Towards Our Vision for 2020 Delivering Outpatient Integration Together Programme Plan

1 V11.9 12/06/15 Contents

Programme context - current state and case for change 4 Programme aim, objectives and outcomes 6 Achieving systematic and sustainable change 7 Approach/methodology 8 Programme development 10 Programme governance and support for delivery 11 References 13 Appendix 1: Towards our 2020 vision 14 Appendix 2: Programme Driver Diagram 15 Appendix 3: Measures and measurement plans 16 Appendix 4: Programme milestones 18 Appendix 5: Communication Plan and Stakeholder Analysis 19 Appendix 6: Specialty Collaboration Framework 22 Appendix 7: Risk Impact assessment 23 Appendix 8: Resource 24

2 V11.9 12/06/15 PROGRAMME PLAN: Towards Our Vision for 2020 Outpatient Services

Author

Name Title Signature Date Susan Bishop National Lead

Approval

Name Title Signature Date John Connaghan Director for Performance and Delivery

Document History

Version Summary of Changes Document Status Date published 1 Creation of initial document Draft 2 Outline discussed with Executive Lead, Outpatient Draft Programme, PCCO team. Access Support Team. 3 Changes from Clinical Lead, Project Manager Draft 4 Changes to appendices Improvement Advisors Draft 5 Changes to appendices Improvement Advisors Draft 6 Changes to case for change and resources National Lead Draft 7 Incorporation benefits potential Improvement Advisors Draft 8 Addition of priorities matrix Leads Group Draft 9 Addition of schematics Improvement Advisors, changes to Draft resources National Lead 10 Amendments to main content and appendices Draft 11 Amendments to main content and appendices Draft

3 V11.9 12/06/15 Programme context - current state and case for change

Outpatient services have historically been geared towards patients physically attending consultant led appointments on a Monday to Friday, nine to five basis, and predominantly in Acute Hospital sites with some additional provision being made in the community. To date, there has been a strong emphasis placed on ensuring new patients are seen as a priority in order to achieve the 12 Week First Outpatient Appointment Standard.

Audit Scotland (2014) highlighted that the delivery of this standard remains challenging for all Boards; through 2013/ 2014  7 Boards failed to meet the access target for two consecutive years  3 Boards were in a worsening position in failing to meet the target in 2014  4 Boards were within 5% of achieving the standard.

In 2012 a shared vision of a different outpatient service fit for 2020 was developed, together with a route map to get there. ‘Towards Our 2020 Vision for Outpatient Services’ describes a system whereby people have access to the best available healthcare information, support and care delivered by the right person in the right place and at the right time for them. Delivery of this vision needs to be underpinned by technology enabled care, centred on and pulled by the person.

The Transforming Outpatient Services Programme (2012 – 2015) developed by NHS Boards across Scotland in partnership with the Scottish Government, building on evidence based practice, identified a suite of change concepts to improve the experience for patients at various stages of their journey.

 Use of clinical dialogue, advice only and referral feedback to reduce unnecessary referrals and delays for patients  Reducing ‘Do Not Attends’ through adoption of patient reminder services  Centralised e-Triage in multidisciplinary teams to give people the right care without delay

4  Getting patients on the right pathway through transforming Community Allied Health Professional Musculoskeletal Services

These concepts were designed, tested and implemented in various Boards, underpinned by shared learning, change packages, and the use of a Knowledge Hub together with improvement support.

The success in delivery of new ways of managing outpatient services was in part predicated on having ‘good enough’ data both nationally and locally to highlight areas for improvement and measure change. The National Return Outpatient Data Group has been working with clinicians and managers to improve the quality and use of return outpatient data from a very limited starting point.

The learning from 9 Boards funded to undertake 14 projects aimed at redesigning outpatient pathways and innovation, has enabled us to identify, test and evidence high impact changes across NHS Scotland Outpatient Services. In order to ensure that every person receives the right care, from the right person, at the right time and in the right place, the pace of adoption of these high impact changes needs to increase, to enable Boards to realise the benefits.

The Local Delivery Plan guidance for 2015/16 contained a renewed commitment to ensure that first referrals to outpatient services are seen within the 12 week waiting time standard. This requires focus on sustaining gains made, whilst delivering a specific set of priorities, alongside the effective management of review patients.

There are acknowledged challenges in matching demand and capacity and achieving best value in use of resources. Clinicians also point to the need to ensure patient safety and excellence in care, particularly in managing any necessary follow up appointments and discharging people from outpatient services.

Creating the conditions and the momentum for large scale change is paramount to succeeding in achieving the vision for 2020 and the new outpatient programme for 2015/18 reflects that.

