2015) focused on implementing person-centred

improvements across health and social care services.

This programme is a key strategic priority for Scotland and is viewed as

fundamental to the delivery of the person-centred quality ambition within the NHS

Scotland Healthcare Quality Strategy and is also essential in the delivery of the 2020

vision for Health and Social Care which articulates a commitment to care being

provided to the highest standards of quality and safety, with the person at the centre

of all decisions. It also has a role to play in the delivery of Reshaping Care for Older

People as part of Single Outcome Agreements, which propose the development and

delivery of collaborative, integrated and people centred care provision, whether in

hospitals, homes or in the community.

The direction of the national collaborative has been set around ‘point of care

experience’ by the Scottish Government’s Quality Unit and Health Improvement

Scotland (HIS). The aim for NHS Boards being that by 2015, 90% of people using

services will have a positive experience of care and get the outcomes they expect.

NHS Ayrshire & Arran has now established a Programme Board and Strategic

Planning Group to ensure the involvement and engagement of key NHS, 3rd Sector,

Local Authority and public stakeholders in the development and delivery of the

collaborative locally and the development of a local workplan.

The agreed local plan for year 1 includes the establishment of a local collaborative

and network of interest, and the commencement of activities in support of the

following key deliverables:

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http://www.scotland.gov.uk/Resource/doc/311667/0098354



http://www.tsh.scot.nhs.uk/External_Links/docs/2020%20Vision.pdf



http://www.scotland.gov.uk/Resource/0039/00398295.pdf

http://www.scotland.gov.uk/Resource/0039/00398295.pdf

1. Key deliverable A distributed, values based leadership culture from the point of service delivery through all leadership levels. Activity: Implementation and embedding of our agreed corporate values. Monitoring: Ongoing monitoring will be carried out through the annual Staff Survey and the work programme of the Culture Steering Group.

2. Key deliverable Person-centred values and behaviours being evident in words and actions at all levels within the organisation. Activity: The on-going development of the existing customer care commitments programme along with associated education package. Monitoring: Ongoing monitoring will be carried out through monitoring of the Board’s Customer Care Commitments In addition, measurement will be obtained from the national patient in-patient survey (Better Together) bi-annually.

3. Key deliverable Values and behaviours form the basis of recruitment and development of staff. Activity: Development of the current recruitment process for nurses (in the first instance) that incorporates essential recruitment criteria that is based on person-centred values. Monitoring: Monitoring will be undertaken through locally developed performance indicators and PDRs.

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4. Key deliverable Dignity, respect and compassion frame all communication and interaction with people who use our services. Activity: Development of a local pilot of ‘teach-back’ education, supporting the national health literacy programme, and further development of work on coproduction. Monitoring: Ongoing evaluation and monitoring will be undertaken on the impact of this with patients/service users.

5. Key deliverable Physical and cultural environments support the delivery of person-centred care Activity: Implementation of the ‘Caring Behaviours Assurance System’ (CBAS) as an intervention that empowers the clinical team to carry out environmental and cultural reviews on a routine basis. Monitoring: Each service will develop their own set of person-centred quality standards that will direct their activity and these will be monitored by the programme centrally and through service level governance arrangements.

6. Key deliverable There are reliable opportunities to personalise supporting interventions for every person all of the time. Activity: Establishing reliable delivery of the five ‘must do with me*’ elements through inclusion in nursing admission processes and documentation and AHP practices. 1. What matters to you? 2. Who matters to you? 3. What information do you need? 4. Nothing about me without me 5. Personalised contact (flexible access) Monitoring: Monitoring will be carried out by the ‘real-time experience programme’ at point of care through its rolling programme of environmental and cultural review and interviews with patients. In addition, this aspect is also being evaluated through the national patient in-patient survey (Better Together).

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7. Key deliverable Learning has been effectively implemented to address incidents, service or system failures (arising from all forms of feedback - internal/external scrutiny, complaints, feedback, SAER’s/AER’s best practice guidance etc). Activity: Patient/Service user views and feedback is actively sought and there is clear alignment to that feedback within quality improvement plans. Monitoring: Quality improvement plan monitoring.

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4 Safe Care

3.1 Scottish Patient Safety Programme (SPSP) Since 2008, Ayrshire has been engaged in delivering the workstreams of SPSP within adult services and has involved senior leadership and clinicians to support the progress of the programme. This has driven the spread of improvement activity and built momentum towards a culture of safety and continuous clinical improvement with the aim of delivering reliable, safe care across the system. The organisation of the Scottish Patient Safety Programme has now been reviewed; going forward there will be 4 national programmes:

Acute Adult Maternity and Childrens' Quality Improvement Collaborative includes

Maternity, Paediatrics and Neonates Mental Health Primary Care

Key deliverable - Acute Adult Programme

Maintenance of all previous adult workstreams Reduction of HSMR by 20% Introduction of the Scottish Patient Safety Index (SPSI) to ensure 95% of patients using inpatient services receive harm free care in the following areas; Pressure ulcers Falls Catheter associated urinary tract infection Cardiac arrest.

Activity: Refocus the work programme and improvement support to ensure delivery of Deteriorating Patient and Sepsis Venous Thrombo Embolism work Safer Medicines Heart Failure Surgical Site Infection SPSI

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The next steps for Acute Adult Safety programme will be delivered through the organisational priorities, patient safety essentials and point of care priorities outlined below: Organisational Priorities Infrastructure for Safety Strategic Prioritisation of Safety Patient Safety Essentials Hand Hygeine Leadership Walkrounds Communications: Surgical Brief and Pause Communications: General Ward Safety Brief Intensive Care Unit (ICU) Daily Goals Ventilator Associated Pneumonia Bundle Early Warning Scoring Central Venous Catheter Insertion Peripheral Venous Cannula Point of Care Priorities Deteriorating Patients Sepsis Heart Failure Pressure Ulcers Surgical Site Infections Venous Thromboembolism Catheter Associate Urinary Tract Infections (CAUTI) Falls with Harm

Monitoring: The programme of work for the Acute Adult Programme will be overseen and monitored by the Medical Director. Each subset will be delivered through the activity of a working group, each working group will have senior clinical leadership and dedicated improvement support. The monitoring of the programme will be against each of the nationally specified measurement criteria.

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Key deliverable - Maternity and Children’s Quality Improvement Collaborative The Paediatric Safety Programme was established in summer 2009. Following a restructure in 2012/13, it now forms part of the Maternity & Children's Quality Improvement Collaborative (MCQIC) together with the neonatal safety programme. Paediatric Programme - reduce avoidable harm by 30% by December 2015. Neonatal Programme - 30% reduction in avoidable harm in Neonatal Services Maternity programme Increase the percentage of women satisfied with their experience of maternity

care to > 95% by 2015 Reduce the number of avoidable events in women and babies by 30% by 2015 Activity: Various improvement work in relation to each of the programmes is currently underway. Monitoring: Each programme of work will be delivered through the activity of a working group, each working group will have senior clinical leadership The monitoring of the programme will be carried out locally and against the nationally specified measurement criteria.

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Key deliverable –SPSP Mental Health(SPSPMH) SPSPMH is a 4 year programme, 2012 – 2016, with an overall aim of reducing harm experienced by individuals in receipt of care from mental health services, with a focus on adult psychiatric inpatient units and forensic inpatient units. There are 5 workstreams for SPSPMH: Leadership and Culture - (mandatory) Safer Medicines Management Restraint and Seclusion Risk Assessment and Safety Planning Communication at Transitions. Activity: NHS Ayrshire & Arran has been involved in 3 of the workstreams Risk Assessment and Safety Planning Safer Medicines Management work streams Leadership and Culture Phase Two of the Risk Assessment work stream plans to focus on evidencing person centred and partnership approaches to risk assessment and safety planning, including as part of preparation for discharge. The Safer Medicines Management work stream will focus on methods to reduce potential for adverse events in people on high risk medicines. Currently developing a model that would support the spread of some of the measures throughout MH services Monitoring: The progress of the programme is supported by a working group with senior clinical leadership and dedicated improvement support. The monitoring of the programme will be carried out locally and against the nationally specified measurement criteria

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Key deliverable – Primary Care SPSP The Primary Care programme is concerned with reducing the number of events which could cause avoidable harm from healthcare in the primary care setting. The aims of the programme are: reduce mortality by 15% reduce adverse events by 30% The programme is made of up the following three work streams: 1. Safer medicines 2. Safe and effective patient care across the interface 3. Leadership and culture Activity: Work around medicines reconciliation is being undertaken with improvement in all participating GP Practices. Particular focus has been around the care of patients on Warfarin therapy with improvement noted regarding monitoring and patient education, those practices that do not offer Warfarin therapy services have been involved in the DMARDs workstream. Safety Culture surveys are being utilised along with Global Trigger Tools across Primary Care. Monitoring: The progress of the programme is supported by a working group with senior clinical leadership and dedicated improvement support. The monitoring of the programme will be carried out locally and against the nationally specified measurement criteria.

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5 Primary Care

5.1 Developing a Coherent Strategic Vision for the Development of Primary Care in Ayrshire & Arran

In December 2009, NHS Ayrshire & Arran endorsed the direction set by the Board’s

strategic review of Primary Care Services – Your Health: we’re in it together. In

doing so, there was a clear commitment to delivering the strategic direction set

through extensive stakeholder engagement and involvement, namely:

Delivery of ‘gold standard’ primary care services for Ayrshire &

Arran;

Creation of the culture and environment necessary to deliver

transformational service change;

Removal of the artificial barriers between primary, secondary and

community care, thereby enabling the development of truly integrated patient

pathways;

Radically shifting the balance of care to provide an even greater

proportion of healthcare in primary and community care settings;

Further developing and enhancing the local primary care workforce

to improve its capacity and capability, as well as its responsiveness to the

healthcare needs of local populations;

Re-establishing a meaningful, constructive relationship between

NHS Ayrshire & Arran and the people it serves; and

Through the process of strategic development, promoting

initiatives designed to reduce inequalities in participation in the design and

development of health services and ensure the resulting outputs are targeted

at reducing inequalities in health and access to healthcare.

This direction set the scene for local developments designed to support people at

home longer, such as Telehealth Pods, Community Wards and GP- led Anticipatory

Care Planning. Further, this strategic direction set a clear context for improving the

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quality of services offered by General Practice, such as the targeting of access

improvement initiatives, the development of new arrangements for the management

of performance concerns in Primary Care and the introduction of the Scottish Patient

Safety Programme in Primary Care.

That said, there is still much to be done in terms of improving how primary,

secondary and community care work together for the benefit of local people; tackling

inequalities and targeting resources within areas of deprivation and recognised

health need; and in modernising and developing primary care to support the desired

shift in the balance of care.

In formalising plans to deliver these changes, it is necessary to firstly test the

strategic direction set five years ago and refresh this to ensure congruence with the

key tenets of the 2020 Vision.

To this end, in early 2014/15 NHS Ayrshire & Arran will re-engage stakeholders in an

evaluation of the current strategic direction for Primary Care and assess this in terms

of its alignment with wider organisational and partnership goals, including the

Community Planning outcomes.

This will lead to the development and agreement of a current, relevant and tangible

vision for Primary Care that offers a clear strategic context and solid planning

foundations to support the innovation, development and targeting of Primary Care

resources and services within each of the Health and Social Care Partnership

localities. This vision will be agreed by Autumn 2014.

With a clear strategic vision in place, work will begin to develop robust, time bound

plans to strengthen, grow and develop primary care to ensure General Medical

Services are configured to deliver services that will meet the needs of patients with

long-term conditions and complex needs; support vulnerable children and families;

target and address inequalities; and offer alternative planned and unscheduled care

in community settings to enable tangible shifts in the balance of care. These plans

will be formalised and agreed with all partners for inclusion in the 2015/16 Local

Delivery Plan.

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5.2 Creating the Capacity to Support Innovation and Development

To maximise the effectiveness of these plans and to achieve the strategic vision that

will be established for Primary Care, it will be necessary create the clinical capacity

required to support innovation and development within Primary Care. NHS Ayrshire

& Arran must therefore utilise the available incentives and levers to generate

interest, support and capacity at a General Practice level.

The Primary Care Workforce Planning Survey 2013 highlighted pressures on the

Primary Care workforce across Scotland. This is reflected in feedback from local GP

Practices, with many reports of difficulties in attracting GP Principals, GP Trainees

and indeed Locum GPs. Further, an analysis of the age profile of the current

Primary Care workforce in Ayrshire & Arran highlights the likely impact over the next

decade of General Practitioners retiring earlier and fewer young Doctors choosing to

work locally.

Specifically, if the current retirement profile persists, then it can be assumed that

approximately 25-30% of the Primary Care Workforce in Ayrshire & Arran will retire

in the next decade, while the number of GP Trainees only accounts for 12% of the

workforce, leaving a significant deficit in a workforce that is already working at

capacity to effectively manage the growing incidence of chronic disease and

complex patient needs.

It is therefore important that NHS Ayrshire & Arran supports General Practice to

ensure sufficient capacity is available in the future to continue to meet the needs of

the local population and work in partnership with other service providers to meet the

needs of vulnerable children and families; support older people to live longer at

home; and tackle health inequalities and promote positive lifestyles.

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To this end, the Medical Director has established a local Workforce Planning Group

to assess the recruitment issues within General Practice and to explore solutions to

these at a local, regional and national level. Following the initial meeting of this

group, work is underway at a senior Medical Management level and with colleagues

from NHS Education Scotland (NES) to examine and address the issues, reported

by trainees, that are impacting on the attractiveness of Ayrshire & Arran. In 2013

54.5% of the GP Trainee posts advertised in Ayrshire & Arran were filled and

improving the attractiveness of these posts will therefore form a key element of the

local action plan.

It is, however, recognised that improving the number of training posts filled will only

offer a potential long-term solution to the workforce pressures locally. NHS Ayrshire

& Arran must therefore look to alternative, short-term opportunities to develop the

capacity of General Practice locally.

A review of the NHS Ayrshire Doctors on Call (ADOC) Out-of-Hours service is

currently underway, with an initial report due to be submitted to Directors by the end

of January 2014. While the outcome of this review cannot be determined at this

time, many of the options being considered are based on a change to the skill-mix

within the service from the traditional GP Principal model to models that also involve

Salaried GPs and Nurse Practitioners.

A key principle underpinning all of these models is that all Salaried GPs and Nurse

Practitioners employed by NHS ADOC on a full-time basis would have 30% of their

capacity dedicated to in-hours General Medical Service provision. In addition to the

personal benefits to these staff members in terms of a balanced working life and

opportunity to maintain skills and competence, there is an added benefit in that the

capacity of the local Primary Care workforce would be enhanced.

The potential future models for NHS ADOC will be further developed, refined and

assessed during Spring 2014 with a view to selecting a preferred model by early

summer. A full appraisal of the opportunity this offers for developing the capacity of

the Primary Care workforce will follow thereafter, with progress being reported

through future Local Delivery Plans.

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5.3 Maximising the opportunities offered by the new Contractual Arrangements

While looking to develop the capacity necessary to strengthen Primary Care, NHS

Ayrshire & Arran is also committed to working with local General Practice to ensure

the opportunities offered by changes in the contractual arrangements are maximised

in terms of delivering improved patient care.

To this end, NHS Ayrshire & Arran has formed a General Medical Services

Implementation Group, with representation from the Local Medical Committee, the

Primary Care Management and Corporate Support Services. This group is charged

with jointly reviewing, interpreting and agreeing the local application of changes to

the National Contractual Arrangements.

The priority areas for the GMS Implementation Group in 2014/15 will be:

Developing core standards and monitoring arrangements to ensure Practices

continue to deliver those elements of the Quality Outcomes Framework that

are subsumed into Core Contract;

Creating a core capacity and demand dataset that will support Practices and

the NHS Board in understanding and responding to access issues and directly

inform workforce planning;

Supporting Practices to engage fully in the new Health and Social Care

Partnership structures;

Establishing a local framework, based on the local Primary Care Information

System, to support the rollout of continuous quality improvement in General

Practice; and

Mainstreaming the Scottish Patient Safety Programme in Primary Care.

