Health Portfolio Radiology Programme and North of Scotland Planning Group Joint

Workshop Report Version 1.0

18 August 2016

Courtesy of Emese Toth (2016)

SHARED SERVICES RADIOLOGY PROGRAMME

NORTH OF SCOTLAND

PLANNING GROUP

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Table of Contents 1. Background ............................................................................................................................... 3 

2. Introduction ............................................................................................................................... 4 

3. The National Shared Services – Overview and Principles .................................................... 5 

4. The National Radiology Model ................................................................................................. 5 

5. The Royal College of Radiologists’ Perspective ...................................................................... 5 

6. Out of Hours / 7-Day Service – The Glasgow Perspective ...................................................... 6 

7. Setting the Scene ........................................................................................................................ 6 

8. The Workshop ............................................................................................................................. 7 

8.1  Objectives ........................................................................................................................... 7 

GROUP EXERCISE 1 – HOW DO WE IMPLEMENT THE NATIONAL RADIOLOGY MODEL ON

A REGIONAL BASIS – within normal working hours .................................................................... 7 

GROUP EXERCISE 2 – HOW DO WE IMPLEMENT THE NATIONAL RADIOLOGY MODEL ON

A REGIONAL BASIS – Out of Hours (OOHs) ............................................................................. 10 

9. Next Steps ................................................................................................................................. 13 

Appendix 1 – Workshop attendees ............................................................................................. 14 

Appendix 2 – Shared Services overview and principles ........................................................... 16 

Appendix 3 – The National Radiology Model ............................................................................. 17 

Appendix 4 – The Royal College of Radiologists’ perspective................................................. 18 

Appendix 5 – OOH / 7-Day Service – The Glasgow perspective .............................................. 19 

Appendix 6 – Setting the Scene .................................................................................................. 20 

Appendix 7 – Post-Workshop Survey Results ........................................................................... 21 

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1. Background

In January 2015, the National Health Service (NHS) National Services Scotland (NSS) Programme Management Services (PgMS) was commissioned by the Guiding Coalition (now Senior Leaders’ Forum), made up of Board Chairs and Chief Executives, to take forward the NHSScotland Shared Services’ mandate to deliver sustainable, efficient services which will ultimately improve service user experience. One work stream of Shared Services is the Health Portfolio, set up to consider a “Best for Scotland” approach for some of the functions within Diagnostics (Laboratories and Radiology), Medical Physics, Pharmacy Aseptic Dispensing and Public Health. Through engagement with key stakeholders via a Visioning Workshop and a series of engagements, The Shared Services Radiology Programme team developed a vision for Radiology services in Scotland in the form of a National Radiology Model. The National Radiology Model Strategic Document was approved by NHS Board Chief Executives on the 9 August 2016. The following hyperlink refers to this document: http://www.sharedservices.scot.nhs.uk/health-portfolio/programmes/radiology Radiology services in the north of Scotland are facing real challenges, many of which could be improved by implementation of the National Radiology Model on a regional basis. The North of Scotland Planning Group (NoSPG) approached the Shared Services Radiology Programme Team to jointly plan a Workshop. The objectives of the workshop were to explore how the national model may be implemented on a regional basis and identify what would be needed to ensure a robust, sustainable radiology service for the north of Scotland. Through initial engagement, information about the current landscape of diagnostic imaging in Scotland was collated123456. This information was used as a foundation for the joint Workshop held on Thursday 18 August 2016. The workshop attendees are captured in Appendix 1. Over the course of the day, key stakeholders were taken on a journey from the acknowledged current state to identification of the challenges and future service requirements needed for a sustainable future diagnostic Radiology service in Scotland. It was unanimously recognised that the status quo is unsustainable. Specialist clinical input was provided by the Radiology Programme Subject Matter Expert (SME), Hamish McRitchie, Consultant Radiologist, NHS Borders. This report provides an overview of the activities and the outcomes of the joint NoSPG/Shared Services Radiology Programme Workshop.

1 (2015) Sinclair A-M: “Radiology Political, Economic, Sociological, Technological, Legal and Environmental (PESTLE) Analysis”; Summarised Version (2016) Kerr, LW.