5 The programme development is driven by the need to manage increasing demand and expectations, new advances in medicines and technologies together with changes in professional roles. It will also respond to the continual generation of new ideas from health and social care providers and what people say matters to them.

The programme will focus on supporting consistent implementation across Scotland of a suite of changes to improve flow prioritised to the needs of each Board. Alongside this is the development of technology enabled outpatient services integrated across primary and secondary care, social care and Third and Independent Sectors.

Programme aim, objectives and outcomes

The aim of the programme is that all people are seen in the right place, at the right time, by the right person with the right information. The outcome indicators for the programme are: A decrease in the number of new outpatient appointments at NHS Board level establishing local stretch targets whilst ensuring no patient waits for more than 12 weeks for a new outpatient appointment, Achieve upper quartile for the return:new ratio for a range of specialties. Decrease DNAs to 7% by April 2018 for a range of specialties.

The objectives of the programme are for all Integration Joint Boards, working with NHS Boards, Local Authorities, other partners and patient and public to:  Manage flow through consistently and sustainably delivering a suite of changes prioritised to meet the needs of each Board  Advice, referral feedback and clinical dialogue  Multi-disciplinary eTriage  Patient Reminder Services  Managed return appointments

6  Implement new technology enabled, integrated outpatient services for people with long term conditions  Identifying and enabling those things that can be done once for Scotland in partnership with relevant Government policy leads and national organisations. This includes the national return data set, which is already in progress.

The programme supports NHS Boards and Health and Social Care Partnerships working together with other public sector, Third Sector and Carer organisations and citizens to identify what the priorities are for their system, how to do what needs to be done, rapid sharing of knowledge, allocate resources and build infrastructure needed, track improvements and identify benefits. (See driver diagram in Appendix 2 describing the theory of change for the programme.)

The programme will also make an important contribution to delivery of the national health and wellbeing outcomes, integration outcomes and personal outcomes. It will contribute to a number of other policies and programmes that support the 20:20 Vision for Health and Social Care. Important synergies exist with Unscheduled Care, People Powered Health and Wellbeing, Workforce 2020, Innovation, Seven Day Services, Efficiency and Best Value, The Technology Enabled Care Programme and the Multi-morbidity Action Plan.

Achieving systematic and sustainable change

There are many technical and human factors that prevent changes from spreading, whether small or large scale (NHSIQ 2014). Learning from small scale projects and initiatives has made it possible to build up knowledge about how to create the right conditions for adoption, to implement and sustain reliable improvements. These include developing strong and energised leadership for change, policy alignment, using networks and connections, assessing readiness for change, knowledge management, understanding intended and unintended consequences of change, knowing how to measure costs and benefits and determining factors that will affect reliability and sustainability (Ovretveit 2013, Fixen 2005).

7 Approach/methodology

This new outpatient services programme will focus on implementing at scale what has already been found to be effective plus new integrated service models centred on the person and designed to be technology enabled.

Evidence and experience of large scale change programmes show us that this will need:  Constancy of purpose to get to a condition that is unrecognisable from before and brings positive benefits.  Changes in structures, processes and patterns of behaviour  To be widely spread across boundaries and multiple systems, challenge our thinking and impact on what we do in our lives at work.

Building new networks and connections and mastering knowledge management are essential. The local NHS Board Outpatient Leads will inform what needs to change, what it will feel like and how it will happen. A Clinician Forum will build on existing networks and the enthusiasm, energy and ideas of clinicians. Different ways of framing and reframing a vision for 2020 will be used to help engage hearts and minds in being part of this programme of change. (Appendix 1) For the programme to be successful many people will need to embrace technology in their practice just as they, and people in our communities are doing every day.

Theory of change Evidence tells us that to be successful teams must decide on and stick to a theory of change through the programme. This programme will use driver diagrams to describe the key interventions that people believe will make a big difference, how one change will reinforce another and how the changes in multiple parts of the system and organisations will drive teams towards and contribute to achieving the main goal. Improvement measures added to the driver diagram will help visualise the changes, track progress being made and expected outcomes. (Appendix 3)

8 Learning networks, action phases of 30 – 60 days and PDSA cycles will support teams to form clear goals, plan changes and measurement, take action and measure change and learn from the results.