At the same time, NHS Ayrshire & Arran will work with a cohort of its existing 17C

Practices to explore the potential to prioritise the design, development and delivery

of services that are targeted and tailored to local need. Underpinned by a thorough

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assessment of local need, this approach will offer Practices an opportunity to redirect

resources from those activities they believe offer no significant benefit for patients to

a new suite of services aimed at improving health; protecting vulnerable individuals

and families; and supporting people at home longer. The effectiveness of this

approach will be assessed using jointly agreed outcome measures.

This will be progressed jointly with the new Health and Social Care Partnerships in

the Shadow year to ensure a holistic view of local needs is taken and that all

opportunities for joint working with other community health services, social services

and the third sector are fully considered. With a key emphasis on developing the

relationship between local communities and their General Practice, this approach will

be fully defined during 2014/15, with a view to a five year pilot from 2015/16.

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6 Deep End GP Practices Approach There is recognition within NHS Ayrshire & Arran that General Practice, as the main

provider of healthcare services, must be at the heart of identifying and responding to

local health needs, particularly when these needs are exacerbated by deprivation,

inequalities, poor life circumstances and a reduced ability to make positive lifestyle

choices.

Communities facing these challenges are likely to have particular needs in terms of

the numbers of vulnerable children and families; high levels of multiple chronic

disease and complex care needs; increased incidence of mental health and

addiction problems; and the level of support required to live safely at home as

individuals become increasingly frail.

While only two Ayrshire & Arran Practices featured in the original Deep End project,

both of which serve the Doon Valley, it is clear from the latest Scottish Index Multiple

Deprivation (SIMD) data that a number of communities across the County are

experiencing increasing levels of deprivation. How to respond to these changes will

therefore be a key priority for the new Health and Social Care Partnerships.

It will be important for all stakeholders involved in the new Locality Planning

structures to be engaged in assessing local needs and designing services that are

targeted at and tailored to meet these. In doing so, cognisance will be taken of the

principles from the Deep End project, with particular consideration being given to

supporting Practices in:

Increasing the clinical capacity available to meet local needs;

Targeting capacity and support on a case-by-case basis;

Developing the GP-Patient relationship and focusing on co-production as a

norm;

Forming multi-disciplinary, multi-agency teams around the GP Practice; and

Sharing experience and learning with other Practices.

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Taking account of factors such as levels of deprivation, disease prevalence and

rurality, it is recommended that priority be given to designing services for the patient

populations served by:

Ballantrae Medical Practice;

Tanyard Medical Practice (Cumnock);

Dalmellington Medical Practice;

Drs McMaster, Moore and Brooksbank (Girvan);

Eglinton Medical Practice (Irvine);

New Cumnock Medical Practice;

Riverside Medical Practice (Patna, Rankinston, Coylton and Dalrymple); and

Cumbrae Medical Practice.

The Primary Care Management Team will work closely with colleagues from Public

Health and all other stakeholders through the new Health and Social Care

Partnerships to assess the health needs of these populations, determine how

services should be configured to best meet their needs and devise plans for the

delivery of targeted and tailored services from General Practice. The planning phase

of this work will be concluded in 2014/15, with new service models being delivered

from 2015/16.

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7 Unscheduled and Emergency Care 7.1 Out of Hospital Care Action Plan The NHS Ayrshire & Arran Out of Hospital Care Action Plan is a key component of

the Local Delivery Plan (LDP) that will shift care away from acute hospital wherever

appropriate, by strengthening local integrated based health and social care services

for patients in their own communities.

The Out of Hospital Care Action Plan is fully aligned to other unscheduled care

improvements. A main building block is the Board’s Local Unscheduled Care Action

Plan (LUCAP) and the Building for Better Care (BfBC) capital investment programme

that will see new fit for purpose unscheduled care facilities provided at both of the

Board’s two main acute hospitals, University Hospital Crosshouse (UHC) and

University Hospital Ayr (UHA).

The four year change fund was established in 2011/12 to facilitate a whole system

redesign of Older People’s Services, and Ayrshire partners have worked together to

develop a 10 year Reshaping Care for Older People Vision, supported by separate

three year action plans for each local authority partnership. The vision is that older

people in Ayrshire and Arran shall enjoy full and positive lives within their own

communities wherever possible. 2014/15 will be the final year of the change fund

and decisions will be made regarding integrating service changes to mainstream

services within the new health and social care partnerships.

Based on new working relationships between statutory, voluntary and independent

sectors the services being developed are person centred; outcome focused, based

on prevention wherever possible and designed to promote resilience within local

communities.

Key Community Services elements of the Out of Hospital Care Action Plan which will

be further developed and actioned in 2014/15 include:

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Reducing emergency admissions from care homes through coordinated training

and support involving multi-agency teams, including dementia training.

Community based Intermediate Care Integrated Care and Enablement teams

supporting rapid, integrated interventions to encourage independence and

avoid hospital admission.

Community Ward teams comprising GPs, Advanced Nurse Practitioners and

Administrators in East, North and South Ayrshire using SPARRA data to

support community based care of complex patients with pattern of high

admissions.

Enhanced out of hours nursing services working jointly with Ayrshire Doctors

On Call services, out of hours social work and home care from Single Point of

Contact to provide more care at home, including palliative care and provide

A&E staff with community based alternative to admission.

Enhanced district nursing training and Primary care based shared care working

between acute physicians and GPs to support Chronic Obstructive Pulmonary

Disease (COPD) care at home.

Support for GP leadership and Multi Disciplinary Team working in community

and island hospitals to facilitate local care and avoid acute admission.

Enhanced falls service including pathways, training and links to tele-care.

Allied Health Professions service change and enhancement including move to

7 day working and integrated Occupational Therapy (OT) approaches.

Integrated care planning across community, primary care and acute using Key

Information Summary (KIS) data to reduce length of stay and avoid admission

where possible.

Robust evaluation of the Change Fund projects with approved projects

mainstreamed to contribute to integrated approaches.

Development of community based hubs where single point of contact will

operate day and night to coordinate intermediate care services which will help

GPs to avoid admissions and support acute hospitals to discharge patients

safely from the front door and reduce their length of stay.

Continued support to operational managers and local staff to deliver

transformational change during the transition from Community Health

Partnerships to Health and Social Care Partnerships.

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Focusing on the personalisation agenda, linked to roll out of co-production and

self management approaches in order to encourage people more actively to

manage their own health and wellbeing over a long period.

Development of geriatrician led frail elderly pathways to support safe care at

home.

Communications strategy to publicise and celebrate change, share

performance data and promote understanding across sites and services.

Likewise in regard to Primary Care there now are active plans and investments

that will further develop and strengthen Primary Care in Ayrshire and Arran.

Key Primary Care elements of the Out of Hospital Care Action Plan include:

An Enhanced Services Commissioning Plan introduced a Local Enhanced

Service (LES) designed to support the signposting of patients who are utilising

General Medical Services and Emergency Department (ED) services when

alternative, more specialist services could better meet their needs.

GP led Anticipatory Care Plans for registered patients who GPs believe to be at

significant risk of emergency admission or unscheduled care.

A care home pilot that will reduce emergency admissions to acute hospitals

from care homes, a reduction in poly-pharmacy and wasted medicines.

NHS Ayrshire & Arran has the highest or second highest prevalence rates in

Scotland for nine of the seventeen disease groups and a review of the emergency

admission data from the corresponding time period confirms NHS Ayrshire & Arran’s

admission rate for a selection of these disease groups, is higher than the Scottish

average. Based on this information local GP Practices shall be invited to select three

from the following four admission categories to review as part of the QOF QP

Process – Respiratory Disease, Digestive Disorders, Poisoning and Circulatory

Disease.

These plans and the targeted interventions and redesigns they describe will

strengthen community and primary care services in support of the unscheduled and

emergency care agenda. The Out of Hospital Care Action Plans is transformational

and sustainable, bringing about fundamental changes that will deliver against all

related HEAT targets and the 6 key quality outcomes of the NHS Quality Strategy as

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well as sustained delivery and improvement against the relevant HEAT targets will

provide tangible evidence of progress towards the 2020 Vision.

7.2 Sustainable performance on 4-hour A&E waits. The 4-hour performance standard is the key performance indicator of a how an acute

hospital site and the unscheduled care system are performing.

The Board’s Emergency Care Quality Improvement Programme (ECQIP) is

addressing this challenge through changes and actions set out in the LUCAP which

are fully consistent with the new ways of working and new clinical models required

for the Building for Better Care capital investment programme: that all taken together

will transform unscheduled care in Ayrshire and Arran and deliver sustained 4-hour

standard compliance.

The Board’s BfBC capital investment programme sets out a new vision of how acute

unscheduled care will be organised in the future. The Board’s LUCAP is

implementing many of the clinical pathway improvements set out in BfBC, to

accelerate progress and bring about transformation of services ahead of the new

build fit for purpose facilities.

Detailed analysis has been undertaken to identify important areas, and the following

actions and measures will be put in place or further developed in 2014/15:

Standardisation of processes within wards to review, test and implement

improvement at ward level throughout the two main acute hospital sites,

including ward round scheduling, implementation of a ward round tool,

determination of estimated date of discharge, criteria led discharge, more

morning discharges and a range of care quality standards

Implementation of e-Whiteboard systems linking both EDs with their respective

medical AMAUs, e-Whiteboards across all acute wards

Introduction of an electronic IT driven Bed Management Hub to allow better

management of patient flow. This will release time and allow the Bed

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Management Team to support improvements at ward level with a view to

securing earlier discharge for patients

Discharge Planning improvements being taken forward in conjunction with

partners including Social Work and Local Authority

Introduction of standardised approaches to weekend service planning to

maintain patient flow and minimise transfer of patients out with specialty beds.

Provision of 6 additional beds at UHA to offset the current modelled bed deficit

as part of interim step to the new Combined Assessment Unit

Additional medical posts in Acute Medicine, Geriatrics and Emergency

Medicine

Introduction of Pharmacy led medicines reconciliation in EDs

Commencement of a Clinical Decisions Unit at University Hospital Ayr (UHA) to

support the introduction of ambulatory care pathways, early senior clinical

decision making, rapid diagnostics and evidence based clinical management.

The Clinical Decisions Unit (CDU) pathway management model is one of the

key strands of the new service model that will be incorporated into the new front

door service (BfBC) as ambulatory care, utilising the proposed new 11

ambulatory care bays on the University Hospital Crosshouse site and 8 on the

University Hospital Ayr site.

Flow Co-ordinator within each Emergency Department to support the

management of patient flow

Further work in support of the HEAT 10 target to reduce Emergency

Department (ED) attendances including introduction of robust clinical

leadership, better integration of mental health and addiction services,

identification of frequent service users to allow proactive management of these

patients and specific actions to reduce dependence of parents on the ED for

routine advice in relation to the care and treatment of children

Expansion of Acute Medical Receiving Unit at Crosshouse Hospital ahead of

the new planned Combined Assessment Unit (CAU) as part of Building for

Better Care

Proposed introduction of patient safety huddles early each morning on both

acute sites to lead and deliver safe and effective patient flow

These actions will support the delivery of more effective, safe and person centred

care and performance against the 4 hour standard at each hospital. The Board’s

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Local Unscheduled Care Action Plan (LUCAP) includes HEAT performance

trajectories that will track progress to ensure sustained improvement to deliver the 6

key quality outcomes highlighted in the NHS Quality Strategy.

7.3 Increase flow through the system The plans set out in the LUCAP will also contribute to improved patient flow through

the system

The plans centre on pathway driven care underpinned by access to senior decision

making in the early part of a patient’s unscheduled care journey and emphasis

placed on deciding whether to admit a patient as opposed to admitting a patient to

decide what action to take thereafter: again all consistent with the principles and

vision set in Building for Better Care.

The following LUCAP actions are now being implemented or maintained in 2014/15

to support the shift to the new model of care and the requirement to increase flow

through the two main acute hospitals.

An additional receiving Physician working weekends at UHA. The purpose of

this development was to increase access to senior decision making at

weekends and to improve patient flow through earlier discharge. Evaluation of

this development has demonstrated a 10% increase in weekend discharges

and further improvements will be sought in the year ahead.

New GP patient assessment models have been introduced on both main acute

hospitals where GP patients are admitted directly to a unit staffed by Acute

Physicians and rapidly assessed to determine treatment options and whether

admission to a bed is required. The median time to see a doctor has been

already been reduced and work will continue in the year ahead to make further

improvements including further expansion of Acute Physicians and time

allocated to continual assessment.

A new 7 day Consultant Cardiology Service has been established to provide

patient access to a senior decision maker 7 days a week resulting in enhanced

patient assessment and better patient movement through the two coronary care

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units and general cardiology wards. The introduction of a 7 day consultant

presence now supports the placing of Temporary Pacing Lines (TPL) that is

best carried out by cardiologists.

New Frail Elderly Pathways have introduced within both EDs. A Consultant

Elderly Care Medicine is leading a multi-disciplinary team to assess vulnerable

frail elderly patients and seek alternatives to admission. This work has had very

encouraging results and the aim is to maintain progress in the year ahead.

A new surgical pathway has been introduced at UHA to ensure surgical

patients are seen earlier by a senior decision maker.

In the year ahead work will be carried out with diagnostic services on both sites

to support patient assessment and rapid diagnosis radiology investigations will

be undertaken and reported within a few hours of request.

The interventions and redesigns outlined above are expected to make a difference

for many patients and in overall terms by improving the flow through the two main

acute hospitals. The LUCAP performance framework contains appropriate measures

to evaluate flow and sustained 4-hour target performance will deliver safer more

effective patient care that is person centred and particularly sensitive to the needs of

vulnerable older people: again making 6 key quality outcomes real for patients in

Ayrshire and Arran.

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8 Integrated Care

This priority area has two key deliverables:

1) New Bill;

2) Preparatory work with NHS Board, Local Authorities, third and independent

sector and the building of effective Integrated Health and Social Care

Partnerships.

8.1 New Bill

Deliverable (1) involves the Bill being introduced to Parliament and gaining Royal

Assent. Although this is primarily a deliverable for Scottish Government, the Board

has been proactive in its support of the process evidenced by:

providing a detailed written response for the Health and Sport Committee in

support of Stage 1;

appearing as a witness for the Health and Sport Committee during its Stage 1

consideration of the Bill (Director for Strategic Planning, Policy and

Performance);

serving as the Health Board Chief Executives’ representative on the Bill

Advisory Group (Director for Strategic Planning, Policy and Performance);

co-Chairing the national Joint Strategic Commissioning Steering Group which is

supporting sections of the Bill (Director for Strategic Planning, Policy and

Performance).

8.2 Health and Social Care Partnerships

Deliverable 2 includes development and delivery against new Single Outcome

Agreements and the building of effective Integrated Health and Social Care

Partnerships.

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The Board has taken action to ensure that Community Health Partnerships continue

to have a focus on the delivery of the new Single Outcome Agreements. Steps

taken include a revision of the Scheme of Delegation from the Board to the CHPs

and the setting up of a Performance Workstream in support of integration which will

ensure an effective link between the Partnerships and SOAs.

Along with its partners, the Board has set up a comprehensive framework for

undertaking the preparatory work which will support the new partnerships. The main

elements of this are:

An option appraisal of the models of integration following which the Board and

all three Councils adopted the Body Corporate for the three Ayrshire

Partnerships;

Agreement across the partners of a High Level Programme Plan (attached).

To date the only major areas of slippage relates to the appointment of Chief

Officers in East and South which was completed in February 2014. The

appointment in North was made in accordance with the programme

timescales;

Agreement across the partners of the workstream which will support the

production of the Integration Plan (attached). All workstreams have identified

leads and programme management support for each has been arranged. All

workstreams feed into an overarching Programme Plan;

Transition Integration Boards have been set up for all three Partnerships with

agreed terms of reference and standing orders. On 1 April 2014, these

Boards will become Shadow Integration Boards which will run the

partnerships during the shadow year 2014-15;

Agreement across the partners that all three Integrated Joint Boards will take

effect from 1 April 2015; and

A pan-Ayrshire group has also been set up to undertake preparatory work on

the Strategic Plan which the partnerships will be required to produce.

