ANNUAL REVIEW 2007/08

SELF-ASSESSMENT

JULY 2008

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NHS LOTHIAN ANNUAL REVIEW 2007/08

Agenda

1: Executive summary

1.1 2007/08 highlights

2: Progress on 2006/07 Annual Review Action Points 2.1 Phasing out Availability Status Codes (ASC) 2.2 Waiting times 2.3 Financial performance 2.4 Management of three acute hospitals 2.5 Rezoning medical admissions 2.6 Extended opening times for primary care services 2.7 Edinburgh BioQuarter 2.8 Royal Hospital for Sick Children Business Case

3: Improving health and reducing inequalities 3.1 Increasing healthy life expectancy in Lothian 3.2 Drugs, alcohol and tobacco 3.3 Coronary Heart Disease (CHD) and Stroke 3.4 Sexual Health and HPV vaccination programme 3.5 Improving health for children and young people 3.6 Immunisation programmes 3.7 Screening programmes 3.8 Health Impact Assessment 3.9 Keep Well Project 3.10 Community planning 3.11 Working with other organisations

4: Shifting the balance of care towards primary and community care 4.1 Primary Care Modernisation Strategy 4.2 Mental health services 4.3 Management of long term conditions 4.4 Pharmacy 4.5 Prescribing 4.6 Optical and Dental Services 4.7 CHP/CHCP development 4.8 Anticipatory care

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5: Access to services 5.1 Waiting times and progress towards 18 weeks referral to treatment 5.2 Diagnostic waits 5.3 Cancer waits 5.4 A&E waits 5.5 Access to primary care 5.6 Access to NHS dental services 5.7 Delayed discharges

6: Service change and redesign 6.1 Sites and services vision 6.2 ICIC 6.3 Lean in Lothian 6.4 Patient Focus and Public Involvement 6.5 Carer’s Information Strategy

7: Improving treatment for patients 7.1 Enabling and supporting patients to be partners in their care 7.2 Making healthcare safer 7.3 HAI and Infection Control 7.4 Modernising services through better use of technology 7.5 Spreading best practice

8: Finance, efficiency and workforce 8.1 Financial performance and planning 8.2 Efficiency savings and efficient Government targets 8.3 Workforce issues and workforce planning 8.4 Aligning workforce, financial and delivery plans

9: Local service issues 9.1 St John’s campus visioning 9.2 MMC repatriation of funding from NES 9.3 Capital support for Lothian large schemes

Agenda Item 1: Executive Summary

1.1 2007/08 Highlights

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` NHS Lothian Annual Review 2008 Agenda Item 1

1: Executive Summary

Key Points

• NHS Lothian has continues to provide high quality services and care to the 809,764 people who live in Lothian and many more in the South East of Scotland • Although we are working hard to meet – and exceed – targets, we are committed to continual improvement and modernisation to achieve the levels of Scotland and the world’s best • We can show improvements in key clinical areas, such as cardiac services and care for people with long-term conditions • We are making more use of new technology to improve our patients’ experience of healthcare and at the same time are striving to make care more patient-centred • We remain committed to health improvement and tackling health inequalities and are, for example, targeting stop smoking services in deprived areas • We continue to work across boundaries – organisational and geographic – to provide high quality care and make the best use of resources

Below are some stand-out examples of our achievements

1.1 2007/08 highlights

Immunisation programmes Primary immunisation rates remain very high at over 98%, exceeding the Scottish Government target of 95%. Significant improvements have been made in Measles, Mumps and Rubella (MMR) uptake at 5 years. Three out of four CH(C)Ps now exceed the 95% target for MMR1 at 5 years. In 2007/8 flu vaccination uptake for over 65s is positive at 77%, above both the Scottish Government target and national average.

Drugs alcohol and tobacco The Lothians and Edinburgh Abstinence Programme (LEAP) is a treatment and rehabilitation programme for clients wanting to achieve a substance free recovery. LEAP was launched in September 2007 and 22 patients have already graduated. The two-year pilot programme operates seven days a week and provides aftercare support as well as access to self-help groups.

During the year we improved access to Stop Smoking services. We put additional support into the acute sector, targeting maternity services and we developed a pharmacy-based scheme. In the first quarter of 2008, 1,430 people were recorded as setting quit dates, up from 1,051 in the same period the previous year.

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Sexual health NHS Lothian’s Healthy Respect has continued to deliver a multi-faceted approach combining education, information and services. The HIV Comeback Tour campaign increased awareness of HIV and testing and demonstrates the strength of partnership working. The campaign won the award for best photography and the Gold Award in the Communications in Business (CiB) awards for 2007.

Prescribing NHS Lothian continues its excellent track record in primary care with the lowest cost per patient per annum (£149) in Scotland. This means a saving to NHS Lothian of £28.1m compared to the Scottish average prescribing costs for 2007/08. In addition, the Lothian Joint Formulary (LJF) is recognised as one of the most highly developed formularies in Scotland, encouraging safe, effective and economical prescribing.

Dental services More than three quarters (75.5 per cent) of children in Lothian were registered with an NHS dentist by the end of December 2007, notably above the Scottish average of 71.7 per cent. This was achieved by working closely with general dental practitioners.

Waiting times and progress towards 18 weeks referral to treatment By the end of December 2007, NHS Lothian achieved all of the HEAT targets set by the Scottish Government for waiting times. No patients waited more than 18 weeks for inpatient, day case, or outpatient treatment. No cataract outpatients waited over 11 weeks and no inpatient / day cases waited over 7 weeks. Treatment was delivered for all patients in need of cardiac intervention within the required target timeframes. Finally, the target of a maximum 9 week wait for key diagnostic scopes and scans was met six months ahead of schedule and has continued to be maintained.

Patient Administration Systems throughout Lothian have been upgraded to support New Ways. The model and level of training and awareness raising undertaken in NHS Lothian during the transition has been commended by ISD as a standard to be attained by other boards. NHS Lothian has also been selected as national partner board for the 18 weeks target from referral to treatment for routine patients, which is to be achieved by 2011.

Cancer waits During 2007 NHS Lothian steadily improved compliance with the headline 62- day target. The combined total for all tumour groups increased from 80.4% in the first quarter of 2007, to 94.5% by the end of the year. Provisional data for the first quarter of 2008 shows an improvement to 95.6%.

Delayed Discharges NHS Lothian, in partnership with local councils, has again met all its delayed discharge targets. The April 2008 census reported the best results since ISD begun collecting the data in 2000. Overall, 50 patient discharges were delayed in comparison to 89 for the previous year, and zero delays were

2 NHS Lothian Annual Review 2008 Agenda Item 1 reported in short stay and over six weeks categories. All members of the Lothian Partnership are committed to maintaining the zero standards for short stay and over six week delays and to maintaining the overall numbers of patients delayed, in line with the 2007/8 target figure.

Lean in Lothian Lean in Lothian, in partnership with GE Healthcare, has used Lean methodologies to achieve substantial improvements in mental health, primary care, acute services and key support services. The project involves training staff to spot opportunities for change and gives them the power to make improvements in patient care. The 14 projects delivered in 2007/8 have had significant immediate impacts on staff and patient experience by improving efficiency, reliability, and greater equity of response. Better use of resources has led to reductions in the number of patients who don’t attend (DNAs), targeting of staff time to delivering direct care, reduced waiting times, and faster turnaround time for results. Examples include: • One-stop new patient clinic in place in the breast service, allowing most patients to get an outcome at first appointment • Breast service follow-up process has been redesigned, reducing patient visits to hospital and focusing clinical staff time where needed • 40% reduction in pathology laboratory turnaround times, and average 30% reduction in turnaround time for essential theatre instruments • Same day sorting, triage and appointing of outpatient referrals in gastro- intestinal and general surgery at RIE • increased therapeutic activities and staff skills development programme in acute mental health wards

HAI and Infection Control Good progress has been made on the overall HEAT target. Since 2005 there has been a fall of 11.24 per cent in the number of Staphylococcus Aureus Bacteraemia episodes. This equates to a reduction in numbers from 498 in 2005-06 to 442 in 2007-08. Other areas of good work include average compliance of above 95% on national monitoring and audit requirements for cleaning services; more than 670 trained Cleanliness Champions, above the target of 461 set by NHS Education; reductions in infection rates for hip arthroplasty (0.78%) and caesarean section (2.9%) which are below the national averages (1.64% and 8.24% respectively).

Financial performance and planning NHS Lothian delivered its financial targets in 2007/8 while also achieving early pay back of brokerage of £3m. NHS Lothian successfully lobbied for implementation of the NRAC report in full, and this has been approved by the Cabinet Secretary. The approved five year financial plan has confirmed that additional funding of £3m in 2008/9 and £5m per annum for the next four years will be made available to reduce the NRAC funding gap from £55m to £32m.

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Workforce and efficiency savings The overall workforce of NHS Lothian increased by 1.8 per cent over the year and there was a 7.6 per cent drop in employees leaving. This was as a result of modernisation of recruitment and retention processes. Overtime costs have been reduced by a fifth (around £1.4m), and changed banding payments for training grade medical staff have meant decreased expenditure of around£1.6m. Average sickness absence in 2007/8 was 4.9%.