2 Source: Scottish Health Service Costs, year ended 31st March 2015.

3 Source: National Records of Scotland mid-2014 Population Estimates by Council Area and NHS Board, gender and 5 year age band National Records of Scotland 2012-based Population Projections by Council Area and NHS Board (single years 2012-2037); No age or gender breakdown.

4 (2016) NHSScotland Shared Services Health Portfolio Radiology Programme “National Radiology Model” 

5 (2015) The Royal College of Radiologists Standing Scottish Committee: “The clinical radiology workforce in Scotland 2014” 

6 (2015) Cannon, J., Jones D. “Extract from Highland Radiology Stakeholders Presentation” and updated Grampian and Western Isles Data

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2. Introduction Cathie Cowan, Chief Executive, NHS Orkney welcomed participants to the workshop and explained that the National Radiology Model developed by the Radiology Programme in conjunction with stakeholders had recently been approved by all of the NHS Board Chief Executives in Scotland. The Chief Executives gave a clear mandate to implement this model on a regional basis. Cathie said that she had been asked to lead this exciting piece of work in the north of Scotland on behalf of the NHS Board Chief Executives. She stated that the status quo of the Radiology service in the north is unsustainable and that collaborative work is required to implement the model on a regional basis and identify what is needed to ensure a robust, sustainable Radiology service for the north of Scotland, including the Out of Hours period. This set the objective for the workshop.

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3. The National Shared Services – Overview and Principles Brian Montgomery, Shared Services Health Portfolio Director, outlined the national context, including policy and strategy within which Shared Services sits. He explained that the Senior Leaders’ Forum had confirmed its commitment and given a mandate for change in terms of Shared Services and a ‘Once/Best for Scotland’ approach, balancing the need to ensure quality, efficiency, effectiveness and value for money. NHS Board Chief Executives had set a task to develop a sustainable model for Radiology services in Scotland outwith existing Health Board constraints. This challenge had been met with the development of the National Radiology Model Strategic Document which was agreed by NHS Board Chief Executives in August 2016. NHS Board Chief Executives agreed a regional approach to the implementation of this model, although some elements will require a national approach. Brian stressed that the day would present a unique opportunity for stakeholders to influence the shape of services in their region. Appendix 2 refers.

4. The National Radiology Model Hamish McRitchie, Radiology Programme SME provided further context for the benefits of taking a Shared Services approach. He outlined the process and content of engagement which had led to the development of the National Radiology Model. Hamish explained how there are underpinning requirements (specifically, IT Connectivity, to allow requesting and reporting across Scotland and to collect data across Scotland). IT Connectivity will also allow the development of a National Radiology Data Mart. However, the principles of the National Radiology Model can be implemented on a regional basis. In his presentation he described an existing support model based on how Radiology and other geographically dispersed clinical services supported patient diagnosis and management. This model has been developed through crisis, but the principles are applicable on a regional basis. It was recognised that the aforementioned underpinning requirements as well as robust governance mechanisms would require to be in place. Appendix 3 refers.

5. The Royal College of Radiologists’ Perspective Jason Walker, Consultant Radiologist, outlined the Royal College of Radiologist (RCR) Perspective. He described the RCR’s documentation which outlines the benefits of a network approach to radiology service delivery including the grouping of radiologists to increase the capacity to provide continuous cover across the range of specialties. Jason asserted that this network approach is preferable to outsourcing and that teams working together across traditional boundaries have the potential to deliver significant gains as well as the required quality of reporting for the NHS. Key to this network approach is a common Radiology Information Systems (RIS) and Picture Archiving and Communications Systems (PACS), standardised clinical governance, and standardised reporting practices. Jason added that careful consideration requires to be given to governance issues. Jason detailed a Strengths, Weaknesses, Opportunities and Threats (SWOT) analysis of a networked approach, how the benefits far outweighed any negatives, and how weaknesses and

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threats can be overcome. He gave examples of where the network approach is already working successfully and concluded by saying that there is a need for a change in the Radiology service model due to the existing workforce challenges and increased demand that Radiology services are facing. Appendix 4 refers.

