2020 Local Delivery Plan - NHS Borders · The NHS Borders 2014/15 Local Delivery Plan (LDP) sets...

2020 Local Delivery

Plan 2014/15

Planning & Performance

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Contents

GLOSSARY ............................................................................................................... 3

INTRODUCTION ........................................................................................................ 5

SECTION 1: IMPROVEMENT AND CO-PRODUCTION PLAN ................................ 6

PERSON-CENTRED CARE .................................................................................................... 7 SAFE CARE ......................................................................................................................... 8 PRIMARY CARE ................................................................................................................. 12 UNSCHEDULED AND EMERGENCY CARE ............................................................................. 12 INTEGRATED CARE ............................................................................................................ 17 CARE FOR MULTIPLE AND CHRONIC ILLNESSES ................................................................... 18 EARLY YEARS ................................................................................................................... 21 HEALTH INEQUALITIES ....................................................................................................... 23 PREVENTION ..................................................................................................................... 25 WORKFORCE .................................................................................................................... 27 INNOVATION ...................................................................................................................... 30 EFFICIENCY AND PRODUCTIVITY ......................................................................................... 31

SECTION 2: A STRATEGIC ASSESSMENT OF A HEALTH BOARD’S CAPABILITY AND CAPACITY TO DELIVER THE 2020 VISION FOR PRIMARY CARE ............................................................................................... 33

SECTION 3: . NHS BORDERS CONTRIBUTION TO THE COMMUNITY PLANNING PARTNERSHIP ................................................................................................. 48

APPENDIX 1: HEAT TARGET RISK NARRATIVES AND TRAJECTORIES ........ 62

APPENDIX 2: KEY LOCAL PLANS ..................................................................... 104

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Glossary ADP Alcohol and Drugs Partnership

AHP Allied Health Professional

BECS Borders Emergency Care Service

BHIH Borders Health in Hand

BI Brief Intervention

BIST Borders Improvement Support Team

BME Black and Minority Ethnic Communities

BSL British Sign Language

CAMHS Child and Adolescent Mental Health Service

CDI Clostridium Difficile Infection

CEL Chief Executive Letter

CHCP Community Health and Care Partnership

CHW Child Healthy Weight

CPC Child Protection Committee

CPP Community Planning Partnership

DCE Detect Cancer Early

DNA Did Not Attend

ED Emergency Department

eMART environment Monitoring and Reporting Tool

ENP Emergency Nurse Practitioner

EY Early Years

GCCAM Good Corporate Citizenship Assessment Model

GRFW Get Ready for Work

HAI Healthcare Acquired Infection

HEAT Targets Health Improvement, Efficiency, Access and Treatment Targets

HLN Healthy Living Network

HSMR Hospital Standardised Mortality Rate

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IRIO Integrated Research and Innovation Office

ISD Information and Statistics Division of National Services Scotland

JIT Joint Improvement Team

KSF Knowledge and Skills Framework

LASS Lifestyle Advisor Support Service

LD Learning Disability

LES Local Enhanced Service

LTC Long Term Conditions

LUCAP Local Unscheduled Care Action Plan

MAU Medical Admissions Unit

MCN Managed Care Network

MIU Minor Injury Unit

NES NHS Education Scotland

P&CS Primary and Community Services

QPQOF Quality and Productivity Quality and Outcomes Framework

SAB Staphylococcus aureus bacteraemia

SAS Scottish Ambulance Service

SBC Scottish Borders Council

SGHD Scottish Government Health Department

SIGN Scottish Intercollegiate Guidelines Network

SIMD Scottish Index of Multiple Deprivation

SME Substance Misuse Education

SOA Single Outcome Agreement

SPSI Scottish Patient Safety Indicator

SWHMR Scottish Women Hand Held Medical Record

TNA Training Needs Analysis

VAW Violence Against Women

VSM Value Stream Mapping

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Introduction The NHS Borders 2014/15 Local Delivery Plan (LDP) sets out the work undertaken and planned to achieve local and national performance targets and to achieve the 2020 Vision for NHS Borders. This year is a transitional year for the Local Delivery Plan reflecting the focus on delivering the 2020 Vision by creating a more joined up and interlinked plan. The format of the LDP has been updated to reflect this with the introduction of the Improvement and Co-Production Plan that sets out the actions that NHS Borders are taking to deliver the 2020 Vision across the 12 Priority Areas laid out in the Route Map to the 2020 Vision for Health and Social Care. The backdrop to the LDP is of course the national and local integration programme which is hastening in anticipation of the April 2015 national deadline for the integration of adult health and social care. Locally we have restricted the first stage of this programme to adult health and social care but we recognise the importance of ensuring greater cohesion and improving joint working relationships across all of our services. The Strategic Assessment of Primary Care section highlights the shift in focus towards providing more care in the community and has allowed us to identify the resource shift that is required to make this happen. The Local Delivery Plan once again includes a section on the Community Planning Partnership outlining the key tangible contributions NHS Borders will make during 2014/15 towards improving health, economic and social outcomes for people in the Scottish Borders. As the delivery ‘contract’ between NHS Borders and the Scottish Government, our LDP also maintains the focus on delivery against the national HEAT (Health improvement, Efficiency, Access to services and Treatment appropriate to individuals) targets. We have included the full risk narratives and trajectories for the continuing HEAT targets in order to make this a more cohesive document. NHS Borders is currently consulting (March to June 2014) on a new Clinical Strategy which will provide us with 6 key principles that will underpin service design and delivery. These principles will ensure NHS Borders is an efficient and effective organisation and our performance and quality is amongst the best in Scotland. Furthermore the principles are in line with and fully support the 2020 Vision for Healthcare in Scotland. This transitional Local Delivery Plan will set the tone for future years with a firm emphasis on joint working, integrated planning processes and the co-production of services with staff, patients, public and partners.

John Raine Calum Campbell Chairman, NHS Borders Chief Executive, NHS Borders

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http://www.scotland.gov.uk/Resource/0042/00423188.pdf

http://www.scotland.gov.uk/Resource/0042/00423188.pdf

Section 1: Improvement and Co-Production Plan

This is the first year of the Improvement and Co-Production Plan which is intended to be a 5 year transformational plan setting out how we will deliver on the 2020 Vision. In this transitional year we have begun by structuring our Plan around the 12 priority areas of the 2020 Route Map. We have used this structure to present some of the key areas of work undertaken and planned that will help us achieve our 2020 Vision for NHS Borders, but it should be noted that this Plan is not inclusive of all the improvement work that is ongoing.

Our I&C Plan will be developed further for the 2015/16 LDP and beyond, ensuring that we present a more detailed delivery plan aligned to local planning processes and timescales as well as national ones.

The 12 priority areas are divided into 3 domains known as the Triple Aim. Our plan is split into 3 corresponding sections. The 3 sections are:

1. Quality of Care 2. Health of the Population 3. Value and Sustainability

A 2020 Vision for NHS Borders reiterates and emphasises the commitment to patient safety, and sets out how we want to make things even safer to drive up the quality of our local services and improve the experience of patients, families, carers and our staff.

Although not covered directly by any of the 12 priority areas the physical infrastructure of NHS Borders plays an important role in allowing us to deliver services effectively and efficiently. As such NHS Borders remains committed to improving property and facilities management. The Board aims to ensure all services are fully accessible and facilities are fit for purpose to meet the needs of the population.

The executive leads for each priority area are as follows:

Priority Area Executive Lead 1 Person-Centred Care Evelyn Fleck

2 Safe Care Evelyn Fleck

3 Primary Care Sheena MacDonald

4 Unscheduled and Emergency Care Sheena MacDonald

5 Integrated Care Jane Davidson

6 Care for Multiple and Chronic Illnesses Jane Davidson

7 Early Years Eric Baijal

8 Health Inequalities Eric Baijal

9 Prevention Eric Baijal

10 Workforce June Smyth

11 Innovation Jane Davidson

12 Efficiency and Productivity Carol Gillie

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1. Quality of Care

Quality is a key tenet of the 2020 vision for healthcare in Scotland and forms the basis of all our services in NHS Borders. Our vision is for NHS Borders to be a leader in Scotland, in the quality and safety of care we provide. We will maintain our focus on patient safety as our top priority and provide safe, effective and person-centred services in order to achieve our quality ambition.

We recognise that the pursuit of quality spans all our services, and will increasingly involve working in conjunction with external partners. This section sets out some of the actions planned to increase partnership working and in particular the co-production of services with the service users. It will also show how we intend to maintain and improve the quality and safety of our services.

This section will set out the actions NHS Borders is taking in the priority areas of: • Person-Centred Care • Safe Care • Primary Care • Unscheduled and Emergency Care • Integrated Care • Care for Multiple and Chronic Illnesses

Person-Centred Care

Executive Lead: Evelyn Fleck Learning from and spreading best practice

NHS Borders will continue to develop a work stream of quality improvement activity and a local handbook of good practice to ensure effective delivery of the national Person-Centred Health and Care Programme (2012). This programme of work aims to improve person-centred practices in relation to care experience, staff experience, co-production and leadership. A central theme of these four work streams is promoting caring and person-centred behaviours so that staff are equipped with the skills to offer person-centred care with compassion and kindness.

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Seeking and acting on feedback

NHS Borders encourages feedback from patients, carers and family members, and about the services they receive. Feedback and complaints are invaluable sources of learning that help us improve the care and support we provide. NHS Borders welcomed the introduction of the Patient Rights (Scotland) Act (2011) that gives every patient the right to provide feedback or make a complaint and they are given the support they need to do this. Our priority is to make our feedback and complaints processes as accessible as possible and empower front line services to manage and learn from the feedback received. Over the coming years we will continue to elevate the profile of patient and carer stories as they have proved to be a useful learning tool for improving patient care and emphasising person-centredness. As well as learning from complaints and feedback, NHS Borders involves patients and carers in the design and planning of services to improve the quality of care and support provided. NHS Borders will continue to take forward the recommendations made in the Participation Standard for Scotland, by continually evaluating and improving the way we involve patients and the public in improving services. NHS Borders will align complaints, feedback, advocacy support, carer support, Third Sector engagement, volunteering, patient experience and public involvement work into an overarching Public Involvement Strategy. The strategy will be co-produced by people that use our services, and along with our local Person-Centred Health and Care Programme it will aim to put patients, their families and carers at the centre of everything we do. We will seek the views of all protected characteristic groups in line with the public sector general equality duty.

Safe Care Executive Lead: Evelyn Fleck

The provision of safe care has many elements to it but by far the most comprehensive programme of work is the Scottish Patient Safety Programme. The continued implementation and delivery of this programme will continue to be effective in ensuring we are using the latest evidence-based tools and techniques to improve the reliability and safety of everyday health care systems and processes. Scottish Patient Safety Programme

The following is an update, with an overview of progress, to date, of the implementation of the Scottish Patient Safety Programme (SPSP) and it also presents an assessment of spread and sustainability across the programme’s key workstreams. Background The diagram below details the current scope of the SPSP within NHS Borders:

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Patient Safety in Acute Care

The NHS Borders patient safety programme for acute services was initiated in 2008 focusing on the key improvement priorities agreed by the SPSP. The overarching aims of the programme were to reduce hospital standardised mortality (HSMR) across NHS Scotland by 15% by December 2012. The second phase of SPSP was announced in June 2012 by the Cabinet Secretary, with the overarching aim being to reduce HSMR across NHS Scotland by 20% by December 2015 (a further 5% reduction based on the December 2012 aim) and to embed ‘harm free care’. The second phase was formally launched by the Cabinet Secretary at the Adult Acute learning session held on 28/ 29 August 2013 with the aim statement that 95% of all patients receiving acute care should be free from harms as identified by the Scottish Patient Safety Indicator (SPSI). This was also reiterated in CEL 19, which forms the basis of the local delivery plan for the SPSP in 2014/ 2015.

Ten Patient Safety Essentials

These ten interventions have now been proven to reduce harm to patients and therefore it is proposed that a zero tolerance approach will be phased in and adopted within acute services in NHS Borders. The 10 patient safety essentials are:

• hand-washing • leadership walkrounds • communications: surgical pause and brief • communications: general ward safety brief • ICU daily goals • VAP bundle • early warning scores • CVC insertion • CVC maintenance • PVC maintenance bundle

The current self auditing system of these measures shows good reliability in all acute clinical areas within NHS Borders, and this will continue to be

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validated by random spot checks, regular mentoring and training of staff, and scrutiny during Executive leadership walkrounds. Embedding the ten essentials into normal every day practice will require NHS Borders to establish monitoring arrangements. These arrangements will be established at three levels: within operational delivery mechanisms, through self assessment by clinical areas and externally through inspection by peers. It has been agreed that Operational Managers will visit their clinical areas with a requirement that a specific number of patients are reviewed over the course of a month. External monitoring will continue, via a rolling cycle, through walkrounds and spot checks by Clinical Governance and Quality and Infection Control Teams. Non-compliance will be managed through the appropriate HR policy, consistent with any other capability or conduct issue, once training and coaching has been rolled out across the Borders General Hospital (BGH). Training will be by means of 1:1 nurse education; per ward, by the Patient Safety Programme Manager and Patient Safety Assistant; through the mandatory Clinical Update sessions; and as part of a local marketing strategy currently being scoped.

Adult Acute SPSP Priorities

In addition to the 10 patient safety essentials the Cabinet Secretary also announced the ‘nine plus two’ key priority areas to become the ongoing improvement focus of NHS Boards. Workstreams are being established and testing work on all new measures will commence in early 2014.

Adverse Event Management

NHS Borders have incorporated the actions required of NHS Boards through the National Approach to Learning from Adverse Events Framework cascaded by Health Improvement Scotland. The Boards priority this year will be to ensure implementation of the revised local Adverse Event Management policy as well as continuing to develop as a learning organisation.

SPSP Measurement Plans Mental Health P2

Measurement Plan v0 AcuteAdultSafetymeasurementplan v1 0.p

Maternity Care Measurement Plan FIN

Scottish Patient Safety Indicator (SPSI)

NHS Boards are required to work towards the achievement of the SPSI with the over arching aim of ensuring that 95% of patients experiencing acute care will be free from harm as defined by the SPSI. Again, for 2014/2015 local testing of process measures will form a key role in achieving the ‘Indicator’ target.

Diabetes Improvement Programme

2014/15 will see the development of a rolling programme of improvement for diabetes care and treatment. This will include: identification of key areas for improvement; initiating tests of change; development of improvement measures and tools to monitor progress and demonstrate sustainability.

Stroke Care Bundle

Ongoing routine data collection to facilitate performance monitoring and drive improvement against individual components of the stroke care bundle. There will be a greater focus on outcome measures, please see the LDP Action Plan for 2014/15 on the next page.

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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 Borders general hospital with a diagnosis of stroke must receive all the key elements of the stroke care bundle.

>than current position

80.7%

90% in 2.5% increments each quarter.

Daily monitoring of all stroke admissions with regard to bundle documentation by looking at every patients pathway and by examining all individual elements of the bundle, using the established exception reporting, and taking appropriate action when there is any deviation. Where deviation is identified, support and education will be given and through such mediums as ward handovers, clinical huddles, safety briefs and clinical governance forums, data feedback and actions to rectify will be shared with all relevant clinical teams.

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%

Sustain

To ensure sustained performance by monitoring and reporting on daily basis.

CT scan

90% of stroke patients will have a CT scan within 24 hours of admission.

90%

96%

Sustain

Maintain high standard of open communication and support from CT to preserve high level of achievement.

Swallow screen test

90% of stroke patients will have a swallow screen on the day of admission.

90%

89%

>90%

Ongoing rolling programme of swallow screen education to MAU, ED and BSU clinical staff with appropriate data feedback to clinical teams.

Aspirin

100% of ischaemic stroke patients will have aspirin by the day following admission.

100%

92%

100%

Target doctors induction programme. Promote stroke bundle documentation in all areas of admission to hospital. Education programme for all clinical staff around SIGN guidelines regarding aspirin administration.

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Primary Care Executive Lead: Sheena MacDonald

See Primary Care Strategic Assessment. The effective delivery of primary care is at the heart of the 2020 vision and is linked inextricably with all of the other 11 priority areas. As requested NHS Borders has undertaken a strategic assessment of our capability and capacity to deliver the 2020 vision for primary care. This assessment contains the strengths and weaknesses of our current delivery of primary care and sets out the local actions that are proposed to support the expansion of primary care. The work highlighted by the Strategic Assessment may overlap with work included within other sections of this Improvement and Co-Production Plan, this serves to highlight the joint working that already exists within NHS Borders and which we seek to build upon.

Unscheduled and Emergency Care Executive Lead: Sheena MacDonald

Connected Care

The aim of Connected Care is to create a foundational support to the achievement of health and social care integration via a clinically-led health and social programme across hospital, community and individual settings, that delivers the overarching outcome of no delay, no unnecessary hospital stay and no delay in care intervention. This is a bold proposal and will require a significant behavioural shift towards a health and social care system that demonstrates Connected Care. It is a substantial aspiration that will change individuals’ and families’ expectations, achieved through increasing staff opportunity to maximise the effectiveness of care interventions and support, supported by system synergy to achieve behavioural change. It will be driven using the hospital settings as an anchor and core facilitator of quality care in the community, across all agencies and partners. It is predicated upon the hospital as the core proxy measure for whole system care. It supposes that if no person is in hospital who does not require hospital care, and hence is medically fit, the quality of peripheral care in the community will increase exponentially to create a virtuous cycle of successful Connected Care. The prime beneficiary being the people who require health and social care interventions and the prime measures of success will be:

1. No patient in hospital who is medically fit for discharge 2. Hospitals operating at 80% occupancy 3. A reduced need for care through more anticipatory and more

responsive care provision specifically:

• a reduction in readmission rates to hospital

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• more efficient throughput of assessment for non hospital based care

• speedier access to a range of community based social and health care supports

These measures will cumulatively represent a significant shift away from inappropriate hospital based care and will introduce efficiencies into the system that will allow for reinvestment of up to 25% of relevant resource across the system that will allow this proposal to be sustainable and that will maximise further opportunities for shifting the balance of care through investment in system and process change, and in further developing community-accessible solutions. In scope

• All hospitals within the Scottish Borders • All adults over 65 plus those adults classed as frail • Potential admissions to hospital from the community

Out of scope

• Children and Young People • Settings out with the Scottish Borders

Factors of Improvement This proposal utilises two fundamental factors to improve the delivery of care services across the health and social care spectrum. These improvement factors correlate with the three prime measures of success. The first and primary factor is that hospital stay is the highest risk to the morbidity and mortality of older people [Hoogerduijn et al, 2007].

There is substantial evidence that at least 20% of all patients in hospital do not need to be in a hospital bed and are ready for discharge, having been identified against recognised criteria as medically fit and waiting for further intervention to facilitate a safe discharge, e.g. social care assessment. A further percentage will be people who were inappropriately admitted to hospital due to no other safe intervention at the time of presentation. Within the NHS in the Scottish Borders it has been established following Day of Care Audits, that at least 20% of patients do not require hospital care. This is broadly consistent across the country, ranging from 20% to almost 30%.

The second factor is that some admissions are unnecessary, and will contribute to people being in hospital when that is not what is needed by an individual person.

Prevention of admission is an essential approach to inappropriate or unnecessary hospital usage. Yet we know that factors resulting in admission for older people are complex and multi-factorial. The provision of sensible and sensitive support in the community or individual setting will be important. This will require careful selection as some approaches that seek to reduce admission for the frail elderly are unsuccessful. There is better evidence for those approaches that reduce length of stay, and manage an admission rigorously to clinical necessity [D’Souza & Gupta, 2013]. Both are required as a blended

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response to ensure a successful and far-reaching quantum of impact.