In addition, the Board has set up a Health Integration Steering Group which includes

membership of the Area Clinical Forum and Area Partnership Forum. This will

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ensure a pan-Ayrshire health approach across the partnerships where appropriate

and avoid fragmentation.

The Board and its Partners are engaging with relevant stakeholders to ensure most

effective use is made of the shadow year (2014 - 2015). Membership of the key

bodies will include carers, service users, staff (partnership), clinical/professional

groups, as well as the third and independent sectors.

The formation of the new Partnerships will have an influence on many of the other

sections of this Local Delivery Plan including Primary Care and the role of

Community Planning Partnerships. Again, these relationships will be developed

further during 2014 – 2015.

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8.3 Implementation of Health and Social Care Partnerships – High Level Programme Plan

Action By Whom Start Complete By Agree Model of Integration

NHS Ayrshire & Arran Board and North, South and East Ayrshire Councils

May 2013 June 2013

Authority to proceed to establish shadow Health and Social Care Partnership


May 2013 June 2013

Authority to proceed to appoint Chief Officer(previously Joint Accountable Officer (JAO))


May 2013 June 2013

Create Transition Integration Board (TIB)


June 2013 April 2014

Appoint Chief Officer


June 2013 October 2013

Create Shadow Integration Board (SIB)


June 2013 April 2014

Establish Integration Joint Board


April 2014 April 2015

Establish broad service configuration, including the hosting of services


May 2013 October 2013

Finalise service configuration


October 2013 April 2014

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9 Care for Multiple and Chronic Illnesses

9.1 Key pressure points in the entire pathway for the most common illnesses will be identified and actions agreed.

The most common illnesses affecting the lives of people in Ayrshire and Arran are

generally linked to the diagnoses of Diabetes, Stroke, Heart Disease and Respiratory

illness which taken together account for much of the chronic and acute disease and

illness burden in the Board area.

NHS Ayrshire & Arran is working in partnership with a wide range of agencies to

improve care for those with multiple and chronic illnesses. The Board’s Managed

Clinical Networks (MCNs) remain a key focus for this work, engaging with patients

and families to develop whole patient pathways, utilising new technologies and

supporting self management. In the year ahead it is planned to bring the MCNs even

closer to operational service management to support implementation of measures

which support whole system working. MCNs will continue to play a vital role in

regional planning, national planning and the implementation of national standards for

specific disease management for example implementation of SIGN guidelines.

A key focus in supporting patients with long term conditions in their own homes will

be the use of telemedicine, in line with the Scottish Government’s National Tele-

health and Tele-care Delivery Plan for Scotland 2015. NHS Ayrshire & Arran has a

proven track record in this field of work and has received funding to contribute to two

European projects - United 4 Health and Smart Care which will increase the pace of

change, aiming to deliver tele-health as a mainstream service for patients with long

term conditions and at risk of hospital admission.

This work will be led by a multiagency group chaired by the Board’s Executive

Medical Director and be supported by MCN led acute and community based

services.

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NHS Ayrshire & Arran has received Health Foundation funding to roll out self

management practises and learning across with the system. ‘Co-creating Health’

initiatives have been embedded and patients have benefitted. An Action Plan will be

implemented during 2014/15 and regular reports will be sent to the Health

Foundation and the NHS Board.

Learning Networks to maximise staff and patient learning in Co-creating Health and

tele-health have been established.

Other priorities for 2014/15 to support pathways of care for patients with the most

common illnesses to support care at home and in the community wherever possible

are:

Effective discharge planning with a focus on delivering the Scottish

Government’s priorities for improvements in unscheduled care: bringing forward

time of discharge to earlier in the day, set patient sensitive times for wards and

discharge lounges in conjunction with Scottish Ambulance Service (SAS);

increase weekend discharge rates; review site capacity plans and reinforce site

management of Estimated Date of Discharge (EDD); roll out electronic white

boards, achieve 100% performance in minors flow in A&E. This work will be a

key priority for the new acute management teams in 2014/15.

Out of hours service provision, which is key to successful care at home. Out

of Hours District Nursing capacity has been increased through Change Fund

monies, to support care at home particularly palliative care, and also provide

more support to high admitting care homes. Links between community nursing

and the Emergency Departments are being strengthened. A review of the

Ayrshire Doctors On Call Service (ADOC) is underway, including consideration

of multi-disciplinary solutions to agree arrangements which deliver safe

effective and affordable out of hours community care.

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Supporting Care Homes and working with the Independent Sector to

increase clinical skill and capacity including pilot work to align named GPs to

specific care homes. Anticipatory Care Planning for care home residents also

features in these plans. The impact of Change Fund initiatives in relation to

care home residents is being evaluated including the impact of increased

dementia nursing, diabetic and podiatry care.

Developing alternatives to admission such as the introduction of Community

Wards provide a viable alternative to admission for high score Scottish Patients

at Risk of Admission or Readmission (SPARRA) patients with long term

conditions who require additional clinical home at home to avoid unnecessary

admission to acute hospital beds. The District Nursing Workforce is also being

trained and developed to provide consistent standards of care across the Board

area. Other initiatives which were initially piloted are now being embedded into

practice e.g. provision of antibiotics in the community.

Action Plans for Community Hospitals will be developed in line with the

requirements of the Community Hospitals Refresh Strategy and shaped to meet

local health needs. The GP led multidisciplinary approaches in community

hospitals, funded by the Change fund, have been highly effective and work will

continue to ensure learning and new ways of working are sustained beyond

2015.

End of life care associated with the main illnesses is a pressure point that is

being addressed via the Board’s Living and Dying Well Action Plan and the

development of care pathways in conjunction with local hospices.

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9.2 Through more detailed analysis of existing data, people will be identified as at risk and anticipatory care plans will be agreed.

Anticipatory Care Planning (ACP) for patients with long term conditions aims to

ensure assessment and co-ordination of care, in partnership with patients. The ACP

planning processes are entirely consistent with SG priorities and supported by a

range of current local and national strategies including the Board’s Person Centred

e-Health Strategy, SG QUEST guidance, GP Quality and Outcomes Framework, the

LUCAP, the Board modernising Community Nursing Strategy and Allied Health

Professional Delivery Plan.

In line with QUEST guidance a whole systems patient flow approach has been

adopted using the SPARRA risk prediction model to identify suitable patients for an

ACP that can updated and made available for any future contacts with health or

social services.

NHS Ayrshire & Arran is distributing data on Scottish Patients at Risk of Admission

of Readmission (SPARRA) to prioritise additional care and support to these people if

required. There are currently 12,000 patients on the SPARRA register with a risk

score of 40% or more.

GPs are now working on the 40-60% risk group to complete Anticipatory Care Plans

and Key Information Summaries (KIS). GP practices hold regular MDT meetings to

specifically discuss ACPs. These meetings can involve GPs, Practice Nurses,

Community Nurses, Community Pharmacists, AHPs, Mental Health, Social Services

and other stakeholders. This wide involvement of relevant stakeholders ensures that

all pertinent information is made available to all Partners and incorporated within the

ACP.

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At December 2013 1,700 Anticipatory Care Plans (ACP’s) were in place under the

Local Enhanced Service (LES). In 2014/15 these ACPs will be further rolled out and

developed in discussion with patients and their families, and ACPs will be measured

to determine the impact of these plans against hospital admissions and length of

stay as well as other qualitative measures.

In 2014/15 the two Emergency Departments will embed ACPs into the everyday

working of the Departments. ACPs will be conveyed to acute hospital services on

patient’s admission through integrated IT systems and the use of the KIS. A training

programme is underway to ensure that Emergency Department and acute receiving

staff take account of the particular needs and circumstances of the patients

concerned.

In addition, NHS Ayrshire & Arran has a one year Change Fund project supporting 6

Anticipatory Care Nurses to identify patients on SPARRA list at highest risk of

readmission who would benefit from an ACP. District nurses are undertaking full

nursing assessment of these patients and developing self management plans and

single shared assessments. In 2104/15 it is planned that this new way of working will

form part of the day to day practice of all District Nurses and for already appointed

additional Social Work staff to work with General Practices, Community Nurses,

patients and their carers to develop ACPs.

The ACP agenda is now being driven forward by a designated ACP Programme

Board who will ensure there is sufficient Social Worker and Community Nurse

resource to support GP practices and that staff training needs are met along with

provision of supporting documentation, including standard operating procedures and

step by step guides.

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10 NHS Ayrshire & Arran Service Improvement Group for

Chronic Pain The Ayrshire and Arran Service Improvement Group (SIG) for Chronic Pain was

established in November 2012, following successful pump prime funding from the

Scottish government.

The SIG is the vehicle for implementing the Scottish Service Model for Chronic Pain

Management in NHS Ayrshire & Arran in line with the aims stated in the funding bid.

A detailed action plan outlines workstreams, actions and owners. Summary

information for priority areas is provided here.

10.1 Pathways / Referral Criteria

Referral criteria have been established to, and within, the secondary care pain

management service. This includes a template within SCI gateway incorporating

specific questions to improve referral information. This allows appropriate vetting to

the most appropriate clinician within the pain service.

The pain management programme (PMP) commenced in January 2014. This

programme will rotate between North and South Ayrshire. The current resource

allows only one group per week. Demand for a PMP, in the future, may outweigh

capacity. Further evaluation and review of this component of the service is required

to ensure compliance with the referral to treatment target.

The specialist nursing role within the service has been mapped in line with current

patient pathways. Future scope to increase the role within medical review clinics

and the PMP as well as providing low level psychological support to promote patient

self management have been highlighted as future resource needs.

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10.2 Data Collection / Measurement

Data collection and evaluation of the chronic pain service is now embedded into

practice. This information will evidence a future business case to ensure

sustainability of the service. The data entry is supported by our recently appointed

administrative support.

10.3 Multidisciplinary Team (MDT) working / shift to community based activity

The pain management service in South Ayrshire has recently relocated to a primary

care site (the MSK Centre at Biggart Hospital, Prestwick). This allows co-location of

the full MDT which will facilitate improved joint working and co-ordination of care for

the patient.

A weekly MDT meeting has been established at the Crosshouse site allowing for

MDT vetting of referrals and case discussion and plans for formalising a MDT

meeting in the South Service are underway.

10.4 Information / Education for Health Care Practitioners

Education and resources for Primary Care Allied Health Professionals (AHPs) have

been developed to support the delivery of evidence based treatment for less

complex patients with shorter durations of pain. This training is supported by use of

the STarT Back and MSK Screening Tools to identify those patients at high risk of

poor outcome. The recently appointed pain management physiotherapist will

continue to provide support to primary care AHPs through a model of peer review,

combined clinics and education and training, ensuring long-term sustainability.

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The AsSET psychological skills and education training programme will be rolled out

to secondary care specialist nurses and primary care AHPs to enhance skills to

promote self management of chronic pain. Primary care guidelines for the

management of persistent pain are currently being developed. An educational

meeting for GPs was arranged but was cancelled due to the low number of

registrants. Future educational sessions are being discussed at present.

10.5 Supporting Self Management

The Pain Association Scotland (PAS) group in South Ayrshire is well attended and

feedback is positive regarding subjective report on benefit. A further PAS group has

been developed for North Ayrshire and is due to commence a 4 week intensive

group then monthly support group in April 2014.

A series of physiotherapy patient information materials have been developed and

shared for use on the NHS Inform MSK Zone. Further patient information materials

focusing on medications, self management and procedures have been developed.

All patient information will be hosted on the Chronic Pain Scotland website, once

operational.

10.6 Service Sustainability The majority of service redesign is now complete. Evaluation and audit of the service

is ongoing to evidence outcomes. Focus over the next year is to ensure the long-

term sustainability of the resources currently funded by the pump prime money from

the Scottish government. Further specialist nursing support for the service is vital to

sustain the pain management programme with appropriate capacity. Additional

psychology resource is also required to reduce waiting times in line with the referral

to treatment target. A funding application will be submitted to the Ayrshire and Arran

Clinical Resource Group for the ongoing funding of the above resources.

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11 Early Years The Early Years Collaborative (EYC) was launched on 1 October 2012 to advance

implementation of the Early Years Framework drawing partnerships together to build

on the work they are currently taking forward, developing a clearer understanding

about the application of improvement methodology based in part on the Scottish

Patient Safety Programme (SPSP) and sharing learning about effective early years

practice and evidence based interventions.

Investment in Early Years leads to better outcomes for our children and young

people and significant health benefits later in the life course leading to efficiencies in

future spend for public sector services. The EYC is based on Community Planning

structures; as such it is vital that all Community Planning partners fully understand

and are committed to the principles and practices of the EYC. Representatives from

CPP’s are fully engaged and actively support local initiatives.

The Early Years Framework (EYF) published in December 2008, signified an

important milestone in encouraging partnership working to deliver a shared

commitment to giving all children the best start in life and to improving the life

chances of children, young people and families at risk.

The objective of the Early Years Collaborative (EYC) is to accelerate the conversion

of the high level principles set out in Getting it Right for Every Child (GIRFEC) and

the Early Years Framework into practical action. This must:

Deliver tangible improvement in outcomes and reduce inequalities for

Scotland’s vulnerable children.

Put Scotland squarely on course to shifting the balance of public services

towards early intervention and prevention by 2016

Sustain this change to 2018 and beyond

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http://www.scotland.gov.uk/Publications/2009/01/13095148/2

The rationale for early intervention and the anticipated benefits in improved

outcomes is well evidenced, and has the potential to be ground breaking not only

impacting upon children and services pre birth through to 5 years but it is anticipated

to have significant benefits later in the life course.

Looking after Every Child 2008 - 2017: The Children and Young People’s Health

Strategy for Ayrshire and Arran forms the basis of the Health chapter of each of our

Local Authority led Integrated Children’s Services Plans which jointly reflect our

response to the Early Years Collaborative. This strategy is to be reviewed in 2014 to

reflect the changes to our approach and new legislation and policy. The Integrated

Children’s Services Plans are managed and developed through the Children’s

Officer Groups in East, North and South Ayrshire. These are the principal

mechanisms for partnership working and are co-chaired by Health and the Local

Authority.

Health representatives on each group work towards maintaining a consistent, public

health focused approach to improving the health and wellbeing of our children and

young people, recognising issues of equity across Ayrshire and Arran. These groups

build upon the current positive working relationships ensuring a collaborative/ co-

production approach is maintained in relation to the EYC.

Our responses to the EYC are underpinned by actions already underway in the

Refreshed Framework for Maternity Care in Scotland, Reducing Antenatal Health

Inequalities –Outcome Focused Evidence into Action Guidance, Improving Maternal

and Infant Nutrition a Framework for Action. We are amongst the first of the Scottish

Health Boards to fully implement the Scottish Health Programme – 27-30 month

review. (http://www.scotland.gov.uk/Resource/Doc/337318/0110676.pdf)

Significant progress has been made across NHS Ayrshire & Arran in early year’s

services. Examples of changes include:

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http://www.scotland.gov.uk/Resource/Doc/337318/0110676.pdf

Modernising Community Nursing, which took account of the evidence and

policy landscape relating to early years, children and families and the need to

respond with a nursing workforce that has the capacity and capability to focus

on children. We are progressing the redesigning our Community Nursing

Service to ensure a clear and specific focus on early years. We have put in

place a number of initiatives to ensure that they have a full understanding of

GIRFEC and the Early Years Collaborative and how it relates to current

culture, systems and practice.

Implementation of Family Nurse Partnership (FNP): Local Authority Partners

have been fully engaged from the outset and plans are well in place to ensure

future funding and to enable us to learn from the very successful work that

has been taken forward. There are clear linkages between the work of and the

learning gained from FNP and the redesign of our Community Nursing

Service.

Implementation of AYRshare (an interagency communication framework which

will lead to a more effective integrated approach to assessment). This is a

shared development with relevant partners and we have a well established

programme in place to ensure this supports practitioners and complies with

and supports relevant policy and legislation

Implementation of the single child’s plan and common chronology (ensuring we

are compliant with the GIRFEC transformational change programme) is on

target and we hope to see full implementation well ahead of our statutory

deadline of August 2016

Development and Introduction of the Vulnerable Pregnancy Service

The Early Years Collaborative has a series of Stretch Aims (Stretch Aims can be

defined as outcomes that cannot be achieved without changes to current culture,

systems and practices). These aims are broken into four principal workstreams.