Efficiency savings were also achieved by reducing the overall use of supplementary staff by 10% (217,130 hours), resulting in a decrease in spending of £1.1m for 2007/8. In addition, spending on agency nurses is down by £2.7m on the previous year.

Health inequalities We continue to implement our strategic approach to addressing health inequalities. This includes ensuring all health services are responsive to the needs of the most disadvantaged using Rapid Impact Assessment and Equity Audit to identify and address any potential barriers; providing targeted services for some groups of people e.g. ethnic minorities; and partnership work to address the underlying causes of social inequality.

Child Protection Over the last year 1,097 NHS Lothian staff took part in our new e-learning programme. We have continued to build on the learning from critical incidents and inspection reports. The shared information system, C-me, has enabled West Lothian to share relevant information electronically, successfully and securely, across agencies to protect children. Child Protection Alerts are now visible within hospital A&E and Children’s Services’ electronic information systems. The priority that Child Protection has across NHS Lothian was demonstrated by the high attendance (over 300) at the 3rd Annual Child Protection Conference in June.

Hospital sites NHS Lothian is strongly committed to continue to deliver its stated aim of having three acute adult hospital sites. The importance of all 3 hospital sites is emphasised through our planned developments and investments already made. For example investments and developments at St John’s hospital include: • Perinatal Unit • Redesign of front door services – A&E and medical assessment unit • Enhanced cardiology services • Head and neck centre • New endoscopy facility • Development of elective short stay surgical centre • Development of specialist dental facility and dental training support

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Agenda Item 2: Progress on 2006/07 Annual Review Action Points

2.1 Phasing out Availability Status Codes (ASC)

2.2 Waiting times

2.3 Financial performance

2.4 Management of three acute hospitals

2.5 Rezoning medical admissions

2.6 Extended opening times for primary care services

2.7 Edinburgh BioQuarter

2.8 Royal Hospital for Sick Children Business Case

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` NHS Lothian Annual Review 2008 Agenda Item 2

2: Progress on 2006/7 Annual Review Action Points

Highlights of key areas of progress on 2006/7 Annual Review action points will be covered in the Chair’s presentation. Further detailed progress on the action points is included within the appropriate sections of this self- assessment.

2.1 Phasing out Availability Status Codes (ASC)

Significant preparatory work towards reducing the number of patients waiting with an Availability Status Code was undertaken in 2006/7 and 2007/8 to support the transition to New Ways. This was a significant change in how waiting lists are managed.

It was necessary to reduce the numbers of ASCs to match the anticipated volume of patients whom would be deemed to be unavailable for treatment under New Ways. The target for Lothian was estimated at 2,044 or under for inpatients and this was successfully achieved and improved upon.

Inpatients/day cases waiting March’07 June’07 September’07 December’07 with an ASC codes Target Planned Trajectory 4996 4013 3030 2044 Actual 5506 5310 4699 1819

To support this change, policies and procedures have been reviewed, training of administrative staff was undertaken and awareness raising sessions for all staff groups, including GPs and hospital clinical staff have been held. This level of input was commended nationally and highlighted to other boards as the ideal model. Refresher training took place in May 2008 and further training is planned as part of the NHS Lothian data quality drive during 2008/9.

Lothian’s Patient Administration Systems have been upgraded to support the use of New Ways and work is also underway to enable the Dental Institute Patient Administration System to update records on the national data warehouse system.

NHS Lothian will continue to work closely with ISD, to support a high level of data quality in the National Data Warehouse.

2.2 Waiting times

• Progress detailed within Agenda Item 5 ‘Access to Services’ within section 5.1 Waiting times, A&E, Hip fractures, Cancer etc.

2.3 Financial performance

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• Progress detailed within Agenda Item 8 ‘Finance, Efficiency and Workforce’.

2.4 Management of three acute hospitals

Lothian continues to deliver its stated aim of having three acute adult hospitals accepting unscheduled medical cases with the necessary critical care and other required back up. Maximising opportunities and making best use of all three hospitals – St John’s Hospital, Royal infirmary of Edinburgh and the Western General hospital – is central to our Better Acute Care in Lothian (BACiL) programme. Increasingly the three sites function as one virtual hospital. This has seen the introduction of common service standards across Lothian’s sites and investment at SJH in the form of enhancement of the cardiology service and redesign of the model of care in the medical assessment unit. Work has also begun on upgrading and expanding SJH’s endoscopy unit and day surgery capacity. BACiL is one of the four strands of our strategic programme of modernisation, called - Improving Care, Investing in Change (ICIC). Progress on a number of developments and achievements are discussed under agenda item 6 – Service change and modernisation.

2.5 Rezoning medical admissions

Rezoning was added to the portfolio of Better Acute Care in Lothian (BACiL) during the Improving Care Investing in Change public consultation period.

During 2007/8 modelling work was undertaken in response to recommendations from a public engagement workshop held in February 2007. The work was also given further impetus by a rise in unscheduled activity at all three hospital sites. Rezoning was seen to have the potential to rebalance this activity. A significant amount of activity could be rezoned from RIE to SJH and a smaller amount from RIE to WGH. The exact amount will be dependent on where boundaries are redrawn.

The outcome of the modelling exercise was presented at a follow-up workshop in February 2008 involving an expanded group of stakeholders. This confirmed technical feasibility of rezoning of emergency medical activity. The proposal was acceptable to stakeholders on clinical grounds and there was agreement that it would have quality gains in terms of equity and speed of access to services on all 3 sites, as well as the service being in a stronger position to meet its waiting times targets. While NHS Lothian can deliver the healthcare component of rezoning, the public engagement process highlighted the need to have the appropriate public transport in place. Challenges remain relating to the ability of transport providers and social work services to support the revised flows for patients and for their families and visitors.

The output of the workshop is being considered by the subgroup that reports to the BACiL Project Board.

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2.6 Extended opening times for primary care services

Progress detailed within Agenda Item 5, Access

2.7 Edinburgh BioQuarter

The Edinburgh Bioquarter is the commercial science park development to the south and west of the Royal Infirmary of Edinburgh at Little France. Scottish Enterprise has acquired the land and developed the basic infrastructure. The University of Edinburgh has agreed to purchase land for further development of the medical school, and, in a partnership with Scottish Enterprise and Scottish Government, has secured funding for the development of a Centre for Regenerative Medicine. The centre will be led by Professor Sir Ian Wilmut (of Dolly the sheep fame). Scottish Enterprise and the University of Edinburgh selected Alexandria Real Estate Equities as the commercial partner to develop the bio science park, and identified NHS Lothian as the key strategic partner in this development. A Partners Forum has been established, chaired by John Swinney, the Cabinet Secretary for Finance, which had its first meeting on 5th February 2008.

NHS Lothian is a key partner in this development. The proximity of the teaching hospital and its patients and staff, who together are a key resource for clinical and basic science research in common diseases, is a major benefit. NHS staff contributes to research, which is undertaken by the clinical academic staff employed by the University of Edinburgh and who have honorary contracts with NHS Lothian. NHS Lothian benefits from over £9 million of NHS R&D support funding to provide the infrastructure to support a high-quality, externally funded clinical research. NHS Lothian has back-to- back intellectual property rights (IPR) agreements with University of Edinburgh as well as with commercial partners, and also agreements to secure transfer of tissues and samples while retaining appropriate IPR.

The Bioquarter development offers NHS Lothian the potential opportunity of taking a direct equity stake in the development, and particularly in the early support to emerging biotechnology companies, in a model pioneered by Alexandria called the Accelerator. NHS Lothian would then benefit from the total return on capital invested as well as the IPR agreements providing significant revenue to reinvest in NHS facilities. The site also offers the opportunity to redevelop the NHS Lothian clinical laboratories onto a single integrated site and an information technology (IT) platform that is in close proximity with Phase 1 clinical trial partners, emerging medical devices and investigation technologies, and provide a comprehensive platform for translational medicine clinical research.

• NHS Lothian’s Chief Executive, Medical Director and Director of Acute Services and Workforce, together with representatives from Scottish Enterprise visited a number of Alexandria developments in San Francisco and Seattle to share, learn and gather intelligence on similar developments in the USA.

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• Professor James Barbour gave a presentation to Scottish Government Cabinet Secretary for Finance and Sustainable Growth on the Edinburgh BioQuarter development plans at the first meeting of the Partners Forum held at the RIE Little France. Attendees included representatives from our partner SEEL, Alexandria, University of Edinburgh and City of Edinburgh Council.

2.8 Royal Hospital for Sick Children Business Case

The Outline Business Case for the new children’s hospital has progressed through approval processes in NHS Lothian and with SEAT Boards and was submitted to NHS Lothian Finance and Performance Review committee in June 2008, and then to the Capital Investment Group (CIG) for its meeting in July 2008.

Further work on bed modelling took longer than anticipated and this delayed discussions with the other SEAT Boards to reach agreement on each Board’s share of the future funding for the children’s service. The other Boards have now agreed in principle to their share of the additional revenue costs.

Funding of £48.5 million from CIG towards the capital build has been confirmed.

It has been agreed that the RHSC Project should be subject to the Gateway Process – and will enter this process at Gateway 1 (“Delivery Strategy”) to “assess the OBC and the delivery strategy before any formal approaches are made to prospective suppliers or delivery partners”. This was undertaken in June and July, 2008 in parallel to submission of OBC.