The way we work across health and social care and how we work with our partners in the Private and Third Sector creates many of the issues, and we work increasingly in circles and cycles that are multi-directional and take sub-optimal advantage of complementary opportunities. Programme Delivery The delivery struts of the programme will be accessible across health and social care as a combined unit as follows:

1. System Elastic – the establishment of flex beds for assessment, intermediate care or an improved care environment for patients awaiting adaptations,

2. Triple Track Consistency – the coordination of consistent assessment and discharge within hospitals.

3. Home Advantage – rapid access to home care. 4. Leading Realtime - real-time delivery, performance and information-

driven decision making Success measures The three key measures of success are :

1. No patient in hospital who is medically fit for discharge 2. Hospitals operating at 80% occupancy 3. Create the conditions to reduce the need for care by 25% through

more anticipatory and more responsive care provision.

NHS Borders Clinical Strategy and Unscheduled Care

The Current Service Our current delivery model for the provision of GP out of hour’s services is heavily reliant on a salaried GP workforce supplemented by a cohort of GP with a sessional contract but with no fixed commitment. GPs are supported in the evening and overnight by district nursing teams, and specialist practitioner nurses. Over the last year it has become increasingly difficult to recruit to vacant posts within the GP Out of Hours service and it has become increasing problematic to fill all shifts, particularly within peripheral units. In response to the increasing workforce challenge, during the course of 2013/14 NHS Borders has moved to consolidate GP resource to a central co-ordinating site in order to ensure that a safe and effective service can be maintained across the entire region according to patient need. While the service has reduced the number of operational sites, the actual reduction in available GP hours has been marginal. The move is entirely aimed at ensuring NHS Borders has a much more resilient delivery model given current work force issues. However, it is also recognised that, in light of the national workforce issues that exist with GPs working in the out of hours period, the potential for new models of service delivery that remove this dependency needs to be explored. NHS Borders is currently consulting on a new Clinical Strategy based around 6 key principles that can be applied across the board to clinical and non-clinical services. These principles will help shape the future of service provision within the Scottish Borders. Listed below are the impacts these would have on unscheduled care.

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How the service could look if the Key Principles were applied Applying the principles outlined in the Clinical Strategy might suggest that NHS Borders should look to maximise the individual contributions made by Community Nursing Teams, the Borders Emergency Care Service (BECS) and the Emergency Department by looking at combining and pooling resources in responding to unscheduled and emergency work. This would increase individual service resilience and offer the potential for maximum service effectiveness. Principle 1: Services will be Safe, Effective and High Quality This service would be provided across a range of areas, but in the first instance in an integrated Emergency Department and Borders Emergency Care Service (BECS). It would be provided by a multidisciplinary workforce (professionals with different fields of expertise) with generic skills. This would increase resilience of the service and increase the pool of staff to deal with all situations including home visits. All staff would be trained to a common and established standard. Patients would access unscheduled care through a single hub - whether this is by walking into the department, being referred by NHS 24 or through professional to professional contact. Principle 2: Services will be Person-Centred and Seamless A single point of contact and a team with generic skills would be provided. Patients would be seen in a co-ordinated and seamless way, without multiple handovers and various clinicians involved in their care, and as close to a patients home as it is safe and effective to support. Principle 3: Health Improvement and Prevention will be as important as treatment of illness As part of the wider work in unscheduled care, anticipatory care plans would be developed for all patients that might benefit from such an approach. For patients with long term conditions this means their needs will be anticipated and NHS Borders will strive to address any problems before they become clinical emergencies. Self management would be encouraged and patients would know who to turn to for help without recourse to the emergency care service. Principle 4: Services will be delivered as close to home as possible The services would make greater use of technology to assess patients in their own homes or place of care. Home visits and assessments would be carried out by the most appropriate clinician, for example the paramedic, the nurse or a doctor. If a visit to hospital is necessary this assessment would take place in the central hub with access to diagnostics and specialist opinion as appropriate and where necessary. Communication between professionals would be improved to ensure that only patients that require specialist hospital assessment will be transferred. Principle 5: As a consequence of the above principle, admission to hospital will only happen when necessary, and will be brief and smooth. By assessing all patients brought in by ambulance in a central hub, access to specialist advice and investigations would help minimise the need for admissions. The wider unscheduled care redesign would focus on ambulatory care and rapid seven day access to hospital assessment. This would prevent the need for admission unless medically necessary. The integration of services would ensure that services in the community wrap

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around the patients, allowing them to stay at home for as long as possible. Principle 6: Services will be delivered efficiently, within available means A changed service would move away from NHS Borders’ current workforce dependencies. A new redesigned service would be delivered within the existing resource package yet deliver a resilient, responsive, safe and effective service that continues to meet the needs of the local population. What would be different: The service would be integrated and seamless. Changes in the workforce would make the service less dependent on the doctor and as a consequence much more resilient for the long term.

Compliance with 4hr HEAT target

NHS Borders has consistently met the access target during 2013/14 and aims to continue to do so during 2014/15. NHS Borders’ current performance can be seen below: 4 Hour Compliance Oct-13 Nov-13 Dec-13 Jan-14

Borders 98.0% 97.9% 97.9% 96.4%

While the current national target for the access standard is 95%, NHS Borders has committed to maintaining performance at or above 98%. During 2014/15 NHS Borders will continue to plan for service delivery at 98%.

Change Fund Projects

Integrated Assessment Rehab Service – this project aims to ensure service users are appropriately admitted and remain in hospital for the minimum necessary period, and are, where possible, supported to independence in their own home. Fast Reaction Team - The team will consist of a seven day Link Worker post and Support Worker posts to facilitate a 48 hour maximum continuous care and support service for:

• Response to anticipatory care plan activation • Response to crises referrals via GP & district nurses to prevent • admissions to hospital • To assist with responding to early supported discharge

The Connected Care project is also funded by the Change Fund.

Key Documents

Local Unscheduled Care Action Plan (LUCAP) The 2013/14 LUCAP embedded below forms the basis of plans to make and sustain improvements in the provision of unscheduled care. This plan will be updated for 2014/15 over the coming months once again with a significant emphasis on planning for winter.

LUCAP ACTION

PLAN.doc

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Integrated Care Executive Lead: Jane Davidson

Integration of adult health and social care

There has been considerable work progressed to develop a comprehensive programme approach to ensure effective arrangements for the Integration of Adult Health & Social Care. Scottish Borders have agreed to progress the Body Corporate model. Key timescales for 2014/15:

• Establishment of a new body by 2015. • Agreement of the strategic plan – June 2015. • Agreement of Integration plan – March 2015. • Shadow Board arrangements to be in place by April 2014

including Shadow financial and performance reporting. • Appointment of Chief Officer post April/May 2014. • Workforce Plan/Organisational Plan agreement and

implementation. • Updated IT arrangements in place by April 2015.

The focus has been on improving outcomes for patients, service users, carers and broader communities and a number of key priority outcomes have been identified which underpins our approach. These are:

• People are safe and dignity and human rights respected. • People are as well as they can be and have positive experiences. • Carers feel valued and supported in their caring role. • Reduced delays/ length of stay.

A programme board has been established led by the Chief Executives of NHS Borders and Scottish Borders Council and and a number of project groups have been set up and are led by senior executive leads across the NHS and Council with appropriate stakeholder representation. These groups include: Commissioning and Locality Planning: to produce a joint strategic plan including service redesign proposals and locality planning with appropriate engagement and consultation. Governance and Legal: to establish robust governance arrangements as part of the integration plan. Workforce Development: to support the development of a workforce organisational and training plan and advise on workforce issues. Financial Arrangements: to develop effective joint resourcing arrangements. Information and Performance Reporting: to provide solutions for information sharing and put in place joint performance reporting arrangements. A focus on clinical and care governance has been recognised as important across all of these areas to monitor quality and ensure a joint

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Anticipatory Care

Anticipatory care is now part of QOF within the Quality & Productivity Domain (see indicators for 2013 / 14 below). QP005(S). The contractor participates in an external peer review with either a group of local practices, or practices from within the board area, to compare its data on emergency admissions and to share the learning from at least 25 per cent of the Anticipatory Care Plans (ACPs) completed for QP007(S), and proposes areas for internal practice improvement and service design improvements for the NHS Board. QP006(S). The contractor produces a list of 5 per cent of patients in the practice, who are predicted to be at significant risk of emergency admission or unscheduled care. This list can be produced using a risk profiling tool accessible to practices e.g. SPARRA, or where this is not available/required (by local agreement), alternative arrangements can be agreed between the NHS Board and LMC.

approach to service improvement in the new arrangements. Underpinning this is the implementation of a joint action plan arising from a joint review of the recent Mid Staffordshire and related reports which is currently being taken forward.

Joint strategic commissioning and resourcing plan

A commissioning & locality planning group has been established to develop the Strategic Plan with all key stakeholders. A joint resourcing group has also been established with key tasks to develop a shadow budget and reporting arrangements.

Engaging professionals and partners

Communication and engagement of all key stakeholders is recognised as an important part of change management and this will be a key priority area for the partnership over the coming months.

The Programme arrangements include all key stakeholder groups and professionals. A revised joint staff forum has been set up including union representation from both the NHS and Council along with processes to ensure public and patient views are central to the development of the new arrangements as they emerge.

Assets-based approach

There is a focus on delivering key outcomes for people using services and building on the strength of individuals and those of communities / localities. This work is carried out in several ways including: through the Early Years Health Improvement workstream, building community capacity with peer support and parent led initiatives; and by the Healthy Living Network (Joint Health Improvement Team) through community led health projects. This work will continue to build on good practice and current partnership work.

Care for Multiple and Chronic Illnesses Executive Lead: Jane Davidson

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QP007(S). The contractor identifies a minimum of 15 per cent (in 2014/15, 30 per cent) of those patients from the list produced in indicator QP006(S) who would most benefit from an Anticipatory Care Plan (the ACP must include a poly-pharmacy review, be shared with the local out of hours service and has an appropriate review date). The frequency of each patient’s review should be determined in the light of their clinical and care needs. The contractor will be responsible for ensuring that an appropriate system is in place for monitoring and reviewing the patients identified in this cohort. QP008(S). The contractor holds at least 4 meetings during the year to review the needs of the relevant patients in the practice ACP cohort, to agree any required changes in the patient management and to share learning/ identify learning needs. These meetings should be open to multi-disciplinary professionals who support the practice’s patients. QP009(S). The contractor produces and submits a report to the Board before 15 March 2014 on internal practice and wider NHS Board system changes that may benefit patients with Anticipatory Care Plans (ACPs). The report should include Significant Events Reviews (SERs) on 1/1000, to a maximum of 3 patients per practice, of patients with ACPs from the cohort in QP007(S), who were admitted during the QOF year, after their ACP had been created. If less than the required number of patients with ACPs were admitted during the QOF year then the practice should write SERs of the care of an equivalent number of these patients who remained in the community. Borders GP practices are all now using the Key Information Summary (KIS) for patients identified as requiring anticipatory care planning. KIS documents are shared with out of hours services and A&E clinicians to ensure continuity of care for patients. Two of the 2013 / 14 Local Enhanced Services have specific requirements linked to anticipatory care planning: Polypharmacy and Care Homes.

Care Homes LES 201314.pdfforRoutem

Polypharmacy LES 2013-14 for Routema

The two Enhanced Services referenced within this section relate to over 75s; this is intentional as these are specific Enhanced Services in support of standards and targets relating to improving care, reducing emergency admissions and attendances for this age group. However, the QOF Anticipatory Care indicators listed in this section cover all adults, not just over 65s or over 75s; the multidisciplinary team in each practice consider which adult patients from their registers, caseloads and local knowledge are more vulnerable or complex and who would benefit from having anticipatory care plans and take this forward in line with the indicators. It must be noted that GP practices are able to choose which indicators they wish to work on and in which enhanced services they wish to

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participate. In Borders all 23 GP practices are participating in the Polypharmacy Enhanced Service and QPQOF Anticipatory Care.

Long Term Conditions

NHS Borders has previously developed “Living Well with Long Term Condition: A Strategy for the Management of Long Term Conditions in Adults 2008 – 2013” (see below) which established workstreams, actions and principles relating to adult care (all ages). This work has been mainstreamed and embedded into standard practice or incorporated within ongoing improvement programmes and therefore a specific follow up Long Term Conditions Strategy was felt to be unnecessary. The generic pathway developed as part of the original strategy continues to be used in planning and improving services for adults with multiple co-morbidities and is embedded separately below for ease of reference.

Approved LTC

Strategy 3rdDec08.pd composite LTC pathway.pdf

Co-Morbidities

While there are a number of specialist services within NHS Borders which support patients with single conditions (e.g. Diabetes Specialist Nurses), in primary care, clinicians work daily with adults with multiple co-morbidities as a matter of course. In addition, the Managed Care Networks in Borders work together to provide a more integrated approach to care and support wherever relevant e.g. around palliative care (both malignant and non-malignant). Protected learning sessions (e.g. TiME) for primary care clinicians support training & education and access for patients and members of the public to information and resources is available (e.g. Borders Health in Hand website).

Chronic Pain Service

In the last six months the chronic pain multidisciplinary team has been re-established providing a bio-psychosocial approach to chronic pain management as recommended by the Scottish Model. Clinics are now available across disciplines in psychology, physiotherapy, specialist nursing and occupational therapy. Previous services have also been re-established, which has been a waiting list incentive (Allied Health Professional acupuncture list and Pain Self Management Programme) and new services are being planned (evening psychology appointments and Qutenza patch treatments). Over the next year it is anticipated that full demand and capacity and service sustainability proposals will be developed as well as identification of potential for further development in line with the national Scottish model of chronic pain management, (a strategy which is supported by the Scottish Government). Goals include revising systems for collecting and collating activity data, development of links with primary care and provision of outreach services.

Detect Cancer Early

Use of quarterly submission data to facilitate identification of epidemiology of individual cancers to inform local service provision and delivery.

2. Health of the Population

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The changing demographic profile within the Borders poses challenges for population health improvement, with significant growth projected in the number of older adults and reduction in the proportion of the population of working age, which will alter dependency relationships. Overall the health profile of people in Scottish Borders compares well with Scottish averages on most indicators. However the Single Outcomes Agreement in 2013 noted that this masks considerable variation within the Borders among local communities on a number of key indicators, (e.g. households living in poverty, breastfeeding rates, smoking rates, etc). These variations are associated with deprivation and, in particular, rurality as this has an impact on access to services. Demands on health care services can be reduced by improving population health and well-being. NHS Borders has an important role to play in this along with our key partners within Scottish Borders Council and the third sector. This section will set out the actions NHS Borders in taking in the priority areas of:

• Early Years • Health Inequalities • Prevention

Development of integrated locality model of service delivery

NHS is a partner in the development of Early Years Centres in four areas of high deprivation across Borders with wider roll out over time and as resources allow. Through these Centres, partners will implement a multi-agency approach, underpinned by the GIRFEC methodology, to support families with a focus on those who are hard to reach. Further development of locality Early Years Networks will take place as a means to improve communication, information sharing and equity of approach. We will use data from 27 month Child Health Reviews to improve attainment of developmental milestones.

Parenting support

The staged implementation of the recent joint Parenting Strategy includes participation in Wave 4 of the Psychology of Parenting programme from 2014. We will engage with learning disability services to support expectant and new parents with a learning disability. Implementation of GIRFEC practice model will support smooth transitions into and between services.

Maternity care and maternal and infant nutrition

We will continue to implement the renewed antenatal education programme, with a focus on promoting early access and consistency of messages for families across different services. We will develop information, support and pathways to enhance maternal health outcomes and reduce health inequalities in relation to tobacco,

Early Years Executive Lead: Eric Baijal

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alcohol and mental health. Promotion of maternal and infant nutrition will take place, including Baby Friendly Initiative Stage 3 accreditation for community and maternity services. Child Healthy Weight programme implementation in early years settings will be focusing on building the capacity of the early years workforce to support nutrition and on targeted work with vulnerable families.

Community capacity building

Continued delivery of collaborative programmes through Healthy Living Network and Community Learning and Development and the third sector to develop skills, confidence and opportunities. Wider engagement with parents in service planning and delivery will also be taken forward.

Early Years Collaborative

Implementation of improvement programme to achieve agreed priorities relevant to the four national stretch aims. Key areas of action include: establishing baseline data; training in improvement methodology for Early Years practitioners; development of tests of change and relevant scaling up. Improvement work will focus on the key changes highlighted nationally as priorities, including promotion of attachment and relationships; income maximisation and uptake of entitlements to services and benefits.

Early Years and early intervention

This is a Community Planning Partnership priority area and more information and actions planned and undertaken can be found in the NHS Borders Contribution to the Community Planning Partnership section.

Performance Measurement

Local improvement measures are being developed to enable monitoring of performance and to demonstrate progress towards the stretch aims and local strategic objectives.

Key Documents

Joint Early Years Strategy Contains Early Years Collaborative stretch aims.

Y:\early years\Early Years Strategy.pdf

NHS Borders Child Health Strategy Desired outcomes and measures of improvement included in strategy appendix.

CHILDYP STRATEGY FINAL.pdf

Maternity Care Action Plan Contains objectives for antenatal access, smoking in pregnancy and

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breastfeeding rates.

Y:\maternity\Mat planning grp\ACTION

Health Inequalities Executive Lead: Eric Baijal

Assets-based approach

Public Health is supporting older people’s community capacity building work in promoting access to exercise and physical activity in community and care settings. Enhancing volunteering to support health outcomes is important:

• Borders Healthy Living Network is developing a stronger volunteer base for community led health improvement across life stages.

• Peer support volunteering to support breast feeding will be expanded.

Tackling inequalities faced by people with a learning disability

The named NHS Borders lead for this work is Dr Allyson McCollam. The recent Learning Disability Needs assessment will be used to inform service planning and improvement and the Learning Disability Commissioning Strategy. Established health improvement work within Learning Disability (LD) services will be reflected in the developing local action plan for 'The keys to life', the national strategy for people with LD. This is being driven by the LD service in partnership across Scottish Borders. LD and Public Health are working together to promote awareness and develop skills and knowledge among service users, carers and frontline staff around: nutrition, healthy lifestyles, relationships and sexual health. We are active participants through LDS representation in the national LD Health Inequalities networks and were successful in securing Scottish Government funding for 3 specific health improvement LD projects:

• the 'Healthier Me' project - weight management and healthy lifestyle

• a sexual health project • iMUSE and intensive interactions which supports and promotes

communication, resilience and interaction. This is supported by Health Inequalities funding.

The first two were informed by data gathered from previous LD specific health check projects. We carry out proactive screening with all people with Downs Syndrome for dementia from the age of 30 onwards as well as having a reactive pathway for all referrals for dementia screening. We will also be a pilot site later this year for the implementation of a

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Health Outcomes Framework.

ADP is working with Social Work colleagues to develop appropriate approaches to alcohol screening. We have an LD liaison service to the Borders General Hospital supporting people with LD in planned and unplanned admissions. We also have plans to introduce a flag within TrakCare in the hospital for people with LD. There is still a need to improve identification of people with LD in primary and secondary care to ensure effective person-centred responses to needs and to enable data collection. Through our lead in Public Health we have also intimated our interest in engaging with the national work streams regarding data collection and management. An LD representative sits on the Equalities steering group within NHS Borders. We provide an introduction to Learning Disability within corporate induction training within NHS Borders.