6. Out of Hours / 7-Day Service – The Glasgow Perspective Anne Marie Sinclair, Consultant Radiologist and Lead Clinician for SCIN described two change management projects that she had led within NHS Greater Glasgow and Clyde (GG&C). The projects were a centralised on-call and extended day/weekend working for Radiologists working within NHS GG&C. She outlined the drivers for the change and stressed that although it was not a desirable situation, the crisis within the on-call radiology service served as a catalyst for change. She asserted that parallels could be drawn with the current status of Radiology services across Scotland. The Kotter Change Management Model was adopted to facilitate the change. Various barriers were experienced during the change process. Anne-Marie stressed the need to assemble a group that had the power and energy to lead and support a collaborative effort and that all relevant stakeholders were represented. The on-call system for NHS GG&C and the extended working day were successfully implemented. Anne Marie outlined the lessons learned and concluded by quoting Nelson Mandela: “It always seems impossible until it is done”. Appendix 5 refers.

7. Setting the Scene Mike Bisset, Medical Director for the NoSPG set the scene for the workshop portion of the day by outlining the strategic planning context and stating that there are now over twenty clinical networks supported by a regional model of care. He gave an overview of a recent north of Scotland Clinical Stakeholder event where delegates had been challenged to think about services in the north of Scotland in a different way. The main themes which had emerged from the event indicated that people wanted to breakdown silos and to explore different ways of achieving a balance between centralisation and locally delivered services. Mike outlined some reasons why change may be resisted but asserted that the National Clinical Strategy was clear that there should be planning of hospital networks at a national, regional or local level based on a population paradigm. Barriers to change and how these might be overcome were also discussed. Key enablers for regional or national working were detailed including clinical engagement, planning IT, clinical governance, operational management, finance and clinical leadership. Mike concluded that the key to regional working required a new set of rules, but that essentially the key was to implement a process of co-production. Appendix 6 refers.

8. The Workshop 8.1 Objectives

Brian reiterated the National Radiology Model and challenged delegates to discuss the opportunities within that National Model for the north region. He reminded participants that the objectives of the Workshop were to work in a collaborative way to implement the national model on a regional basis and identify what is needed to ensure a robust, sustainable radiology service for the north of Scotland. GROUP EXERCISE 1 – HOW DO WE IMPLEMENT THE NATIONAL RADIOLOGY MODEL ON A REGIONAL BASIS – within normal working

hours

Courtesy of Emese Toth (2016)

Breakout groups were formed and attendees, supported by facilitators from the Radiology Programme and the NoSPG were asked to discuss how the National Radiology Model may be implemented in the north of Scotland, within normal working hours. Participants were asked to discuss the following areas: Using the Principles within the National Radiology

Model, how do you implement the model in the North? Based on the principles of a National Radiology

Model, what does a North Regional Radiology Model look like?

Who should lead the implementation? Who else should be involved in the implementation?

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Key themes which emerged from the discussion are grouped in the table below:

How do you implement the model in the North? What does the regional model look like?

General endorsement of National Radiology Model Model should be stepping stones – regional to national National Virtual Reporting Model – smaller Boards would

have access to larger Boards’ expertise and MDTs’ review. Bring back Reporting from the Private Sector. Would need uniformity of coding within RIS.

Need IT connectivity Need Core Data Set – Need to identify the baseline to

understand the true capacity vs. demand and future forecasting

Make radiologists happy – ensure there is something for everyone and then will get commitment to reformed service. Need incentives to retain staff.

Why just north of Scotland? Radiology requires a nationwide solution to some rotas, not just the north.

National In-sourcing Model – need national work lists and uniformity of payments for reporting depending on complexity, using a points based system (use Graeme McKillop’s model).