Supported by a fifth workstream focused on leadership.

Workstreams 1 and 2 are led by health and have a strong collaborative base with all

public sector partners with significant involvement from the third sector. Workstream

3 has three strands lead by our local authority partners, they also have a strong

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collaborative base and there is significant cross boundary working. The stretch aim

for workstream 4 has now been agreed “To ensure that 90% of all children in each

Community Planning Partnership area will have reached all of the expected

developmental milestones and learning outcomes by the end of Primary 4, by end-2021” and we are actively working with CPP’s to enable them to understand the

significance of the addition, to engage with the workstream, to assist in the

development of the operational definition and associated driver diagram.

11.1 Workstream 1:

The multi agency/professional Ayrshire wide group has been established and a

driver diagram has been developed reflecting local needs whilst retaining the

overarching stretch aims of the EYC. This was achieved and developed with

representation from the three Local Authorities and Health. Draft terms of reference

have been developed and numerous tests of change are in progress across Ayrshire

& Arran to meet the National agenda. The overall aims of workstream 1 are closely

linked to the Maternity Care Quality Improvement Collaborative. The involvement of

patients is critical to this process.

11.2 Workstream 2:

This multi professional, multi-agency and pan Ayrshire group has been established

since March 2013 and the priority areas identified for each CPP area incorporated

into an overarching WS2 Driver Diagram.

The focus of this workstream at present is:

Activities to assist with increasing parent’s knowledge, capability and capacity

Sharing of information across services around child well being

To increase the % of parents completing parent led assessments

Improve parental understanding and engagement in the 27-30 month review

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Develop care pathways from birth in the priority areas of Communication and

Language, Oral and Dental Health, Physical illness and/or injury, Nutrition

Increase referrals following Health Visitor assessments from birth

Increase the use of Solihull parenting approach.

Each workstream take notice of and integrate their improvement and change

programmes to ensure continuity across a child’s lifespan.

Our Public Health Department has been tasked to work with CPP’s and partner

agencies albeit with a specific health focus, to coordinate and develop a more

strategic approach, working from the evidence base outlined within our child health

fact file, adopting a life course approach that will be reflected within our Children and

Young People’s Health Strategy and link with our partners integrated service

planning processes. We will establish evidence based strategic over view that will

assist us to focus on prevention and early intervention, identify areas that will offer

the greatest impact from available resources and the key changes and tests of

change that will most effectively support this ambition.

The aforesaid is core to our Children and Young People’s Health Strategy. The

strategy is currently being reviewed and we will ensure that the work currently being

undertaken in early years is well represented. The strategy will be underpinned by a

fact file (Health Profile) consisting of:

An overview of the current profile of children’s health in Ayrshire and Arran

This will comprise a demographic profile of children, epidemiology of the most

common conditions and diseases children face, and a description of the

service provision currently available for children.

A study of the early life course of children to show potential linkages between

parental conditions and behaviour and the subsequent impact on the child

(such as smoking in pregnancy). For this we will need to be able to link

datasets and we are applying to ISD to link (particularly) mother to child data

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and child to child data where a particular child appears in multiple datasets.

The aim of linking these datasets is not to focus on individual children but to

gain insight into the determinants of health in young children and their impact

on different parts of the health system.

The strategy will be the driver for a performance framework (Action Plan) which will

outline on an annual basis the priorities for the year ahead and monitor progress on

a quarterly basis. A Director-led Child Health Strategy group (EYC) to ensure

effective coordination and management of the process is in the process of being

established.

NHS Ayrshire and Arran is fully engaged with workstreams 3 and 4 and are working

to ensure that anything developed in workstreams 1 and 2 are built upon and

developed as part of our life course approach, we clearly see the need to ensure

effective linkages between all workstreams to enable us to capitalise on the

foundation developed within the preceding workstream. Workstream 4 is being

developed with the same principles moving away from islands of good practice to the

adoption of a model that reflects continuity of care, across the life course.

GIRFEC is central to this approach and we have agreed that to ensure robust

linkages between GIRFEC and the Early Years Collaborative that Public Health will

lead the implementation of the strategic approach to GIRFEC and the Children and

Young People’s Bill (Scotland) 2013, ensuring a collaborative approach,

engagement and awareness of all parties, with a specific focus on the work of our

CPP’s, ensuring relevant parties are aware of their duties and responsibilities. We

will also have a clear focus on our interface with adult services with an aim to ensure

that we further develop our family focused approach.

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12 Health Inequalities

12.1 Introduction NHS Ayrshire & Arran has three local authorities within their area. Details below

indicate the key areas of work which are ongoing within each of the Ayrshires to

work towards tackling Health Inequalities and successful achievement of the

Community Planning outcomes.

12.2 Keys to Life The current NHS Ayrshire & Arran strategy for people with learning disabilities (We

want good health… the same as you 2009-2014) focuses on health improvement

and reducing inequalities. As part of the strategy there has been close collaboration

between learning disabilities services and primary care to identify patients with a

learning disability. The planning for refreshing this strategy is underway and the new

guidance will be used to restructure the strategy so that it encompasses the specific

recommendations of the guidance and Keys to Life. A revised strategy and action

plan for health improvement and reduction of health inequalities will be drafted to be

consulted on and presented to the NHS Board in late 2014.

In response to Keys to Life, Dr Margaret Watts, Consultant in Public Health

Medicine, has been designated the named public health physician and, in

conjunction with the clinical lead for learning disabilities, has led a workshop in

February on the revised strategy and the integration of the Keys to Life work. The

outcomes of this workshop are still being finalised but will encompass recognition of

the workstrands for information, accessibility, training, feedback including caregivers,

health promotion and anticipatory care, and identification of people with learning

disabilities in general services. The work will be progressed giving due recognition to

the context of change in relation to major pieces of social legislation such as the

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Public Bodies (Joint Working) (Scotland) Bill and the full rollout of self-directed

support.

Over and above the health improvement aspects which, as indicated above, have

been developed over a number of years in Ayrshire & Arran, action is already

progressing on gaining commitment to this work from the primary care, acute and

third sectors, all of which participated in the February workshop. Primary care

partners have also progressed rapidly with the identification of aspects for the secure

database of people with learning disabilities and have access to a wealth of health

information about the Ayrshire & Arran population who have learning disabilities.

This will form part of the information and identification workstrands. The initial work

will focus on exploring health behaviours, disease precursors and disease states.

The Health Improvement and Health Inequalities Steering Group (from the

workshop), chaired by the Public Health lead consultant, will meet every 6 weeks

and establish a programme of work to deliver on the required outcomes within the

necessary timeframe.

12.3 Welfare Reform – Mitigating the health impacts in NHS Ayrshire & Arran

The public health community in Scotland recognise that the welfare reform and the

recent and prolonged economic recession are going to have a disproportionately

negative impact on the most vulnerable population groups and that socio-economic

and health inequalities are likely to widen.

NHS Ayrshire & Arran participates fully in the East, North and South Ayrshire

Community Planning Partnerships to improve health and reduce inequalities in

health. In addition to this, discussions have begun with the main welfare reform

contacts from East, North and South Ayrshire Councils and NHS Ayrshire & Arran to

scope where joint work can take place to mitigate the impacts on health and

wellbeing.

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A wide range of activities to improve health and reduce inequalities already exists

within health strategy action plans and within the jointly agreed SOAs for East, North

and South Ayrshire. These are monitored on a quarterly basis and impact is

assessed through evaluation and changes in data indicators (SOA targets) over the

longer term.

NHS Ayrshire & Arran is working closely with the Scottish Public Health Network and

Health Scotland and have contributed to the development of an outcome focused

plan: Mitigating the impact of Welfare Reform on Health and NHS Health Services.

This provides a set of principles and guidance for NHS Boards to use to inform their

local activities in collaboration with their community planning partners. It is

supported by the Chief Medical Officer at the national level and elements of it will be

put in place locally during 2014.

12.4 Ayrshire and Arran

We work in partnership with our three Local Authority partners towards the delivery

of the Health and Community Planning elements of the Single Outcome Agreements.

We aim to look at inequalities across a range of issues which includes health as well

as social determinants such as education, employment, income and so on.

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12.5 North Ayrshire Locality Team Action Plan Key Priority Action Community Planning Groups Neighbourhood Planning: Participating in the Neighbourhood Planning approach which is concerned with

targeting resources at communities with the most need. Alcohol and Drugs Partnership: Supply of alcohol data – SIMD data and other public health headline data to inform local policy. Contribute to decision making process on finance – commissioning – planning of evidence based interventions – related service development – workforce planning for drug and alcohol services – campaigns and events involving staff and community – taking a whole population approach and targeting interventions to address alcohol and drugs issues which contribute to health inequalities. Leads the Communities and Prevention Implementation Group which supports education of parents and children through school programmes; delivers public awareness campaigns; accesses funding for specific programmes within schools and communities to raise awareness of alcohol and drugs. North Ayrshire Licensing Forum: provides information to guide licensing decisions. North Ayrshire Officer Locality Group for Adults and Older People: Contribute to the Older People’s Sub-group by providing information and evidence to support the development of preventative and anticipatory care. Safer North Ayrshire Partnership: Support to the action plan and highlight evidence base to support delivery. North Ayrshire Violence Against Women Partnership: Contribute to strategy development and implementation and to the implementation of campaigns Community Engagement Reference Group Public Health has linked with this group to implement a pilot asset based approach to improving community mental health and wellbeing in an area experiencing high inequalities in health.

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Health Improving Care Establishments (HICE): Developing a framework for children and young people who are looked after and accommodated within Ayrshire. This action reports to the North Ayrshire Officer Locality Group for Children.

Programmes Early Years: Managing and evaluating the Asset Based Community Development Early Years Project which focuses on tackling health inequalities and improving health and wellbeing in 0-8 years. This pilot will end soon but the learning and approaches will be used to inform approaches to support health and well being for 0-8 years. Parenting and Family Support Steering Group: Links to the Integrated Children’s Services Partnership and supports parenting across North Ayrshire using the Solihull Approach. Role is in delivering training in Solihull. Early Years Collaborative: Attend all learning sessions and disseminate information. Undertaking relevant PDSA cycles within children’s services.

Physical Activity North Ayrshire Physical Activity and Sport Strategic Partnership: focus on targeting physical activity interventions and ultimate reduction in inequalities in physical activity participation Greening NHS Estate Supporting the development of pathways on NHS estate and linking to local community and community projects to encourage increased physical activity.

Tobacco: Formed local partnership group to implement the local Tobacco Strategy. This enables local action to be targeted to areas with greater need and for interventions to be context specific.

Schools Link with the local health and wellbeing co-ordinators network to support implementation of health and well being strand of curriculum for excellence.

Data provision for partners Data Interpret and present data and public health information and evidence based practice– SIMD – Census – Child Health – Alcohol – Tobacco – and local NHS Service information

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12.6 South Ayrshire Locality Team Action Plan Community Planning Partnership Outcome Area NHS Contribution

Public Health is a member of Community Planning Implementation Group where work is being driven forward across all outcome areas. The group supports the CPP Board in the development of SOA and other CP policy areas such as CP and resourcing, self assessment and cross cutting priorities

Economic Recovery and Growth

We are not leading or contributing to any work in this area

Employment

See employability submission (attached separately) A team of Healthy Working Lives advisors are based within the Public Health department who promote workplace health and work closely with local workplaces offering a variety of free services including policy development and employee wellbeing surveys.

Early Years and Early Intervention

Support to Health and Wellbeing Co-ordinators within Education on the experiences and outcomes within the Curriculum for Excellence framework. Provision of detailed resource support for outcome areas. Ensuring current, evidence based practice shared via the local education intranet (GLOW). Early years collaborative - staff from across the whole organisation engaged with this. Supporting Joint Improvement Group (as sub group of OLG children)to develop a performance management framework and develop a programme for self evaluation for children’s services

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Safer and Stronger Communities

Public Health staff co-ordinate routine enquiry training for NHS staff and new nursing students at UWS. Identification and early intervention in relation to gender based violence via routine enquiry will become integrated into practice of frontline NHS services. Public Health is a member of the SA Alcohol and Drug Partnership and

• Lead/ chair the Prevention, Education and Communities strand of the strategy.

• Provide information/ data to guide licensing decisions

• Lead development of key areas of Public Health work e.g. social marketing, training, schools based work, FASD, whole population events etc

• Contributes to commissioning and performance management elements of the strategy

Health Inequalities and Physical Activity Public health staff are a key partner and contributor to the development of a number of asset based programmes within South Ayrshire. Within the Wallacetoun area of Ayr Public Health staff have delivered a Health Issues in the Community course (HIIC). A cascade training approach was used with participants, and subsequently there has been further participation in healthy cooking skills, smoking cessation and activities arranged by the residents themselves. Supporting ABCD work in Lochside area through ADP. Community builder post in place- managed by SAC Public Health staff have contributed to the planning of activity in recognition of the Commonwealth Games. Staff from Public Health leading development of Greening the NHS Estate with colleagues from Corporate Support services and Green Exercise Partnership (Forestry Commission, Scottish Natural Heritage, Health Scotland) PH led a strategic review of NHS estate and is leading a National Demonstration Project in Ailsa/ Ayr campus which includes

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development of access infrastructure (paths) and extensive woodland management and tree planting/ regeneration. This transformation of land use will improve quality of life for staff, patients, visitors and wider community and help to increase physical activity and lead to improved physical and mental health and wellbeing. Public Health staff are engaged in a number of Learning partnerships across South Ayrshire, supporting preventative initiatives. Leading the development of a pan Ayrshire Health and Homelessness Action Plan and Performance Framework in partnership with local authorities and third sector Developing a strategic health inequalities self assessment for the organisation. Promoting adoption across CPPs

Older People Public Health staff are leading the development of a framework for Health Promoting Care Homes.

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12.7 East Ayrshire Community Planning Partnership: Table 1 Reducing Inequalities in East Ayrshire Action Plan In East Ayrshire, the CPP Board hosted a Strategic Health Summit on 6 August 2013, the purpose of which was to afford the opportunity to: improve our understanding, across the Community Planning Partnership, of the causes of health inequalities; learn about what works in addressing the problem; and identify what we can do, both individually and collectively, to tackle this situation. Following on from the Health Summit, a small working group was tasked with researching current thinking on what works in terms of reducing health inequalities and identifying a route forward for the CPP Board, including an action plan, which could be taken forward in the short term and will inform thinking as we take forward the Community Plan Review. The draft action plan is attached below. Actions Lead Responsibility Timescales Agree reducing inequalities as a key priority in the new Community Plan with all Partners demonstrating commitment.

CPP Board

2014

Ensure that addressing inequalities is central to the comprehensive Community Plan Review

• Finalise the audit of existing initiatives to reduce inequalities

• Evaluate the initiatives – considering the evidence of what is working and what is not in reducing inequalities

• Agree the principle of shifting resources away from areas where least impact is

evidenced to areas where effective reduction in inequalities can be demonstrated

• Pilot the self-assessment framework as a tool for ensuring that future priorities/actions taken forward through Community Planning are designed to address inequalities

PPP Division Multi-agency Working Group (to be nominated by JOG) CPP Board Multi-agency Working Group (to be nominated by JOG)

December 2013 Early 2014 2014-15 January-March 2014

Continue to develop and support a shared understanding of all partners, Elected Members and Board members of the relationship between health inequalities and wider social determinants

All Partners

Ongoing

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Consider the approach taken in Stirling in relation to linked data sets and its potential application in East Ayrshire

Multi-Agency Short-Term Working Group

Early 2014

Consider progress in relation to asset based working in communities and, if appropriate, build a commitment to this approach as a means to reducing inequalities into the new Community Plan

CPP Board

2015

Table 2: General Response Community Planning Partnership Outcome Area NHS Contribution

Public health is represented and contributes to the work of Community Planning

Partnership across the variety of thematic groups in place which support the strategic direction within the east locality.