We intend to work with Scottish Public Health Network (ScotPHN) and the Scottish Learning Disabilities Observatory (SLDO), guided by examples of good practise, to develop:

1. A secure database of adults with learning disabilities in the Scottish Borders complete with CHI numbers

2. A specific plan to measure some aspect of health/health care for this population

3. A health/health care improvement plan for this population and to develop existing ones.

Targeting resources to the most deprived

Development of partnership approaches in priority areas of high deprivation (Burnfoot and Langlee initially) to improve health and enhance access to health and social care. This includes targeted outreach of key programmes such as Keep Well. Targeted programmes for protected characteristics groups (eg. for migrant workers) shaped in response to identified needs to promote service access and uptake. Actions being taken forward by NHS Borders to mitigate the impact of welfare benefit reforms include:

• staged introduction of routine questions on finances into patient assessments to facilitate effective signposting to support services

• awareness raising and training for staff, • monitoring impacts on health care demand.

Further promotion of physical health for people with mental health problems through targeted programme delivery in acute and community mental health settings. To address common mental health problems, NHS Borders is working with partners to improve pathways to assistance with social and financial issues that affect health, such as access to: money advice, social support, opportunities for learning, arts and culture and skills

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development.

Health Inequalities and Physical Activity

This is a Community Planning Partnership priority area and more information and actions planned and undertaken can be found in the NHS Borders Contribution to the Community Planning Partnership section.

Prevention Executive Lead: Eric Baijal

Anticipatory care

• Lifestyle Advisor Support Service supports lifestyle change to reduce risk of ill health associated with CVD, diabetes and stroke

• Keep Well programme targets hard to reach groups • Counterweight and Lifestyle Advice offer person-centred

approaches Please see Care for Multiple and Chronic Illnesses section for more information on anticipatory care plans.

Gender Based Violence

NHS Borders continues to support the Pathways project that provides a co-ordinated interagency response to domestic abuse. NHS Borders leads locally on prevention work on behalf of the VAW Partnership. Public Health coordinates awareness raising and training within NHS Borders to improve early identification of domestic and other abuse and appropriate signposting to support for those affected.

Health Promoting Health Service

Plans are underway for a significant development of the NHS estate to promote physical activity and health and wellbeing, with the Green Partnership. Improvements are being implemented in pathways from secondary care to: smoking cessation services; physical activities opportunities, and support for mental health. E-learning will support workforce development in health behaviour change approaches.

Alcohol whole population approach

Alcohol Brief Intervention delivery continues in priority settings and also LASS, Keep Well and Community Mental Health Teams. Supporting development of wider settings including social work, police custody suites and exploring with learning disabilities services. Working with Education and Police colleagues to develop consistent model of substance misuse education in schools and young people’s settings.

Promoting healthy weight

NHS leads on implementation of a multi agency action plan to reduce barriers to healthy eating and physical activity in range of settings across the life span. Priorities are: promoting access to and availability of sustainable food; the development of knowledge and confidence in the health and social care workforce; reducing inequalities.

Sexual health Building capacity in partner organisations and educating young people and other target groups about healthy relationships and prevention of

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3. Value and Sustainability

As a health board we are faced by the familiar challenges of constrained resources and greater demand for our services. As such we recognise that in order to provide a sustainable model of service delivery we must promote innovation and encourage different, more efficient ways of working.

In addition we will continue to focus on our staff, our most valuable asset, who are central to the delivery of person centred, safe and sustainable healthcare. Included below is the approach we are taking to implementing Everyone Matters: 2020 Workforce Vision and how we plan to engage with staff and partners.

We work to a common set of corporate objectives and values which guide the work we do, the decisions we take and the way we treat each other. By promoting excellence in organisational behaviour we believe we can improve patient experience and the quality of care we provide.

This section sets out the actions NHS Borders in taking in the priority areas of:

STI’s, HIV and unwanted pregnancy.

DCE Communication activities maximise opportunities to raise awareness of the campaign amongst existing networks working with deprived communities and vulnerable groups. This includes supporting staff working within these settings to actively promote the uptake of screening, raise awareness of signs and symptoms, and encourage individuals to access their GP to get ‘checked out’ if at all concerned. Actions include assessment of uptake of screening from targeted areas, and an online staff survey to evaluate the effectiveness of the awareness campaign.

Tobacco Building capacity for tobacco prevention with young people in partnership with Community Learning & Development; targeted promotion of Smoke Free Homes.

Long term conditions management

A new project is being developed to support improvements in the self-management of long term conditions (LTCs) amongst older people. Supported through the ‘Older People’s Change Fund’, with a focus on those who are newly diagnosed or struggling to cope, this 2 year project will use trained volunteers to support implementation of agreed treatment plans. Overall aims include: • improved access to assessment, information, advice and support

(practical and emotional) for individuals and their carers; • improved health and well-being and reduced health inequalities; and • reduced demand for frequent calls and visits to GPs/Practice Nurses; The project will incorporate programme development, opportunities to test out new ways of offering support, and evaluation of impact.

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• Workforce • Innovation • Efficiency and Productivity

Plan for the 5 priority areas for action as set out in Everyone Matters: 2020 Workforce Vision Implementation Framework

1. Healthy Organisational Culture NHS Borders will ensure that our organisational and departmental inductions promote the values and behaviours expected of staff through building awareness of our corporate objectives. Adherence will be measured through the mandatory induction standards. Current staff have a responsibility to be aware of our corporate objectives and display the values and behaviours expected. Mechanisms to measure if this is happening will be introduced in the coming year, e.g. through joint development reviews/appraisal processes and reviewing patient/staff feedback etc. The iMatter Staff Experience Continuous Improvement Model will be introduced across NHS Borders. The Employee Director is engaging in this work at a national level. NHS Borders are committed to involving staff in decisions that affect them. Examples of this include the process adopted around redesign work which advocates the direct engagement of staff, and opportunities to engage at local level partnership forums. This year we are working on ensuring that all areas have the opportunity to engage in local partnership forums.

2. Sustainable Workforce NHS Borders will continue to facilitate a more joined up approach to Workforce Planning ensuring all relevant stakeholders (internally and externally are involved). The Vacancy Authorisation process ensures scrutiny on the recruitment and development processes within the board. Scenario Planning Techniques will be used to develop long term workforce planning projections in specific hot spot areas e.g. unscheduled care. The Local Workforce Modelling Tool supports us to consider workforce changes and potential impacts on services. NHS Borders made significant progress in relation to data quality in preparation for the introduction of eESS, and have continued to maintain high standards now that eESS is the Core system within HR for Workforce Data. Regular data reconciliation between HR and Payroll and data quality assurance checks will support NHS Borders to provide high quality workforce data. The lead officer will be an identified member of the workforce and resourcing team within NHS Borders with a specific remit around quality control.

Workforce Executive Lead: June Smyth

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NHS Borders are also considering the development of Ward View to a hospital wide model which would help in identifying areas of potential pressure in the system and allow proactive decision-making on staffing levels. Our Workforce Plans will continue to include education and training needs and be closely linked with education governance/learning and development strategies. Workforce Risks will be monitored using our existing Workforce Risk Assessment Template as part of all redesign processes. Workforce risks from ongoing service redesigns are collated onto our central Service Redesign Inventory ensuring risks across Acute, Primary and Community services are considered. Potential early release schemes will be considered in the context of the Audit Scotland “Early Departures” report, and be driven by recommendations highlighted in our Local Workforce Plan to ensure Service Sustainability is at the heart of decisions.

3. Capable Workforce NHS Borders Statutory and Mandatory Training Authorisation Performa will be used to identify all courses that are required by specific staff groups, e.g. Clinical/Support Staff etc. This will support the aim to ensure that all staff are appropriately trained and have access to learning and development. There will also be further development of the Training Needs Assessment. NHS Borders has now achieved the JDR Target/Standard for the last few years. Managers are supported to do this by champions who support them to develop realistic trajectories and provide technical support where required. A working group will further consider the template questions asked during Joint Development Reviews. This will help to ensure that Joint Development Reviews are meaningful. The Senior Charge Nurse Review is an example of where we are building capacity and capability to improve the quality of what we do. NHS Borders are currently piloting having this role as supernumerary and the development of dashboards etc is giving managers information required to improve quality. The Patient Safety Programme and Executive Walkrounds further support our aim to ensure a capable workforce and the exec team use this opportunity to promote corporate objectives, KSF etc. In relation to recruitment NHS Borders are considering introducing mandatory training for managers / recruiting staff re recruitment, and redefining NHS Borders recruitment around caring behaviours and competency based approach.

4. Integrated Workforce

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NHS Borders are developing managerial structures and processes across Clinical Boards and more integrated structures across acute and primary care. This will support NHS Borders aim to bring Clinical Services across primary, acute and community together. An integrated approach will support discharge planning and patient flow across the system, including with partners from across health and social care, therefore improving the quality of care for our patients. Specific examples of developing a more integrated workforce include:

• 11 O’Clock Team – Daily patient flow meeting in the BGH. • Community Day Hospitals reference group. • Joint Workforce Group, chaired by the Director of Workforce and

Planning. • Integrated Workforce Planning and Development Meeting with

SBC and NHS Borders • Joint Early Years Network • Joint Learning Disabilities Group • Joint integrated staff forum • Early years assessment team including Surestart midwives

5. Effective Leadership and Management NHS Borders continue to offer new managers first line manager training. This course gives managers practical skills required and support mechanisms to manage staff fairly and consistently across NHS Borders. This programme focuses on 3 specific areas; the manager as a leader, managing people and managing performance. NHS Borders also provide an opportunity to Senior Managers to join the Strategic Leaders Development programme which is hosted by Scottish Borders Council. This programme provides an excellent opportunity for senior leaders/heads of service to work with colleagues to develop existing leadership skills in order to meet ever more complex challenges at a strategic level. NHS Borders are engaging in national leadership development courses and work to embed leadership behaviours through our corporate objective is being taken forward through the Board Executive Team. All management training also concentrates on behaviours. 360 appraisal is also used for all staff at Band 8 level and above.

NHS Borders approach to engaging staff & partners

• Ask the Board • Staff Survey • Local Partnership Forums • Staff Side • Chief Executive Forum • Joint Staff Forum

Actions to • 110 employees attended 2020 vision workshops

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embed NHS Core Values

• Progressing Staff Governance Action Plan • Local Workforce Conference • Using Training Events opportunities – e.g. induction and sickness

absence

Innovation Executive Lead: Jane Davidson

How we plan to support innovation

Life expectancy is higher within the Scottish Borders than the average for Scotland as a whole; therefore there is a need to develop an integrated health and social care service that will meet future demand. The Cooksey Report in 2006 highlighted the need for innovation to be translated into health and economic benefits and as integration develops, the role of research will help ensure this is achieved. In order to increase capacity, NHS Borders will encourage research activity within current specialities. This will include non commercial and commercial research studies. Innovative use of research findings will help identify and shape local priorities. The intention is to develop an integrated research and innovation approach across health and social care. It is proposed to do this initially through the Connected Care and Change Fund. Through encouraging staff participation in research, NHS Borders will increase research capacity. The Clinical Academic Strategy developed in collaboration with Napier University will support research in nursing and midwifery. Similar academic partnerships with other education establishments will be sought to support research within other health and social care professions. In addition to increasing academic partnerships, partnerships will also be sought with industry thus increasing research innovation. Dissemination of research outcomes will drive service improvement and shape care delivery. A research and innovation approach will facilitate the monitoring of compliance with research governance requirements across the different organisations bringing all partners in line with health. This will ensure the health and social care needs of the Scottish Borders population are identified and appropriate steps taken to meet these. In addition this will enable a stronger knowledge base to be built and reduce inefficiency. Measurements of success of the research and innovation approach will be: • Number of partnership studies undertaken • Publication of outcomes • Level of income generated

Examples of innovation

• Development of robust measurement tools for performance

monitoring.

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S:\Shared

Documents\srae\Effe

Efficiency and Productivity Executive Lead: Carol Gillie

NHS Borders approach to efficiency and productivity

A number of programmes have been initiated across NHS Borders Health Board to scrutinise services for financial and workforce efficiencies and also to improve quality and increase productivity in all areas. This is in line with NHS Borders financial strategy and will underpin the organisation’s Clinical Strategy. The Clinical Strategy being developed throughout 2013/14 is in recognition of the increasing financial and demographic demands on NHS Borders. The basis of the Strategy work has been to develop 6 key principles for the delivery of safe, effective and affordable services. These principles will require full engagement from our patients, carers, staff and partners, so a public consultation will be held during the Spring 2014. Once the final principles are agreed future service redesign will need to meet these principles. An Efficiency Board was set up to facilitate the delivery of the required recurring and non-recurring efficiency savings which will ensure NHS Borders obtains financial balance. Its aim is to support NHS Borders to deliver safe, effective and sustainable services within available resources. The objectives of the Efficiency Board are to:

• Ensure all recurring and non-recurring savings targets are delivered.

• Identify opportunities for efficiencies across the organisation. • Monitor progress against agreed milestones/trajectories. • Agree corrective action for any deviation from the plan. • Consider, approve and monitor invest to save bids. • Ensure delivery against Efficient Government targets. • Ensure delivery against the NHS Scotland Efficiency and

Productivity Programme. • Overview outputs from efficiency projects to facilitate savings. • Engage with clinicians, when relevant, to ensure clinical

engagement at appropriate levels within each project.

Projects are monitored through the Efficiency Board with Project Managers submitting monthly updates to provide a summary of progress. The Programme for 2014/15 aims to produce £4.575m savings. It is also essential that all clinical and non-clinical services are reviewed to ensure the workforce and models of delivery are fit for purpose. The Productivity and Benchmarking process is well established within NHS Borders to identify and challenge variances in terms of staffing levels, demand and performance. Each service is asked to assess their current workforce skill mix as to whether it is fit for the future and make recommendations on improved performance that can be delivered through changes requested. It has been agreed as one of the action

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points from the Clinical Strategy work that each service’s proposal is scrutinised against the 6 key principles to be agreed after the consultation process. A refined process is being developed for the year ahead. The scheduled work plan for 2014/15 includes reviews of the Nurse Bank, Cardiology, Mental Health administration, ENT, and the Department of Medicine for the Elderly.

Application of nursing and midwifery workload and workforce planning tools

NHS Borders are developing a roll out plan to ensure all relevant areas review workload establishments using the appropriate nationally developed Workload Tools on an annual basis, and produce a summary report of its findings. This will be supported by an associate director of nursing with a lead role around Workforce and a member of the Workforce Planning and Resourcing Team. The Director of Nursing is also a key member of the National Oversight Group.

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Section 2: A Strategic Assessment of a Health Board’s Capability and Capacity to Deliver the 2020 Vision for Primary Care

NHS Board:

Consideration:

Strategic Theme:

Current Service Strengths Current Barriers to Achieving the Future

Vision

Proposed Local Interventions

Necessary resource shift identified

Service planning

1. 2013/14 Local Enhanced Services (LES)

LESs have been realigned in accordance with local priorities, the NHSS Quality Strategy and the Scottish Patient Safety Programme.

Current LES programme:

• Polypharmacy

Capacity within GP practices to respond effectively to numerous Directed and Local Enhanced Services.

P&CS are currently redeveloping the Primary Care Strategy in line with 2020 Vision, local and national priorities.

Liaison is ongoing with General Practices via LNC and GP Sub as well as within P&CS Board to ensure an appropriate number of LESs are established for 2014/15 which incorporate relevant priorities and are in line with

Developing new models of care in primary care settings will require some modernisation resource to establish a strategic primary care development team with designated expertise and time to support local teams develop new models and supporting arrangements.

The integration agenda will reduce duplication of care and workload and will create efficiencies across traditional boundaries. The total impact

BORDERS

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Consideration:

Strategic Theme:


Vision



• Prescribing • BBV • Alcohol BI • Minor Injury • IUCD • Anticoagulant

monitoring (warfarin) • Keep Well • Care Homes • Contraceptive

Implants (Nexplanon) • Near Patient Testing

(DMARDS) • MMR Catch Up

the 2020 Vision.

Pharmacy services have been involved in the development of the Enhanced Services

of the shifts in care to primary care setting and the impact on primary care practitioners and community teams is not easy to identify and plan for. The emerging Joint Commissioning work must help to ensure that the local models of care are fit for purpose.

2. Pathways

Work has been done to improve pathways and referral patterns from primary to secondary care.

• Development of RefHelp as a web-based easily accessible desktop resource for GPs to provide guidance about

P&CS propose to further develop shared care agreements across primary and secondary care e.g. around medicines management.

P&CS propose to develop plans for wider GP roles e.g. in A&E and to develop professional-to-professional

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Consideration:

Strategic Theme:


Vision



referrals and condition management.

• Review of GP referrals to Rheumatology resulting in the development of supportive information and resources for referrers. Similar work done for breast cancer.

• QPQOF work for 2013/14 includes Lothian referral pathway, referrals to rheumatology service BGH, use of and feedback regarding RefHelp

• MCNs: there are 6 MCNs in Borders (Diabetes, CHD, Respiratory Conditions, Palliative Care, Stroke and Neurology). The MCNs workplans aim to improve clinical pathways.

practices

3. Community Nursing Service Redesign

A nursing workforce review and review of treatment

Limited understanding of demand and capacity to

Ongoing dialogue with involved services,

Although the community nursing redesign aims to

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Consideration:

Strategic Theme:


Vision



rooms has been undertaken and is currently being quality assessed for impact on care.

provide a 52 week service.

There are potential challenges for staff impacted by the redesign in terms of adapting to new ways of working.

independent contractors, partner agencies et al to shape appropriate and practicable redesign

maximise skills and support more efficient ways of working within existing resources, the shift in the balance of care from acute to community, coupled with an increasingly complex care requirement for many people now cared for at home compound the capacity difficulties faced.

4. Patient experience, involvement and engagement

• Work is underway to engage with patients and carers in collecting patient stories and gathering feedback to influence improvement using e.g. readmission interviews.

• Public members are an integral part of P&CS Board and other working groups.

It can be difficult at times to identify members of the public who are interested / able to engage and become involved in groups or programmes of work.

There is ongoing discussion and dialogue with the Public Reference Group and Public Involvement Office to ensure the most appropriate ways of engagement and involvement are established for individual groups, service redesign programmes and projects.

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Consideration:

Strategic Theme:


Vision



• Close working with voluntary organisations e.g. Red Cross, Borders Carers Centre etc.

5. Supporting Older People / Reducing Length of Stay / Reducing emergency admissions / readmissions

• Work is underway to

develop a new community services model incorporating community &day hospitals, home-based care and integrated working with acute and social care.

• AHP services have taken forward some service redesign to test different models of working around domiciliary care, reducing physiotherapy waiting times and supporting intermediate care

• Enabling Self-

Lack of capacity across primary care services is a challenge. Resources are required to enable any test of change. Resource sustainability will be essential if the model is then adopted Borders-wide.

There have been challenges around sustainable medical input to community hospitals.

Challenges around self management and capacity & training/education of all

Ongoing dialogue with involved services, independent contractors, partner agencies et al to shape appropriate and practicable redesign and to agree longer-term resource arrangements. Within this, work is ongoing in liaison with LNC and GP Sub to develop an appropriate and sustainable medical model.

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Consideration:

Strategic Theme:


Vision



Management for people with Long Term Conditions Project (led by Public Health).