The National Specialist Children’s Services Review was out for public consultation and the final development and subsequent investment into services is not yet confirmed. For this reason, no assumptions of clinical service change as a result of this review were included within the OBC.

In addition, further work is currently being completed with colleagues in Public Health, to calculate the impact on NHS Lothian Children’s Services of anticipated demographic change. The work also involves close links with the Yorkhill Project in Glasgow.

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Agenda Item 3: Improving Health and Reducing Inequalities

3.1 Increasing healthy life expectancy in Lothian

3.2 Drugs, alcohol and tobacco

3.3 Coronary Heart Disease (CHD) and Stroke

3.4 Sexual Health and HPV vaccination programme

3.5 Improving health for children and young people

3.6 Immunisation programmes

3.7 Screening programmes

3.8 Health impact assessment

3.9 Keep Well Project

3.10 Community planning

3.11 Working with other organisations

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NHS Lothian Annual Review 2008 Agenda Item 3

3: Improving health and reducing inequalities

Key Points • NHS Lothian has a three-strand approach to improving healthy life expectancy: high quality interventions; targeted initiatives and catching people at a young age. Examples include the Keep Well project (described in section 3.9)

• Multi-agency working has improved access to treatment for drug and alcohol problems to vulnerable groups and hard-to-reach groups, such as pregnant women, prison leavers, young people and people who also have mental health problems.

• Our Stop Smoking services have been redesigned with a renewed focus on deprived areas, resulting in a significant rise in numbers of people setting a quit date and succeeding in giving up.

• A major redesign of cardiac services was implemented in July 2007, involving all three acute hospitals and delivering a better service to patients across Lothian and South East Scotland

• Sexual health services are seeing more patients, who also have more choice over where they access services, such as long-acting reversible contraception

• The HIV Comeback Tour, a campaign to raise awareness and promote condom use among gay men, showed good results and also won a major communications award.

• Uptake of immunisation continues to be among the highest in Scotland. We have also been preparing for implementation of the HPV vaccination programme to help protect teenage girls from cervical cancer.

• Work has continued to improve existing screening programmes and to introduce screening for bowel cancer. NHS Lothian has invested in extra colonoscopy sessions to meet demand and is building an additional endoscopy room at St John’s.

• NHS Lothian is working with other organisations, such as councils, on issues ranging from child protection to ensuring the health impact of planning decisions is taken into account.

• We are working with other NHS boards across a variety of clinical areas to ensure better regional planning. Examples include the mental health mother and baby unit at St John’s, the Learning Disability Managed Clinical Network and the planned specialist in-patient service for eating disorders.

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3.1 Increasing healthy life expectancy in Lothian

Lothian’s population

• Lothian’s population is projected to grow at an unprecedented rate over the next decade. Most of the growth will be in the under 65 years of age group in the City of Edinburgh – though West Lothian will also see significant growth in its younger population, mostly related to inward migration. • There will be an expansion in the numbers of older people in Lothian (65 years+) and improved male survival is an important component of this projected growth. • The expansion of Lothian’s resident population will have a tangible impact on the demand for, and sustainability of, NHS services. This will affect particularly primary care and community health services, but the acute hospital sector will also need to respond to the growing numbers of people aged over 85 with more complex care needs. There will also be increased demands on maternity services.

Increasing healthy life expectancy by reducing health inequalities in Lothian’s population

The World Health Organisation estimates that 80% of premature deaths from cardiovascular disease, chronic respiratory conditions and type II diabetes could be prevented by more comprehensive implementation of existing interventions to prevent and treat disease.

Disadvantaged groups have a higher prevalence of disease; poorer risk factor profiles; poorer access to/use of healthcare for similar need; lower uptake of preventive interventions; poorer outcomes and often greater adverse social consequences.

Health inequalities are caused by life circumstances, lifestyle choices, environmental hazards, social status, job strain, lack of job control and poorer ability to access services.

Other relevant risks also need to be considered and addressed: e.g. healthy weight when looking to increase healthy life expectancy.

NHS Lothian has a three strand approach to improving healthy life expectancy: high quality interventions; targeted initiatives; and catching people at a young age. This is in line with the recently published Scottish Government document, Equally Well: Report of the Ministerial Task Force on Health Inequalities. Examples of these approaches across NHS Lothian include: Keep Well project; Homeless GP Practice; Equity Audit; and teaching doctor-patient communications.

Increasing healthy life expectancy by improving health for all Lothian’s population

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While striving to increase healthy life expectancy in a targeted way for disadvantaged groups, we also aim to increase healthy life expectancy for the whole population by addressing wider issues e.g. immunisations, vaccinations, screening and other health promotion initiatives and interventions. The following table shows latest available Healthy Life Expectancy data for Lothian compared to Scotland. (Source: www.scotpho.org.uk)

Life Expectancy and Healthy Life Expectancy 1999-2000 At birth At age 65 LE HLE(LLI) HLE(SAH) LE HEL(LLI) HLE(SAH) Males Scotland 73.0 53.8 64.3 14.5 7.6 11.3 Lothian 73.8 55.6 66.6 14.8 8.0 12.0 Edinburgh City 73.8 57.5 67.4 15.0 8.8 12.1 Midlothian 74.2 54.0 65.5 14.9 6.6 13.1 East Lothian 75.1 54.7 67.7 15.5 7.6 11.1 West Lothian 72.8 51.6 65.6 13.7 7.4 12.1 Females Scotland 78.4 57.0 66.8 17.6 8.9 13.2 Lothian 78.8 59.0 69.3 17.9 9.5 14.2 Edinburgh City 79.0 60.6 70.7 18.4 10.3 15.4 Midlothian 79.0 56.9 66.3 17.7 7.8 13.0 East Lothian 79.3 59.7 71.4 17.9 9.7 13.9 West Lothian 77.5 54.5 65.5 16.5 7.5 10.9 LE – Life Expectancy. HLE – Healthy Life Expectancy. LLI – Limiting Longterm Illness. SAH – Self Assessed Health

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3.2 Drugs, alcohol and tobacco

Drugs and alcohol

In Scotland’s second biggest Health Board, our staff deal with significant levels of drugs and alcohol misuse. NHS Lothian works in partnership with each of the four Local Authority Alcohol and Drug Action Teams (ADATs) to consolidate good practice, develop local strategies and where appropriate, develop new services to help people achieve their potential. General Managers of each Community Health Partnership attend or chair these groups, supported by the Strategic Programme Manager (Substance Misuse)

Our approach is multi-agency, engaging and involving, evidence developing and evidence informed (e.g. development of national guidance and the ACMD Report) and focused on quality (e.g. Harm Reduction Team, Confidential Inquiry into drug related deaths). Example More than 2,010 Lothian residents who were not in contact with specialist drugs services sought help for illicit drug use in the year to March 2007. Example More than 3,900 people are estimated to be on methadone programmes in Lothian. Through work done by NHS Lothian’s Primary Care Facilitation Team to improve supervision of methadone, levels of supervised consumption of methadone increased from 79% in August 2007 to 85% in February 2008.

Through multi-agency working we have been able to improve access to treatment for hard to reach groups such as pregnant women, prison leavers, young people and people with drug, alcohol and mental health problems.

Example During 2007/8, the community Alcohol Problem Service (APS) worked with 2,256 individual patients to address their alcohol problems. The inpatient (Ritson Clinic) assessment and detoxification service managed 356 patient admissions during the year. Example During 2007/8 the Lothians and Edinburgh Abstinence Programme (LEAP) was launched. This is a treatment and rehabilitation three- month programme for substance dependent clients wanting to achieve a substance free recovery. NHS Lothian delivers this initiative in partnership with City of Edinburgh Council and Transition, a voluntary sector organisation aimed at helping people back into the workplace, education or training. Funded as a two-year pilot by the Scottish Government, the programme operates seven days a week and provides aftercare support as well as access to self-help groups. Twenty two patients have now graduated since the launch of the programme in September 2007.

Other developments during 2007/8 include:

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• PrePare, the multidisciplinary pregnancy support team for drug using mothers, continues to provide intensive care and protection, particularly now for women who are chaotic drug and alcohol misusers, who are likely to be homeless and may have offending behaviour. Since it was established in July 2006, PrePare had, by March 2008, provided interventions for 100 women and their families. In addition 36 clients were assessed and provided with a package of care that was delivered by community based mainstream services. • Completion of single shared assessment pilot, currently testing individual items in electronic format, prior to roll-out. Lothian will be the first health board area in Scotland to have an electronic single shared assessment for people with addiction problems. This multi-agency (NHS, local authority and voluntary sector) initiative is overseen by the Pan Lothian Data Sharing Partnership (DSP), chaired by the Director of Public Health & Health Policy. • Through consultation with local partners, the Scottish Government and service users, local ADAT strategies and outcomes have been developed. • Continuing to support and improve the role of Primary Care. • In 2007, NHS Lothian’s Harm Reduction Team (HRT) provided training sessions on ‘Preventing Overdose and Critical Incident Management’ to 132 specialist and non-specialist workers representing NHS, Local Authority, homelessness sectors and outreach workers. • Securing senior management representation on each of the four Licensing Fora in Lothian with a view to raising awareness of the potential impact of Licensing Board decisions on public health • Establishing an alcohol counselling service provided in partnership with Edinburgh and Lothian Counselling on Alcohol (ELCA) as part of Keep Well in Edinburgh, with 41 clients having been supported in the first six months. Referrals continue to increase. • Piloting of an alcohol health promotion post focusing on hard to reach groups within the City of Edinburgh. Work has concentrated on alcohol awareness courses, BME events, outreach work with the Polish community and providing more alcohol awareness materials in various languages

Tobacco

The West Lothian CHCP General Manager chairs the NHS Lothian Tobacco Strategy Project Board, which continues to drive the Stop Smoking agenda in Lothian. The Board continues to engage colleagues in the NHS, Local Authorities and the voluntary sector with the aim of reducing our number of smokers from the current Lothian estimate of 140,220.