Early Years and Early Intervention

Curriculum for Excellence – Public Health provides expertise to the Health & Wellbeing Coordinators within local schools on the specific Health & Wellbeing experiences and outcomes within Curriculum for Excellence. Planning has commenced for specific learning sessions on self harm, mental health and sexual health. Continue to implement the prevention and early intervention elements of the Sexual Health & BBV Outcomes Framework which is linked to the local sexual health strategy. This includes the development of Sexual Health Guidance for all staff working with young people. A resource for education staff has been developed to assist staff to understand sexual development and also how to recognise risky sexualised behaviours. Teenage Pregnancy Action Plan- The 1 year Teenage pregnancy Action Plan has now been completed and a 5 year action plan is under development. This 5 year action plan will be consulted on with Local Authority partners in 14-15. Early Childhood Networks – Public Health contributes to Asset Based work within deprived areas in Kilmarnock. In particular the Shortlees area of Kilmarnock where the concept of fun days for families with a pre-3 year old child has now led to engagement and involvement of a small group of local parents who are being supported to build parenting capacity within their community.

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Public health are supporting the development of the continued rollout of the Solihull Approach, which is an integrated psychodynamic and behavioral approach for professionals working with children and families who are affected by behavioral and emotional difficulties. This action is contained within the actions for workstream 2 of the Early years Collaborative. Public health are part of the East Ayrshire early years collaborative ‘away team’ and contribute across the associated workstreams, developing driver diagrams, using the PDSA health improvement methodology, actively engaging and promoting the work of the collaborative and links with CPP who constitute the ‘home team’.

Safer and Stronger Communities

Public Health actively contributes to tackling Gender Based Violence within the East Ayrshire Violence against Women partnership. This includes White Ribbon Campaign., Bystander Project and Speakers Network. HMP Kilmarnock has a pro active Health Promoting Prison Group currently delivering on their Health promoting Prison Group action plan which will be completed March 2014. This action plan has its foundations in the National Prisoner Health Improvement framework “Better Health, Better Lives”. There are 7 priority areas within the action plan covering topics such as alcohol, tobacco, physical activity, sexual health, oral health, mental health and capacity building. As a result of this action plan 12 prisoners have been trained as Health Champions. These champions are responsible for the delivery of a weight management programme within HMP Kilmarnock in partnership with NHS Ayrshire & Arran Jumpstart team. The Health Champions are currently developing BBV resources to be used within the local prison. A 5 year Health Improvement strategy/action plan for offenders/families and victims will be developed in 2014-15.This strategy/action plan will be developed in partnership with the South West Scotland Community Justice Authority and will build on progress to date. This strategy/action plan will identify for implementation new initiatives and programmes to improve the health of offenders their families and victims.

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Health Inequalities and Physical Activity Public Health is actively contributing to the Commonwealth Games legacy. Public Health are supporting early years colleagues within the locality with a mini commonwealth games event. This builds upon previous event for the Olympics in 2012. Within HMP Kilmarnock a Weight Management programme delivered by Health Champions which is focused on physical activity.

Older People Public Health have been engaging with men over 65 within the most deprived areas to promote AAA screening. To increase the uptake of the screening programme a targeted campaign will be launched within specific geographical areas were uptake is poor.

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13 Cancer Prevention NHS Ayrshire & Arran has developed, and engaged on, a ten-year multi-agency outcomes

focused Tobacco Control Strategy (2012 – 2021). This strategy was endorsed by the NHS

Board in August 2012. It has an associated initial three year action plan (2012 – 2015).

The actions within the plan are sub-divided into prevention, cessation and protection.

This strategy was developed prior to the National Tobacco Control Strategy which was

launched in March 2013. Benchmarking our local strategy against this national strategy

has shown our strategy to be fit for purpose. A multi-agency Steering Group meets

regularly to progress the strategy, this has representatives from Primary Care, Nursing,

Public Health, Mental Health, Medicine, Pharmacy, Maternity Services, Local Authorities

(Education, Trading Standards, Environmental Health), Fire and Police on the Steering

Group.

The strategy is performance managed using Covalent, an electronic performance

management system, and reports are scrutinised by both the Tobacco Control Strategy

Group and also by the Public Health Department Performance Management Group.

Within the strategy the 3 key aspects are being progressed i.e. prevention, cessation and

protection and although there are separate actions for each aspect, in reality there is

significant overlap between these sections. Our specialist smoking cessation service:

Fresh Air-shire deliver both cessation and prevention advice both to individuals and

groups, as well as giving advice on protection issues.

The actions within the strategy are targeted in particular settings e.g. workplaces,

communities, schools, further education establishments, prison and the NHS and also to

key groups such as children and young people, pregnant women and those with mental

health issues etc.

As there is a strong link between inequalities and health, most of our work is targeted in

the more deprived geographical areas, although our service is open to everyone via self-

referral.

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With regards to prevention, a significant amount of work is targeted at children and young

people to prevent them from starting to smoke in the first instance. Examples of actions in

the Prevention section of our local strategy are as follows:

Development of school youth based education and prevention

programmes

De-normalising smoking as acceptable

Targeting specific groups of young people and adults most likely to

smoke

Influencing legislation and policies to further restrict tobacco promotion

to young people and young adults

Training in tobacco prevention work and activities

Within each of these actions there are a considerable number of sub-actions.

Although considerable activity is directed towards children and young people we are also

keen to target working age and older people who are smokers, particularly those with long-

term conditions. Evidence is very strong in relation to better health outcomes for those

who successfully quit smoking.

Through our Pan Ayrshire Tobacco Control Strategy Steering Group and developing

North, South and East locality groups we have connections with Trading Standards around

their work in relation to tobacco advertising. We recently worked closely with South

Ayrshire Trading Standards department on a campaign raising the issue of illicit cigarettes.

As a Steering Group we are cited and keen to influence national policy and have been

proactively lobbying for legislation around plain packaging to be introduced in Scotland.

13.1 Early Detection of Cancer Cancer survival in Scotland is poor compared to the rest of the UK and Europe. Late stage

diagnosis accounts for most of this variation in survival. In response, the national Detect

Cancer Early (DCE) Programme was launched by the Cabinet Secretary for Health and

Wellbeing in February 2012. NHS Ayrshire & Arran is fully committed to implementing this

national programme and has developed local DCE implementation plans.

The HEAT target is ‘To increase the proportion of people diagnosed and treated in the first

stage of breast, colorectal and lung cancer by 25% by 2014/15’. Within Ayrshire & Arran a

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whole systems approach is being taken improve survival from breast, colorectal and lung

cancer. Key partners include public health, primary care, secondary care and the third

sector.

There is an inequalities component to detecting cancer early, in that particular groups

within our population are more likely to have their cancer detected at a late stage. The

public health department has used local data to identify which population groups are most

likely to be diagnosed late, to inform where best to target our awareness raising work.

Bowel screening uptake is low among men living in the most deprived parts of Ayrshire

(particularly in working age men). In terms of breast screening, women living in deprived

areas are less likely to take up their screening invitation, and more likely to have their

cancer detected later. It is essential that local implementation of the DCE programme

does not further widen these inequalities, and that our resources are allocated according

to need.

Our two key objectives are:

To increase uptake of breast and bowel screening programmes within

Ayrshire & Arran, and reduce the inequalities gap in screening uptake that exists,

To increase public awareness of signs and symptoms of cancer, and

encourage people to present early to their GP.

A multi-disciplinary group including representation from cancer services, public health,

Keep Well, NHS communications, Public Partnership Forum (PPF) and cancer patient

representatives provides a forum where the above work can be taken forward.

The public health department is working with a range of partners to achieve the DCE

objectives, particularly targeting communities where late detection of cancer is more likely.

The department is now working with GP practices, pharmacists, Keep Well and Fresh

Airshire, as well as directly engaging with communities. The public health team use a

range of methods to speak to and engage with local communities, in venues including

football matches, bingo halls, and betting shops. These approaches have been informed

by what our target audience are most likely to respond to, and use effective behaviour

change techniques.

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New primary care referral guidelines have been developed nationally for suspected

cancer. NHS Ayrshire & Arran is working with local GP practices to support the DCE

programme, with a particular focus on increasing bowel screening uptake through GP

practices, and implementing the new cancer referral guidelines.

In terms of secondary care, national funding is being used to support the anticipated

impact of the DCE programme, specifically the increase in demand for diagnostic tests.

The national breast and bowel cancer campaigns have already resulted in a substantial

increase in demand within breast and endoscopy services. It is currently too early to say

whether the resulting shift in proportion of cancers being detected at an earlier stage has

been achieved.

Performance will be measured against the HEAT target. There are also plans to evaluate

the impact of the DCE programme on screening uptake and cancer referral rates.

Professionals from NHS Ayrshire & Arran sit on the various national DCE groups, so are

able to inform direction of the national programme.

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14 Workforce

14.1 Context This section provides a résumé of the various strands of activity impacting upon the

workforce that have been underway within NHS Ayrshire & Arran over the past two years

as well as providing high level detail of intended future plans during 2014/15.

14.2 Overarching approach to workforce NHS Ayrshire & Arran annually submits progress updates and information to the SGHD for

three key workforce areas – “Everyone Matters: 2020 workforce vision”, Staff Governance

and workforce planning. During 2014/15 NHS Ayrshire & Arran shall assess how best to

collectively report on these integrated programmes of work, so as to avoid duplication and

enable robust strategic visioning and planning that holistically reflects all drivers which

impact upon the workforce both currently and in the future. KPIs and measurable actions

will arise as an integral element of this work.

14.3 Stock-take summary of 2020 Workforce Vision actions

In the meantime, the table below provides a high level stock-take summary of current

progress and/or initial plans in delivering the Board actions detailed within Everyone

Matters. This work will continue to be updated and refined throughout 2014/15 when more

detailed delivery plans are articulated and reflected as an output of our overarching

approach.

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Theme / Action Current progress / Initial Plans Healthy organisational culture Take action to ensure everyone is clear about the values and behaviours expected of them

Significant work was undertaken during 2013 in engaging staff in developing the local values and behaviours with over 3000 staff across all disciplines and all grades, building on the 2020 Workforce Vision. The Chief Executive held a planning day for all leaders and managers in October 2013, at which the values and behaviours were launched, and emphasis on what is expected of them was articulated. An engagement plan has been designed, piloted and tested in partnership and the ‘Engaging our Staff’ Programme (EoSP) has commenced and roll out commenced during January 2014. Phase (1) is for line managers at all levels in the organisation and they will cascade learning from the programme to their teams. The output of this programme of work is to ensure that our managers fully understand and embrace our culture programme, understand their leadership responsibilities and develop a plan for embedding the values and behaviours within their teams, so that every staff member is clear about the values and behaviours expected of them. The EoSP will be monitored via the Staff Governance Improvement Plans (SGIPs).

Incorporate behavioural competencies (which reflect core values) within recruitment and development review / appraisal processes

Recruitment • Behavioural competencies required for posts are detailed within personal specifications, which are then subsequently

tested at interview. • Details of the organisation’s Purpose, Commitments, Values and Behaviours are included within job packs.

PDR/Appraisal • Behavioural competencies are embedded within local processes for the Executive and Senior Manager cohorts as these

are mapped against agreed objectives. • We will review our existing PDR processes to ensure that behavioural competences reflecting the core values are

included. • The EoSP encompasses the linkage of behavioural competencies as an integral component of ensuring all staff receive a

quality PDR. Roll out iMatter Staff Experience continuous improvement model

NHSA&A will be an early implementer of iMatter during 2014 and dialogue has commenced with the national lead to develop the implementation plan for roll out.

Ensure that local feedback and monitoring arrangements (from patients, staff, service users etc) inform how well the core values are embedded

The results of the 2013 staff survey have been disseminated to operational areas and these will directly influence the Staff Governance Improvement Plans (SGIP) at both operational and organisational levels. In tandem to this and building upon the engagement work undertaken in 2013 to develop the local values and behaviours, further engagement sessions will take place in 2014. We are currently developing the outputs/outcomes of the Person Centredness Programme, as detailed within the Person Centred Health & Care Development Plan, which will provide a direct feedback mechanism as to how service users, patients and their families/carers perceive our success of embedding our core values.

Engage and involve staff in decisions that affect them

A range of engagement and involvement mechanisms exist for staff but it is recognised that through the staff survey, staff have identified that they do not feel consulted/fully involved/can influence decisions that affect them. Focused work will be undertaken during 14/15 to fully understand the feedback that staff provided on Standard 3 – “Involved in decisions that affect them” and agree key actions for improvement.

Sustainable workforce Review workforce planning arrangements to ensure joined-up, consistent approach so that all services are included and

Workforce Planning Programme Board provides organisational overview of workforce planning activity. Internal audit of workforce planning arrangements currently underway and will inform plans going forward to strengthen workforce planning arrangements.

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benefit from the process Demonstrate that workforce planning includes a long-term perspective and supports new and emerging service delivery models

The primary focus of workforce planning, as detailed in the Workforce Plan 2013/14, has been on organisational service priority areas associated with the capital investment in relation to front door and the re-provision and the new North Ayrshire Community Hospital incorporating inpatient mental health services and older peoples continuing care and rehabilitation.

Identify workforce risks and use this information to inform local workforce plans

Workforce Plan 2013/14 expanded upon workforce risks detailed within the LDP 2013/14 with focus upon both risks associated to new service developments and risks in relation to medical and nursing staff groups.

Put in place measures to provide high quality workforce data and identify a lead officer with responsibility for workforce data

The Workforce Modernisation Manager is the lead officer with responsibility for workforce data. A suite of workforce reports are routinely published on the intranet for managers. The Workforce Team within HR manage and provide workforce information for the organisation and undertake quality and data submission regimens as defined by ISD. Workforce data and intelligence is routinely considered by the Workforce Planning Programme Board, Corporate Management Team and Staff Governance Committee.

Ensure that workforce plans include an analysis of future education and training needs and that this is reflected in local learning and development strategies

As part of the workforce planning process following the 6 steps methodology in designing the future workforce learning and development needs are identified. The extant Learning & Development strategy will be reviewed in line with the 2020 Workforce Vision and local needs. Ayrshire Education Partnership brings together local college and universities to discuss and plan future needs.

Implement the Good Practice principles recommended by Audit Scotland in their Early Departures report to ensure that early release schemes are driven by the needs of the Board and their workforce plans

NHSA&A abides by the principles recommended by the Audit Scotland report and any early departure schemes are driven by the needs of the organisation and workforce plans. Prior to any early departure programme commencing there is approval, and ongoing progress reporting, via the appropriate governance mechanisms i.e. APF and Staff Governance Committee, and criteria and costs associated with departures are clearly defined and monitored. All avenues for staff deployment are explored prior to approval of early departures.

Capable workforce Ensure that appraisers and those being appraised understand the purpose of development review/appraisal, their individual and mutual responsibility for ensuring it is meaningful and that conversations review whether behaviours, decisions and actions reflect our shared values

The value of meaningful conversation is at the heart of PDR within NHSA&A and this is cascaded through Directors supported by an APF agreed PDR work plan and reinforced through the Chief Executive On the Road meetings across the organisation. Behaviours and shared values will be incorporated into all future PDR training. There is a systematic programme of support for managers on PDR both face to face and via online intranet resources which further emphasise the importance of meaningful PDR discussion. The EoSP is further reinforcing this approach.

Improve the confidence, capability and capacity of

Plans are in place to increase the number of staff involved in leading and practicing quality improvement and also to improve the capability and confidence of everybody involved. NHS Ayrshire & Arran is running twice-yearly sessions for over fifty staff as

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everyone involved in leading and practising quality improvement

well as Improvement Advisor training and supporting development of our fellows.

Provide fair and appropriate access to learning and development for support staff

Through the personal development planning process appropriate opportunities are identified for all staff. The Health Care Support Workers Mandatory Induction Standards and Code of Conduct provides the foundation upon which support staff receive the appropriate learning and development to fulfil their role. Learning and development is provided in a number of formats both face to face and eLearning in order to encourage staff access as appropriate.

Ensure that Learning & Development Strategy is developed in partnership and addresses longer term learning and development needs up to 2020.

During 2014/15 the extant Learning & Development Strategy will be reviewed in line with the 2020 Workforce Vision.