• Borders Health in Hand (BHIH) website developed to provide people with appropriate information and resources; signpost to relevant support.

• BHIH also holds education resources & information for staff e.g. Self Management Toolkit.

• Crisis Management Sheet developed to enable people to access the right support at the right time.

• Anticipatory Care: Anticipatory care planning is now part of nGMS QOF within the Quality & Productivity Domain and all 23 GP practices are participating. Anticipatory care planning is also integral to 2 Local Enhanced Services:

involved services, culture shift for the public and engagement of independent contractors.

Challenges linked with Anticipatory Care Planning are that GP practices are able to choose which QOF indicators and Enhanced Services they wish to participate in, therefore there can be no guaranteed Borders-wide outcome. Enhanced Services run for 12 months with monitoring and review and can be changed or removed in subsequent year(s) through local negotiation.

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Consideration:

Strategic Theme:


Vision



Polypharmacy and Care Homes

6. Dental Services / Sexual Health / Lifestyle Advisory Service

Dental:

National policy changes require some realignment of dental services across Scotland with a move where appropriate of NHS patients to General Dental Practitioners. In NHS Borders, work is currently underway with local GDPs to progress this, beginning in two localities.

Lifestyle Advisory Service:

The service continues to be

Sexual Health:

Increasing numbers of patients are presenting with complex care needs and although GP practices are supporting more straightforward cases, service capacity is at a premium.

There is concern around the local longer-term sustainability of the “Keep Well” programme should support from national resources cease.

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Consideration:

Strategic Theme:


Vision



successful in providing support to achieve healthy lifestyles and well being, which contributes to better care outcomes and prevention of admissions. Pharmacy

A Draft Pharmaceutical Care Services Plan has been developed and is currently moving through a consultation process before being finalised. The Plan has been developed in consideration of Prescription for Excellence and the ongoing changes across community pharmacy. It highlights a number of opportunities for service development – amongst other things: to explore increased access eg at weekends; business continuity planning across community pharmacies; further development of medication compliance initiatives and medication

Consultation process underway and must conclude before finalising and implementation of a Pharmaceutical Care Services Plan.

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Consideration:

Strategic Theme:


Vision



review processes as well as developing the role of community pharmacies in the discharge process.

Part of this work will include exploration of future clinical leadership.

Unscheduled Care

Out of Hours services are managed within secondary care, however joint working between primary and secondary care is beginning to progress an Unscheduled Care Programme which will consider future service development and redesign. This programme which is in the very early stages, will explore the potential to develop the nursing role and reduce reliance on medical cover. It will build upon the use of telehealth and telecare and will form part of the LUCAP submission.

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Consideration:

Strategic Theme:


Vision



Interfaces and Integration

• See Service Planning section above for other items related to integrated working and improving interfaces.

• Cheviot project: The project aim is to test and implement a model for integrated health and social care teams in Cheviot locality and to establish the model for integrated teams across Scottish Borders.

• Co-location with Social Work colleagues has been achieved in two localities which has had positive impact upon communication and working practices.

• Close working exists with the independent optometrists who provide diabetic retinal screening services in support of the Borders wide programme.NHS Borders Out of Hours services and ED together with

Challenges can be encountered in achieving full commitment of partner agencies as services change and develop.

P&CS propose to develop plans for the development of the GP interface and within this to explore the use of an appropriate quality dashboard.

P&CS propose to build upon links with other independent contractors i.e. community pharmacists, GDPs, ophthalmologists.

See also the section above on service development.

The Change Fund and other aligned funding streams have already supported a programme of service improvement and redesign with more integrated solutions, and the development of capacity and capability in community settings. The investment has been targeted at programmes of work across Health and Social Care as well as within the Third Sector. This funding has been invaluable in enabling change.

Further work is required to explore any opportunities for disinvestment across the care sectors to enable sufficient capacity in community settings and through Primary Care contracting arrangements. It has been recognised that there is an increasing

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Consideration:

Strategic Theme:


Vision



Scottish Ambulance Service are currently piloting paramedics working to support out of hours unscheduled care activity.

• NHS 24 is a partner organisation in work to explore service redesign of out of hours services.

resource gap particularly around the support of care needs at home.

Building Community capacity will become an integral part of the integration agenda discussions with community planning partners.

Further clarification is required on the resources required for the delivery of integrated services as the Health and Social Care Partnership is established and how this will affect the funding of primary care.

Infrastructure

• Independent contracts are managed within P&CS but capacity is at a premium and all

• A Review of Primary Care Premises has been undertaken across health centres and priority sites have been identified for redevelopment or major reconfiguration. Work is

Current expertise is invested in one source and a spread of risk is required. Availability of Capital resources.

P&CS propose to explore options around the contract support role.

Work continues through the Primary Care Premises Modernisation programme to identify resource requirements for the development of premises within the capital planning process.

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Consideration:

Strategic Theme:


Vision



underway to progress outline plans in order to be prepared should any capital resources be made available. Work is also ongoing regarding minor works to improve facilities for patients and staff.

Workforce

• Productivity & Benchmarking has been undertaken in line with NHS Borders procedures which has led to review of P&CS clinical services re staffing levels, skill mix etc and of the management structure.

• A review of admin support is underway.

• A robust vacancy management process is in place.

• eKSF, JDRs and Training Plans are routinely monitored.

• Releasing Time to Care is progressing across all community nursing

The shift in the balance of care from acute to community, coupled with an increasingly complex care requirement for many people now cared for at home compound the capacity difficulties faced in community nursing.

There has been an increasing difficulty in recruiting to GP hours within BECS out of hours service and a general lack of availability of GP locums to support “in hours” patient care.

The integration agenda may release some efficiency across the workforce and the opportunity to review supporting roles and skill mix in primary care settings e.g. the community nursing review. Full details will be developed throughout 2014 as the new models of care are developed.

It is increasingly difficult to identify resource transfers from secondary to primary care but this continues to be a consideration as part of future service plans within a more integrated system.

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Consideration:

Strategic Theme:


Vision



disciplines. • A comprehensive review

of Treatment Rooms is underway which will result in a redesign of community nursing services (see Service Planning Section above).

Leadership

• Joint posts have been introduced at senior management level across acute & primary care and across health and social care e.g. General Manager, Acute, Primary & Community Services; Associate Director for AHPs

• P&CS personnel supported to take part in national leadership development programmes

• Associate Medical Director in lead role in NHS Borders for Scottish Patient Safety Programme in Primary Care

We will continue to work to identify the resources and support available for leadership in primary care settings. A national framework for these roles is key to how this can be progressed. The sharing of good practice across Health Boards will inform future developments.

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Consideration:

Strategic Theme:


Vision



Data and improvement

P&CS have adopted improvement methodology. Specific information is reviewed as standard practice to inform day-to-day operational decisions. Ad hoc data reports are used as needs be to support tests of change, individual work programmes, strategic planning & service redesign. Data regularly used:

• SPARRA • Bed occupancy • Admissions /

readmissions • Discharge & transfers • Length of stay • Referrals (to all

services; from primary to secondary care

• QOF analysis • Prevalence data • Community profiles

(Public Health) • GRO statistics &

population growth predictions

A huge barrier is the inability for IT systems to communicate with each other effectively. Sharing of information across services and agencies is essential if the 2020 Vision of a coordinated, integrated approach to health and social care is to be achieved. IT systems must interface appropriately between primary and secondary care and also, crucially, between healthcare services and social work services in order to support our patients and public.

Capacity within Planning & Performance is at a premium which can make it difficult for them to respond as they would wish to requests for ad hoc reports. Information

P&CS would highlight the need for development of appropriately interfacing IT systems as described and see this as essential in order to support the success of the 2020 Vision.

P&CS would value the development within NHS Borders of information analyst roles.

Shared resources and planning across care sectors and partner agencies must be explored if this agenda is to move forward in an integrated way.

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Consideration:

Strategic Theme:


Vision



• SBC housing plan • Prescribing • Enhanced Service

Returns • Financial

There is an increasing use of increasing use of electronic tools at the primary / secondary care interface e.g. ECS, eKIS and rollout of ePCS replacing previous Borders Palliative Care handover form; increasing use of EMIS PCS templates and EMIS Web in Enhanced Services to reduce bureaucracy/aid data extraction and reporting.

analyst posts within NHS Borders would offer welcome support and efficiency when planning service development and redesign.

The ever –increasing reliance on electronic systems brings with it increasing maintenance, installation and educational issues which impact on the capacity of IM&T support services.

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?

• Support & resources to ensure IT systems interface appropriately across healthcare sectors and crucially between health and social work services so that relevant information can be shared and patients / public can be properly supported.

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Section 3: NHS Borders Contribution to the Community Planning Partnership

Scottish Borders Community Planning Partnership

This section summarises key tangible contributions that NHS Borders plans to make during 2014/15 towards improved outcomes. These are grouped under 6 priority areas below. Each strand has its own monitoring structures in place to check on progress throughout the year.

Priority NHS Board Contribution in 2014/15 Current and Planned Performance Levels

Economic recovery and growth

Workforce

Maximising the potential of the NHS workforce through:

• Workforce Planning to develop the workforce and align resources with anticipated future demand and priorities.

• Supporting workforce health & well-being and productivity

NHS Borders has a relatively low staff turnover

NHS Borders’ Health Improvement Strategy for the Working Age Population recognises that work is a key determinant of health and continues to progress a range of activity that supports this agenda:

• Occupational health services designed to keep people

Key local deliverables in 2014 -15

• As services are reviewed through our integrated Workforce Planning and Productivity and Benchmarking Process, optimum staffing levels are agreed based on nationally/locally developed workload tools leading to more efficient and effective patient outcomes.


• NHS Borders will progress outcomes of Age as an Asset research conducted by NES to support employees to continue to work.

• The Borders Leadership Programme will

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at work and support those returning to work. • Rapid access to vocational rehabilitation through

Workplace Health Services initiative. • Workplace Health promotion including the Healthy

Working Lives Award scheme. • Development of a support pathway and signposting

resource for healthcare workers to support those to whom health is a barrier to attaining, retaining or returning to work.

Infrastructure and economic development

Engagement through the CPP in development of an effective local infrastructure for Scottish Borders that will provide basis for economic development through the new railway and faster broadband. A stronger infrastructure will contribute to the attraction and retention of staff and provide a platform for increased use of technologies in delivery of health care and related information and advice.

continue in 2014/15 to motivate and develop the leadership cohort.

• NHS Borders Work Place Health Services will continue to expand the number of organisations accessing support and engaging in services.


• The Chief Executive of NHS Borders sits on the Broadband Project Board.

• A stronger infrastructure will support Workforce Planning aim to ensure a sustainable, flexible workforce.

• There are also benefits in improvements in accessibility to Borders General Hospital for out of area patients, and for staff travelling to all locations.

Employment

The NHS has a role, with other partners, in promoting employability by providing training and work opportunities for those seeking entry or returning to the labour market and by maximising the retention of staff who have or develop health conditions.

In collaboration with partners, NHS is working to ease access to work for patients with a range of conditions


• NHS Borders is working with Skills Development Scotland and Borders College to provide training for work opportunities as part of the ‘Get Ready for Work’ (GRFW) scheme. A partnership agreement will be developed with Scottish Borders Council to encompass all elements of employability.

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including those with mental health problems, learning disability and alcohol or drug issues.

NHS Borders are involved in the Joint Staff Forum with Scottish Borders Council.

• Recent discussions have been held with Job Centre Plus to explore further opportunities to support people into employment through the Job Centre Plus sector based work academy scheme within care. Additionally we are offering opportunities in Estates and Facilities who are facing particular aging workforce demography challenges.

• 10 young people have recently been selected to commence placements including in Admin, Catering and Estates and 3 for the Care Services programme as Health Care Support Workers commencing March 2013.


• Implementing the joint development strategy.

Early years and early intervention

Early Years

Local partners are committed to working towards the ‘stretch aims’ set by the Early Years (EY) Collaborative to reduce infant mortality and increase the achievement of child development milestones. This is framed in the context of the locally defined objectives of the joint Early Years strategy, to develop integrated local systems of information, advice and support for parents and to strengthen community capacity.

Public health nursing services are recognised as playing a


• The establishment of 6 Early Years networks with leadership from Community Nurse Managers is now being consolidated.

• Development of a locality model of Early Years provision by August 2014.

• First stages of implementation of national Psychology of Parenting programme from October 2014.

• GIRFEC is now being embedded in practice of maternity and community health staff.

• Improvement methods are being used to

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key role in the leadership and development of local Early Years networks to support families from pregnancy.

The NHS Early Years Change Fund monies support key activities and resources that contribute to the jointly agreed outcomes, in relation to dental health, nutrition, healthy weight, maternal health and antenatal and postnatal parenting support.

Promoting Healthy Weight

Public Health (PH) leads on the implementation of a cross cutting action plan to promote healthy weight for Borders population.

PH and Dietetics services deliver a range of programmes and interventions on nutrition, weight management and health behaviour change across age groups and settings.

A cross service working group involving SBC Education, Catering services and PH is identifying options to improve nutrition for children in school.

Tailored training and awareness raising sessions on food and health are being delivered for community based staff and volunteers working with a range of vulnerable groups.

With wider partners, PH is facilitating the development of

implement pathways of support for women who have increased health and social risks including: smoking in pregnancy, poor nutrition and alcohol or drugs related issues.

• Improved identification of families affected by benefits concerns to ensure effective signposting from health care to benefits advice and support.

• Capacity building in health visiting to address health inequalities.


• Support national outcomes to reduce obesity and overweight.

• Community based programmes on healthy eating and active living.

• Policy recommendations for SBC on nutrition in schools to be developed following publication of new national guidance on nutrition in schools and the food environment around schools.

• Expansion of training programmes for social care staff, carers and volunteers on nutrition and food hygiene, in learning disabilities. Piloting in other social care settings as opportunities arise.

• Continuation of development work on local Food Networks to facilitate access to sustainable food and encourage local growing

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local food network with a view to producing a local food plan.

Suicide Prevention

The local suicide prevention priorities and action plan, led by the Joint Health Improvement Team, in partnership with NHS services and wider partners are being reviewed in the light of the national strategy (2013). Service improvement in mental health contributes to reduce suicide risk, through redesign of facilities, introduction of additional supports for discharged patients and a continued programme of staff training and development. Local programmes have been developed for young people in schools and for men with poor mental health.

Anticipatory Care

The integrated programme of anticipatory care in NHS Borders brings together lifestyle advice, inequalities targeted health checks and weight management programmes, based in primary care.

These combined services provide effective screening and assessment to identify early risk of diseases including

and skills development.


• Revised action plan on suicide prevention informed by new national strategy.

• Improve local information sharing on suicides and associated risks to ensure effective targeting of effort and resources.

• Revised training and development programme for frontline staff and community members.

• Improve pathways to support for people in distress who present to health services.

• Roll out of young people and men’s programmes supported by Public Health.


• Extension of inequalities targeted health checks to vulnerable groups in selected settings outwith than primary care.

• Continued delivery of the integrated service model.

• Achievement of HEAT target. • Maintenance of positive outcomes for

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CVD and diabetes.

Young people

Health Improvement work focused on vulnerable young people is a key component of the work programme led by the JHIT:

• Tobacco prevention, in partnership with Community Learning.

• Substance misuse education (SME) in schools. • Sexual health and relationships. • Child Healthy Weight (CHW). • Young carers health and wellbeing.

Mental health and wellbeing

Joint Health Improvement Team supports partnership work to build capacity to improve mental health and wellbeing in local communities and with key groups and support those with common mental health problems.

Counterweight. • Pilot work with mental health services to

improve access to health screening and to health improvement services for mental health service users.


• Support the implementation of a co-ordinated approach to SME in schools across Borders.

• Capacity building to support implementation of the revised national SHARE sexual health and relationships programme.

• Continued delivery of CHW programme to achieve HEAT target and promote greater engagement in physical activity and healthy eating.

• Tailored health improvement with vulnerable young people including young carers and looked after young people.


• Mental strategy and needs assessment to be produced.

• Promote access to information and support for people experiencing poor mental health.

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CAMHS

The service now responds to young people up to age 18 (previously 16). This is intended to assist with transition into adulthood and to reflect the model of service delivery available elsewhere in Scotland.

Alcohol and Drugs

Whole population approach to Alcohol and Drugs misuse.

The ADP will continue to support work to reduce substance misuse related problems locally through:

• Delivery of Alcohol Brief Interventions (ABIs) in


• The service is working towards more partnership working with children and young people by way of focus groups and satisfaction feedback using new technology, as well as current questionnaires.

• The CAMHS Integrated Care Pathway will provide a more streamlined access to the service and assessment and treatment will be evidence based and effective. Outcome measures will continue to be used to evaluate this.

• To continue to achieve national waiting times for the service.

• Implementation of multi agency guidelines on prevention and management of self harm among young people.


• Delivery of 1,245 ABIs in Borders • Review of ABI delivery in Criminal Justice

Social Work setting and roll-out within Social Work.

• Development of local Early Intervention and Prevention action plan relating to substance misuse

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priority and wider settings. • Active membership of Local Licensing Forum. • Ensuring needs of children affected by parental

substance misuse are addressed (CAPSM).

• Revision and implementation of local CAPSM guidelines in line with GIRFEC arrangements.

Safer and stronger communities, and offending

Alcohol and Drugs Partnership

The ADP delivers joint work in partnership with Community Safety colleagues. NHS involvement includes supporting intelligence work to monitor new and emerging Drug Trends and safe distribution of needles and equipment to injecting drug users.

Adult Protection Violence against Women

NHS is an active partner in local VAW partnership. Public Health is leading on prevention activities including:

• Awareness raising in local communities. • Anti-stigma campaigns in sports clubs and youth

settings. • Extensive training programme with staff across

sectors. • Implementation of CEL 41 routine enquiry in key

NHS service settings.


• Continue Drug Trend Monitoring work actions. • Continue with Needle Exchange programme.


• Continuation of VAW prevention programme. • Collaboration in delivery of Pathways project

outcomes.

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• Facilitating access to new service (Pathways) for women and children affected by domestic abuse.

Offenders health needs assessment

Further work will be undertaken to build on recently conducted offenders health needs assessment, focusing on health improvement priorities.


Improve access to mainstream health improvement opportunities for offenders.

Health inequalities and physical activity

Health Inequalities

Borders Healthy Living Network is managed through Public Health in NHS Borders and facilitates a range of health improvement programmes in 5 high deprivation communities across Borders. Priorities are identified in partnership with local communities.

Current activities are focused on:

Food and health; building social connectedness; strengthening community capacity through opportunities for volunteering for health; poverty and health; mental health and wellbeing, and growing and cooking.

Inequalities related funding is used to reduce barriers to participation in health improvement activities through subsidised access, more local / targeted delivery of


• Increased engagement of community health volunteers.

• Achievement of target adult learning outcomes through health improvement programme participation.

• Targeted work with key sectors and communities: older people; young mothers; fathers and their children.

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specific programmes

Health Inequalities and Learning Disabilities

A health needs assessment for people with learning disability has been undertaken by Public Health in collaboration to inform planning and service development for this population. Health improvement for people with learning disability remains a priority building on effective work in 2013/14 on relationships and sexual health and healthier lifestyles. People with LD, carers, and staff from a range of services are actively involved.

Physical activity

NHS collaboration with Forestry Commission and other partners is identifying opportunities for the greening of NHS Estate.

Active travel is promoted where applicable e.g. through cycle purchase schemes for NHS staff.