During the year Stop Smoking services were redesigned, putting additional support into the acute sector and developing a pharmacy-based scheme to provide additional services in more deprived areas. Taken together we have seen a rise from 1,051 to 1,430 in the numbers of people recorded as setting quit dates comparing January – March in 2007 and 2008.

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Effectiveness of interventions has also improved and the proportion of service users successfully quitting for one month has increased from 34% to 40% in 2008 compared to 2007. We have also maintained our emphasis on reducing inequalities by seeking to engage with people from disadvantaged backgrounds, especially the young, pregnant and poor.

Smoking cessation services have been effective in reaching more deprived populations, but during 2007 the numbers setting quit dates had started to reduce. Services have been reviewed, and are being re-designed to increase their effectiveness and their attractiveness to patients. Staff are actively targeting and engaging new groups within deprived communities thus making access to services for these populations easier. Resources are being re- aligned to reflect need and training is being increased – six brief intervention training sessions were undertaken during the six months from Oct 2007 to April 2008.

3,748 people in Lothian used the Stop Smoking services to set quit dates in 2007 and 1486 of these were successful.

Smoking cessation in healthcare settings

All patients have smoking status recorded in notes: from 2008 it will be possible to collate and monitor these data electronically. During 2008, all patients who are smokers will also receive an information pack to support brief intervention.

Results Pregnant women During 2007, 490 pregnant women were referred to smoking cessation services, of whom, 183 also received pharmacotherapy. A further 177 were referred in the first quarter of 2008 with 40 receiving pharmacotherapy.

Acute services In 2007, 522 patients were referred to our smoking cessation services in the acute division. In the first quarter of 2008 a further 240 were referred, with 74 receiving pharmacotherapy.

Mental health services 98 patients were referred to smoking cessation from specialist mental health services in 2007, with another 32 referred between January and March 2008.

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3.3 Coronary Heart Disease (CHD) and Stroke

NHS Lothian’s Coronary Heart Disease (CHD) and Stroke Managed Clinical Networks (MCNs) actively promote improved services and inform the public about their work. The network’s annual reports can be accessed at their websites at www.lothianchdmcn.scot.nhs.uk and www.lothianstrokemcn.scot.nhs.uk.

Progress and highlights of heart disease services in 2007/08

Number of deaths in Lothian from coronary heart disease per 100,000 population (males and females)

250

200

150

100

50

Deathsper 100,000 population 0 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 Year

The Heart Failure nursing service, a Big Lottery funding project, has been mainstreamed within Lothian. The service is increasingly working closely with the new community long-term conditions nursing service in the CH(C)Ps to ensure a seamless service and continue to prevent avoidable admissions to hospital. A British Heart Foundation nurse provides educational services to practices to transfer skills to the community.

The Lipid Guidelines Group published GP guidelines on the management of hyperlipidaemia (high cholesterol levels) in March 2008, contributing to the prevention of cardiovascular disease through better lifestyle management and appropriate prescribing.

Redesign of Cardiac Services was completed and successfully implemented in July 2007 as part of the Improving Care Investing in Change (ICIC) programme. Three laboratories are co-located to provide the capacity to undertake specialist procedures, such as revascularisation and electrophysiology. This is helping us to meet waiting time targets. A Patient Flow Coordinator guides the patients through the system as beds become available and a single point of contact now exists, serving patients from South East Scotland. A consultant-led cardiology service supports all three acute hospitals in Lothian.

Example

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Patients and carers were involved in improving outpatient and diagnostic services, as part of the Lean in Lothian programme. A preference for a ‘soonest or nearest’ appointment with any consultant was identified. A pilot of single point of referral, triage and appointment booking is taking place to level the demand on existing outpatient services, reducing average waiting times. The redesign involves all five locations for outpatient clinics in Lothian.

The CHD MCN is monitoring the work of the Quality Improvement Teams as they use rapid cycle audit to improve services where there is concern about compliance with the new SIGN CHD Guidelines recommendations.

NHS Lothian and the Scottish Ambulance Service have been working together to enable paramedics to give life-saving treatment to patients before they reach hospital – a system which may well be rolled-out across Scotland. A feasibility study of an optimal reperfusion strategy in ST elevation myocardial infarction (STEMI) began in December 2006 for patients from Lothian and Borders. The study undertaken by NHS Lothian and the Scottish Ambulance Service (SAS) combines primary percutaneous coronary intervention (pPCI) given in the catheter laboratory and pre-hospital thrombolytic therapy (PHT) given by paramedics from the SAS, depending on the time of onset of symptoms and distance (in time) from the interventional centre. The findings, published in May 2008, show that the optimal reperfusion pathway is deliverable and that it provides patient benefits, reducing index admission mortality from 12% to 3.2% in the pPCI I group. Length of hospital stay was also reduced from 6.1 days in all-comers to 3.6 days in patients receiving pPCI. The 12 month follow up of the cohort of patients in the study will be available in January 2009. The findings have been presented to the Scottish Government for roll out to Scotland and are being discussed in the SEAT Regional Planning Group to develop a business case for a Regional service.

Clear referral guidelines were highlighted as a priority for patients with heart rhythm problems to assist appropriate referrals pathways to reduce waiting times and make best use of available capacity. The Arrhythmia Pathway developed by the Arrhythmia Action Group will be launched in summer 2008.

Future CHD Developments for 2008 include

In May 2008 NHS QIS produced draft Quality Assurance Programme Guidance which stated that arrangements for accreditation of local networks will sit with the host NHS boards with external scrutiny of these arrangements being undertaken by NHS QIS. We will agree local quality standards followed by self-assessment and an action plan to ensure accreditation for Lothian CHD MCN.

The MCN continues to address the interface between primary and secondary care, recognising the contribution made by community services to help secondary care meet its target to reduce the total patient journey to18 weeks. Attention will focus on appropriate referral pathways. Further redesign of

10 NHS Lothian Annual Review 2008 Agenda Item 3 outpatient clinics and improved discharge information will support GPs to manage patient in the community.

The SEAT Cardiac Regional Planning Group is devising a regional plan for cardiac services. A regional clinical Subgroup will agree guidelines for referral for unscheduled cardiac interventions to provide equity of access and waiting times throughout the Region.

HEAT targets for 2007/8 relating to CHD

The targets for maximum wait for cardiac intervention from GP referral through the rapid access chest pain clinic not exceeding 16 weeks were all met. Our rapid access chest pain service sees patients typically in two days. We are measuring waits between the diagnosis and intervention ‘chunks’ of the patient journey so that they can be eliminated in all SEAT boards.

Progress and highlights of Stroke Services in 2007/8

Case Study A Stroke Hotline was established in April 2007 and enables GPs to obtain a consultant opinion 24 hours a day, seven days a week as part of their patient consultation. This service continues to make a marked improvement in the appropriateness of referrals to the Neurovascular Clinic and in waiting times for this clinic at the Western General, with more than 80% of patients now seen within seven days. If the patient requires to be seen, a clinic slot can be provided over the phone and the patient is seen generally within two-three days. Since most of further strokes occur within one week of an initial transient ischaemic attack (TIA), this early access to definitive diagnosis and treatment is highly beneficial to patients. The MCN aims to coordinate clinic capacity across Lothian to provide similar access for West Lothian patients.

Early thrombolysis for stroke is normally available in working hours on three adult acute sites in Lothian and is available out-of-hours for all Lothian patients at the Western General Hospital.

Case study A community pilot provides enhanced services for young people with stroke at City of Edinburgh Council Centres where one day per week is a ‘stroke day’. A patient lifestyle management course is now established at the Thistle Foundation. Speech and Language therapy services to fill the gap between a hospital service prior to discharge and pick up by the community teams is now available for more complex patients throughout Lothian. NHS Lothian, in conjunction with CHSS, provides an effective Stroke Liaison Nursing Service that employs five nurses to support patients for 12 months after they leave hospital.

Future plans for 2008 include

• To improve the flow of patients through the Acute Stroke Unit and Rehabilitation Units in South Edinburgh, a short life working group has

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been established, led by the assistant general manager of Edinburgh CHP. This group will develop and recommend action to redesign the service to provide a model of best rehabilitation practice, taking account of the whole pathway of care. • To be engaged in the planning process for the implications to the acute stroke services of longer term plans to move the Department of Neurosciences to the Royal Infirmary site. • To be involved in implementation of the telemedicine facilities. A Steering Group, with input from the Centre for Tele-Health, is helping to take this forward as a regional service.