Measurement plans will be developed at national and local level to determine what success will look like and the differences that teams make which will inform evaluation of effectiveness of programme changes. (Appendix 3)

Analysis of systems, processes and stakeholder commitment

Systems and processes will need to change. The system and process changes should be described in local driver diagrams. Stakeholder analysis will help determine who will lead and commit to these changes. Fig. 1 Examples of systems and processes that may need to change (Adapted from Leading Large Scale Change, Institute of Innovation and Improvement (2011) )

Support and service delivery, handovers and care transitions Professional decision making and practitioner practice Performance improvement and reporting Finance flows, procurement and contracting Service commissioning Information flows and knowledge management systems Public, service user and carer and professional engagement and education processes Communication Human resources Workforce development

9 Programme development

The programme has been co-produced with Board outpatient services leads, clinicians, patients and public representatives with QuEST and Access Support Team colleagues, Scottish Government. NHS Board leads were asked to identify their priorities for 2015/16. All responding Boards identified priorities regarding flow and half of all Boards identified priorities relating to technology enabled integrated outpatient services for long term conditions.

The programme is being developed as three work streams  Managing flow  Delivering integrated primary, secondary and community outpatient services for people with long term conditions enabling people to access care and services at or closer to home. This includes enabling technology by working alongside technology partners to test and implement existing and emergent technologies  Identifying and enabling those things that can be done once for Scotland in partnership with relevant policy leads and national organisations. This includes the national return data set, which is already in progress.

QuEST will support measurement, evaluation and reporting of benefits of the programme. The Measurement Plan is outlined in Appendix 3. The Programme Manager and Programme Team will work with local leads to identify, understand and measure progress and benefits associated with each of the objectives of the programme and each work stream.

The programme will take into account the wide range of stakeholders, the complexity of the landscape and the evolving context and complexity of health and social care integration. The programme and the methodologies are intended to match the aims and requirement to build pace and execute radical change involving all stakeholders at key stages throughout the Programme. Programme milestones are described in Appendix 4. The Stakeholder Analysis and Communication Plan are outlined in Appendix 5.

10 Risks to the success of the programme, issues encountered and mitigation and management will be recorded in a risks and issues log and will be regularly reviewed and acted on. The Risk Impact Assessment is outlined in Appendix 7.

Teams will face constraints in the form of competing priorities, funding, improvement and performance support, knowledge management, information governance, procurement and technological support. Leadership and executive support and enabling work streams will be used to address these.

Programme governance and support for delivery

Local delivery of the programme will be by NHS Boards and their partners with resources for dedicated, Board based Implementation Associates working alongside existing outpatient leads, relevant clinical leads and key technical and innovation partners. Resources will be allocated to local systems on a prioritised basis to fund Board based Implementation Associates. (See Appendix 8)

11 A hub and spoke model will support adoption and spread at increased scale and pace. A small centralised Government team consisting of Programme Manager, National Improvement Advisors, Project Manager, Knowledge Manager/Researcher and Analyst/Information Manager will work together with local Leads and Implementation Associates. The team will support the programme’s focus on consistent implementation across Scotland of a suite of changes to improve flow prioritised to the needs of each Board. This is alongside enabling the conditions for development of outpatient services integrated across primary and secondary care, social care and Third and Independent Sectors and underpinned by use of technology.

The programme will report within Government to the Health & Social Care Management Board and locally to NHS and Local Authority Chief Executives and Integration Joint Boards.

12 References

Bartel, C.A. and Garud, R. (2009) The role of narratives in sustaining organisational innovation. Organization Science, Vol 20 (1), pp. 107-117. Fixen, D.L., Naoom, S.F., Blase, K.A., Friedman, R.M. and Wallace, F. (2005) Implementation Research: A Synthesis of the Literature. Florida: University of South Florida, Louis de al parte Florida Mental Health Institute, The National Implementation Research Network. Bevan, H. and Fairman, S. (2014) The new era of thinking and practice in change and transformation: A call to action for leaders of health and care. NHS Improving Quality. www.nhsiq.nhs.uk Bevan, H., Plesk, P. and Winstanley, L. (2011) Leading Large Scale Change: A Practical Guide. Coventry: NHS Institute for Innovation and Improvement. www.institute.nhs.uk/academy Ibanez de Opacua, A. (2013) Guide on spread and sustainability. Healthcare Improvement Scotland. Kaplan, H.C., Brady, P.W., Dritz, M.C., Hooper, D. K., Linam, W.M., Froehle, C.M. and Margolis, P. (2011) The influence of context in quality improvement success in health care: A systematic review of literature. The Millbank Quarterly, Vol. 88 (4), pp.500-559. Ovretveit, J. (2011) Understanding the conditions for improvement: research to discover which context influences affect improvement success. BMJ Quality Safety, Vol. 20 (S1) pp. 18-23 http://qualitysafety.bmj.com/site/about/unlocked.xhtml Taylor, M.J., McNicholas, C. Nicolay, C. et al. (2013) Systematic review of the application of the plan-do-study-act method to improve quality in healthcare. BMJ Quality Safety, Vol 0, pp.-9. Welbourne, D., Warwick, R. Carnall, C. and Fathers, D. (2012) Leadership of Whole Systems. The King’s Fund.