A range of initiatives and activities is promoted for NHS staff including subsidised exercise classes and Team Challenge programmes.

NHS Borders has been participating in the national pilot to develop pathways to physical activity from primary care,


• Awareness raising and training for stakeholders on healthy weight and physical activity.

• Improved access to appropriate resources to support decisions and choices about relationships, sexual health and keeping safe.


• Implementation of the learning from the pilot on physical activity pathways from health services.

• Development of NHS estate to increase physical activity opportunities and engagement by staff, patients and the wider community.

• Continued support for staff health and wellbeing through physical activity initiatives.

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through the Lifestyle Adviser Support Service.

Tobacco

NHS specialist smoking cessation adviser resources are focused on areas of higher deprivation, with good outcomes.

The service also promotes Smoke Free Homes using a range of methods.

Smoking cessation support in pregnancy is being reviewed as part of an integrated approach to antenatal parent education and support, with maternity and primary health care services and non NHS community services.

Health screening

An outreach component is being developed for current awareness raising and screening programmes such as Detect Cancer Early to maximise reach and engagement. This entails working with homelessness services and third sector services that have existing relationships with key target groups.


• Implementation of tobacco pathway in secondary care.

• Implementing the revised maternal tobacco pathway.


• Piloting and implementation, as appropriate, of outreach awareness raising and screening with a range of groups including mental health service users.

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Enduring Mental Health Needs and Physical Health

A key challenge for 2014/15 is to review access and take up of opportunities for health screening and improvement by the group of people who have severe and enduring mental health needs. This group has been shown by a considerable body of recent research to have significantly lower life expectancy for both sexes than the general population.


• To undertake a review of take up of physical health and health improvement services by this care group.

• To develop and pilot in one area of the Borders a new way of delivering physical healthcare and health improvement services based on the above review.

Older people

Joint Older Peoples Needs Assessment

The recent older people’s health needs assessment provides an evidence base to guide joint commissioning and service development and highlights key opportunities for early intervention, prevention and health improvement with this age group. This will now be built on, through the relevant joint planning structures.

Reshaping Care Fund

The Older People’s Reshaping Care Fund work packages are in the following areas: Well Elderly, Telehealthcare, Pharmaceutical Care, Housing with Care, Extra Care Housing, Living Well with Dementia, Prevention of Falls


• Priorities from health needs assessment will inform service redesign and programme planning, including future use of the Change Fund.

• Implementation of Change Fund project on management of long term conditions in primary care and in partnership with the voluntary sector.


• Reduce emergency admissions to hospital for older adults over 75 and increase the number of these patients who are directly discharged home.

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and Anticipatory Care.

An example of this work is the Older People’s Liaison Service which streamlines protocols and pathways for older people admitted to the Medical Receiving Unit and/or present to Emergency department in hours. It should prevent readmissions and increase the number of patients being discharged directly home.

Community Care

The Teviot Project also receives funding through the Change Fund. It is working towards providing clear referral pathways from acute to the community for patients requiring rehabilitation from Occupational Therapy and Physiotherapy services. Work is ongoing to remove inequalities in accessing therapy in the community after an acute episode of care. More patients should be referred home with packages of care provided in their local environment. Two pathways that are being concentrated on are for stroke and fractured neck of femur patients.

• Continue work on reducing readmissions.


• Increased direct therapy at home for patients through introducing structures across all localities that will support referral pathways.

• Local AHP Leads will create staffing models (integrated multidisciplinary teams) to deliver these pathways, for example utilising generic support workers.

• The existing Community Health Teams ways of working will be reviewed this year also to see if they can be included in these models.

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Community Capacity Building

Community capacity building approaches for health improvement are being tested out in one area of Borders and the learning will be rolled out more widely thereafter. This project aims to engage with older people who find existing health improvement resources and activities inaccessible or inappropriate.

Joint Day Services Transport

Joint Day Services transport provision between NHS Borders and Scottish Borders Council is being implemented for older people. This also involves liaison with the Scottish Ambulance Service.

Older People with Functional Mental Health Needs

Change Fund monies have been bid for to deliver a project focussing on older people with (mainly) depression. This is aimed at reviewing local identification and responses, and is designed to provide balance to the recent understandable emphasis on dementia.


• Community Capacity building health improvement project will be delivered and evaluated.


• Shorter travelling times for patients and shorter sessions at the day service will be the main patient benefits.


• To provide baseline evidence on the current availability, access and uptake of interventions that support older people with functional mental health needs (predominantly depression).

• Based on this analysis, to develop an action plan which responds to gaps in service delivery.

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Appendix 1: HEAT Target Risk Narratives and Trajectories

In this section you will find the risk narratives and delivery trajectories for the current HEAT targets. There are no new targets for 2014/15 and the current ones are as follows: Health Improvement Antenatal At least 80% of pregnant women in each SIMD quintile will have booked for

antenatal care by the 12th week of gestation by March 2015 so as to ensure improvements in breast feeding rates and other important health behaviours

Smoking NHSScotland to deliver universal smoking cessation services to achieve at least 12,000 successful quits, at 12 weeks post quit, in the 40% most-deprived within-Board SIMD areas over the one year ending March 2015.

Efficiency and Governance CO2 NHSScotland to reduce CO2 emissions for oil, gas, butane and propane usage

based on a national average year-on-year reduction of 3% each year to 2015-16.

Energy NHSScotland to reduce energy-based carbon emissions and to continue a reduction in energy consumption to contribute to the greenhouse gas emissions reduction targets set in the Climate Change (Scotland) Act 2009.

Access to Services CAMHS Psy Ther

Deliver faster access to mental health services by delivering 26 weeks referral to treatment for specialist Child and Adolescent Mental Health Services (CAMHS) services from March 2013 reducing to 18 weeks from December 2014. 18 weeks referral to treatment for Psychological Therapies from December 2014.

IVF Eligible patients will commence IVF treatment within 12 months by 31 March 2015.

4-hour A&E

95% of patients will wait less than 4 hours from arrival to admission, discharge or transfer for accident and emergency treatment by year ending September 2014

Treatment Appropriate to Patient Cancer To increase the proportion of people diagnosed and treated in the first stage of

breast, colorectal and lung cancer by 25%, by 2014/15

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75+bed Reduce the rate of emergency inpatient bed days for people aged 75 and over per 1,000 population, by at least 12% between 2009/10 and 2014/15

Discharge No people will wait more than 28 days to be discharged from hospital into a more appropriate care setting, once treatment is complete from April 2013, followed by a 14 day maximum wait from April 2015

SAB CDI

Further reduce healthcare associated infections so that by 2014/15 NHS Boards’ staphylococcus aureus bacteraemia (including MRSA) cases are 0.24 or less per 1000 acute occupied bed days; and the rate of Clostridium difficile infections in patients aged 15 and over is 0.32 cases or less per 1000 total occupied bed days

Dementia To deliver expected rates of dementia diagnosis and by 2015/16, 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

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Health Improvement

At least 80% of pregnant women in each SIMD quintile will have booked for antenatal care by the 12th week of gestation by March 2015 so as to ensure improvements in breast feeding rates and other important health behaviours

NHS BOARD LEAD: Evelyn Fleck, Director of Nursing & Midwifery

Delivery and Improvement

Risk Management of Risk

Women not presenting early enough in pregnancy to midwife/GP for confirmation of pregnancy and subsequent booking.

• The keeping childbirth natural and dynamic (KCND) project and introduction of 1st trimester Down’s screening (11 – 13+6 week nuchal scan) have already done much to necessitate and encourage early booking with the community midwife. Posters and business cards were distributed in surgeries and other localities e.g. pharmacies directing women to their midwife as 1st point of contact. GP’s / surgery staff were made aware that women should be directed / referred to their midwife at around 8 – 10 weeks gestation. These measures need to be refreshed.

• The Health Improvement Team will continue to develop and deliver targeted activities to promote early engagement with pregnant women. These include:

• Bump to Baby Events. These have been successfully piloted in areas of socio-economic deprivation and allow pregnant women, their partners and peers to access information about their pregnancy in a non-clinical setting. Six events are planned for 2013- 14 and will be delivered in partnership with Early Years locality networks.

• Peer Support programme. Following successful piloting, the trained group of peer supporters will provide support to new mothers. Recruitment & training continues as a rolling programme. Currently 8 operational volunteers with 6 more undergoing training Jan/Feb 2014.

• Antenatal Education Parenting Programme. Local PEGS training programme has been run with a roll out plan for delivery of consistent

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parent education developed with Health Visitor and Midwifery collaboration, commencing January 2014.

• The Board was successfully assessed for stage 3 accreditation for UNICEF BFI in January 2014 in both hospital and community.

• Baby Welcome Scheme. There are proposals to run this jointly with Scottish Borders Council.

If women transfer care to Borders later in pregnancy, they will ‘book’ in our system i.e. 34 week transfer from another Board. This will skew local data as they will be counted as a ‘New’ but were unable to book locally prior to 12 weeks.

Ensure that data processes to capture information accurately are implemented to avoid incorrect data being gathered. (see Workforce section)

Workforce


Workforce capability is affected by the difficulty in recording gestation at access of booking

The recently updated Scottish Woman Hand Held Maternity Record (SWHMR V6) prompts comprehensive enquiry and recording of health and social status. This is now in use.

The need for an IT system fit for maternity services has been identified and options, including the maternity TrakCare module are currently being explored. This is effectively a comprehensive electronic maternity record that mirrors SWHMR, with local functionality for providing most if not all maternity audit data, including gestation at booking. Head of Midwifery, Head of IM&T & Director of Public Health currently reviewing requirements and funding.

Surestart midwives are important towards targeting vulnerable and disadvantaged groups

Early years Assessment Team Midwife is funded through Scottish Borders Council and is ongoing. This provides targeted support to vulnerable women and links with Social Work.

Funding of a second Early years Assessment Team Midwifery post and options are being identified for longer term solutions with commitment from Professional Lead for Midwifery to maintain this post in the EYAT until a solution is found.

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Finance


Funding is being explored for the second Surestart midwifery post.

Equalities


The most vulnerable families may miss early booking as women tend to present later and have a higher DNA rate.

Early involvement from the Early Years Team to facilitate and enable attendance at appointments will ensure health and social care needs are met.

Early year’s locality networks are currently being established across Scottish Borders and will strengthen further partnership working to facilitate early engagement with pregnant women.

Health inequalities are perpetuated by ineffectively addressing issues in isolation

Through more integrated planning across disciplines (Midwifery, community services and health improvement, mental health and addictions services), information and support for pregnant women will be better co-ordinated. The Maternity Care action plan will continue to provide a mechanism to make links with other health improvement programmes such as smoking cessation, promoting healthy weight etc. Partnership working in progress with Midwifery and Public Health working together to address Smoking cessation and reviewing Maternal Obesity and planning how to address this issue and developing appropriate pathways. Where available, data on health inequalities within Borders will be used to inform planning and targeting of interventions.

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Trajectory

Percentage of Pregnant Women booked for Antenatal Care by 12th Week Gestation in worst performing quintile

Period Borders

2010/11 79.1%

Jan-Mar 13 84.5%

Apr-Jun 13 85%

Jul-Sep 13 86%

Oct-Dec 13 86.5%

Jan-Mar 14 87%

Apr-Jun 14 87.5%

Jul-Sep 14 88%

Oct-Dec 14 89%

Jan-Mar 15 90%

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NHS Scotland to deliver universal smoking cessation services to achieve at least 12,000 successful quits, at 12 weeks post quit, in the 40% most-deprived within-Board SIMD areas over the one year ending March 2015.

Last year’s:

NHS Scotland to deliver universal smoking cessation services to achieve at least 80,000 successful quits (at one month post quit) including 48,000 in the 40% most-deprived within-Board SIMD areas over the three years ending March 2014.

NHS BORDERS LEAD: Alison Wilson – Director of Pharmacy



Inability to reach target quit attempts in areas of deprivation

The target represents a 13% increase on current performance at 12 weeks

Analysis of activity by Advisors and other providers to enable allocation of resources to fit identified data zones.

Annual marketing campaign via local radio to promote awareness of service. Continued use of in-house publications.

Maintain relationship with Smokeline to ensure appropriate signposting of callers.

Work with Keep Well Service to explore ways of maximising referrals to service.

Pharmacies account for a high proportion of total quit attempts but have significant drop in successful quit rates at 12 weeks compared to 4 week quit rates. We will provide training to support pharmacists increase their quit rates at 12 weeks.

Ensuring adequate data capture of community pharmacy Smoking Cessation scheme

Mandatory annual update training includes reminders and support regarding form completion.

Robust scrutiny of return rates to ensure all data is being captured

Workforce


Ability to release key staff for training to increase appropriate referrals from pregnant women, acute care and mental health services users

Ongoing work to build relationships within the acute setting to ensure access to service is maximised.

Development of plans to increase availability of smoking cessation support by hospital patients including mental health service users (Health

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Promoting Health Service-CEL (1) 2012).

A review of cessation support in pregnancy has been conducted as part of the local Maternity Care action plan and in the context of the new antenatal education syllabus.

Opt out scheme for pregnant women in place along with pathway for midwives to Smoking Cessation service. Piloting an additional midwife intervention at 12 week booking scan to increase the number of and quality of referrals to Quit4Good Service.

A reorientation of service in inequalities areas towards a community development based approach will be resource intensive for advisors and could result in an initial decrease in the number of people seen overall

We will closely monitor the throughput of the overall service and maintain close links with other providers to ensure smooth cross referral.

Opportunities for closer working with the Healthy Living Network are being actively explored.

Finance


Pharmacy contribution equates to 50% of successful quits locally. In the event of the withdrawal of the pharmacy scheme or significant changes in prescribing patterns there may be insufficient funding to continue the payments locally.

In the event of any changes to the pharmacy scheme the existing model of delivery will be reviewed. Long-standing positive relationships exist between community pharmacies and the Smoking Cessation Service; this will help facilitate any proposed remodelling of service.

Equalities


Potential exclusion of population groups from service

Service is available via different settings throughout breadth of Borders, weekend access is via pharmacies. Advisors can offer telephone support/home visits to individuals unable to physically access service.

The monitoring of ethnicity is done via the Minimum Data Set.

Review of service has refocused specialist advisor

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hours with increased emphasis on areas of deprivation.

Trajectory

No of People who have Stopped Smoking 12 Weeks post quit Following Input from Smoking Cessation Service in lowest 2 SIMD Quintiles

Figures below based on provisional figures for delivery of 227 quitters over 1 year, in the 40% most deprived within- board SIMD areas ending March 2015

Cumulative Lowest 2 SIMD Quintiles

Apr 14- June 14 57

Apr14 - Sep 14 56

April14- Dec 14 57

April14-Mar 15 57

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Efficiency and Governance

NHSScotland to reduce energy-based carbon emissions and to continue a reduction in energy consumption to contribute to the greenhouse gas emissions reduction targets set in the Climate Change (Scotland) Act 2009.

NHS BORDERS LEAD: David McLuckie – Director of Estates



Demand for utility services Ever increasing demand for electrically powered equipment, both clinical/non clinical and IT. High usage departments to be monitored, where practical, relating consumption to activity.

Energy efficiency to be considered in the procurement of all goods and in the planning and design of healthcare property modifications, extensions and new construction.

Carbon Management Programme, which identifies capital funded projects, will reduce utility consumption through: energy efficiency, heat recovery, reduced waste etc.

In addition the Property Review Strategy is exploring opportunities to reduce the property portfolio and hence reduce utility usage.

Finally the Building Management System installed in all properties has been utilised to reduce the number of operational hours of heating systems and space temperatures to a minimum.

Potential increase in healthcare Monitoring of consumption must at all times reflect

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activity the service provision of properties in use. Change of use, increase/decrease in activity, increased reliance on electrically powered equipment, as noted above, must be tracked routinely.

Targets within trajectory to be expanded to incorporate the whole estate

Data contained within baseline figures and trajectories is for Hospital sites only, as listed within the HEAT Phase 2 Energy Performance trajectories, dated 15th December 2010.

Community sites will be excluded from national reports pending further work, as noted below.

Receipt of water and electricity usage data in electronic format for community premises

At present all invoices received electronically. . Installation of automatic gas data collectors is complete on all sites; installation of automatic electricity data collectors is underway. Water data will continue to be collected manually.

Modification to eMART, (environment Monitoring And Reporting Tool)

Health Facilities Scotland will take the lead in developing eMART, this in conjunction with contracted utility suppliers. Completion time frame to be clarified but development has commenced.

Ownership Energy consumption is not solely the responsibility of the Estates department; it is the responsibility of all staff; i.e. NHS Staff, Scottish Borders Council Staff and General Practitioners and their Staff, all of whom share accommodation within NHS premises. Simple actions can contribute to improving energy efficiency. Therefore the leadership of Senior staff is essential in improving awareness of all members of staff which will bring about the change culture and behaviour required to make a real difference.

Capital cost and associated payback period for elements of sustainable technology incorporated within Property, capital investment and improvement programme

Sustainable technology, which within full life costing may prove to be more cost effective, invariably the initial capital outlay will adversely impact on the cost of Property capital projects. Certain costs are unavoidable as certain elements are mandatory requirements for Planning consent. Others will be reported within Project Boards for consideration by

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same and the Capital Management Team.

Local Authority Planning consent for elements of sustainable development within Property, capital investment and improvement programme

Workforce


Training and awareness raising programme

Essential to identify a dedicated energy management role within the Estates Department, and in addition actively establish the formation of local champions to take the lead in promoting energy efficiency within operational departments, on all sites. Self assessment and registration with GCCAM in 2010 to promote awareness and sustainable development. (Resource and A4C issue).

Finance


Identification of Capital investment required to support initiatives identified within the Board’s Carbon management programme

Carbon Management Programme will continue to identify a capital investment programme 2012 – 2016, establishing details of costs and pay back periods

Additional funding for 2012-2013 and 2013-2014 from the CEEF fund has been agreed for investment in identified projects. Accurate practical (rather than theoretical) revenue, CO2 and energy savings to be identified on completion of the projects

Cost of utility services Pan Public Sector utility contracts were established, October 2009, the cost of supplies very much influenced by international markets. Out with the control of individual Boards.

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Equalities


Financial restraints will have an impact on meeting legal requirement to provide staff and patients, for those that require it, information in alternative formats

Procurement processes not equality impact assessed

Monitor interpretation and translation policy.

Build in equality impact assessment of procurement processes

Trajectory

Energy Consumption and CO2 Emissions

Year Borders

2009/10 Energy GJ 95,061

2011/12 Energy GJ 91,421

2013/14 Energy GJ 84,157

2014/15 Energy GJ 81,629

2009/10 CO2 Tonnes 3,358

2011/12 CO2 Tonnes 3,167

2013/14 CO2 Tonnes 2,973

2014/15 CO2 Tonnes 2,883

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Access to Services

Deliver faster access to mental health services by delivering 26 weeks referral to treatment for specialist Child and Adolescent Mental Health Services (CAMHS) services from March 2013; reducing to 18 weeks from December 2014.

NHS BORDERS LEAD: Jane Davidson – Chief Operating Officer



Final stage of expansion of the service up to age 18 within current resources:

• This may result in increased waiting times to treatment

• Greater complexity of referrals may ensue.

Demand and capacity modelling has been used to assist identification of issues. A local group continues to drive operational issues across mental health services with CAMHS on moving its upper age limit.