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3.4 Sexual Health

The Edinburgh and Lothians Sexual Health Strategy 2005 – 2010, now in its third year, supports local implementation of the national sexual health strategy,- Respect and Responsibility. Implementation is overseen by a multi- agency Sexual Health Strategy Project Board.

The following table shows activity changes from 2006/7 to 2007/8 in sexual health services across Lothian.

% Service 2006/07 2007/08 Increase (Decrease) Family Planning Service – Dean Terrace 5,126 5,928 (19%) (new clients) Family Planning Service – Dean Terrace 11,070 11,917 8% (return clients) Family Planning Service – peripheral 1,136 1,117 (2%) clinics (new clients) Family Planning Service – peripheral 2,589 3,679 42% clinics (return clients) GUM – Lauriston Place (new patients) 13,769 14,250 3% GUM – Lauriston Place (return patients) 9.631 9,700 1% GUM – West Lothian (new patients) 995 938 (6%) GUM – West Lothian (return patients) 555 696 25% GUM – MSM Clinic (new patients) 388 521 34% GUM – MSM Clinic (return patients) 729 877 20% Healthy Respect Drop-Ins 4,199 5,654 35%

In addition to showing increases in activity in the majority of services, points that can be taken from this table include:

• The Healthy Respect Drop-Ins and the GUM MSM Clinic, both of which are relatively new services, are well established and accessible to the target groups they serve • Increasing return visits shows that people are potentially taking more responsibility for their sexual health, taking on board the need for regular sexual health check-ups and accessing contraception more regularly • Sexual Health Strategy funding was allocated to Lothian in 2004 for three years. Despite static sexual health strategy funding of £606,000 for three years, NHS Lothian is showing, through the above, increased activity on an annual basis. This is in line with the national sexual health strategy, Respect and Responsibility.

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Case study In November 2007 NHS Lothian and its partners launched the second phase of Lothian’s HIV Campaign, the ‘HIV Comeback Tour’. Phase 2 continues to build on the messages of phase 1 (awareness raising and the importance of getting tested) and promotes condom use as the main way of reducing HIV transmission. The campaign continues to be supported with a co-ordinated approach by all local organisations working with the target group of men who have sex with men (MSM). The Campaign won award for best photography and the Gold award (best of 19 categories) in the Communications in Business (CiB) awards 2007. An external evaluation report for phase one of the campaign is currently being finalised and has shown: • increased awareness of HIV • increased awareness of testing • Services are working together, are using consistent messages and co- ordinating activities more effectively

While not directly attributable to the campaign, HIV testing has increased by 23% between 2006 and 2007.

Further work progressed in 2007/8 includes:

• Progress towards integrated sexual health services at Chalmers Hospital • Continuing to build capacity within primary care through providing targeted training sessions at individual practices. The 11 training sessions provided during 2007/8 covered issues such as Implanon (a long-acting reversible contraception) insertion, HPV Vaccine, child protection, Chlamydia and other STI screening. • Improving uptake of vasectomy operations following the service redesign undertaken in 2006. • Employing a Polish speaking clinical support worker at the Family Planning Service. This builds on work already taking place with established minority ethnic communities. • Establishing the Midlothian Sexual Health Promotion Group and developing a draft Sexual Health Action Plan.

Through partnership working, Healthy Respect remains committed to delivering a multi-faceted approach, combining education, information and services within two specific areas of Lothian. In addition, work has continued with schools and drop-ins that were part of Healthy Respect in Phase One.

Key areas of work undertaken by Healthy Respect in 2007/8 in collaboration with partners include:

• Rolling out of the Sexual Health and Relationships Education (SHARE) programme throughout secondary schools in Lothian. 41 out of 74 schools have been trained in SHARE to date. While it is the responsibility of local authorities to ensure that the remaining non-denominational schools are trained, NHS Lothian is supporting local authorities to achieve this target

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through training teachers and other staff working in schools in SHARE and providing Continuing Professional Development (CPD) sessions. • Mainstreaming 25 healthy respect drop-in centres where young people can access sexual health information, advice and contraception • Linking education and clinical settings, as evidenced as good practice in Healthy Respect Phase 1 • Targeting those young people most at risk of poor sexual health outcomes, including young women under the age of 18 who have become pregnant

Healthy Respect is now mainstreamed within NHS Lothian, with successful elements of the demonstration project being carried forward. These elements involve the continuation of SHARE training for secondary schools, provision of Healthy Respect drop-ins, producing resources with reliable information, CPD sessions, network events and support/training for people working with vulnerable young people. Plans for 2008/9 include:

• Implementing the QIS Sexual Health Standards, launched in April 2008 • Extending the reach of the HIV Comeback Tour phase 2 into more mainstream settings • Launching the Midlothian Sexual Health Action Plan • To continue building further capacity within primary care • To pilot a sexual health clinic within the North Edinburgh Integrated Drug Service and improve links between drug, alcohol and sexual health services.

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3.5 Improving Health for Children and Young People

Achievements in 2007/8 NHS Lothian works with partners from the statutory and voluntary sector to improve the health of children and young people in each local authority/ CH(C)P areas. Examples of achievements during 2007 include: • Health Improvement Fund (HIF) funded early years programmes focusing on infant feeding, parenting (e.g. First Steps), injury prevention (e.g. Care Free Kids) and physical activity in the very young (e.g. Busy Bugs). HIF funded infant feeding advisors now work within each of the CHPs in Lothian to provide training, develop ‘breastfeeding friendly’ award schemes and peer support. HIF projects have taken different forms in each CHP. • Parent Education and Children’s Health in Edinburgh (PEACHIE), a joint Edinburgh CHP and City of Edinburgh project, that delivers support to parents pre and post birth, and targets “hard to reach” families. PEACHIE receives £120,000 per annum. The project commenced at the end of November 07, with the first phase of the pilot focused on Pilton Community Health Project and Carrickvale Community Centre. To date, 16 women (pregnant women and carers) have attended the pilot. • PrePare provides pregnancy and parenting support to drug misusing pregnant women in Edinburgh. (see section 3.2) Smoking cessation work through East Lothian CHP has been targeted at hard to reach young people in collaboration with Bridges Project, a voluntary organisation operating in East Lothian and Midlothian which aims to tackle youth poverty, homelessness and exclusion. • Secured commitment and funding to pilot family nurse partnership teams to provide intensive support to young first time mothers. This is an evidence based approach to tackle generational inequalities.

Health promotion NHS Lothian Health Promotion Service, in partnership with City of Edinburgh Council, has developed nutritional standards for breakfast clubs in Edinburgh. To date, 292 schools out of 328 across Lothian have been awarded Health Promoting Schools (healthyschools+) Stage One status; 34 schools have achieved Stage Two and two schools have achieved Stage Three. These developments have helped schools respond to the Scottish Government target that all schools be health promoting by December 2007, and have helped support them to meet the requirements of the new Schools (Health Promotion and Nutrition) Scotland Act. Training delivered through the Health Promotion Service, Capacity Building programme, includes:

• Alcohol awareness for workers with the young BME community • Growing Through Adolescence • Young People and Tobacco (Prevention and Cessation) • Sexual Health and Relationship Education (SHARE)

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Looked after and accommodated children (LAAC) Looked after and accommodated children have holistic health assessments carried out by Looked after Children Nurses with health needs addressed by referral to appropriate health services. Fast track referral routes are in place for sexual, mental and dental health services. All young people are encouraged to register with a GP. Health training and support is also in place for foster carers and residential staff.

Case Study The Edinburgh Reading Champion Project won the Partnership Award at the 2007 Standard Life Achievement Awards. This joint City of Edinburgh Council and NHS Lothian initiative is aimed at promoting reading activities for looked after children and young people in residential care in Edinburgh.

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3.6 Immunisation Programme

Primary childhood immunisation uptake rates at 12 and 24 months

Lothian’s childhood primary immunisations annual uptake rates for the period January 2007 to December 2007 are shown in the following table.

No. in D T P Pol Hib MMR1 MenC Cohort % completed primary course at 12 months Lothian 8949 97.2 97.2 97.2 97.0 96.6 - 96.4 Scotland 56047 96.6 96.6 96.6 96.4 96.2 - 96.5 % completed primary course at 24 months Lothian 8659 98.2 98.2 98.2 98.0 97.3 92.3 95.8 Scotland 54762 98.0 98.0 98.0 97.9 97.5 92.1 96.8 D=Diphtheria,T=Tetanus,P=Pertussis,Pol=Polio,Hib=Haemophilus Influenzae, MenC= Meningococcal serogroup C conjugate, MMR1- Measles, Mumps, Rubella.

Uptake rates across Lothian remained excellent. Uptake of primary immunisation at 24 months of age is generally over 98%, exceeding the Scottish average and the 95% national target. Uptake of pre-school booster for the cohort reaching five years of age by end December 2007 had substantially improved to 92.5%, above Scottish average. Uptake of Hib/MenC booster at 85.5% was the highest in Scotland (national average 74.5%).