13 Appendix 1: Towards our 2020 vision

14 15 Appendix 2: Programme Driver Diagram

16 Appendix 3: Measures and measurement plans

The overall set of measures will attempt to include measures that evidence:  Service delivery outcomes  Cost benefits  Progress towards health and wellbeing outcomes  Experience and satisfaction with services  Mind set and behaviour change  Organisational capacity building  Process and pathway change

Programme Aim: all people are seen in the right place, at the right time, by the right person, with the right information Programme work stream Driver Measure Measure type Expected data Frequency of (by specialty) source reporting

Effective management of Reduce DNAs % of new outpatient DNAs Outcome National Monthly patient and information flow through outpatient Efficient and effective Rate of new referrals (For discussion Process Locally determined Monthly multidisciplinary triage of referrals to determine feasibility of services measurement)

% of electronic referrals (For Process Locally determined Monthly discussion to determine feasibility of measurement)

% of e-advice requests of total Process Locally determined Monthly referrals (For discussion to determine feasibility of measurement) Improve communication at the Rate of new first outpatient Outcome National Monthly primary and secondary care appointments 17 interface % of conversion of e-advice Process Local Monthly requests to new outpatient appointments (For discussion to determine feasibility of measurement) % referrals converted to advice Process Local Monthly requests (For discussion to determine feasibility of measurement) Technology enabled Optimise utilisation of clinic % of new outpatients seen within Outcome National measure/ Monthly integrated outpatient resources 12 weeks local monitoring services for people with Number of patients discharged (For Process Locally determined Monthly long-term conditions discussion to determine feasibility of measurement) Return: new ratio Outcome National Monthly

Efficient use and interfacing of Virtual appointments as % of total Process Locally determined Monthly available technology to enhance appointments (For discussion to the management of patient and determine feasibility of information pathways measurement) Signposting and support for self- Number of patients using’ Process Local Monthly management ‘prescribed’ digital technologies to promote self-management/remote monitoring (For discussion to determine feasibility of measurement) Patient Experience Person centred, safe, efficient and Number of patients complaints Balancing measure Local Monthly effective booking practices related to effective booking practices (For discussion to determine feasibility of measurement) % of appointments ‘cancelled by Balancing measure Local Monthly hospital/clinic’ with <6 weeks’ notice (For discussion to determine feasibility of measurement)

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Appendix 4: Programme milestones

Task ID Task Name Duration Start Finish 1 Programme launch preparation 65 days 01/04/2015 30/06/2015

2 Programme plan finalised and submitted 43 days 01/04/2015 29/05/2015

3 Programme governance structure in place 43 days 01/04/2015 29/05/2015

4 Profile Board baseline data 33 days 15/04/2015 29/05/2015

5 Define local improvement portfolios 43 days 01/05/2015 30/06/2015

6 1st HIA networking event 10 days 03/05/2015 14/08/2015

7 Plan approved and signed off 7 days 29/05/2015 08/06/2015

8 Appoint local associated HIAs 45 days 01/06/2015 31/07/2015

9 National launch 1 day 28/08/2015 28/08/2015

10 Local report out schedule issued 5 days 31/08/2015 04/09/2015

11 Implement local improvement portfolio 154 days 31/08/2015 31/03/2016

12 Programme year- end report issued 5 days 04/04/2016 08/04/2016

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Appendix 5: Communication Plan and Stakeholder Analysis

Level of interest and influence

Influence Interest (5=very Label Stakeholder Group (5=very high; Action high; 1=very 1=very low) low) 1 NHS Territorial Boards 5 5 Manage Closely 2 Special Boards 5 5 Manage Closely 3 Executive Leads 5 5 Manage Closely 4 Integration Leads 5 4 Manage Closely 5 Delivery Group Members 4 5 Manage Closely 6 AHP Leads 4 4 Manage Closely 7 Nurse Executive Leads 4 4 Manage Closely 8 eHealth Leads 4 4 Manage Closely 9 Other Improvement Organisations 4 3 Manage Closely 10 Technology Partners 4 3 Manage Closely 11 Health & Social Care Partnerships 3 5 Manage Closely 12 Scottish Government 3 4 Manage Closely 13 Primary Care Leads 3 4 Manage Closely 14 Medical Clinical Leads 5 2 Keep Satisfied 15 Patients, Public Partners 5 2 Keep Satisfied 16 3rd Sector Leads 4 2 Keep Satisfied 17 Stakeholder Group Members 2 4 Keep Informed 18 Professional Bodies 2 3 Keep Informed 19 Media 2 3 Keep Informed 20 Other Countries 2 2 Minimal Effort