This work has now been completed

The capacity of the service may be compromised by the increased demand incurred by raising the age limit

In particular the recently enhanced Intensive treatment service and the ability to fully implement the SIGN guidelines for neurodevelopmental disorders

The impact on the service will be monitored. This continues to need monitoring.

Pathways for neurodevelopmental disorders have been revised and two nurses have been trained as prescribers.

Whole service undertaking a VSM exercise to identify scope to release additional internal capacity.

Further work to incorporate neurodevelopmental disorders referrals through a seamless pathway within the whole team.

IT system to support returns to SGHD not currently fit for purpose

The team continues to work with ISD, supported by the local Planning and Performance and IM&T teams to improve these issues.

Recent QuEST funded post to improve data issues across the whole system will provide benefit here.

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The Quest post has supported demand and capacity, however the IT systems used in NHS Borders Mental Health are still unable to assist with efficient and effective data gathering. This continues to require a great deal of manual collection.

Workforce


Relatively small changes in workforce (e.g. sickness, maternity leave etc) could have significant impact on waiting times for generic CAMHS referrals

Workforce and financial considerations are considered within the service to ensure maximum utility is derived from dedicated funding from SEAT and NES.

The WTT and access to psychological therapies targets along with the delivery of a CAMHS ICP and Balanced Scorecard place considerable demands on the teams admin support and delivery of accurate and timely data.

CAMHS are participating in the whole system Admin review taking place across MH Services.

This review is still ongoing.

Finance


No additional funding available to support service extending scope to age 18.

Workforce and financial considerations are considered within the service to ensure optimal efficiency.

Equalities


• This HEAT target should be equality impact assessed to identify positive and negative impacts on equality groups

• NHS Borders must adopt fully the equality impact assessment process • NHS Borders must adopt the interpretation and translation policy to ensure that staff are

supported and patient care and safety is improved • Implementation of equality monitoring and patient record markers will support referral,

treatment and care • All health improvement activity / projects and other HEAT target activities to take into

account cultural diversity; disability equality; gender equality; migrant /BME communities; gypsy/travellers

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Trajectory

Percentage of patients who started treatment within 18 weeks of referral: Quarter of Treatment

Month Borders Jul-Sep 12 100% Apr-Jun 13 90% Jul-Sep 13 90% Oct-Dec 13 90% Jan-Mar 14 90% Apr-Jun 14 90% Jul-Sep 14 90% Oct-Dec 14 90% Jan-Mar 15 90%

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Deliver faster access to mental health services by delivering 18 weeks referral to treatment for Psychological Therapies from December 2014.




The breadth of the target (all age, all service) itself creates a potential risk to delivery overall

Governance structure for the target to be finalised and implemented, which is cognisant of the wide ranging nature of the target.

Project Plan and Risk Register to be commenced and regularly updated as the service works on sustained implementation of the HEAT Target.

Current IT system not “fit-for-purpose” to capture necessary information to measure referral, access and treatment information

NHS Borders currently implementing a new Patient Management System. Mental Health modules planned for 2013/14. Exploration on whether this timescale could be brought forward indicated limited opportunity for this.

Introduction of 18 week referral to treatment target for Psychological Therapies by December 2014

The Borders Improvement Support Team has a team of skilled improvement facilitators who will support the service to implement change and new ways of working using lean methodology.

Workforce


Lack of clarity on current capacity to deliver psychological therapies

Lack of clarity on the competence of the current workforce to assess/deliver psychological therapies

Demand and Capacity to be measured utilising Mental Health Collaborative methods.

A workforce survey to measure and monitor competency to delivery psychological therapies and identify training and supervision needs to be redone.

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Non MH Services: lack of staff knowledge and understanding of psychological therapies as may not be seen as core business

Continuing attempts to extend membership and inclusion of non MH Service stakeholders in discussions on rolling out target to all services.

Finance


Impact could be on resources to train staff (including backfill) to create sufficient capacity to respond to indicated need.

Full measure of the risk outstanding. Requires more detailed DCAQ work to be undertaken.

Equalities


Inequity /variable access to psychological therapies current service configuration

Adult Community Mental Health Lean is focussing on the patient pathway from referral to discharge. A clear objective of the project is to reduce variation and standardise access and patient pathway for the Borders population.

Clear eligibility criteria to be agreed and communicated.

Roll out of development work undertaken on contact/activity recording and management of waiting lists will ensure greater transparency and easier analysis to assure on equitable service delivery.

Trajectory

Percentage of patients who started treatment within 18 weeks of referral: Quarter of Treatment

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Month Borders Jul-Sep 13 91.0% Oct-Dec 13 85.0% Jan-Mar 14 85.0% Apr-Jun 14 90.0% Jul-Sep 14 90.0% Oct-Dec 14 90.0% Jan-Mar 15 90.0%

Eligible patients will commence IVF treatment within 12 months by 31 March 2015

NHS BORDERS LEAD: Sheena MacDonald – Medical Director



This target is currently being achieved.

There is a cross border contractual arrangement with NHS Lothian to see all referred patients within 3 months of referral, and to commence treatment within 3 months of first being seen.

Workforce


No current implications

Finance


Increasing Costs Referral based on National EAGISS criteria (2007) so no potential to amend these. Consider seeking contract with another Assisted Conception provider.

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Equalities


Criteria set Nationally EAGISS criteria (2007).

NHS Borders Criteria (2012) give clear guidelines to determine eligible patients.

Trajectory

Trajectory not required to be submitted for LDP.

Treatment Appropriate to Patient

95% of patients will wait less than 4 hours from arrival to admission, discharge or transfer for accident and emergency treatment by year ending September 2014




Sustainability of performance against the Emergency Access Standard of 95% of attendees admitted/ transferred/ discharged requires collaborative working across NHS Borders and with partner agencies aimed at admission avoidance, reduction in length of stay in acute beds and supported care within the community.

NHS Borders will continue to adopt a whole systems approach working closely with Scottish Borders Council in reducing avoidable admissions, and reducing length of stay in both Borders General Hospital and our Community Hospitals thus ensuring capacity for unscheduled admissions.

Within NHS Borders there remains Improvement work is ongoing to address

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variation in discharge/transfer processes.

unnecessary and avoidable variation in our core systems and processes.

NHS Borders continues to perform above the national average for the percentage of patients assessed, treated, admitted/transferred/ discharged within 4hrs of registration at the Emergency Department.

Achievement against the standard remains vulnerable particularly at periods of peak activity and during the late evening and overnight.

Initiatives such as See & Treat and the Emergency Nurse Practitioner (ENP) service ensure that Flow 1 (minor injury) patients do not breach the emergency access standard during the hours these services are operational. See and Treat initiated between 10.00 and 18.00hrs during periods of high demand in ED. Adopting see and treat during busy periods in ED has proved beneficial in terms of reduction of Flow 1 breaches of EAS.

We have extended the hours that our ENP service operates to increase service resilience during the late evening in response to periods where activity peaks, Friday to Monday between 10am and 10pm.

Medical rotas across Borders General Hospital recently amended to ensure junior doctor in ED overnight has previous ED experience. We are also reviewing arrangements for additional capacity at weekends in ED during periods when activity peaks to ensure service resilience.

Reducing unnecessary attendances at ED /admissions to Hospital. Successful professional to professional line in place in Out of Hours periods not mirrored during GP daytime hours.

Collaborative working with colleagues in the Scottish Ambulance Service has resulted in a successful professional to professional line in the Out of Hours period between SAS and the Out of Hours Primary Care Service (Borders Emergency Care Service) whereby paramedics can contact BECS GPs directly for advice/support aimed at reducing unnecessary transfers into hospital.

The professional to professional line continues to be successful in reducing unnecessary admissions to hospital. This initiative is led by the Interim Clinical Lead for BECS.

Development of SAS paramedic practitioners in assessment and

2 x SAS Paramedics have been supported to complete the Minor Injuries and Acute Illness

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treatment at scene to avoid unnecessary journeys to hospital. Issues relating to skills and knowledge retention as SAS in Borders currently unable to support paramedic practitioner roles.

courses affiliated to Queen Margaret University with consolidation of learning within the Emergency Department at Borders General Hospital. The ultimate aim being to reduce ED attendances using a See and Treat model in the community. The consolidation of learning is supported by the ED Consultant at BGH.

Workforce


Sustainability of medical workforce in ED, currently ED is medically staffed by 1 ED Consultant and Speciality Doctors who are qualified GPs. The reliance on junior doctors for overnight service provision remains a risk.

With support from LUCAP funding we have recently appointed a second ED consultant who is due to take up post in April 2014. That provides significant additional assurance around service continuity given the risk inherent in a single handed consultant led service. Additionally NHS Borders is in the process of reviewing arrangements for the provision of out of hours services alongside a review of arrangements for the management of the hospital overnight. This will include arrangement for support and supervision of medical staff in ED overnight.

Succession planning for ENP service.

NHS Borders has increased the number of ENPs working within the service to ensure that there is some contingency for both planned retirement and unexpected absence.

Additionally NHS Borders is reviewing extended nursing roles across Unscheduled Care service to ensure that there is alignment of core skills and competence within these roles to allow for greater collaborative working in future as required (includes Registered nursing roles in the Out of Hours emergency care service, Hospital at night practitioners and Emergency Nurse Practitioners).

Knowledge and skills requisition and Nurses in minor injury/illness centres in Community

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maintenance for nurses in minor injury/illness centres across Scottish Borders.

Hospitals are offered opportunities to refresh skills and knowledge in minor injury/illness management by working in ED. A rolling training programme would prove beneficial to support skills and knowledge requisition.

Finance

Risk Management of Risk There is a recurring reliance on short and long term locum support given current vacant hours.

With the appointment of a new ED consultant the current allocation of responsibilities and hours across the medical work force is under review, the aim is to ensure that we have sufficient substantive hours within the service to cover core service between ED and in the event of collaborative working within the out of hours service as a whole.

Equalities


• All HEAT targets should be equality impact assessed to identify positive and negative impacts on equality groups

• NHS Borders must adopt the interpretation and translation policy to ensure that staff are supported and patient care and safety is improved

• Implementation of equality monitoring and patient record markers will support onward referral, treatment and discharge

A trajectory is not requested within the LDP

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To increase the proportion of people diagnosed and treated in the first stage of breast, colorectal and lung cancer by 25%, by 2014/15

NHS BOARD LEAD: Dr Eric Baijal, Director of Public Health



Identifying patients at early stages;

GPs consider that they currently refer anyone who they suspect of having cancer as soon as possible.

It is crucial to raise awareness to patients around ‘spotting the signs’ and coming forward early, however, there will be a requirement to explore in detail how GP referral pathways could be improved. This needs to be a fully integrated work stream as many of the solutions will be in secondary care.

A Lead Cancer GP was appointed in June 2013, and has been leading on the local introduction of the Bowel Screening SQoF. The majority of GP practice will have submitted an action plan by end January 2014 to deliver a reduction in the proportion of patients who do not participate in the national bowel screening programme. Workshop held at a TiME event in November 2013, to support GP Practices in developing their action plans and learn more about the bowel screening programme.

An audit of GP referrals is being undertaken, with a view to providing guidance back to GP practices on the use of the Urgent Suspicion of Cancers, and referral pathways. In addition a series of visits to GP practices by the Lead Cancer GP and new Lead Cancer Clinician are being planned, and will promote the use of the revised Scottish Cancer Referral Guidelines, and to gain feedback on any issues for cancer services in NHS. The revised Referral Guidelines are currently being integrated with Ref Help.

NHS Borders had already undertaken a considerable amount of redesign of its diagnostic services. There may be some reduction in activity for patients in later stage cancer as proportion reduces but this will not be apparent until further into the delivery of the Programme. We have been able to create some additional colonoscopy capacity, and our waiting times are being now maintained at between 2-3

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Early diagnosis:

In order to ensure that greater numbers of patients are identified, it will inevitably require more diagnostic tests to be carried out. This will greatly impact on diagnostic capacity and waiting times

There will be real challenges in delivery of additional colonoscopy capacity

Treatment:

This target should in principle not greatly increase as more complex later-stage cancer treatments are replaced by simpler, less intensive treatment. This may however be offset by reduction in patients where palliative support is only treatment. There may be an increase in diagnostic surgical treatment and in chemotherapy

Follow-up

Earlier diagnosis and treatment will result in more patients being managed following cancer treatment for longer. This could impact on outpatient and diagnostic capacity in terms of follow-up.

Screening and getting the message out about early detection of cancer: Improved local linkage to screening programmes, especially the breast screening programme, could

weeks.

The impact of the DCE campaign on diagnostic services is still being evaluated at a national and local, and is being monitored.

We need to undertake modelling at both national and local levels to understand and plan for change in treatment pattern. We are finalising are baseline data for our demand and capacity model (using the national toolset C-Port) for chemotherapy, and will be using this to model any changes in demand for chemotherapy treatments.

NHS Borders was successful in its bid to Macmillan for funding for a Transforming Care after Treatment pilot. The pilot work will start in April 2014 and there is a project team set up to take the work forward.

Local communication plan in place, which complements national awareness campaign. Key focus is the hard to reach and vulnerable groups, where screening uptake rates are lower. This work is being taken forward by a number of our existing primary and community services networks such as the Lifestyle Advisory Service and Health Living Networks. Short term funding has also been agreed for a Health Improvement Practitioner, whose role will focus on improving screening uptake rates in the hard to reach groups. A staff survey is planned ( both NHS and SBC staff) on awareness and understanding of the benefits of the Bowel Screening service will be undertaken

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improve the system. We are aware of the current review of the breast screening service.

Workforce


The changing pattern of cancer diagnosis may result in more ‘fitter’ patients needing earlier and longer-term support to live with their cancer. This would impact on current models of CNS and other support provision including primary care.

Earlier diagnosis may change balance of treatment modes. If this results in, say, more chemotherapy or radiotherapy being required, this would need an increase in staff with the required skills

Consider developing remodelled workforce focused on the needs of the changing patient population. Potential capacity issues.

Modelling of impact would indicate where growth is likely to take place. Investment to train additional staff would be necessary. SCAN have been leading on modelling any changes in demand for radiotherapy services

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Finance


There may be either a short-term or longer-term capacity increase required. This would require additional funding.

Patients diagnosed earlier may require drug treatment for longer. This may be offset by reduction in patients requiring very expensive 3rd & 4th line treatments.

There may be potential for some redesign of service delivery models to rebalance resource. However, it is likely that additional funding may be required, either in short term to assist in moving to new model or longer-term if additional capacity is required

Financial modelling of changing pattern of treatment required. This is a longer term piece of work when the impact of the DCE campaign has been clearer.

Equalities


Patients who access health services earlier are generally those in more affluent sectors of society. People in more deprived areas tend to present later.

Focus on encouraging and enabling these sectors of society to access health services earlier will be an essential element of any programme of work. Our awareness campaign will focus on the more deprived areas of the local population.

The direct involvement of third sector groups in delivering DCE will bring user perspectives into the programme and help keep focus on this, and are included in our communication and awareness plan.

Trajectory

HEAT target – To increase the proportion of people diagnosed with Stage 1 breast, colorectal and lung cancer by 25% by end 2015

For NHS Borders the delivery of the HEAT target equates to an additional 15 patient diagnosed at Stage 1 by end of 2015. The Scottish Government has asked that Boards should strive to achieve a level that exceeds this minimum. The 15 additional patients is calculated assuming that the incidence figures will remain at 2010/11 levels. Local monitoring of the annual target is on a quarterly basis, against the year end trajectory, and is

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discussed at the meeting of the DCE Core Team. Monitoring data is shown in the table below:

Period % Change Actual

2010-2011 (published baseline) 26.2%

2011-2012 26.9% 23.6%

2012-2013 27.6%

2013-2014 28.3%

2014-2015 29%

The provisional data for 2011-12 indicated that 550 cancers were diagnosed over the period of which 129 were Stage 1 (23.5%). In order to have reached the anticipated trajectory of 26.9%, 148 stage 1 cancers were required to be diagnosed during 2011/12. During 2011/2012, fewer cancers were diagnosed (550) overall compared with the baseline year of 2010/11 when 603 cancers were identified. Part of this was due to the increase in screen detected cancers seen during the bowel screening programme prevalent round that lasted from Nov 2009- Oct 2011. Due to the smaller number of cancers in the Borders compared to other Boards, year on year variation is to be expected.

Reduce the rate of emergency inpatient bed days for people aged 75 and over per 1,000 population, by at least 12% between 2009/10 and 2014/15




Availability of robust data across all care settings

The national Links have improved and further to the introduction of TRAK local anomalies across community and local authority have been identified and work is ongoing across IM&T and Performance & Planning to better manage information capture across the different IT systems.

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Shared vision of key deliverables within health and social care

Local Single Outcome Agreement includes this target. Joint CHCP Planning and Delivery committee oversees delivery of this element of SOA.

Pathfinder Board and Programme Board formed to progress integration arrangements.

Interdependency between Social Work & Health to keep older people safe in their own home is dependent upon sufficient resources i.e. staffing, equipment, finance and carer support

Dependency on capacity of health staff to support complex care planning to prevent admission / readmission

NHS Borders and Scottish Borders Council are working together through the Reshaping Care Board to plan and resource new ways of working within the community

Intermediate Care has been established in a number of Care Homes and continues to be rolled out across the Borders. This incorporates shared support worker roles and third sector involvement.

Increasing use of Key Information Summary for anticipatory care planning to increase sharing of information with out of hours to prevent avoidable admissions.

Unpredictability of clinical presentation at any point in time may result in increase in demand / reason for longer bed stays

“Anticipatory care planning and prevention of admission” Local Enhanced Service has been in place over the last 2 years and has created the foundation for further development in line with revised GP Contract.

Very robust whole system winter and festive period planning in place.

Continuing to build upon the risk prediction work across primary care and evaluation of supporting community services, self-management programmes to support people to remain at home where possible and avoid hospital admission and to support appropriate early discharge.

The rolling LTC Training & Education Programme for Primary Care services continues.

Pulmonary Rehabilitation programme now established with the use of telemedicine equipment to link to remote classes from a central “hub”.

Consistent approach to clinical management of in-patient cohort

Work continues within P&CS to embed new contract for GPs looking after Community Hospitals that will include focus on length of stay and patient pathways.

Revisions to nGMS will place ACP at the core of QOF. NHS Borders will use the next round of

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enhanced services to develop this and build on the work already done.

Productivity & Benchmarking reports are now regularly issued to all GP practices highlighting variances in referral rates, admission rates use of investigations offering support where appropriate and highlighting system or individual referrer issues requiring change and development.

The MCNs continue to take a key role in developing training and education processes across the in-patient settings. Specific initiatives within BGH are being taken forward by MCNs to support reduction in length of stay e.g. diabetes service.

Consistent and timely approach once patient “fit” for discharge

CHCP Discharge/Transfer policy contains strict timelines and recommendations to minimise delays in discharge. Benchmarking information regarding community hospital lengths of stay being presented on regular basis to senior clinicians.

Discharge/Transfer Policy being reviewed and Action Plan for 2014/15 to be developed with a Service Improvement focus/approach driving the implementation of change.

Clinical leadership in particular GP engagement in this agenda as a result of the constraints of independent contractual arrangements with GP

Maximising opportunities of enhanced service funding, e.g.

• Development of enhanced service for dementia

• Audit on readmissions based on Advisory Board guidance

• Enhanced service for care homes • DMARDs LES 2014/15

Clear clinical and managerial leadership at board level for developing this agenda through Associate Medical Director Primary Care, General Manager Primary Care and LTC Manager.