Huge improvements were made in MMR uptake at 5 years. MMR1 uptake at age 5 was 94.7% with 3 CHPs exceeding the 95% target. MMR2 uptake at age 5 increased to 87.7%, also above Scottish average.

Hib catch up campaign The Hib catch-up campaign was introduced from 5 November 2007. In line with the catch up, the age at which pre-school immunisation is offered in Lothian is being progressively reduced from four and a half years of age so that by March 2009 all children will be called up from three years four months of age.

BCG programme A one-off screening and BCG programme for school children with risk factors for tuberculosis was undertaken. A questionnaire was delivered in spring 2008 to around 120,000 children P1-S4 in Lothian for self assessment of risk factors for TB.

Flu programme A flu subgroup was set up, with a main aim to improve flu vaccination uptake - particularly in the under 65 at-risk groups and staff. A communications campaign placed alerts in the NHS Lothian staff newspaper Connections,

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team briefs, pay slips and the Edinburgh Evening News. There were no supply issues in 2007/8 and the programme was implemented on schedule.

2007/8 data from Health Protection Scotland (HPS) reported 77% uptake in over 65s in Lothian. This is above the 70% target, above the national average uptake of 75%.

HPV Vaccination Programme

Two Scottish Government circulars, CEL 17 (2007) November 2007 and CEL 5 (2008) February 2008, confirmed that a routine HPV immunisation programme will start in Scotland in September 2008 for girls aged 12/13 years (year S2).

A catch-up campaign for girls aged under 18 years will also begin in September 2008. Girls in S5 and 6 will be vaccinated in school year 2008/9 and girls in S4 and 5 in school year 2009/10.

Before the programme announcement: • Guidance agreed by the Area Drug and Therapeutics Committee and Medical Directors was issued to GPs in August 2007 on the use of these vaccines • Edinburgh and West Lothian schools participated in a national HPV prevalence study (and pilot).

During 2007/8 preparations for implementation of the programme progressed

• A LICOG (Lothian Immunisation Co-ordinating Group) subgroup on the HPV programme was set up with widespread representation and will continue to work through 2008/9. A further subgroup on delivery was also set up. • A financial planning template was prepared for NHS Lothian Prioritisation Planning Committee. The committee earmarked £400,000 for 2008/9 and £500,000 for 2009/10 • An implementation plan and action plan were drafted • Monthly reports were submitted to the national steering group with risks and issues identified • Planning started on delivery in schools through the delivery subgroup and in timetabling • Arrangements were planned for cold chain maintenance • Discussions were held with GPs (GP sub and GPPC) and Area Drug and Therapeutics Committee on Lothian recommendations for women aged 18 to 25.

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3.7 Screening Programmes

Pregnancy and newborn screening programmes

In 2006 there were 9,028 recorded births to Lothian residents, and this has increased to 9,377 for 2007, according to General Register Office Scotland data.

Pregnancy screening Pregnancy screening includes a dating scan, a nuchal translucency scan and blood tests for communicable disease/ immunity and risk of fetal anomaly.

Communicable disease There were 10,100 samples received for communicable disease screening during pregnancy in 2007. Uptake was high, with only 1% of pregnant women declining HIV, hepatitis B or syphilis tests, and 0.2% declining rubella tests.

Less than 0.2% of pregnant women were identified with newly diagnosed HIV, hepatitis B or syphilis. Overall, 3.6% of those tested were identified as having no/low immunity to rubella. Identification during pregnancy enables early intervention to reduce the risk of transmission from mother to child.

Fetal anomaly screening The complete follow up data for fetal anomaly scanning will not be available until all women tested during 2007 have completed their pregnancy. The service is about to undergo major development as described below.

Newborn screening Newborn screening currently includes bloodspot testing and hearing tests.

Bloodspot testing: During 2007 9,414 bloodspot tests were performed in Lothian, all within 14 days of birth, with testing refused for less than 0.1% of babies. Overall 98% of samples were received by the laboratory in Yorkhill Hospital, Glasgow, within 7 days of testing. In total 0.2% of bloodspot tests required specialist follow up by paediatricians in Lothian.

Universal newborn hearing screening: 9,359 tests were performed during 2006/7. The quality of screening exceeded the standards required by NHS Quality Improvement Scotland, with 99% of babies completing the screening process within 10 weeks, and less than 1% referred to paediatric audiology for diagnostic assessment.

Plans for 2008/9 Fetal anomaly screening will be an area of major development during 2008/9. Two stage fetal anomaly screening will be implemented in Lothian by the end of December 2008. Four trainee sonographers have been recruited and are being trained. Additional ultrasound equipment has been purchased and facilities are being developed to meet the increased demand on ultrasound

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services. Changes are also planned by the screening laboratory to enable the provision of a first trimester screening service for Down syndrome.

Breast Screening Programme

In 2007 the annual attendance rate for NHS Lothian women was 74.7% (compared to a Scottish rate of 75.7%). The three year attendance rate for NHS Lothian women was 75.3% (compared to a Scottish rate of 76.5%).

Figures exceed the minimum standard required by Quality Improvement Scotland QIS (>70%) but fall below the desired target (80%).

Performance against a range of other QIS criteria is excellent and has exceeded minimum standards and targets (i.e. cancer detection rate, benign biopsy rate, early recall, assessments) with the exception of prevalent recall rate at 10.8% which just exceeds the minimum standard of 10%. The Scottish average is 9.8%.

Initiatives which have been established to improve uptake rates include: • Offering extended hours for mammography covering the early mornings and evenings. • Operating an enhanced mobile screening service to local areas constrained by transport links. • Introducing a new scheduling service to improve access. Consequently mobile units visit particular locations more frequently and for longer. • Liaising with general practice teams prior to the Breast Screening Service visiting a particular location in order to raise awareness of attendance, provide health promotion materials and address local issues with administrative and clinical staff. • Providing dedicated health promotion expertise to the Breast Screening team whose role it is to provide support to general practices with low uptake rates. • Working with national charities to raise awareness amongst women of the benefits of breast screening. • Surveying the views of women in Lothian in order to ascertain their opinion of the service and their suggestions for improvement.

Progress against 2007/2008 objectives • In June 2008 a business case for two view mammography at every round was agreed with the National Services Division of NHS Scotland. This work has provided detailed information on staffing, revenue and capital requirements of introducing 2 view mammography into screening practice. Operational plans have been developed in line with national policy. Staff recruitment and training are ongoing • An updated programme for visiting locations in the SE of Scotland has been introduced. This change to visiting schedules provides a more constant presence to CH(C)Ps, particularly in rural areas. It also reduces the massive cyclical variation of referrals to the symptomatic breast units which previously caused significant difficulty in achieving waiting times targets.

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• Implementation of “one stop” assessment has been introduced. This initiative is targeted at maintaining and improving the reporting of diagnostic results by reducing the number of visits required to achieve a final diagnosis. Staffing challenges around consultant radiology staff means we have not yet been able to extend this to all those patients who require stereotactic guided biopsies.

Plans for 08/09 include • Meeting national plans to introduce two view mammography means addressing areas such as staff recruitment and training, IT and data requirements, administration and roll-out. Implementation of the two views is planned to begin in April 2009 in line with the agreed national timetable. • Falling uptake rates for breast screening across Scotland require debate at national level. At a local level the SE Breast Screening Programme plans to monitor the impact of the new screening schedule, to evaluate results from a consumer survey aimed at improving access, and to work with general practices and health promotion specialists to target low uptake groups and areas. • The streamlining of the review process, together with the establishment of “one stop” assessment, will be monitored against appropriate QIS standards targets.

Bowel Screening Programme

Since 1st May 2008 NHS Lothian has participated in the National Bowel Screening programme, with over 8,000 Lothian residents aged 50-74 invited each month by the National Screening Centre in Dundee to return stool samples for screening. NHS Lothian is investing £1.5m a year into the screening programme, as well as contributing £0.4m to the National Screening Centre in Dundee.

Over the past two years we have been planning implementation of the programme in partnership with our colleagues in the National Services Division, Health Scotland, the National Screening Centre and the Scottish Government. Our screening colonoscopies will be performed at the Western General Hospital and St John’s Hospital.

A key capacity requirement to ensure success of the programme is diagnostic colonoscopy. NHS Lothian has invested in five additional sessions of colonoscopy per week, which provides for 25 screening colonoscopies per week in Lothian, in line with our activity forecasts for the Bowel Screening programme. NHS Lothian is also taking forward a major capital development at St John’s Hospital, which will provide an additional endoscopy room.

We have recruited new staff for the programme into colorectal surgery, radiology, pathology, critical care, theatres and anaesthetics and oncology. We are also recruiting to a new post of Endoscopy Clinical Services Manager and this post will cover the operational management of the Bowel Screening programme, including supporting the monitoring of activity and uptake, to help direct and develop the programme.

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The key to maximising the success of the programme is ensuring high uptake and we have developed a communications strategy specifically for this programme. This aims to encourage participation in the whole eligible population but particularly targets those in groups likely to have lower uptake: – men, deprived populations and ethnic minority groups.

Looking forward, we aim to meet the challenging 60% uptake target and will actively review this and positivity rates to maximise the success of the programme. The monitoring and evaluation group will lead work to achieve the QIS Standards.