Integrated workforce Use the guidance provided to inform the appointment of Chief Officers and other joint appointments

The Board has been working closely with all 3 Local Authorities to progress the creation of these posts and agree the corresponding appointments process for the three Health and Social Care Directors. North Partnership postholder in post from 1st December. East and South posts are currently out to advert using a joint advert with interviews scheduled in the last week of February 2014. Joint working is underway to develop an agreed set of principles to guide the approach to all joint appointments below the Director. An HR/OD integration workstream has been created with the first meeting planned for February 2014.

Continue local actions and development work to support the integration of primary and secondary care

Recognising the need to improve Patient Safety at the interface between Primary and Secondary Care, particularly through more accurate and timely communication, a Clinical Forum has been convened in Ayrshire and Arran. This Forum convened for the first time on 29 November 2013 and offered an opportunity for an open and constructive dialogue between General Practitioners and Hospital Consultants, specifically focused on how the integration of Primary and Secondary Care can be improved as patients make the transition between care sectors. Three priorities for action were identified at this session, namely:

• Alignment of Patient Safety agendas at the Interface; • Delivering timely and accurate patient information; and • Developing a more positive culture between Primary and Secondary care.

In the final quarter of 2013/14, the report capturing the feedback from this event will be shared widely with Clinicians in Primary and Secondary care and work will commence on the development of action plans to deliver the identified priorities. Further joint clinical meetings will be scheduled to explore progress against plan and to focus on developing dialogue and relationships between Primary and Secondary care.

Make better use of existing mechanisms, such as community planning partnerships, to identify opportunities to share resources, including workforces

During 2014/15 the Shadow Integration Boards and the Directors of Health & Social Care Designate will progress the integration plans and preparedness for full integration. Currently, NHS Ayrshire & Arran works with Local Authority partners and Third Sector partners to deliver services in partnership. Examples are: • Podiatry, where a social enterprise model has been adopted for personal footcare services, with NHS Ayrshire & Arran

providing training and support for volunteers to provide this service. Services have been available in East and South Ayrshire since May 2013 and the North Ayrshire partnership is due to commence in Spring 2014. At the current referral rate, the service will be fully sustainable by 2015 and the new services are demonstrating an almost 100% satisfaction rate among

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service users. The project has also helped volunteers to gain workplace experience and, in one instance, full time employment in healthcare.

• NHS Addiction Services, which is a key partner within each of the three Ayrshire Alcohol and Drug Partnerships. The service has been involved in the development and implementation of the Recovery Orientated System of Care (ROSC), fundamental to which is the sharing of resources and an improved integrated response to Alcohol and Drug issues. Examples include a methadone reduction / cessation project, East Ayrshire OT alcohol falls project, multi agency training on alcohol and drug issues. The service has also been involved along with local authority / third sector and service users in the joint commissioning of new alcohol and drug recovery services whilst also promoting and supporting local communities of recovery e.g. café hope, conversation cafes and various peer support groups. In addition benefit has been realized especially within North Ayrshire with part of NHS Addiction Services being co located with North Ayrshire Council Services within Caley Court, Stevenston.

Effective leadership & management Plan to build local leadership and management capacity and capability as part of the workforce plan to deliver the 2020 Vision

The plan is to build on the development work already in place to support and develop leaders and line manager’s people skills, so that managers play a key role in driving service and culture change.

Ensure that line managers at all levels are clear about their people management responsibilities and are held to account in how they carry out these responsibilities

The Staff Governance relaunch programme was a key route to reinforce the responsibility line managers have for good people management arrangements. The objective setting and appraisal process underpin this. A variety of programmes exist which address the people management responsibilities of our line managers and EoSP will re-enforce and compliment this. A specific Line Manager Support programme is in place which encompasses the people management agenda. Through PDR additional support to address any gaps or development needs in this area will be identified.

Identify the development, training and support needs of line managers at all levels, particularly in relation to people management, and ensure these needs are met Ensure that leaders and managers at all levels understand and demonstrate the values and behaviours expected of them as well as their responsibilities in relation to the Staff Governance Standard and Quality Ambitions

The annual Senior Manager planning conference in October each year provides the Chief Executive and Directors to reinforce the employer and managerial responsibility for Staff Governance. In October 2013 the agreed Purpose, Commitments, Values and Behaviours were launched, and emphasis on what is expected of all managers was articulated. Through the EoSP all managers and staff will understand the values and behaviours and how these complement wider agendas such as Staff Governance and the Quality Ambitions. The Staff Governance Standard is embedded within NHSA&A as evidenced in the SGIPs which are routinely scrutinised by the Staff Governance Committee.

Ensure that leaders and managers are aware of and abide by national governance arrangements/structures

We will undertake work to identify gaps in the knowledge of the managers and leaders in our organisation in relation to national governance arrangements and structures. Following this baselining we will undertake work to ensure all leaders and managers are fully aware of what is expected of them.

Ensure that the approach to ongoing leadership and

The Workforce Strategy underpins the Board’s Health and Wellbeing Strategy – Our Health 2020. The values and behaviours are a central theme to all leadership interventions be it individual or at a team level. They feature in

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management development supports 2020 Workforce Vision and the quality ambitions, and reflects the leadership and management policy statement

our Board Manual for Non-Executive and Directors and all leadership and management programmes of work.

Ensure that managers and leaders identify and focus on the strategic workforce actions needed to deliver the 2020 Workforce Vision.

The plan is to connect up the Board actions to support Everyone Matters, with Staff Governance improvement actions with embedding our Culture programme, which will ensure that this is embedded in managers and leaders local plans to agree the range of workforce issues facing them.

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14.4 Use of the Nursing Workforce & Workload Planning Tools

The application of the nursing and midwifery workforce and workload planning (NMWWP)

tools is an ongoing programme of activity within NHSA&A with use on a regular basis and

as such we now have historical trend data to build upon. NHSA&A overarching approach

to nursing and midwifery workforce planning is detailed within the Workforce Plan 2013/14

and this reiterates the importance of the triangulated approach to incorporate professional

judgement and quality measures which will enable flexibility in decision making on staffing

needs at local level.

It is recognised that there is variability in the maturity/development status of some of tools

compared to others and as a result there is a requirement for several ‘runs’ to validate the

resultant outputs e.g. mental health inpatient tool.

Tools have been and will continue to be, utilised where applicable to inform the nursing

staffing requirements that are necessary for the key service development areas within

NHS Ayrshire & Arran i.e. the front door and reprovision of North Ayrshire Community

hospital

The intelligence provided from application of the tools will form a substantive determinant

in how the planned investment in nursing staff during 2014 is deployed across operational

areas within the organisation.

14.5 Workforce Risks

The workforce risks detailed within the Workforce Plan 2013/14 remain extant these

encompassed:

Operational workforce risks in relation to our service priority areas such

as staff deployment, development of new roles etc; and

Broader workforce issues faced by the NHSA&A with regard to:

remuneration; fixed term contracts / the limitations of non-recurring ringfenced

funding streams; geographic problems such as provision of services on islands as

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well as wider rurality factors; demographic factors such as age and gender; and

workforce supply issues which are common on a pan NHSScotland basis

specifically for small occupational groups and specific medical staffing specialities.

Mitigation of these risks will be progressed locally however there is recognition that some

aspects of risk can only be progressed on a pan NHSScotland basis specifically in regard

to workforce supply and succession planning for particular staff roles and specialisms.

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15 Employability

15.1 Community Planning Partnership Areas of North, South and East Ayrshire

The unemployment rates in North, South and East Ayrshire local authority areas are

higher than the Scottish average at 13.1%; 8.4% and 11% respectively compared to

7.8% in Scotland (Nomis, 2013). In addition, the percentage of the working age

population claiming Employment Support Allowance and Incapacity Benefit is also

higher in North, South and East Ayrshire than in Scotland as a whole at 9.2%, 7.9%

and 8.6% respectively compared to 7.7% in Scotland.

An active economy and availability of quality work are key to addressing the health

inequalities gap. Research has demonstrated that there is a strong link between

unemployment and deterioration in physical and mental health and well-being,

resulting in an increased use of medication, health services and higher hospital

admission rates. Conversely, returning to employment after being out of work can

result in significant health improvement and increased levels of self-esteem and

positive mental health and wellbeing. For those with ongoing health conditions,

remaining in work is shown to be beneficial to health as it can help recovery from

sickness and decrease the risk of long-term incapacity (Waddell and Burton, 2006).

Health Works (2009) advocates the role of the NHS in addressing poverty and

deprivation through improving the health of those in work and furthest from the

labour market; reducing the risk of unemployment as a result of poor health; and

supporting those currently out of work due to ill health to return to employment. It

also recognises that the workplace is a key setting for improving the health and

wellbeing of the working age population.

In 2012/2013 a working sub group of the three Community Planning Employability/

Economic Development Partnerships, which was chaired by NHS, led the

development of a local outcomes framework, based on the national outcomes

framework for Health Works, published in October 2010. The group was

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representative of NHS Ayrshire & Arran ( Public Health, Working Health Service,

AHPs) Job Centre Plus; Scottish Government; Local Authorities, Skills Development

Scotland; and employability providers (CEIS Ayrshire and Access to Employment).

The local framework was also been informed by a multi agency stakeholder event

attended by staff from NHS, employability and learning providers, local authorities

and the Scottish Government. This framework has been developed to inform the

strategic direction, performance management and development of programmes and

services which support the contribution of NHS Ayrshire & Arran, in partnership with

its Community Planning Partners, to the delivery of the Health Works Strategy.

Working for Health Equity: the Role of Health Professionals (2013) highlighted that 8

people a second are seen by the NHS, yet not enough attention is given to social

and economic problems (the fundamental causes) of their poor health. The NHS is

not an employability service but can be an active partner in supporting employability

in the following ways which are captured in the outcomes framework (with the

exception of Healthy Working Lives which has its own work stream):

as a major employer with a diverse workforce which is

representative of the communities it serves;

as a Community Planning Partner delivering on the Single

Outcome Agreements in Ayrshire;

as a provider of services supporting patients with health barriers to

enter or return to work as part of rehabilitation, care and recovery;

as a local player in the employability pipeline who can make

referrals to employability and learning providers; and

as a Health Improvement Organisation, supporting local

employers through the Healthy Working Lives Award scheme.

Progress has been made towards achieving a number of the outcomes in the

framework across Ayrshire. This includes:

delivering training to over 400 frontline public sector staff to

support them to be more aware of the health benefits of employment,

understand the barriers to employment and how they can be overcome; and

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be more confident to discuss employability issues with patients/ service

users and support them to make positive steps towards work;

creating a Single Point of Contact in each of the three CPP areas

to facilitate NHS signposting to employability services.

Hosting a number of networking events to support the

development of collaborative approaches, cross referrals and more effective

communication between health, local authority, third sector and employability

staff .

Delivering health information and support sessions to people who

have recently been made unemployed to enable them to remain ‘job ready’.

Hosting Working Health Services: This initiative is telephone based

and offers employees of small to medium businesses support, advice and

fast onward referral to appropriate local services which will enable them to

remain in or return to work.

Hosting an Individual Placement and Support service within mental

health services.

Developing Vocational Rehabilitation approaches. NES funded

awareness raising sessions were delivered to build the capacity of Allied

Health Professionals and specialist Nursing staff to recognise the importance

of work in the rehabilitation process. Allied Health Professionals (AHPs) are

integrating questions around work in addition to alcohol, tobacco, obesity

and mental health (WATOM) into assessments and practice. A new

Musculoskeletal Pathway is also under development which will include a

significant focus on supporting individuals to return to work.

Delivering Healthy Working Lives: A small team within the Public

Health department deliver a range of specific services to support workplaces

throughout Ayrshire & Arran, including the NHS, to promote the health and

wellbeing of employees

NHS Ayrshire & Arran also supports a number of employability programmes which

support young people and those furthest from the labour market to gain the

knowledge, skills and experience to take advantage of employment opportunities in

the NHS. These include:

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15.2 Youth Contract (placements offered in locations throughout Ayrshire)

a) Work Experience

NHS Ayrshire & Arran will offer work experience placements to young

unemployed people. Work experience placements will last normally for

8 weeks and will enable the young person to gain new knowledge,

skills and experience of real work.

b) Sector-Based academies

NHS Ayrshire & Arran is currently exploring opportunities to establish

sector based academies which will provide young people with pre-

employment training, work experience and a guaranteed job interview.

The aim is to establish a sector- based academy within an area where

there is high turnover.

15.3 Employability Fund The fund brings together a number of national training programmes to provide a

more flexible, outcome-focused provision for individuals across Ayrshire. It’s focus is

to offer “real life” work experience placements for young people.

15.4 Transitional Employment This initiative provides vocational training and work experience for long term

unemployed aged 16+. Trainees work towards a National Progression Award in

Office Skills equivalent to SVQ level 2 in Business Administration. NHS Ayrshire &

Arran offer work experience and practical skills, over 3 days per week. The

placement period is between 20 and 26 weeks.

15.5 Modern Apprenticeships Modern Apprenticeships (MAs) offer people aged 16+ paid employment, combined

with workplace training and off-the-job learning, in order to gain new and enhanced

skills and recognised qualifications. NHS Ayrshire & Arran currently have Modern

Apprenticeships in Administration & Clerical (Band 2 – 2 years training period), and

Plumbing & Public Health, Electrical Services, and Mechanical Fitter (Band 4 – 4

years training period).

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15.6 Schools Work Experience Placements NHS Ayrshire & Arran participate in the schools’ Work Experience Placement

Programme. This involves taking secondary school pupils, (normally 4th to 6th year),

for one week’s placement within various departments throughout the organisation,

thus giving the pupils some understanding of the working environment and also

ensuring that they are better prepared for working life. Not only does this forge links

with the local community, it also helps promote the organisation and attract local

school leavers, as future NHS Ayrshire & Arran employees.

15.7 College Work Experience Placements

NHS Ayrshire & Arran work in partnership with local colleges to provide employability

training and work experience placements to students e.g. in 2013, NHS Ayrshire &

Arran offered placements within the Health Records department to students from

Kilmarnock College who are studying for a HNC in Care and Administration Practice.

These placements are supplemented by employability training which includes

application form/interview skills workshops.

15.8 Skills for Work Ayrshire College Kilwinning Campus offers a pre employment training programme

which is supported by NHS Ayrshire & Arran who provide placement opportunities

within Catering, Domestic, and Portering departments. In addition, NHS Ayrshire &

Arran provides practical support by offering employability workshops to participants

to enhance their ability to gain a job.

15.9 Project Search Project Search is a one year education transition programme which provides training

and education for students with disabilities to find and maintain employment. The

main partners currently are NHS Ayrshire & Arran, East Ayrshire Council and

Kilmarnock College. Over the course of a year, 10 students with learning disabilities

will rotate through a series of job placements, offering on the job experience of work

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skills combined with classroom tuition. This should provide the opportunity for many

Project Search graduates to gain permanent paid work at the end of the course.

In September 2013 the Corporate Management Team in the NHS endorsed the

recommendation that a new strategic partnership for work heath and wellbeing is

formed which will replace the working group referenced above. This group will be

chaired by the Director of Organisational and Human Resources which emphasises

the high level commitment of the organisation to this agenda. It is anticipated that

this group will drive the strategic direction of the NHS contribution towards delivering

the employability outcomes in the Single Outcome Agreements. A stakeholder event

is being planned for Spring 2014 to inform the direction of this group. In addition a

self assessment will be carried out across the organisation to establish a baseline for

the priorities within the outcomes framework which will report at this event and

provide the basis of a development programme.

Over the next 5 years a strategic approach to health and employability will be

developed within the organisation and a performance management framework will

be put in place which will pull of the threads of activity together. This is likely to

include the following:

Number of frontline NHS staff trained.

Number of referrals received by employability agencies (Single

Points of Contact).

The Scottish Centre for Healthy Working Lives has a Service Level

Agreement with each NHS Board area incorporating a number of KPIs that the local

teams are expected to deliver on. Data is collected through the HWL database and

monthly reporting is carried out in addition to end of year reporting. In addition to this,

local performance management is carried out using the Health Improvement at a

Glance system.

The Working Health Service is monitored through SALSUS. Output

measures include no of referrals and consultations. Individual health and

work outcomes are also measured.