Inadequate or poorly supported informal carers resulting in admissions for “social” or care reasons

Enhanced support for carers through local enhanced service for carers including - direct funding to Princess Royal Carers Trust for awareness raising and training, health checks for CHD for carers aged 45-65, promotion of carers pack and local support for carers.

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Close working with Princess Royal Carers Trust through developed enhanced service has been established as standard practice.

Demographics in Borders already show higher than average over 65 population and predicted future changes will show this to increase further

Cross-sector discussions and joint planning oversees ensures reshaping care plans are developed to accommodate future demographic changes.

Difficulties in developing alternative provision to admission e.g. intermediate care, community services input at home

The following actions are planned or underway to improve performance relating to the target:

• Development and implementation of a new contract for GPs looking after Community Hospitals that includes a focus on length of stay and patient pathways in those settings.

• The Anticipatory Care & Prevention of Admission for people with Long Term Conditions Local Enhanced Service (LES).

• Outcomes and lessons learned from Intermediate Care Demonstrator Programme informing developments in the Cheviot locality.

• Work is underway in P&CS to maximise the benefits of co-location projects that have been implemented in two localities. Lessons learned will inform developments in other areas.

• COPD Pulmonary rehabilitation programmes are now established across the Borders.

• Expansion of intermediate care options across care home settings.

• “Borders Health in Hand”, the Long Term Conditions website is being updated and further expansion is planned.

Workforce

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Ongoing resources to deliver and support participation in training & education programmes linked with any changes in clinical practice, clinical guidelines and protocols

Links with existing programmes and education processes involving NES, JIT, and enhanced services programmes for GPs.

The LTC Training & Education Programme for Primary Care services continues and has been expanded.

Appropriate skill-mix and community services to support appropriate early discharge

Primary & Community Services (P&CS) are undertaking the Releasing Time to Care in the Community alongside a workforce review within community nursing services. This will maximise efficiency and enable appropriate redesign and skill-mix.

Integration of health and social care at locality level aimed at improving pathways and processes to support earlier discharge.

Finance


New Community Hospitals GP contract

Service repercussions are being monitored and addressed through the existing consultation and negotiation network

Integrated resource framework Already aligning budgets around intermediate care and pooled budget around delayed discharges. Utilisation of the Change Fund.

Equalities


• All HEAT targets should be equality impact assessed to identify positive and negative impacts on equality groups

• NHS Borders must adopt fully the equality impact assessment process • NHS Borders must adopt the interpretation and translation policy to ensure that staff are

supported and patient care and safety is improved • Implementation of equality monitoring and patient record markers will support referral,

treatment and care • All health improvement activity / projects and other HEAT target activities to take into

account cultural diversity; disability equality; gender equality; migrant /BME communities;

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gypsy/travellers

Trajectory

Rate of Acute Occupied Bed Days for People Aged 75+ per 1,000 population Aged 75+

Year Ending Borders Mar-10 5,878 Mar-11 5,293 Mar-12 4,912 Mar-13 3,659 Apr-14 3,685 May-14 3,685 Jun-14 3,685 Jul-14 3,685 Aug-14 3,685 Sep-14 3,685 Oct-14 3,685 Nov-14 3,685 Dec-14 3,685 Jan-15 3,685 Feb-15 3,685 Mar-15 3,685

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No people will wait more than 28 days to be discharged from hospital into a more appropriate care setting, once treatment is complete from April 2013; followed by a 14 day maximum wait from April 2015.

NHS BOARD LEAD: Jane Davidson, Chief Operating Officer



Amend and implement revised NHS Borders/Scottish Borders Council Discharge and Transfer Policy

Improve data input and reporting from TRAK and EDISON to support operational management, provide real time information, support monitoring arrangements and ensure accurate submissions to Scottish Government.

Using best practice management arrangements (i.e. audits/self assessments) the partnership will ensure “pathway blockages are cleared”.

Development with Scottish Borders Council of an updated health and social care action plan for 2013/14 reflecting the means by which the aims of the revised policy will be realized.

Ensure comprehensive implementation and sustainability Plans are in place within both organisations to ensure adherence to policy.

Workforce


Adequately inform, manage and develop staff/teams to deliver target

Comprehensive Implementation and sustainability Plan, which should include revised training arrangements for NHS and Social Work staff.

Engage in service redesign work with Scottish Borders Council to support the aim of ensuring no delays more than 14 days as a minimum performance requirement.

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Finance


Demand for service in terms of volume and cost of increased Packages of Care, equipment and alterations to patients homes

Ability of partnership to flexibly manage budgets to follow shifts in the balance of care

Redesign Projects within localities to incorporate capacity building for Community Nursing, AHP and Social Work Teams

Responsive escalation processes to address patient flow issues with particular regard to resolution of delayed discharges blockages.

Reshaping Care Board to support projects that will assist in mapping resource requirements to inform service planning and development.

Equalities


Ensuring that successful locality based initiatives are spread throughout the rest of NHS Borders.

Ensuring that discharge planning arrangements are geared to the needs of individual patient needs.

Ensuring safe transfers and discharges.

Reshaping Care Board to support partnership in assessing and promoting successful initiatives.

New policies must be sensitive to patient condition pathways.

Patient safety discharge checklists, audits and other clinical governance arrangements in place to monitor safe patient discharge management.

Sharing and consideration of critical incident reports between NHS Borders and Scottish Borders Council by the partnership’s Delayed Discharge Group.

Trajectory

No people will wait more than 28 days to be discharged from hospital into a more appropriate care setting, once treatment is complete from April 2013; followed by a 14 day maximum wait from April 2015.

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28 DAY TARGET

Period Borders Apr-13 0 Apr-14 0 Jul-14 0 Oct-14 0 Jan-15 0 Apr-15 0

14 DAY TARGET

Period Borders Oct-12 4 Apr-14 7 Jul-14 7 Oct-14 5 Jan-15 5 Apr-15 0

Further reduce healthcare associated infections so that by 2014/15 NHS Boards’ staphylococcus aureus bacteriamia (including MRSA) cases are 0.24 or less per 1000 acute occupied bed days; and the rate of Clostridium difficile infections in patients aged 15 and over is 0.32 cases or less per 1000 total occupied bed days

NHS BORDERS LEAD: Evelyn Fleck – Director of Nursing & Midwifery



Current trends indicate that this is a challenging target for NHS Borders so there is a risk that the target is not

Every SAB is subject to a Root Cause Analysis (RCA) investigation with any related actions added to the Infection Control Work Plan. Progress against the Work Plan is monitored by Board Committees as well as a

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achieved.

monthly SAB Prevention Group. Infection data is collated on a monthly basis and presented in run charts and pareto charts by cause and location. Infection data is correlated with other indicators such as CNS and MRSA screening compliance by location. A CDI Prevention Group was established in January 2013. In addition, a process for conducting reviews of severe cases was introduced. These systems provide additional focus to reviewing and learning from CDI cases, and enable oversight on the implementation of resulting action plans. Actions are prioritised taking account of the data analysis and implemented using Patient Safety tools and techniques. Progress against the SAB and CDI action plans is critically reviewed by a recently formed Healthcare Associated Infection Strategic Control Group (HAI SOG). In addition, this group, chaired by the HAI Executive Lead (Director of Nursing & Midwifery), will provide support and guidance to instil a Borders wide collaborative approach to achieve the new HEAT target.

There is a risk that concentration on hospital acquired infections results in lack of focus on HAI across the whole healthcare economy e.g. interventions to minimise all SABs (MRSA or MSSA) and Clostridium difficile in hospital and primary care settings.

Our surveillance is pan board, taking in both primary and secondary care. As actions targeted to achieve ‘quick wins’ take effect, focus has moved to addressing issues related to more complex patient journeys.

There is a risk that a failure to implement the three supporting antimicrobial indictors related to prescribing as detailed in CEL 11(2009) will adversely impact on the boards ability to reduce Clostridium difficile.

There is now an Antimicrobial Pharmacist for NHS Borders in post, working closely with the Consultant Microbiologist as part of the Antimicrobial Management Team. All prescribing indicators are being audited as recommended.

There is a risk that competing priorities and lack of time and resources do not allow staff to fully investigate cases of SAB and Clostridium difficile (through

All cases of SAB have full detailed review. ICNet functionality has been developed to capture the review data. Following a recent upgrade to ICNet, further development

98

tools such as Root Cause Analysis or the CDI Severe Case Investigation Tool) results in a lack of understanding of where best to target interventions.

is ongoing to capture learning on ICNet from CDI case reviews. The Prevention of CDI Group provides a focus on learning from CDI cases and implementing preventative measures. The capacity of the Infection Control Team has been enhanced with effect from 7th January 2013, with the successful appointment to two new permanent posts; 1.0wte Infection Control Nurse and 0.5wte Surveillance Support Officer.

There is a risk that care bundles aimed at reducing SABs and Clostridium difficile will not be rolled out in the most appropriate way with which to achieve the biggest impact.

The enhanced surveillance undertaken means that we know which areas to target in order to achieve maximum impact. The Patient Safety lead is a member of the SAB Prevention Group and also attends monthly Infection Control Team meetings.

There is a risk of a lack of business continuity for Infection Control Teams (i.e. through staff leaving or moving posts).

The resilience of the Infection Control Team has been enhanced with effect from 7th January 2013, with the successful appointment to two new permanent posts; 1.0wte Infection Control Nurse and 0.5wte Surveillance Support Officer.

There is a risk that there is a lack of cross working between infection control professionals (e.g. between Infection Control Managers, Infection Control Teams, Antimicrobial Teams and Health Protection Teams).

Members of the Infection Control Team perform dual roles. Cross working is effective at all levels and this is supported by regular meetings with other departments such as Health Protection and Occupational Health. On a monthly basis, the Patient Safety Lead and Antimicrobial Pharmacist join the Infection Control Team meeting.

There is a risk that there is a lack of ownership for the prevention and control of infection at all levels in the organisation.

The ICT continue to educate staff across all disciplines and grades, that infection control is a personal responsibility for everyone and not to rely on others to perform it.

There is a risk that there is a lack of clear leadership for infection prevention and control within the board.

We have a designated lead for IP&C at the board (Director of Nursing) providing this leadership.

There is strong support for all aspects of IP&C from the board in general, including from the CEO and Medical Director.

There is a risk that short term focus on targets will not result in sustainable improvement.

We are fully committed to sustained improvement and benefit from the expertise and support from national agencies such as HPS, NES, HIS. Infection rates are consistently monitored by our ongoing robust surveillance techniques already in place. Progress

99

against the Infection Control Work Plan is monitored by Board Committees.

The target is not for HAI SABs but for all SABs. In an area with a rural economy and a high elderly population, a significant proportion present from the community. These can be managed but not predicted or prevented.

Risk to be tolerated. People will acquire SAB infections in the community for a whole host of reasons prior to admission. SAB infections do occur without healthcare interventions and the members of the population highlighted are at greater risk. Infections that are contracted prior to health care intervention are picked up during surveillance as part of the diagnostic process.

The parameters that govern the mandatory testing for C.difficile changed in April 2009; diarrhoeal samples from all patients above the age of fifteen (15) years old will be tested.

NHS Borders have been successfully adhering to this protocol since April 2009. During 2013 NHS Borders adapted their CDI testing protocol in accordance with guidance from HPS.

There is a risk of failure to deliver and sustain improvement due to unfocussed actions and poor implementation of change.

Intelligent use of data is used to prioritise actions to maximum effect (e.g. use of pareto charts).

Patient safety methodology is used to test and spread new practice.

Workforce


There is a risk that front-line staff don’t comply with bundles.

Bundles are implemented with support from Patient safety lead using patient safety tools and techniques to embed. The Infection Prevention and Control Team currently conduct regular audits of compliance with PVC bundles and are leading on an improvement programme for compliance with the insertion bundle, whilst Patient Safety are simultaneously leading on an improvement programme for compliance with the maintenance bundle.

100

Finance


Finance relating to hand hygiene coordinator and MRSA screening is currently non-recurring.

This funding has been used to appoint to the new permanent posts previously described. This represented a financial risk to NHS Borders.

It has been confirmed that government funding associated with the hand hygiene function will cease from March 2014. However, new funding for 2-years has been provided to introduce a HAI Quality Improvement Facilitator.

C.difficile screening changed from April 2009 to mandatory testing of all diarrhoeal samples from patients over 15 years – estimated increase of around another 100 samples per month tested at a cost of around £4 -5 each.

No significant resource implications have been made apparent (staff or reagents) since April 2009.

2nd antimicrobial nurse funding is currently not permanent.

The funding for this position has ceased, therefore the post is no longer in place.

Equalities


There is a risk that the importance of infection prevention measures are not adequately communicated to patients whose first language isn’t English or who may have learning difficulties.

Many of the HAI related public and patient information leaflets are available in multiple languages, including Braille. Mechanisms are in place to produce these on request.

Trajectory

Staph aureus Bacteraemia: cases per 1000 acute occupied bed days

Quarters Borders Jun-12 0.37

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Mar-13 0.36 Jun-13 0.30 Sep-13 0.29 Dec-13 0.28 Mar-14 0.27 Jun-14 0.26 Sep-14 0.26 Dec-14 0.25 Mar-15 0.24

C. difficile infections: cases per 1000 acute occupied bed days

Quarters Borders Jun-13 0.47 Sep-13 0.46 Dec-13 0.43 Mar-14 0.40 Jun-14 0.37 Sep-14 0.35 Dec-14 0.33 Mar-15 0.32

To deliver expected rates of dementia diagnosis and by 2015/16, 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.




Available capacity to respond is shown to be inadequate.

Uptake of this new service to be monitored through the multi-agency Dementia Planning Group, and issues escalated timeously.

This new service needs to be responsive to people newly

Develop appropriate throughput by engagement with other relevant services offering support.

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diagnosed with dementia. Evaluate the initial year of service operation to explore scope for working differently to assist availability and responsiveness as necessary.

Workforce


Service is delivered through a small number of staff and is therefore more at risk with staff leaving.

As the service is hosted through a 3rd sector partner, ensure support is available to respond to potential workforce gaps in a timeous way.

Through the Dementia Planning Group, explore scope for contingency planning to reduce the risk of delivery shifts through staff vacancies.

Finance


Service currently funded through Older Persons Change Fund over 2012/13 – no confirmed funding for majority of 2013/14.

Submit a further application for Change Fund finance during 2013/14.

Identify through Dementia Planning Group prospects for alternative funding.

When assuming HEAT Target will rollover, consider through same forum future financial sustainability.

Equalities


As a new service, requirement to demonstrate that access and delivery is equitable across the Borders.

Monitor activity data to reassure that service access is standardised.

Trajectory

Trajectory not required in LDP

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Appendix 2: Key Local Plans

NHS Borders has a broad range of local plans and strategies that are being delivered and developed across the organisation. Below is a matrix containing a (by no means exhaustive) list of plans/strategies in place locally that impact upon the delivery of the 12 priority areas of the 2020 Vision. This further demonstrates the interconnected nature of these priority areas and emphasises the necessity of collaborative working.

Priority Area

Local Plan/Project/Strategy

Pers

on-C

entr

ed

Car

e

Safe

Car

e

Prim

ary

Car

e

Uns

ched

uled

and

Em

erge

ncy

Car

e

Inte

grat

ed C

are

Car

e fo

r Mul

tiple

an

d C

hron

ic

Illne

sses

Early

Yea

rs

Hea

lth In

equa

litie

s

Prev

entio

n

Wor

kfor

ce

Inno

vatio

n

Effic

ienc

y an

d Pr

oduc

tivity

Local Unscheduled Care Action Plan (LUCAP)

X X X X X

Connected Care

X X X X X X X X X X

NHS Borders Patient Safety Programme

X X X X X X X X

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Stroke Care LDP Action Plan

X X X

Joint Early Years Strategy

X X X X X X X

NHS Borders Child Health Strategy

X X X X X X

Maternity Care Action Plan

X X X X X

NHS Borders Research Strategy

X X X X X X X X

NHS Borders Clinical Strategy

X X X X X X X X X X X X

NHS Public Involvement Strategy

X X X X X X X X X X X X

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Appendix-2014-29 Borders NHS Board

NHS BORDERS – 2014/15 FINANCIAL PLAN Introduction A proposed financial plan has been submitted to Scottish Government in March as part of the Local Delivery Plan submission. The financial plan submitted was subject to approval by the Board on the 3rd April 2014. The plan covers the next three financial years for revenue and five financial years for capital. The Scottish Government has agreed its 2014/15 budget with indicative figures provided for the following year. The next comprehensive spending review is planned for 2015/16. An integral part of the financial plan is the efficiency programme, which currently consists of a series of detailed projects with estimated cost savings, which will be taken forward during the course of the 2014/15 and future financial years. Aim The purpose of this paper is:-

• Section 1 - to provide an overview to Board members of the key elements within the revenue financial plan for 2014/15.

• Section 2 - to explain how it is proposed to address the cost savings challenge which the Board faces in order to achieve a balanced financial outturn in 2014/15.

• Section 3 - to highlight key assumptions and financial risks. • Section 4 - to broadly outline the scale of the financial challenge which the Board is

likely to face in 2015/16 and 2016/17. • Section 5 - to provide an overview to Board members of the key elements within the

capital plan. Background The financial challenge that the public sector is embracing is clear and well understood. It is essential that our services are provided and developed appropriately within the financial envelope available to us and for which the Board is responsible. In order to continue to deliver quality patient care the organisation must keep a firm grip on its finances as well as drive improved quality and efficiency which is critical to service delivery and public credibility. That means having a clear focus that is firmly and openly set on providing patient care that is safe, effective and affordable and includes efficiency plans and goals.

1

Appendix-2014-29 Section 1 - Overview of 2014/15 Financial Plan (a) Financial Summary A high level overview of the Board’s financial plan for 2014/15 is provided below in Table

1. This shows the overall movement in both recurring and non-recurring funding and expenditure which are anticipated in 2014/15.

TABLE 1 - FINANCIAL OVERVIEW

Surplus/ Funding Expenditure (Deficit) Note £000s £000s £000s Base budget carried forward from 2013/1/14 219,836 219,836 0

Recurring funding and expenditure items for 2014/15

General funding uplift for 2014/15 4,713 Excludes Change Fund as cost neutral

Other Funding Uplifts 382

Projected spending growth in 2014/15 7,161 See appendix 1

2014/15 cost savings (2,066) Requirement for 2014/15

5,095 5,095 0 2014/15 budget excluding non-recurring funding and expenditure items 224,931 224,931 0

Non-recurring funding and expenditure items for 2014/15

Non-recurring cost provisions 2,509 Specific expenditure items Non-recurring cost savings (2,509) Requirement for 2014/15 - 0 0 2014/15 BUDGET 224,931 224,931 0

(b) Salient Points

A number of key points are important to draw out from the above summary of the Board’s 2014/15 financial plan. These are:

i) The Board is able to present a balanced financial plan for 2014/15. ii) The projection of expenditure growth of £7.161m is the aggregate of a range of

additional expenditure commitments which the Board is required to meet in 2014/15. Appendix 1 sets out a full list of these additional expenditure commitments, and shows these are unavoidable rather than discretionary commitments, and in many cases are existing cost pressures where expenditure is already underway.

iii) The Clinical Excellence fund, (£500k), focused on patient safety and requiring cost neutrality remains in the plan. Due to the success of this fund over previous financial

2

Appendix-2014-29

years it has been built into the plan with the aim of achieving progress and maintaining momentum throughout the organisation in the quality agenda.

iv) Short term non recurring funding has been identified in 2014/15 to fund areas such as, the Commissioning Team and Project Management Support.

v) There is a sum of £1.0m recurrently and £1.0m non recurrently identified as a contingency in order to manage potential pressures arising during the year. This is set aside given the experience of the organisation previously in managing unforeseen clinical pressures.

vi) As recurring savings targets were fully achieved in 2013/14 the savings challenge for 2014/15 is directly related to the funding levels and expenditure commitments identified in the new year.