Regional SLAs. Only by setting region-wide SLAs could you begin to balance the local variation

One interventional rota (low hanging fruit) Retain face to face access to expert opinion – could use

IT solution. Retain clinical peer trust National outsourcing of ‘X’ work – if you isolate parts of

the Radiology workflow then you could more easily identify where the bottle necks are once the demand is applied to specific tasks and not roles and locations. If you managed these nationally then you look at the workforce in the whole and could more easily apply the appropriate resources where required. This might be some outsourcing or it might be sessions of regional reporting, or it could be a recently retired clinician able to fill a rota hole for reporting at short notice from their home location.

Virtual Regional Radiology Board. This could be the host for the governance issues that otherwise prove difficult when one participant in one Board passes on an opinion on a patient residing in another Board and whose care is accounted for there. A virtual Board could more easily host rotas, etc.

Cross boundary reporting. Flexible Job Planning and options for some home working –

Virtual working is a great opportunity where your work isn’t always where you live. Also utilise recently retired or staff with young families.

Workflow analysis – define roles – what are the tasks, who should undertake them and where could they be done?

Radiologist working week – could be a split of local and regional work. Whilst purely reporting for long periods might be mundane, this could be balanced by the fact that more interesting cases would be encountered that might not otherwise by seen in a remote locality.

Attract more trainees to the north – Deaneries and placements and possibly a North Radiology Faculty

Clinical Decision Support required. Will help manage expectations of Patients, Primary Care and other Practitioners.

Regionalise MDT work?

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Who should lead the implementation? Who else should be involved in the implementation?

Clinical Lead with Managerial support Clinicians Public MSPs? Radiologists Integrated Joint Boards eHealth HIS (Health Improvement Scotland) Board management ‘Critical friends’ NES (National Education Scotland) Deaneries BMA (British Medical Association) HR Finance Special Board for diagnostics Clinical support services (rotas) Transport services

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GROUP EXERCISE 2 – HOW DO WE IMPLEMENT THE NATIONAL RADIOLOGY MODEL ON A REGIONAL BASIS – Out of Hours (OOHs)

1. Overview of Shared Services 1.1. Introduction

Breakout groups were formed and attendees, supported by facilitators from the Radiology Programme and the NoSPG were asked discuss how the National Radiology Model could be implemented in the north of Scotland, Out of Hours. Participants were asked to discuss the following areas: Using the Principles within the National Radiology

Model, how do you implement the model in the North? Based on the principles of a National Radiology

Model, what does a North Regional Radiology Model look like?

Who should lead the implementation? Who else should be involved in the implementation

and what resources are required?

Courtesy of Emese Toth (2016)

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Key themes which emerged from the discussion are grouped in the table below: How do you implement the model in the North

- OOHs? What does the regional model look like - OOHs?

Mapping of skill mix across region Workflow Modelling OOHs – What is the current

workload OOHs; how does that divide up across the region; what OOH peaks lead to ‘highest’ demand by types of work. This will identify what the rota needs to do. What then does the OOH model need to look like?

One interventional rota (low hanging fruit) How much can be virtual – Can it all be achieved

remotely and what’s left? Start with Glasgow model – but recognise

geographic and IT hurdles. Tailor the model to the north.

Role for Trainee – benefits of trainees covering OOH rota, but consultant’s contribution is essential. Can trainees from other regions participate in the model?

Four Hubs – working as a network but with national cover, too. Each Hub could serve its locality but would also be available to support some national requests. Through central management you could have each hub being a first, second or third port of call to support a central pool of requests.

Rotas – Possible one Board is on shift and another is on call whilst the other two are off. Change 1st on-call to second on-call

Define Hours – Need common definitions for Core hours ,Extended day/weekend and On-call

Remove public holidays – therefore filling the rota is easier and has less local barriers and variation.

Embrace some acceptable variation – example of where NHS Western Isles Health Board wanted a particular specification of images and as long as this was detailed it could be achieved. Offering variation in terms of how time can be taken back.

Must Reflect Customer Need Improved cross-Board collaboration – at the small scale, not

just big questions. There is no need to wait until all the big questions are answered.

Quality Assurance (QA) – essential for network to work. Added benefit is that OOH Trainee Reports are accepted as high a standard as during the day.

Need patient pathways Common report style required across hubs – Name, GMC# &

contact # for report author; No. requestor (direct lines). The essential dialogue between clinicians had to be retained wherever possible. Communicating from one area in Scotland is no different from communicating from one building to another.