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Monitoring arrangements for the training and work placement

schemes which may include: tracking individuals from initial engagement to

job outcomes (where successful) in the NHS and individual follow up,

support and review throughout their engagement in the process.

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16 Innovation

Following on from the stock-taking activity the following areas have been identified

as key priorities:

Raising the profile and importance of innovation within the culture

of the organisation.

Having a dedicated role to support innovation

Expanding innovation networks

Improving coordination from Scottish Government

Introducing innovation outcome measures taking account of the

key barriers to adoption of innovation including finance, communication and

the openness of the organisation to risk.

Key specific projects which include a focus on innovation:

Secondary Care service delivery focussing on length of patient

stay and care in the community

Use of technology to deliver safe patient-centred care – Telehealth

and Telecare initiatives.

Enhanced version of the SPARRA Risk Prediction tool to enable

clinicians to prioritise patients with complex health needs that would benefit

from anticipatory health care and prevent unnecessary A&E admissions.

Safety monitoring of respiratory patients in the community following

discharge from secondary care.

There is recognition that the priorities for innovation may not be limited to these

projects in the following 12 months and the Board is responsive to the new ideas

generated by staff, partner agencies, SMEs and third sector bodies to address the

challenges of healthcare delivery for NHSScotland 2020. Hence reporting of

outcome measures may not be limited to the projects highlighted above.

NHS Ayrshire & Arran clinicians have a strong track record in respect of innovation,

working with Scottish Health Innovations Ltd (SHIL), in developing new products to

address generic problems in a clinical setting. The products are used locally and are

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available nationally for purchase. Existing patent protection will also allow

development into the international market. The organisation has been particularly

successful in working with SHIL to attract external sources of funding to develop

these products to a stage where they can be adopted across the healthcare service.

To ensure this success in supporting staff to be innovative continues and the culture

within the organisation continues to evolve a number of activities will be undertaken.

Opportunities to ensure that staff can engage to develop their ideas will include:

Intellectual Property (IP) clinics

World Cafe events

Promotion with managers that innovation should be part of job

plans and objectives

Adoption events to promote both local and national innovation

projects. This will include matching innovative ideas with the needs of the

Board and engaging with other Boards to be ‘test sites’ for innovation from

other areas.

Delivery of this challenging agenda needs to recognise the risks that a Board

undertakes when being innovative such that failure of a project will not be viewed

negatively as the experience and knowledge can be utilised in future projects. Within

this context the activity will be monitored and audited to ensure that delivery of the

outcomes detailed in the plan are delivered.

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17 Efficiency and Productivity – recommendations to increase shared services

The national Shared Services Programme Board is chaired by John Burns, Chief

Executive, NHS Ayrshire ad Arran and this national group oversees progress on

shared services within Finance, Human Resources and Facilities and Estates. Each

of these programmes is taken forward collaboratively with staff side and Health

Boards to deliver efficiency savings through shared services. These are enabled by

technological innovations and standardisation on systems nationally including the

financial ledger system, a new national HR system (eESS), e-Payroll, and e-

Expenses.

17.1 Finance NHS Ayrshire & Arran has been a leading player in the shared financial services

programme. Over the last 5 years all boards in Scotland have been using the same

financial ledger and over the last 2 years all have moved onto a single managed

technical service (National Single Instance). This has allowed contracts for

hardware support, disaster recovery etc, to be significantly reduced with a saving a

£500,000 related to this.

Over the last year the service has also implemented a single national system support

team to provide helpdesk, standing data update and systems upgrade support to all

finance teams in NHS Scotland. This is a virtual team of around 25 people who are

based in 4 locations across Scotland, but managed by NHS Ayrshire & Arran. The

development of this single national team has released savings of around £300,000.

Negotiations with the provider of the financial ledger software, Advanced Business

Systems, are ongoing to seek to reduce the maintenance cost and in 2014/15 a

reduction of £450,000 in capital charges will be shared amongst all Boards in

Scotland. In total, the costs of the service across Scotland have reduced from

around £3.8 million to £3 million in 2013/14 and this will reduce further to around

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£2.6 million in 2014/15. NHS Ayrshire & Arran has released £80,000 in efficiency

savings locally for 2014/15 and would expect to be able to achieve further savings as

more transaction processing is shared between Health Boards in future years.

Development of new shared models and agreement of realistic performance targets

and timescales, based on available technology, is being led by five focus groups:

Purchase to pay

Order to cash

Financial accounting

Management accounting

Payroll, expenses and SSTS

17.2 Human Resources (HR) Baseline data was collected in February and March 2013 from all HR departments.

From the baselining exercise the ratio of HR staff to total staff employed within each

Board was calculated. This is a recognised HR benchmarking standard across all

organisations. Typically in a devolved model of HR (as in the NHS in Scotland) the

ratio would be 1:130 to 1:150 however in a typical organisation which has elements

of HR delivered through a shared service model, this ratio would be 1:250. The

outcomes from the data demonstrate that the ratios in NHS Scotland vary from 1:35

to 1:150, with the majority of Boards falling between 1:50 and 1:120.

The implementation of eESS provides a great opportunity to standardise and

improve the quality of service, increase productivity by reducing and automating

administrative functions and encourage greater consistency in policies. Once fully

rolled-out, eESS will support not just HR teams, but also will support managers via

desk-top self-service; this will create opportunities to enable HR staff to focus further

on areas where they add value to the function as a whole.

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There are now 3 workstreams progressing through to developing a single business

case and undertaking an options appraisal process. These comprise

Recruitment,

Employee Services and

Medical Staffing and Trainees.

Early workshops with HR staff, partnership colleagues and some operational

managers established a set of characteristics that will be used to assess any

emerging models against. It is planned to progress through a formal options

appraisal process, resulting in a preferred model or models for consultation

beginning in April 2014.

17.3 Facilities and Estates The national Facilities Shared Services Programme aims to deliver high quality

services that are good value for money, is being taking forward work under five

workstreams:

Capital and Hard Facilities Management

Operational Management of PPP/ PFI Contracts

Sterile Service’s

Transport and Vehicle Fleet Management

Waste Management

There is service and staff representation on each of these groups. Areas of

opportunity include sharing of expertise and capacity between Boards, maximising

national contracts, energy/ fuel/ carbon efficiency, standard specifications, shared

vehicle maintenance and best practice.

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17.4 Capital and Hard Facilities Management (Hard FM)

Development of strategic plans is being implemented to look at options for the future

delivery of Capital Planning and project services. Local board staffs, as well as

Partnership representative are involved in this work.

A national Hard FM Short Life Working Group was established in September 2013

which is developing to identify collaborative opportunities for the procurement of

estates equipment to enable increased efficiency and value for money to be

achieved from collective purchasing. Work is progressing to examine the options for

the delivery of specialist operational estates functions across NHSScotland

incorporating 3 options: local (individual NHS Board), regional (geographically

based), and national. The options appraisal process will identify a preferred option

which will be presented to the Facilities Review & Shared Services Programme

Board in October 2014 for approval after going through Board’s governance groups.

17.5 Private Public Partnership (PPP)/ Private Financial Initiative (PFI)/ Non Profit Distributing (NPD) Contract Management

An options appraisal workshop identified listed options for the future delivery of

operational PFI/PPP contracts in NHSScotland. The Review & Shared Services

Programme Board approved the preferred option in December 2013 and authorised

the development of a Business Case for the establishment of a central specialist

support team to provide expert advice on PFI/PPP/NPD/HubCo issues and act as a

single point of contact for contract management teams within NHS Boards. The

responsibilities of this support team will include training and developing capability in

client side expertise, providing central advice on legislation/guidance, sharing and

dissemination of best practice nationally, providing independent review and support.

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17.6 Sterile Services

The Sterile Services workstream seeks to ensure maximum efficiency of the physical

assets provided and that capital is invested in a manner which allows NHS Board to

provide decontamination services within the statutory frameworks.

A data collection exercise has been carried out on capital equipment across CDU,

Endoscopy and Primary Care. This has identified investment needs and

development opportunities. Further work is being carried out with the Endoscopy and

Primary Care SLWGs to identify investment necessary to comply with national

technical requirements. This work will be developed during 2014 with local Board

staff input.

17.7 Transport and Vehicle Fleet

The transport Fleet Short Life Working Group (SLWG) in September 2013 identified

collaborative opportunities for standardisation of vehicle specifications and joint

procurement of vehicles. This recommendation is currently being progressed by the

service for the small pool car. The SLWG also carried out an options appraisal for

vehicle Fleet Management. This identifies and costs the options for the NHSS fleet

management operation’s and the benefits and potential efficiencies which can be

achieved through delivering the various parts of the operation locally, regionally and

nationally. This work includes efficiencies that could be realised through the wider

introduction and utilisation of telematic's. Local staff are involved in the development

of this topic.

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17.8 Waste

The changes required by the Waste (Scotland) Regulations 2012 Act provide

opportunities to modernise and deliver more sustainable solutions in the

management of waste materials generated by the Board. Staff are working on the

following;

By 1 January 2014, to source segregate dry materials (paper, card, plastics,

metals, and glass) for collection (to increase the quality of recycled materials and

reduce these wastes going to landfill) and

From 1 January 2016, to source segregate food waste for collection and

treatment, usually by anaerobic digestion (as a minimum to cease macerated

food waste entering the public sewer system, which is banned from that date).

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18 Strategic Assessment of Primary Care in NHS Ayrshire & Arran

NHS Ayrshire and Arran set out a clear strategic vision for shifting the balance of

care within Your Health: We’re in it together. Your Health is a Board approved

strategy, developed through extensive public engagement, that sets out a vision and

associated action plan for a paradigm shift in how patients, the health service, other

community services and the third sector engage to fully meet health needs. This

model of strategy development was innovative and received significant praise at a

national level as an example of good practice in putting local people at the heart of

service planning and redesign. As such it offers a firm foundation for the work the

Health and Social Care Partnerships will now lead on engaging local communities in

assessing health needs, as well as the design and delivery of services to meet

these, harnessing the opportunities afforded by the Integration fund to innovate and

pilot services that are targeted and tailored to local need.

At the time of its development, it was recognised that to effectively shift the balance

of care, a multi-factorial approach is required that will secure cultural shifts across

public and patient groups, as well as statutory agencies and the third sector.

The direction set within this strategy focused firstly on raising awareness and

understanding of healthcare options amongst the public and in 2012 the launch of

the Rights and Responsibilities, specific to each Contractor Group in Ayrshire and

Arran, set the scene for this. The Strategy also recognised the importance of self-

management and paved the way for embedding and mainstreaming the co-creating

health approach developed locally with support from the Health Foundation.

Recognising the need to shift the balance of care within Primary Care, Your Health

highlighted the need to improve patient education in terms of the availability of

services from a range of Practitioners and the introduction of Know Who To Turn To

was a key component of this.

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Turning to more specialist areas, Your Health set a clear direction for the

development of Practitioners with a Specialist Interest to offer an alternative to

Hospital referral. To date work has built on the models of care developed for the

Primary Care-based Diabetic, Anti-coagulation and Disease Modifying Anti-

Rheumatic Drug services and focused on specialist interventions in Primary Care for

patients who are at the end of life and for patients who have an addiction.

Similarly, the vision within this strategy recognized the benefits to be derived from

delivering as much care as possible within a community setting and made specific

recommendations for Primary Care based access to a wider range of diagnostic

testing. Progress has been made in this area with access to cross-sectional imaging

for a small number of specific conditions, resulting in patients attending their out-

patient appointment with a full range of test results available to the Consultant.

Your Health also recognised the benefits that telemedicine can offer in supporting

people within their local communities and set the strategic context for piloting

telemedicine for patients with Respiratory disease and those with Heart Failure.

Finally, in recognition of the high levels of emergency admission in Ayrshire and

Arran, Your Health set out a vision for the provision of community based alternatives

that led to the appointment of the Community Nurse Consultant to offer leadership

for home based care and the introduction of the Community Ward model, supported

by the Change Fund.

While much has been already been done locally to shift the balance of care towards

more Primary Care and Community Based services, there is a recognition that

efforts need to be increased significantly to achieve the level of impact required to

enable the release of resources from specialist services to community-based

alternatives. It is important that efforts are targeted and co-ordinated to derive

greatest benefit and that, while the priority areas for action as identified in Your

Health: We’re in it together, remain extant, there is a need to revisit these under the

leadership of the new Health and Social Care Partnerships to ensure all agencies,

stakeholders and the public are fully engaged in the redesign of Community and

Primary Care services and that opportunities to shift the balance of care are

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maximised in line with identified need and priorities at a locality and Partnership

level.

To that end, the planning of a detailed work programme, led by the Health and Social

Care Partnerships, will begin during 2014/15. This will be at the heart of locality

planning in the Shadow Year. This planning will reflect direction set nationally such

as that contained within Prescription for Excellence to enable better alignment of

professional Pharmaceutical and General Medical Services; pan-Ayrshire

opportunities for change, such as Optometry-led Glaucoma and Wet AMD

follow-up and the development of GDP-led Oral Surgery Services; and locally

defined need and priorities aimed at supporting people in communities.

It is proposed that the following timeline will be enacted:

April 2014 – Discussions with the Directors of the Health and Social Care

Partnerships to agree process and engagement of structures;

May – Sept 2014 – Engagement of stakeholders through locality planning to identify

opportunities to shift the balance of care;

Oct – Dec 2014 – Development of plans to shift the balance of care, including

financial planning for resource shift;

Jan – Mar 2015 – Prepare for implementation of changes;

April 2015 – Enact changes.

At the same time, NHS Ayrshire and Arran will be reviewing its model of OOHs

service delivery to respond positively and proactively to the growing pressures

associated with difficulty in securing General Practitioner involvement. This will

involve examining how models may be involved to incorporate a greater role for

other professionals such as Nurse Practitioners and Paramedics, while working with

NHS 24 to improve the relationship and better align the prioritisation of patient need

between the national body and the local service providers.

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NHS Board:

Consideration: Strategic Theme:

Current Service Strengths Current Barriers to Achieving the Future Vision

Proposed Local Interventions

Service planning

The current local Community Health Partnership (CHP) Fora offer an opportunity for multi-disciplinary working across all aspects of the Primary Care and Community workforce. Further, the GP Locality Groups and Pharmacy Locality Groups offer an opportunity for a detailed exploration of profession-specific issues. The Professional Committee structure in Ayrshire and Arran is well established and well utilised in terms of offering advice on service change proposals.

The absence of a jointly agreed vision and delivery plan at locality level combined with a lack of devolved budgetary responsibility is a barrier to Practitioners effectively contributing to and influencing integrated service provision.

There is a desire and commitment to ensure Primary Care is embedded in the Locality Planning arrangements within the new Health and Social Care Partnerships. Work is underway to explore how the existing locality planning arrangements for General Medical Practitioners and Community Pharmacists can be developed to support Locality Planning. The devolution of Primary Care Budgets to Health and Social Care Partnerships and Locality Planning structures is being explored.

NHS Ayrshire & Arran

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Your Health: We’re in it together, is a Strategy produced by NHS Ayrshire & Arran in 2009 and sets out a clear vision and direction for the delivery of care a primary care and community levels as a norm. Ayrshire has seen significant shifts in the balance of care in terms of the management of Diabetes, Rheumatic conditions and some Dermatology cases, as well as the introduction of H-Pylori testing to reduce the need for endoscopy and the significant expansion of Sexual Health services.

These shifts have been achieved through new funding, with the integrated staffing and resourcing models applied in Hospital services preventing the shift of resources.

There is a desire to support further shifts in the balance of care with options to develop Primary Care based Orthopaedic, Gynaecology and Pain services, as well as a fully developed Primary Care Dermatology Service with direct access for General Practitioners. The delivery of such models must be within the existing resource envelope and the staffing and resourcing models in Hospital services will need to be simplified to support the corresponding shift of resource.

The development of the Primary Care Information System in Ayrshire and Arran had enabled the automated creation of Practice-specific datasets to inform contract review, QOF review and service planning. This system is already available to local GP Practices and they used this as the data source for QOF QP in 2013/14 thereby developing the knowledge and skills for further interrogation and analysis.

The analytical skills and expertise at a Practice level will be variable and Practice Managers will be required support. There is a need to raise awareness within Health and Social Care Partnerships of the opportunities offered by the Information System in terms of Locality Planning.