(c) Funding Uplift

For 2014/15, the Scottish Government has confirmed a funding uplift of 2.7% (£4.7m), less a reduction to the Change Fund 0.2% (£0.2m) which is reflected in the Board’s financial plan. The resource allocation for territorial Boards overall has been uplifted by 3.1%.

(d) Expected Expenditure Growth

As noted above, a full summary of the Board’s recurring expenditure projections for 2014/15 is provided at Appendix 1. This explains the approach which has been taken in preparing expenditure growth estimates for each of the main cost drivers and provides background information on key assumptions.

Section 2 - Cost Savings Challenge 2014/15 A key element of the Board’s plan to achieve a financial breakeven outturn in 2014/15 will be it’s efficiency savings programme. The following provides an overview of the programme for 2014/15 and how the Board will approach this challenge. (a) Level of Challenge

NHS Borders must deliver substantial efficiencies in 2014/15. The recurring and non recurring targets for 2014/15 gives a base efficiency level of £2.075m added to which is the clinical excellence funding (£0.5m) and the contingency; taking all of this together, the efficiency programme is required to generate £4.575m (2.5%) of funds, of which a minimum of £2.066m should be recurrent. In addition to the cash releasing efficiency programme non cash releasing schemes will progressed resulting in overall increased efficiency and productivity of 3%.

(b) Approach The Board approach continues to be delivery of the required savings through an efficiency savings programme, rather than assigned targets. The programme for 2014/15 has been developed over the last eight months in conjunction with the Clinical Boards, the Clinical Core Strategy Group and other key groups. The Board will link closely with the NHS Scotland Efficiency and Productivity Framework and the national meetings of the Efficiency Board Leads Network in order to report progress to the Scottish Government and to make best use of networking to share good practice. The Framework published in February 2011 has 5 core work streams :

3

Appendix-2014-29

• Outpatients, community and primary care • Whole systems patient flow • Prescribing • Procurement • Shared services Table 2 below is a summary of the 2014/15 NHS Borders programme categorised by risk to delivery of savings. For all of the schemes detailed below project documentation has been completed and reviewed by the Strategy Group. There will be a continued intense focus on efficiency and productivity by the Clinical Executive, who will support the delivery of value for money and effective patient care. Monitoring of the programme will be undertaken by the restructured Efficiency Board.

TABLE 2 - 2014/15 EFFICIENCY PROGRAMME PROJECT AREAS Low Risk To Savings Delivery- £2.0m • Support Services • Improved Procurement • Nursing Skill Mix • Mental Health • BGH Admin Review • Estates Rationalisation Medium Risk To Savings Delivery £1.4m • Prescribing Procurement and Wastage • Review of leased car scheme • LD Commissioned Services

High Risk To Savings Delivery £1.2m • Repatriation of Activity • Income Generation • Productivity and Benchmarking • Medical Efficiency • Public Health Interventions

(c) Delivery Each scheme will be run as a project, with individual project sponsors responsible for

developing and delivering a project plan with key milestones. All projects will be proactively managed through the Aspyre system.

For each project a project initiation document, project plan and savings trajectory has been

approved by the Strategy Group. The strategic direction of the organisation will continue to be progressed by the Strategy Group taking into account issues of service redesign, modernisation and continuous service improvement.

4

Appendix-2014-29

As schemes are agreed the project plan implementation and savings trajectory will be monitored through the Efficiency Board and expected to deliver. The Efficiency Board will receive monthly updates on all plans thereby ensuring any need for corrective action is taken promptly and will report routinely to the Clinical Executive Operational Group. The Financial Position Oversight Group as part of its terms of reference will take an active interest in the progress of the efficiency programme.

Section 3 - Key Assumptions and Financial Risks The key assumptions on which the Board’s financial plan for 2014/15 has been based are described within Section 1 above. In addition Appendix 1 describes the assumptions used to project recurring expenditure growth in 2014/15. There are assumptions which are of particular significance in terms of potential financial risk. These are discussed below, together with an assessment of the likely risk. (a) Pay Growth

Pay Awards for 2014/15 have been finalised. The pay award costs have been calculated at £300 per person for staff earning below £21k, a 1% increase in pay for all staff and the cost of increments as per current terms and conditions. Claims submitted linked to equal pay are being managed on a national basis and no financial liability has been assumed in the financial plan - LOW

(b) Prescribing Cost Growth Detailed work on the projection of increases in costs and volumes has been prepared by the Board’s prescribing advisers for 2014/15. Benchmarking comparisons between Boards on drugs costs and the level of uplift has also been undertaken. Following consideration of all of this an uplift of 6.00% on drugs costs has been set for 2014/15. The work undertaken provides an assurance on the robustness of this level of uplift. This will be an area which will continue to be closely monitored during 2014/15 and the past experience of unanticipated pressures arising during the year informs the risk assessment – HIGH

(c) Out of Area Referrals

In the case of out of area referrals, for both acute and non acute, work is ongoing to ensure that all referrals are appropriate and necessary. Good progress has been made in this area however, this will continue to be a financial pressure in the new year – HIGH

(d) Non Pay Uplift

Non-pay uplift has been estimated at 1.5% and in the case of utilities 10% funding has been put aside for 2014/15. There is a great deal of uncertainty in this area particularly linked to utilities in the world market and the impact this will have on all supplies costs – MEDIUM

(e) Cost Pressures

Service cost pressures identified during 2014/15 have been reviewed by the Strategy Group. Where it was considered that these pressures were unavoidable funding has been

5

Appendix-2014-29

identified in the financial plan. In the case of pressures not funded a course of action has been agreed - MEDIUM

(f) Discretionary Spend Controls The additional controls that were put in place during 2013/14 will remain in place for the foreseeable future in order to support the financial position – LOW

(g) Efficiency Delivery Plan The financial plan, as outlined at Section 1, requires the delivery of efficiencies of £4.575m

to achieve financial balance for 2014/15. Individual schemes within the programme have been identified and are being progressed. The issue of staff turnover together with the overall level of efficiency required means that this will be extremely challenging - HIGH

Section 4 - 2015/16 and 2016/17 A summary of the Board’s outline financial plan for 2015/16 and 2016/17 is provided at Appendix 2. This contains indicative allocation uplift for 2015/16 as per the Scottish Government budget and estimates for 2016/17 both of which are subject to the next comprehensive spending review. The plan is based on a series of assumptions regarding expenditure growth. As the allocation figures are indicative and the impact of the spending review is unknown it is difficult to plan with certainty beyond 2014/15, therefore the figures for future years should be considered only a broad outlook at present. (a) Funding

At this stage, the financial plan assumes that the base uplift for 2015/16 will be at the level stated in Scottish Government budget at 1.8%, plus funding for an integration fund which will result in a net increase of 2.2%. For 2016/17 a 1.8% uplift has been estimated. These figures have been presented as indicative for planning purposes.

(b) Expenditure

The main planning assumptions used to forecast likely future expenditure growth for 2015/16 and 2016/17 are as follows:

2015/16 2016/17

Revenue Growth 2.2% 1.8% Pay Awards 1.0% 1.0% Non Pay Inflation 1.5% 1.5% Income 1.8% 1.8% Drugs 6.0% 6.0% Capital Growth 0% 0%

The NHS pension scheme is currently being revalued and there are concerns that this may result in increases in employer’s contributions to the superannuation scheme. For the purposes of planning it has been assumed there will be a 2% increase in employer’s costs from 2015/16.

6

Appendix-2014-29

In the case of national insurance, as a result of the introduction of the flat rate state pension, reduced (contracted out) contributions rates for employees and employers will be withdrawn in 2016/17. The estimated cost of this has been included in the financial plan.

(c) Financial Challenge

Based on the assumptions set out within 4(a) and 4 (b) above, and after providing for currently approved service commitments including a general provision of £2.0m for as yet unidentified cost pressures, the Board would face a financial challenge of £6.469m and £6.197m in 2015/16 and 2016/17 respectively.

Work has been ongoing during 2013/14 to identify efficiency opportunities for the next three years in line with the Board’s financial plan and clinical strategy. An outline programme has been developed although schemes beyond 2014/15 are less well defined.

Section 5 - Overview of 2014/15 Capital Plan (a) Financial Summary

The development of the current 5 year rolling capital plan has been under the direction of the Capital Planning Group which is chaired by the Director of Estates and Facilities with membership from a variety of key stakeholders within the organisation. In terms of capital, NHS Borders has had to pare down its plans as capital funding has significantly reduced in recent years. Capital investment is key to the delivery of safe and effective patient care and to releasing significant efficiency gains from the rationalisation of the estate and supporting service redesign.

The capital plan submitted as part of the 2014/15 Local Delivery Plan is in line with the recent allocations. In addition to a formula capital resource (£2.4m), funding for Galashiels Roxburgh Street and the final phase of integrated health strategy (IHS) is included within the capital allocation. It has been assumed that capital receipts generated during 2014/15 will be retained by NHS Borders. The expenditure profile linked to Galashiels Roxburgh Street and IHS has been adjusted to reflect the progress of the capital plan. NHS Borders continues to work closely with colleagues at Scottish Government to manage the overall capital situation. While the work done to date informs our capital plan, further changes are likely to be made for a variety of reasons. Importantly, the plan should be prioritised and informed by service redesign and the efficiency programme, as well as the quality and patient safety agenda. Beyond the period of the recent allocation letter from Scottish Government the level of formula has been assumed to be similar to that of 2015/16. The capital plan is shown in Appendix 3 and in summary includes:

• Rolling programmes for IM&T; Estates & Facilities and Medical Equipment are reinstated.

• Linking to the recently issued State of the Estate (SoTE) report and recognising the information which will be available from the Asset and Property Management Strategy, NHS Borders has committed resource over the duration of the plan to address priority areas.

7

Appendix-2014-29

• The capital plan will need to align with NHS Borders clinical strategy which is currently out to consultation.

Appendix 3 summarises the Board’s 2014/15 capital plan and idenfies the high risk areas associated with the plan. The Capital Planning Group will continue to work to progress development of schemes connected to the efficiency, estate rationalisation and patient safety agenda.

Recommendation Board members are requested to review this report and approve the 2014/15 financial plan and note the indicative outline of the financial challenge in 2015/16 and 2016/17. Rationale for submission to NHS Borders Board

The Board must agree the financial plan. This report sets out an overview for the 2014/15 year and indicative outline for 2015/16 and 2016/17.

Policy/Strategy Implications

The financial plan underpins the strategy of the Board. It impacts upon delivery of statutory financial targets.

Consultation

Regular briefings on the financial outlook are provided to the S&P Committee, Board Executive Team, Strategy Group, Clinical Executive, Clinical Boards and other senior groups throughout the year.

Consultation with Professional Committees

Briefings and discussions are ongoing.

Risk Assessment

The Board has a statutory requirement to remain within its funding limits. Risks are highlighted in the paper and will be reported upon throughout the year.

Compliance with Board Policy requirements on Equality and Diversity

Relevant issues should be addressed in the development of detailed plans and business cases.

Resource/Staffing Implications

Resource implications are described throughout the report.

Approved by Name Designation Name Designation Carol Gillie Director of Finance Author(s) Name Designation Name Designation Janice Cockburn Deputy Director of

Finance

8

Appendix-2014-29 APPENDIX 1 - 2014/15 FINANCIAL PLAN – PROJECTION OF RECURRING REVENUE EXPENDITURE GROWTH Each of the main drivers which influence expenditure has been reviewed to assess and project the level of provision which requires to be made for additional expenditure. These are categorised as follows within the Board’s financial plan.

(i) General: general cost increases which are driven by factors such as pay awards, non-pay inflation, prescribing growth, scale of capital programme etc.

(ii) National Initiatives: where there is an impact on NHS Borders services. (iii) Service Development: cost increases previously agreed which are driven, in the main, by

decisions made at local or regional level involving NHS Borders, to fund local service development/improvement.

On the basis of currently available information, the Board’s assessment of the anticipated expenditure growth it faces going into 2014/15, within each of these categories, is set out below: Area of expenditure growth Projected

Projected Increase

£000s

Notes

(i) General Pay Inflation 1,516

Prescribing cost growth/ inflation. 1,597 Current projections by prescribing advisers of likely cost increase related to volume and price increases within Acute and Primary Care before cost savings initiatives.

Capital expenditure programme 411 Reflects the capital programme and the associate revenue costs Non pay uplift 659 Provision for general inflation increase of 1.5% plus utilities at 10% Other providers 781 Estimated provision for inflation increase on all contracts with external

providers subject to negotiation but assumed at 2.7% Primary Medical Services 124 Increased estimated at 1% assumed this will be cost neural TOTAL 5,088 (ii) National Initiatives ScotStar 34 Reprovisioning of neo natal ambulance services Policy Custody Service 75 Transfer of custody healthcare SEAT/National Risk Share 100 Regional Developments such as radiology Vaccination Programme 91 National vaccination programme phased implementation Travel 255 National increase in mileage rate TOTAL 555 (iii) Service Development Patient Related Income 300 Reduction in patient rated income from Northumberland Medical Staffing 396 Related to productivity& Benchmarking Including support for

ophthalmology, oral surgery and radiology Auto enrolment 406 NHS Borders must automatically enrol all employees in a pension

scheme unless they choose to opt out. NHS Borders budget will now be fully funded for superannuation

Other 416 Including dental practice advisor and obstetrics ABP TOTAL 1,518 Total Projected Expenditure Growth 7,161

9

Appendix-2014-29 APPENDIX 2 - SUMMARY OF REVENUE FINANCIAL PLAN

2014/15 2015/16 2016/17 Non Non Non Recurring Recurring Total Recurring recurring Total Recurring recurring Total Notes £000s £000s £000s £000s £000s £000s £000s £000s Opening Surplus/(Deficit) 0 0 0 0 0 0 0 0 0 1 Funding General Funding Uplift 4,713 4,713 3,979 3,979 3,309 3,309 2 Other Funding Uplifts 258 258 214 214 217 217 3 FHS NCL 124 124 125 125 126 126 4 5,095 - 5,095 4,318 4,318 3,652 - 3,652 Expenditure General Pays (incl A4C) 1,516 1,516 1,649 1,649 1,538 1,538 5 Supplies & Services 659 659 476 476 494 494 6 Drugs 1,597 1,597 1,693 1,693 1,795 1,795 7 Capital Charges 411 411 260 260 342 342 8 Other Providers 781 781 534 534 544 544 8 FHS NCL 124 124 125 125 126 126 10 5,088 5,088 4,737 4,737 4,839 4,839 Expenditure Other National Initiatives 555 61 616 2,487 2,487 1,510 1,510 11 Service Developments 1,518 1,448 2,966 2,063 500 2,563 2,000 500 2,500 12 Contingency 1,000 1,000 1,000 1,000 1,000 1,000 13 2,073 2,509 4,582 4,550 1,500 6,050 3,510 1,500 5,010 Savings Cost Savings Plan 2,066 2,509 4,575 4,969 1,500 6,469 4,697 1,500 6,197 14 In Year Surplus/Deficit 0 0 - 0 0 - 0 0 -

10

APPENDIX 2 – SUMMARY OF REVENUE FINANCIAL PLAN

Notes of Appendix 2 1. Opening position in 2014/15 with a balanced budget. 2. General funding uplift is 2.7% in 2014/15, 2.2% in 2015/16 and 1.8% 2016/17. 3 Other Funding uplifts – this has been estimated at 2.7% for 2014/15 and 1.8% in subsequent

years for other income sources such as healthcare provider and locally collected income. 4. Assumed uplift for FHS non cash limited funding is 1% in each year and is considered to be cost

neutral. 5. In 2014/15 this covers general pay uplift of £300 per person for staff earning less than £21k. Pay

awards for each year are assumed to be 1% and increments will be paid where appropriate. 6. This covers anticipated price inflation related to existing contractual commitments and includes

1.5% for general cost inflation and general growth, plus an additional 10% for increased utility costs in 2014/15.

7. This is based on prescribing advisers’ detailed cost projections for acute and primary care services equating to a 6.0% increase.

8. Provision for increase in capital charge costs and costs associated with the capital programme. 9. Provision for inflationary uplift of service level agreements with other NHS boards for NHS

Borders residents. This has been estimated at 2.7% for 2014/15 and 1.8% in subsequent years. 10. Provision for increased spend on FHS non cash limited services is equal to assumed increase in

funding allocation so overall impact is cost neutral. 11. This national initiatives such as vaccination, NSAG initiatives, national insurance and

superannuation. 12. This grouping includes all other service commitments for example, service planning processes in

particular auto enrolment, medical staffing, travel rates and all other cost pressures. 13. This as held in contingency in anticipation of any unforeseen financial pressures. 14. Cost Savings plan to be achieved during the financial year.

11

APPENDIX 3 – CAPITAL PLAN Capital Plan for 5 year period 2013/14- 2017/18

14/15 15/16 16/17 17/18 18/19

£000s £000s £000s £000s £000s Board Capital Resources

Formula Allocation 2,407 2,615 2,615 2,615 2,615

Project Specific Funding 1,700 500 3,500 1,000

Other Centrally Provided Funding 1,000 2,600

Capital Resource Limit Total 3,407 6,915 3,115 6,115 3,615

Capital Receipts retained by Board

Newstead 300

Westgrove 500

Orchard Park 100

Fenton Lodge 195

Total Capital Receipts Applied 595 500 0 0

Total Board Capital Resource 4,002 6,915 3,615 6,115 3,615 Prioritised Capital Schemes

Radiology Equipment 250 100 900 250 750

Uncommitted 595 500

Clinical Strategy Capital Requirement 267 3,325 275 925 425

Car Parking 300

IM&T Rolling Programme 200 300 300 300 300

Estates Rolling Programme 200 200 200 200 200

Risk Assessed Backlog (SoTE) 1,500 500 350 350 350

CEEF

MEC Rolling Programme 200 200 200 200 200

Feasibility Work 200 200 200 200

Melrose & Selkirk Health Centre 500 3,500 1,000

Roxburgh Street Health Centre 300 1,900

Project Management 190 190 190 190 190

Total Capital Expenditure 4,002 6,915 3,615 6,115 3,615

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APPENDIX 3 – CAPITAL PLAN Notes of Appendix 3 The following describes the high risks to the plan:- • Work is on going with hubco on the Galashiels Roxburgh Street heath centre referred to

above. There remains a high risk that the cost of the scheme is above the level included in the allocation.

• There is limited opportunity across the plan to allow for opportunistic investment, spend to save schemes or for unforeseen events – the risk is high that investment will be needed.

• IM&T, medical equipment and estates rolling programmes have been reinstated • NHS Borders has assumed capital receipts within its capital plan will be retained locally

during 2014/15. Discussions are ongoing for future years but for the purposes of this plan it has been assumed that they will be fully retained by NHS Borders. Due to the general condition of the housing market the risk to the achievement of sales proceeds at the level estimated in the plan is high.

• The plan does not include any capital requirements arising from SEAT schemes. • Business Cases for the elements of the final phase of IHS have not yet been formally

approved by the Board.

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