Ownership of Rota – ‘Good Samaritan’ has no place in our model. Those who contribute must feel ownership for the various geographical areas.

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Offering a variety of options rather than one hard and fast solution is likely to engage more support.

Risk Assess the model Test the model – as much and as often as is

necessary and test again. Don’t expect one size to fit all the north and don’t expect the first attempt to immediately arrive at the complete solution. Try and try again.

Who else should be involved in the implementation?

Clinician Lead with Managerial support Extended stakeholders – Identify those who could be impacted by a revised OOH model and try to bring them into the fold. By definition this won’t just affect those directly within the service but all those who use and receive the service’s output too. Clinicians Public MSPs? Radiologists Integrated Joint Boards eHealth HIS Board management ‘Critical friends’ NES Deaneries BMA HR Finance Special Board for diagnostics Clinical support services (rotas) Transport services

9. Next Steps The North of Scotland Planning Group and the NHSScotland Shared Services Radiology Programme team will define a set of actions from the outputs of this workshop. A small north group will be formed to support the regional actions and the national ones will be taken forward as part of the Shared Services programme, over the coming months. We aim to hold another regional stakeholder meeting in December 2016 / January 2017 and progress work in the meantime based on discussions at the meeting.

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Appendix 1 – Workshop attendees

Name Job title Organisation

Eileen Anderson Consultant Radiologist NHS Highland

Mark Ashton Clinical Director for Clinical Support Division

NHS Highland

Mike Beach Radiology Services Manager NHS Orkney

Lesley Berry Unit Operational Manager NHS Grampian

Jonathan Brodie Consultant Radiologist NHS Highland

Scot Dundas Lead Radiographer, CT/Cardiovascular NHS Tayside

David Eason Consultant Radiologist NHS Highland

Rafik Hamdy Consultant Radiologist NHS Grampian

Roderick Harvey Medical Director NHS Highland

Alex Javed Service Manager, Laboratories & Radiology

NHS Highland

Jane MacDonald Acting Radiology Manager NHS Western Isles

Andrew Macleod Consultant Radiologist NHS Highland

Cameron Matthew Divisional General Manager NHS Grampian

Kenneth McDonald Consultant Physician and Associate Medical Director

NHS Highland

Karen McNicoll Divisional General Manager, Clinical Support Services

NHS Highland

John Miller Consultant Radiologist NHS Highland

John Reid Consultant Radiologist NHS Western Isles

Alan Riddoch Radiography Manager NHS Grampian

Marthinus Roos Medical Director NHS Orkney

Anne Serman Programme Manager NHS Tayside

Helen Shannon Consultant Radiologist NHS Highland

Mark Shannon Radiography Manager NHS Grampian

Graeme Smith Director of Modernisation NHS Grampian

Katherine Sutton Deputy Director of Operations NHS Highland

Alistair Todd Consultant Radiologist NHS Highland

Shonagh Walker Clinical Director Radiology NHS Grampian

Struan Wilkie Consultant Radiologist/Clinical Lead for RIS/PACS

NHS Grampian

Speakers

Mike Bisset Consultant, NoSPG NHS Grampian

Cathie Cowan Chief Executive NHS Orkney

Hamish McRitchie

Consultant Radiologist and Subject Matter Expert, Radiology Programme, NHSScotland Shared Services

NHS Borders

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Name Job title Organisation

Brian Montgomery

Health Portfolio Director, NHSScotland Shared Services

NHS National Services Scotland (NSS)

Anne Marie Sinclair Clinical Director NHS Greater Glasgow & Clyde

Jason Walker Consultant NHS Highland

NoSPG (North of Scotland Planning Group)

Jim Cannon Director Regional Planning NoSPG (North of Scotland Planning Group)

Alan Connor (Facilitator) Senior Project Manager NoSPG (North of Scotland Planning Group)

Lisa Wood Project Support Officer NoSPG (North of Scotland Planning Group)

Radiology Programme Team

Fiona Agnew (Facilitator) Project Manager NHS National Services Scotland (NSS) – Shared Services

Ben Cabrelli (Facilitator) Project Manager NHS NSS Shared Services

Linda W Kerr Programme Manager NHS NSS Shared Services

Emese Toth Project Support Officer NHS NSS Shared Services

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Appendix 2 – Shared Services overview and principles

Radiology Workshop Presentation_B Montgo

Note: Double click on the PDF document above to view the slide show of Brian Montgomery’s presentation.