20 Frequency Strategy Activity Responsibility (Weekly, Monthly, Quarterly etc.) Representation on Project / Programme Board; i.e. Delivery Group, Efficiency National Lead, Clinical Leads and Portfolio Board, PC Leads, SOSDG, RTC, ISG, RCIN, Unscheduled Care Programme Quarterly or less Work Stream leads Board Regular face-to-face contact; i.e. Primary Care Division, JIT, Health & Social Care Manage Integration, AST, Unscheduled Care, eHealth, LIT, Board Leads, Special Boards, National Lead, Work Stream Leads Weekly – fortnightly Closely Commissioned Project Team Leads, Specialty Collaboration Leads Collaborative platform, i.e. presentations and resources on to the following: Work stream leads Post events/ weekly Knowledge Hub, QI Hub, PGP Knowledge Network Tele-video conferencing / WebEx sessions; i.e. Programme Stakeholders, THTC Work stream leads Quarterly or more Stakeholders, Specialty Collaborative, Releasing Time to Care (RTC), ROPG Emails / letters; i.e. Primary Care, All Boards, SG colleagues, AHP Leads, Nurse National Lead, clinical leads and Ad hoc Exec Leads, Delivery Group Work Stream leads Programme sub-group meetings / updates / letters; i.e. ROPG, programme stakeholder group, Specialty Collaboration, Managing Patient Flow Group, Programme Manager and work Quarterly or more Executive Leads, TEC DOA Core Delivery Group, Primary Care Leads, Integration stream leads Care Leads National Lead, work stream leads Social / Digital media: Stakeholders Weekly and clinical leads Meetings for individuals re specific projects; Primary Care, eHealth, JIT, AHP Leads, National Lead and Work Stream Ad hoc Nurse Exec Leads leads Project meetings; i.e. Primary Care, GMS Contract, RTC Integration Project; Health National Lead Every 2 months & Social Care Partnerships Targeted presentations to particular groups; i.e. QI Learning Sessions, Primary National Lead, clinical leads and Annually or more Care Leads, AHP Leads, Nurse Exec Leads, QuEST Directorate Work Stream leads Meetings for individuals with specific projects: i.e. 3rd Sector, Medical Clinical Keep National Lead and Clinical Leads Monthly Satisfied Leads Patients, Public Partners National team Monthly Targeted presentations to particular groups: i.e. GPs National Lead and clinical Leads Ad hoc

Email / letter: i.e. 3rd Sector, Medical Clinical Leads National Lead and Clinical Leads Ad hoc Email / letter: i.e. media, stakeholder group Programme Manager Monthly Keep Website: i.e. Professional bodies, media, stakeholder Group Programme Manager Weekly Informed

Webcasts, podcasts, video conferencing: i.e. stakeholder Group Work stream leads Event specific Blogs, social media; i.e. stakeholder Group Programme Manager Weekly Leaflets, display boards: i.e. stakeholder Group Programme Manager Event specific 21

National lead,, clinical leads and Presentations to wide audience; i.e. Professional bodies Annual work stream Programme Manager and work Collaboration platform: i.e. stakeholder Group Weekly stream leads

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Appendix 6: Specialty Collaboration Framework

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Appendix 7: Risk Impact assessment

ID Risk description Likelihood Impact Risk Score Countermeasures (L) (I) (L) x (I) 1=low, 5=high 1=low, 5=high Ineffective communication/ partner- National Clinical Lead to support the development of Clinical 1 ship working between primary and 4 5 20 Leads Forum, representation from both 1° and 2° Care secondary care 2 Inadequate buy in from all healthcare Undertake stakeholder analysis. professionals, management and 4 5 20 Develop stakeholder communication plan admin and patients/carers Stakeholder engagement as per communication plan 3 Insufficient cultural/ behavioural 3 5 15 Involve patients/ service users at a local and National level. change by patients and public

* Equality and Diversity Assessment to be undertaken

25 Appendix 8: Resource

Events/meetings £30,000 Design and publication £10,000 SLAs for Programme Management, Project Management and support, Improvement Advisors, Knowledge Manager, £360,000 Clinical Leads, Analyst Allocations to Health Boards for Implementation Associates £610,000 Specialty Collaboration £560,000 TOTAL £1,570,000

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