The Primary Care Management Team continues to offer learning events for Practice Managers. There will be extensive engagement of Health and Social Care Partnerships throughout the Shadow Year to raise awareness of this data source.

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Through the Primary Care Information System, the Primary Care Management Team has access to a robust assessment of health need based on disease prevalence at a Practice level, information which is vital to assessing the future capacity and capability required to meet patient needs. Within Ayrshire and Arran there are no closed lists and no ‘open but full’ lists, with patient freely able to register with the Practice of their choice.

Historically, there has been a reluctance on the part of General Practice to share information relating to appointments and GP Sessional Commitment.

Agreement has now been reached with the Local Medical Committee that appointment and sessional data are required to complement the disease prevalence rates and thereby inform a rigorous assessment of capacity and capability. Work will be completed in 2014/15 to agree and populate a core dataset to support this analysis.

Interfaces and Integration

Feedback from General Practice indicates that there are high levels of integrated working with Social Work. Further, there are strong and robust links between NHS ADOC and General Practice.

Concerns have been raised about the relationship between General Practice and Community Nursing Teams. There have also been concerns about the relationship between Primary and Secondary Care, particularly at the interface.

An evaluation of the changes to the configuration of the District Nursing teams has concluded and an action plan is being developed for delivery in 2014/15. During 2014/15 the evaluation of changes to the configuration of the Health Visiting teams will also be concluded and an appropriate action plan devised. The first meeting of NHS Ayrshire & Arran’s Clinical Forum was hosted by the

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Medical Director on 29 November 2013 and an initial improvement plan has been devised for delivery in 2014/15 along with a commitment to continued engagement of Primary and Secondary Care clinicians in discussion to improve Patient Safety at the interface.

Managed Clinical Networks operate well locally, with GP engagement well established. Through employed Clinical Leads, GPs are also involved in all of the current CHP Structures and can therefore influence the planning of services. The GP Locality Groups are well attended and offer an opportunity for colleagues from Health and Social Care to engage directly with General Practice to discuss service change. Similarly, the Community Pharmacy Locality Groups are well established and offer a forum for the profession to inform locality planning, with the Chair of these groups also engaging in the CHP Forum.

The linkages between the GPs engaged in MCN and CHP planning activities and the wider GP body and formal professional committee structure need to be improved. There needs to be improved links between the Pharmacy Locality Group and both the Area Pharmaceutical Professional Committee and the new Health and Social Care Partnership structures.

In establishing the new Health and Social Care Partnership structures and GP involvement within these, there needs to be much more visible links back to the wider professional body. Work is underway to strengthen links with the APPC and consideration should be given to the wider engagement and involvement of Community Pharmacy in Health and Social Care Partnerships, with appropriate links back to the wider professional body.

Infrastructure The Primary Care Management function It will be important that the Work is underway to formally

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in Ayrshire and Arran will continue to operate as a single function across the Health and Social Care Partnerships to ensure a consistent approach to the interpretation and application of the relevant legislation, regulation and guidance, as well as in dealing with performance concerns in Primary Care and providing assurance to all stakeholders on the quality of Primary Care Services.

Management Team do not become isolated and excluded from the Health and Social Care Partnership structures as this could be counter-productive in terms of the development of Primary Care Services at a locality level.

define the relationship and responsibilities / accountabilities that will be attributable to the Primary Care Management Team and the Health and Social Care Partnerships to avoid any potential barriers or pitfalls.

NHS Ayrshire & Arran now has a robust Primary Care Premises Development plan, which ranks future developments in priority order based on a thorough assessment of current accommodation and its impact on service delivery.

The revenue budget available to support premises developments in Primary Care will be exhausted when two new developments are completed in 2014/15.

Work is underway to develop business cases for the top 7 priorities for development with a view to exploring alternative funding routes in 2014/15.

NHS Ayrshire & Arran has now completed two years worth of IT refresh in General Practice, with a programme in place to complete the refresh by the end of 2016/17, thereby ensuring a modern IT infrastructure is in place.

The rural nature of NHS Ayrshire & Arran is posing problems in terms of the line-speed connection between main sites and branch surgeries for a number of Practices as the infrastructure struggles to cope with the increased bandwith required by some systems such as Docman.

A development plan has been created to provide direct, private lines between main sites and branch surgeries to ensure sufficient infrastructure exists. This will require significant capital and revenue funding and support has been sought for this.

Workforce

The Medical Director has convened a workforce planning group to explore and develop plans to resolve the pressures associated with recruitment to General Practice in Ayrshire and Arran.

Approximately 30% of the GP workforce in Ayrshire and Arran could retire over the next decade. GP Trainees only make up 12% of the current workforce, leaving a potential deficiency in the future GP workforce.

A robust workforce plan will be developed for NHS Ayrshire & Arran during 2014/15, underpinned by an evaluation of capacity and demand. Work is underway to address

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The Medical Director is leading a review of NHS ADOC, the local Out of Hours General Medical Service, with a range of potential new models being developed and evaluated.

There are a number of factors impacting on Ayrshire and Arran’s ability to attract GP Trainees. The current workforce model for NHS ADOC is dependent on Principal GPs and Locum GPs covering the vast majority of shifts complemented by a small number of Nurse Practitioners. This model has resulted in the rotas becoming increasingly difficult to populate.

the issues concerning GP Trainees to make Ayrshire and Arran as attractive as possible. Many of the models being explored offer a much greater role for Salaried GPs and Nurse Practitioners who would also have a dedicated role in day time General Practice to help develop capacity and maintain their skills and competencies.

Leadership

The current Clinical Leadership structure has served NHS Ayrshire & Arran well in terms of engagement at CHP level and in offering clinical leadership and advice in development activities within health.

There is a need to develop additional capacity to support the Integration agenda and to secure the desired level of GP input to this. Further, there is a need to develop clear objectives for Clinical Leaders that support the future direction of Health and Social Care Partnerships and the Primary Care Management Team. Finally, the capabilities and competencies of the Clinical Leads need to be defined, particularly in relation of their OD and cultural change functions in securing, developing and nurturing wider GP involvement.

Discussions will take place between the Medical Director, the Associate Medical Director – Primary Care and the Directors of the Health and Social Care Partnerships to agree a new framework for these roles, to develop their objectives and agree the training and development required.

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Data and improvement

Locally, the contractual processes run smoothly to support the delivery of General Medical Services and the reintroduction of Contract Review visits in 2013/14 have enhanced assurance of this.

While offering the benefit of a standardised approach to securing General Medical Services, the contractual arrangements can inhibit innovation and the targeting and tailoring of services to local need.

During 2014/15, NHS Ayrshire & Arran will be working with existing Section 17C Practices to redefine the terms of the contract with the sole aim of enabling Practices to focus their resources towards meeting the specific needs of the populations they serve. This will be evaluated over time to determine the merits of a wider approach.

The Primary Care Information System in Ayrshire and Arran has already linked many of the Primary Care data sources that exist, thereby providing a resource to underpin clinical governance activities, contract reviews, QOF reviews and the forthcoming Continuous Clinical Improvement Programme and Quality Visits.

There is a need for better linkage between primary, community and secondary care system to allow patient journeys to be fully mapped through healthcare. There is also a need to better integrate Health and Social Care systems to aid information flow and service planning.

The Primary Care Management Team will seek to explore these issues and develop a workprogramme to embed the Primary Care Information System in wider data systems through the Health and Social Care Partnerships.

With a dedicated data analyst post, the Primary Care Management Team in Ayrshire and Arran has been in a strong position to link datasets and develop the Primary Care Information System.

There is a concern that as the joint working with Health and Social Care Partnerships develops and demands increase for more information and analysis, there may not be sufficient

This will be closely reviewed through the Shadow Year and into 2015/16 to determine any likely additional needs.

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specialist capacity within the team.

What support / facilitation / action does the health board consider is necessary at a national level in order to address the challenges that you have identified during the consideration of the above themes?: Facilitation is not required at this stage, although this may change. It would be useful if Scottish Government highlighted what proportion of ring-fenced or special allocation funding (such as waiting times) is assigned to Primary Care, what this will be used for and what the anticipated outcomes will be.

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19 Heat Risk Management Plans and Delivery Trajectories

19.1 Introduction The HEAT Risk Management and Delivery Trajectories have all now been reviewed. There are no updates to the existing Delivery Trajectories and therefore there is no requirement to submit updated Risk Narratives. Attached is the new Risk Narrative together with the associated trajectory template for: The Stroke Care Bundle. Trajectories and Risk Narratives will be submitted outwith the formal Local Delivery Plan process for the following: IVF Waiting Times; and Dementia Post Diagnostic Support

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Stroke Care Bundle To increase the proportion of stroke patients receiving a bundle of care on admission from 64% December 2013 to 74% (up 10%) by Q4 2014/15 NHS BOARD LEAD: Liz Moore

Delivery and Improvement Risk Management of Risk Stroke is the third most common cause of death in industrialised countries and the most common cause of permanent disability. Ayrshire & Arran currently admits 800 new patients with acute stroke every year. Building on recent developments and delivering further improvements in stroke services will be a major challenge in view of future demographic changes.

The Stroke MCN provides a co-ordinated approach to stroke management in Ayrshire & Arran and takes an active role in improving stroke services and monitoring and progress. Liaison and communication with other health boards in Scotland and with Scottish Government will support learning and sharing of experience. The stroke service will take a whole systems approach based on patient pathways.

Flow of patients through the stroke unit may impact on the admission of new patients to the unit.

The development of Hyper-acute units within the acute stroke units has led to improved management of stroke patients and reduced length of stay which facilitates patient movement through the unit. The development of community based intermediate care and enablement services in partnership with local authority partners will support reductions in length of stay and aid patient flow.

The four elements of the bundle have to be met individually to meet the overall bundle trajectory. Current pathways don’t fully support delivery of all four standards.

Work is underway to improve the pathways affecting the bundle elements ie. Admission, swallow screening, CT scanning and Aspirin. Regular exception reporting highlights areas for improvement for all the elements of the stroke bundle. The stroke action plan is being reviewed and updated. The results of audits are discussed at Clinical Governance meetings and there are regular cross

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site meetings and monthly monitoring for individual sites to highlight differences in practice and performance and share experience and knowledge.

90% of all patients admitted to hospital with a diagnosis of stroke must be admitted to a stroke unit on the day of admission, or the day following presentation at hospital.

Ayrshire & Arran consistently meet and exceed this standard. This will be monitored to ensure that the standard continues to be met.

90% of stroke patients will have a CT scan within 24 hours of admission.

A new electronic referral system has been introduced to notify the radiology Department that the patient requires a scan within 24 hours of admission. CT referral cards giving information on the referral process have been developed as an ‘aide memoir’ and have been distributed to all junior doctors to help improve referral times. CT training is being rolled out to generic radiographers to increase the number of staff able to carry out CT scanning. Access to CT scanning is being reviewed.

90% of stroke patients will have a swallow screen on the day of admission.

A Learnpro module has been developed and will be used in conjunction with ward training to ensure that all relevant staff members are trained in swallow screening.

100% of ischaemic stroke patients will have aspirin by the day following admission.

A PGD is in place on both sites to help ensure timely administration of aspirin. Awareness of the importance of STAT aspirin is also being re-emphasised with the introduction of the Acute Stroke CT Referral card which should help compliance. Actions to improve compliance with the CT standard will have a positive impact on aspirin administration.

Workforce Risk Management of Risk Difficulty in appointing to Consultant posts will impact on the further development of the stroke service. A recently advertised post remains unfilled.

A review of Consultant and Specialty Doctor job plans has allowed resources to be redeployed internally to create an additional Consultant post. Job plans have been reviewed to ensure posts are attractive to any potential candidates and job will be

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more widely advertised. Insufficient nurses with expertise in stroke would compromise the service and the delivery of stroke standards.

The Lead Nurse for Stroke will ensure that staff competencies are maintained and that education programmes are in place. An integration programme is in place across the two acute stroke units which allows nursing staff to work flexibly across the two acute stroke units to ensure that skills and knowledge are shared. A review of nurse staffing levels has been undertaken and the results are currently being evaluated.

Finance Risk Management of Risk Inability to manage increased activity and throughput within existing resources.

A review of stroke services will consider how services can be redesigned to allow increased activity to be met within existing resources. In the meantime a review of Consultant and Specialty Doctor job plans has allowed resources to be redeployed internally to create an additional Consultant post. A review of nurse staffing levels has also been undertaken and the results are currently being evaluated.

Equalities Risk Management of Risk Delivering acute stroke services on two sites could lead to differential performance in meeting the stroke standards and lead to inequities of care. The stroke service is currently under pressure to deliver the same service on both acute hospital sites due to the some local variation in departments involved. Improving the bundle for the whole stroke population when there are four separate elements on two sites is a challenge

The Stroke MCN provides a co-ordinated approach to stroke management and takes an active role in improving stroke services and monitoring and progress. Regular cross site Service Delivery Groups and a joint Clinical Governance structure is in place to monitor and act on variations in pratice Joint stroke protocols have been written which apply to both sites and are available on Athena. A stroke bundle audit will be undertaken on a monthly basis. Exception reports are run 2 weekly and will be subject to vigorous investigation and analysis to enable service improvements to be identified and put in place.

Given the remote, rural and island geography of Ayrshire and Arran there is a risk that patients may experience differential access to services.

This risk will continue to be monitored and managed through the Stroke MCN.

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LDP ACTION PLAN 2014/15 SCOTTISH STROKE CARE STANDARD

TARGET

2013

2014/15

ACTION

Stroke Care Bundle By March 2015, an increased number of patients admitted to hospital with a diagnosis of stroke must receive all the key elements of the stroke care bundle.

>than current position

64%

74%

Continually monitor performance towards individual standards i.e. Admission, swallow screening, CT scanning and Aspirin by regular exception reporting to highlight areas for improvement and implement actions to address areas of concern. Provide regular feedback to stroke teams on performance towards bundle and offer any education / support for areas requiring improvement. Audit results will be discussed at Clinical Governance meetings and at regular cross site meetings to highlight differences in practice and performance and also share experience and knowledge.

Access to a stroke care unit 90% of all patients admitted to hospital with a diagnosis of stroke must be admitted to a stroke unit on the day of admission, or the day following presentation at hospital.

90% 98%

98% Consistently meeting and exceeding this standard. This will be monitored to ensure that the standard continues to be met.

CT scan 90% of stroke patients will have a CT scan within 24 hours of admission.

90% 82% 90% Continue to monitor performance towards standard. An “acute stroke “option is now available on both the electronic systems [added to PMS January 2014] used for requesting a CT brain scan. This allows radiology to identify stroke patients as a priority. Medical staff from January 2014 have

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been asked to include on the request the time of patients admission to A/E to ensure scan window of 24 hours is known to radiology. Compliance will be monitored An aide memoire’ card has been developed and distributed in January 2014 to all junior doctors to help improve referral times. The card provides information on the referral process for CT brain scans. This card will be issued to all new doctors as they start. Referral times will continue to be monitored. Quarterly CT audits to monitor the CT referral pathway will be undertaken and feedback given to relevant stakeholders. CT training is being rolled out to generic radiographers to increase the number of staff able to carry out CT scanning. Review access to CT scanning for stroke patients.

Swallow screen test 90% of stroke patients will have a swallow screen on the day of admission.

90% 84% 90%

Continue to monitor performance towards standard. A Learnpro module is being developed and will be used in conjunction with ward based competency assessment to ensure that all relevant staff members are trained in swallow screening. Speech & Language Therapists continue to deliver face to face training and ward based competency assessment whilst

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Learnpro module is being developed Exploring feasibility of stroke unit nurses attending A/E to carry out swallow screen.

Aspirin 100% of ischaemic stroke patients will have aspirin by the day following admission.

100% 81% 100%

Continue to monitor performance towards standard. A PGD for Registered Nurses is in place on both sites to help ensure timely administration of aspirin. Awareness of the importance of STAT aspirin is also being re-emphasised with the introduction of the aide memoire card in January 2014 for Acute Stroke which should help improve compliance. Actions to improve compliance with the CT standard will also have a positive impact on aspirin administration.

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