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Appendix 3 – The National Radiology Model

Radiology Workshop Presentation_H McRitc

Note: Double click on the PDF document above to view the slide show of Hamish McRitchie’s presentation.

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Appendix 4 – The Royal College of Radiologists’ perspective

Radiology Workshop Presentation_J Walker

Note: Double click on the PDF document above to view the slide show of Jason Walker’s presentation.

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Appendix 5 – OOH / 7-Day Service – The Glasgow perspective

Radiology Workshop Presentation_A Sinclai

Note: Double click on the PDF document above to view the slide show of Anne Marie Sinclair’s presentation

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Appendix 6 – Setting the Scene

Radiology Workshop Presentation_M Bisset

Note: Double click on the PDF document above to view the slide show of Mike Bisset’s presentation

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Appendix 7 – Post-Workshop Survey Results

Participant feedback and comments Of the 27 participants present at the North of Scotland Planning Group Workshop, feedback captured via the Lime Survey evaluation questionnaire was received from 15 people, a 56% response rate. Participants provided positive endorsement in respect of the workshop registration process and facilities.

The majority of respondents advised that they believed the presentations were excellent and just about the right length:

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The majority of respondents agreed that the workshop activities were appropriate and sufficient time was allowed to participate:

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The most important message respondents wanted the Radiology Programme to take away from the day were:

Complexity of getting people to work collaboratively The goals are unrealistic with the current workforce constraints.

National strategy required. Pool of participants in Grampian and Highland far too small to

provide safe sustainable on call service. Glasgow model not applicable due to disparities in regional staffing levels and geography.

In no order:

o Inverness is too far away. o It rapidly became clear that the Regional strategy needs to be the whole of Scotland

and is unviable without including the Central belt Radiologists. o The concept of a virtual Radiology Board is very attractive and is much more

unlikely to be influenced by stakeholders that do not have a vested interest in a Regional Consultant service plus act as a neutral ground for key decisions on the best service for Scottish hospitals.

Facilitators were excellent in their allotted role.

The whole day was non-threatening and it was made clear that there was no such thing as

a bad idea.

It was a good initial meeting to get together with other radiology colleagues and listen to difficulties, achievements and thoughts. Hope to continue with such meetings to bring the trusts closer to optimum integration. Great ideas.

Expensive way to get basic info. Been told for over a decade what problem were. No one wanted to listen and now too late as services collapse. What has CMOs advisor been doing?!!!!

People commented on having been here before - important therefore to see actions to support changes that keep services safe and sustainable in respective Boards.

That there was perhaps not enough participation/attendance from radiographers who may

well be part of the solution. That some local radiologists seem to have a very fixed view of the future which may limit options.

Combined out of hours service requires a sufficient numbers to ensure success. Local

radiologist on call still necessary at present. Radiology planning dire. Remote and rural radiology service in Scotland in jeopardy without immediate transformational change.

Do you have any comments that you would like to make about the workshop?

Worth attending. Hopefully it will act as a catalyst for people to work together. The workshop leader seemed inappropriately positive and pleased at the conclusion of the

event considering the clinicians seemed in agreement that no progress was appropriate with the current lack of radiologists in the north of Scotland. Bizarre.

Resource heavy - let’s see if the outcome warrants it!

Great workshop for someone who doesn't work in Radiology.

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Facilitators did well to keep certain individuals from dominating groups.

Nice to escape the unbearable workplace for a day.

Really helpful and positive, well organised.

Needed greater buy in from Grampian and Tayside to be worthwhile.

The majority of respondents strongly agreed that on the whole they had been able to fully participate in the workshop. The overall workshop rating was satisfactory.