Diabetic Retinopathy Screening Programme

The Diabetic Retinopathy Screening Programme is fully implemented across Lothian.

Health Boards are now required to provide retinopathy screening for all people with diabetes over the age of 12 based on the NHS Quality Improvement Scotland standards.

There are now just over 30,000 people with diabetes in Lothian. People with diabetes who are eligible for screening are identified from the diabetes register (SCI-DC). They are invited for digital photography of the retina (the gold standard), at one of three hospital clinics or a mobile unit at least once a year. Images are assessed by trained graders at Princess Alexandra Eye Pavilion. If it is not possible to take a grade-able image, they are invited for examination by slit lamp. Written results are sent to the patient, their GP and diabetes consultant.

National software has been developed for this programme. Unfortunately it is not yet able to provide reliable data on uptake and results of screening.

All staff in the programme are undertaking formal accreditation appropriate to their roles. Within 2007/8 the programme has been implemented across all areas of Lothian and by mid 2008 all eligible people with diabetes had been invited for screening at least once.

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3.8 Health Impact Assessment

Health Impact Assessment (HIA) provides a mechanism by which health issues can be considered in policymaking in all sectors. In particular, HIA focuses on differential impacts of policy making and seeks to mitigate those policies that will increase health inequalities. Most HIAs are done in partnership with local authority and other partners.

Within NHS Lothian we have adopted an approach to equality and diversity impact assessment (EQIA) that allows consideration of wider health issues and population groups beyond the six ‘equalities strands’. All new NHS Lothian plans and strategies must be subjected to Rapid Impact Assessment that aims to identify unidentified impacts on health and health inequalities.

Example Within the past year, a detailed HIA of the master plan proposals for the new town extension at Winchburgh in West Lothian was completed. West Lothian Council is now consulting on draft supplementary planning guidance that would require HIA of all major new developments. We have also commented on a number of outline planning applications, notably those for Leith port and north west Portobello master plan.

Other HIAs are completed (e.g. of the City of Edinburgh Council Homelessness Strategy Action Plan) or are in progress (e.g. redevelopment of the Royal Commonwealth Pool).

NHS Lothian is now developing a strategic framework for the built environment and health. This will identify principles to inform new developments. The initial focus is to inform capital investments within NHS Lothian to demonstrate that the NHS can act as an exemplar in this area. In the longer term, the framework will also form the basis of work with partner organisations. A health impact assessment of the Royal Victoria Hospital re- provision is planned in the next year as part of the development of this strategic framework.

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3.9 Keep Well Project

We have continued to implement Keep Well in 14 Edinburgh general practices. These practices are using a variety of methods to reach people aged 45-64 and offer an assessment, focusing on risk factors for cardiovascular disease. The aim is to identify people with undetected risk factors and provide interventions to address these. The long-term goal is a reduction in cardiovascular disease in these communities, and therefore, a reduction in inequalities in cardiovascular disease across Lothian.

Uptake of Keep Well

The table below shows uptake of Keep Well assessments. By the end of April 2008, all eligible patients had been invited and 38% had had an assessment. Efforts are now concentrated on encouraging those who have not attended for assessment to do so.

No Total target population 23,790 Clinically inappropriate to invite 699 Informed refusal to participate 991 Engagement contacts 37,243 Assessments 9004 DNAs 1068

Actions already undertaken to increase engagement include:

• Initial contacts have been by letter in most cases. Practices are now using telephone invitations and are inviting people opportunistically if they attend for other reasons. • To help people who may find it hard to attend during working hours, out of hours assessments have been offered at four different sites across the City to serve each of the four clusters. • Working with NHS 24 to plan a comprehensive telephone engagement service that will allow people to be telephoned in evenings and weekends. NHS 24 will also provide follow up reminders to those who book appointments via this route. • Ten community pharmacies will be involved in seeking out eligible patients and support them to make appointments having already received training for this.

Further work over the next year will include developing plans for future sustainability of Keep Well in Lothian.

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Keep Well in Practice Complete data on clinical risk factors identified and patient management are not yet available for all practices. However preliminary analyses of the data that are available suggest that a minimum of 10% of the people assessed have been found to be at high risk of cardiovascular disease. Now that this has been identified, these people should now be receiving appropriate follow up and management to reduce their risk. More than 500 patients have started the weight-loss programme Counterweight, of whom 220 have attended at least 4 sessions. These patients have lost an average of 3.5kg weight. A total of 188 patients so far have received support from the outreach workers, who provide 1:1 support for the neediest patients who need help to engage with services. These patients have a range of complex problems and have been helped to access services that can help them as well as help with motivation to address lifestyle change.

Feedback from patients who have received Keep Well health checks has been very positive. They have made comments such as: It was excellent to be able to discuss different aspects of my health and not feel rushed” and “a useful, helpful and constructive service, thank you!”

Equity Audit Equity Audit is a useful tool that uses quantitative data and qualitative methods when looking to improve health and reduce health inequalities. We use it to explore how well existing services meet the needs of disadvantaged groups and to identify what changes are needed to improve access and/or outcomes for disadvantaged groups. Previously considered core public health work, this is now formal NHS Lothian policy and there is a systematic approach available for all to follow.

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3.10 Community planning

NHS Lothian continues to engage with a wide range of partner organisations to affect long-term change in the health of the nation. This includes participation in the Community Planning processes across the four local authority areas, to ensure that key health outcomes are reflected within Community Plans. This will be further supported through the implementation of a community planning framework for NHS Lothian.

Key areas of work that have been developed through partnership working over the previous year include: • Lead role for NHS Lothian within the Edinburgh Partnership to drive forward the strategic outcome of ‘improved wellbeing for all through physical activity’ as part of multi-agency approach. The action plan will focus on improving the health of the city and reducing health inequalities. • Active involvement in a range of violence reduction programmes across the Community Safety Partnerships. NHS Lothian is a key partner in the Edinburgh Violence Reduction Programme, with emphasis on reducing alcohol related violence, violence against women and other street violence. • Work with the Lothian Violence Against Women Training Consortium has delivered comprehensive skills-based training programme for NHS staff based on our NHS Domestic Abuse Toolkit for Staff. • Ongoing engagement with Midlothian Community Planning Partnership resulted in the creation of a refreshed and refocused Community Plan aligned with the joint health improvement plan. • Continued commitment to the Healthcare Academy and the Joined up for Jobs strategy has delivered supported employment opportunities within Edinburgh for those further away from the labour market, recognising the key link between employment and health. • Working with Council partners on key health and homelessness actions, which are now embedded within the new Homelessness Strategies in place for Edinburgh and West Lothian. This has supported our high levels of compliance with the national Health and Homelessness standards. • Ongoing health and homelessness work with the Lothian and Borders Community Justice Authority, ensuring a further strengthening of the multi- agency partnerships approach to improve health and reduce inequality for this difficult to reach group. • Joint working through the Community Justice Authority regarding the health and wellbeing of the prison population and people recently released from prison. This has developed throughout the year and an action plan for 2008/9 has been produced

There is further involvement with Edinburgh Council at managerial and operational level in pilot initiatives such as: • the North Edinburgh Get It Right For Every Child (GIRFEC) Domestic Abuse Pathfinder Project

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• the new national government-funded programme for children affected by domestic abuse (The CEDAR Project) • a programme of training and support for health staff that ensures better identification and safety of women and children, allowing an appropriate multi-agency response.

The joint management within CH(C)Ps and local authorities continues to grow and develop, resulting in more seamless, integrated service delivery and benefits for communities. This includes: • Co-location of health and social care services within West Lothian, improving and increasing access for local people • Building on the West Lothian CHCP pilot of the pioneering use of technology such as Telehealth is being rolled out across Lothian. This will improve the quality of life for residents in Lothian resulting through the reduction of unnecessary hospital bed nights and institutional care

Case study Telehealth This project provides a large scale (400 patients) controlled trial to assess the benefits of home-based telehealth monitoring for long term conditions, such as chronic obstructive pulmonary disorder (COPD) patients, and/or heart failure. Specifically, the aim is to provide early and continuous monitoring for the health and social needs of people with selected long-term conditions, to reduce the likelihood of acute episodes, and hence, reduce the demand for expensive interventions such as unplanned hospital admissions. It uses a Personal Health System (PHS) located in the patient’s home, which is easy to use and which allows video contact with patients and carers. It measures symptoms and vital parameters such as blood pressure, blood glucose, blood oxygen saturation level, peak flow and weight using linked monitoring devices. Data submitted to the PHS is securely transmitted via broadband to a central (Lothian) call centre manned by trained support staff, who may contact the patient or their health care providers if readings are out of range. At the end of July 29 homes have been connected and the rest of the 400 homes will be connected by the end of 2008 subject to satisfying a number of criteria including broadband connection availability.

Single Outcome Agreements provides the opportunity for Community Health (and Care) Partnerships to further strengthen their joint working with Councils and other community planning partners. The SOA’s have all been developed at a local level with responsibility and accountability agreed between local authority and the CH(C)Ps. Key areas include: • Shared health and social cares outcomes for delayed discharge; mental health; long-term conditions; health improvement / inequalities; community care; and drugs and alcohol • Review of assets in partnership with East Lothian Council and Midlothian Council during 2008/9. Also a commitment to further develop the model of Partnership Centres in West Lothian.

30 NHS Lothian Annual Review 2008 Agenda Item 3

3.11 Working with other organisations

Multiagency partnership - Child Protection Services

The investment in staff within Child Protection services from 2005-7 allowed continuing growth and development of service provision within Health and the Health contribution to interagency work. Progress achieved in 2007/8 includes:

• The multi-agency working within the Amethyst Unit at the Vega Building in the Gyle continues to provide a focus for staff to respond rapidly in an interagency manner to child protection cases • The Child Protection e-learning programme for all staff within NHS Lothian is underway with 1,097 trained up to March 2008. This is now a requirement for all new NHS Lothian staff • Tailored Level 2 Child Protection Training has been developed for sexual health service providers. In total, 56 professionals (consultants, GPs, nurses, Caledonia Youth staff and Family Planning staff) have attended • The Edinburgh & Lothians Inter-agency Child Protection Procedures were ratified by ELBEG and have been successfully implemented across all Local Authority areas. The NHS Lothian Child Protection Procedures and protocols are currently out for consultation and will be implemented in 2008/9. • The Lothian Child Care Concern model, which provides practitioners with the tools to formalise and evidence their assessments and gives clear guidance for interagency working, has been implemented and is contributing to the assessments of need ensuring that appropriate services can be delivered. • A stakeholder event in January 2008 led to a formal proposal to SEAT for the establishment of a Managed Clinical Network for Child Protection for South East Scotland. SEAT regional planning has recognised that this is a priority for action in 2008/9. • Steady progress has been made in establishing specialist mental health services for sexual abuse across Lothian. All children and families who require a specialist mental health service response to child sexual abuse will be able to access services in their local area by the end of 2008. • The third annual Child Protection conference, with international class speakers especially from the USA, was held in June 2007 on domestic abuse. More than 300 delegates attended and the evaluation was extremely positive.

Record keeping and information systems

• Work is progressing on multi-agency chronological record keeping in a number of areas – a successful seminar was held in November 2007 with practitioners to progress definitions and explore practice issues. In West Lothian work has been completed to enable practitioners to view a health chronology within Community Information System (CIS) which will be a

31 NHS Lothian Annual Review 2008 Agenda Item 3

model for the rest of Lothian. Work is also continuing on the multi-agency chronology within the shared information system C-me. • West Lothian C-me shared information system provides core records, and alerts to relevant professionals via a secure messaging facility. The electronic initial referral discussion functionality went live at the end of April 2007 and is proving very valuable in sharing information at an early stage • The on-line Child Protection Register continues to work well. The Child Protection alert system piloted in West Lothian has been successfully evaluated and recently transferred onto TRAK, our patient administration system. These alerts are now visible for all children across NHS Lothian. Its purpose is to enable practitioners to make informed decisions about children known to be at risk, in full knowledge of their child protection status.

Data Sharing Partnership

• The aim of the Lothian Data Partnership is to deliver electronic data sharing and manage the organisational changes necessary to ensure effective and efficient sharing of information and multi-agency working. Membership of the Data Sharing Partnership Board in Lothian consists of director level representation from each of the stakeholder organisations. These are: City of Edinburgh, East Lothian Council, West Lothian Council, Midlothian Council, NHS Lothian, Lothian & Borders Police, the voluntary sector and Scottish Government. • New funding for final year of the current programme will be sought due to a £100K reduction in finance under the Spending Review 07. • The two key priorities set by the Scottish Government for all fourteen data sharing partnerships nationally are to complete the roll-out of electronic single shared assessment for all adult care groups and to implement sharing of information for child protection.

Examples • There has been wider use of the single shared assessment tool, eAssess, including a pilot project in the acute sector. It is anticipated that starting the assessment process while patients are still in hospital will ensure that appropriate support measures can be put in place before they are discharged home. Following positive evaluation of the pilot further training and implementation will start in September 2008 • Steady progress on introducing the single shared assessment for alcohol and substance misuse has been made, with implementation planned for autumn 2008. This new system is to be piloted in Lothian and will enable information sharing between health, social care and the voluntary sector. • The national eCare programme to deliver electronic child protection messaging will be rolled out nationally from the autumn of 2008. Within Lothian, critical upgrades and replacements of key NHS community and local authority social work information systems essential for messaging will be completed in 12-16 months.

32 NHS Lothian Annual Review 2008 Agenda Item 3

HMiE Multi-agency Inspections

• Multi-agency Inspections of Child Protection Services have taken place over the last year in West Lothian with very good result. Midlothian underwent an interim follow up inspection which showed significant progress. Reports continue to highlight the strategic work of ELBEG (Edinburgh, Lothian and Borders and Executive Group) and its chief officers in vision and leadership. • All the reports were positive about NHS Lothian’s progress and health staff’s engagement and leadership of this important area. • Key strengths and areas for improvement were highlighted within each report. Action plans have been developed by all the Lothian Child Protection Committees and lessons shared across NHS Lothian. • Progress against the multiagency action plans is being monitored by the NHS Lothian Healthcare Governance and Risk Management Committee.

NHS Boards - Regional Planning

Overview The South East and Tayside network (SEAT) brings together Borders, Lothian, Fife, Forth Valley and Tayside NHS Boards to look at the needs of this large and complex geographical area – 1.9m people or 38% of the Scottish population. SEAT is one of the three Regional Planning Groups in NHS Scotland. The group uses a collaborative mechanism to work together across a range of services where this can bring benefit to their collective population. The group also works closely with Special Health Boards such as NHS Education Scotland, the Scottish Ambulance Service and NHS 24.

An annual framework for priorities and investment and annual work plan is agreed, based on priorities identified by SEAT NHS Boards, national guidance and stakeholders through an annual stakeholder event. An annual report provides public accountability through SEAT constituent Boards. Working Together for Patients 2007 is SEAT’s 2nd Annual Report and demonstrates benefits to patients from the SEAT NHS Boards working together.

NHS Lothian contributes fully to SEAT, taking an integrated approach to planning and hosting a number of key areas of service change and redesign as well as contributing to a dedicated staffing resource for SEAT. In 2007/8 £18m of revenue and £0.5m capital investments, plus a further commitment of £1.9m revenue and £2.7m of capital, were made in a range of regional services.

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Improving patient care Partnership in practice Learning Disability Managed Care Network (LD MCN) NHS Lothian hosts all consultant posts. This enables greater flexibility of consultant cover, more effective bed management across the region and provides a platform for strategic development of special interests and expertise for a better quality service for inpatients. A Learning Disability Liaison Nurses joint research project involving NHS Lothian and University of Edinburgh is underway which will provide links with implementing the recommendations following a Fatal Accident Inquiry elsewhere in Scotland.

Eating disorders services NHS Lothian hosts this group working with the other two regional planning groups and National Services Scotland. The working group will progress an option appraisal for future provision of NHS inpatient beds within the region to achieve better value for money and consistency of quality frameworks.

Cardiac services NHS Lothian continues to contribute to the Regional Cardiac Services Planning Group. The Regional Planning Group is currently discussing the roll out of the outcome of the NHS Lothian pilot for optimal reperfusion.

Perinatal mental health services During 2007, 21 mothers and 22 babies (one set of twins) were admitted to the regional Mental Health Mother and Baby Unit in Livingston. An evaluation of mothers’ experiences of the unit is planned for 2008. The 25-strong multi- disciplinary team provides support to local services in Board areas.

Forensic Mental Health Services The Regional Forensic Small Team and Lothian’s Orchard Clinic staff and management team are reviewing the possibility of developing either medium secure learning disability or medium secure female forensic services within the Orchard Clinic as part of the national debate around these services. During 2008 the Regional Forensic Small Team and SEAT finance colleagues will define a consortium funding arrangement for the Orchard Clinic.

Services for Children and Young People The Royal Hospital for Sick Children, Edinburgh (RHSCE) Re-provision Project Board works closely with the SEAT Children’s and Young People’s Health Services Planning Group. Clinical protocols and care standards are being developed to identify and support elective day case operative procedures to be carried out closer to children’s homes. A Regional MCN for Child Sexual Abuse services is being considered, with support from NHS Lothian’s associate medical director.

South East Scotland Cancer Network (SCAN) The South East Scotland Cancer Network is well established and works closely with the regional cancer centre at the Western General Hospital in Edinburgh and with local services. NHS Lothian, in partnership with the University of Edinburgh and partner NHS Boards, has developed PET (positron emission tomography) scanning services to enhance access for the SCAN area patients.

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Enhanced workforce capability SEAT’s integrated approach to workforce capability involves aligning service, workforce and financial planning. The scope of workforce planning within SEAT covers the NHS Boards of Borders, Fife and Lothian and aligns with the South East Deanery for Postgraduate Medical Education.

The SEAT Workforce Planning Board supports human resources management, oversees specific workforce planning developments on behalf of SEAT and has a well established multi-organisation planning process.

SEAT Workforce Education and Development Group (SWEDAG) continues to provide a regional forum for identifying and agreeing joint actions. The Group has commissioned a project to develop educational solutions to support the management of long term conditions in the South East of Scotland. It has also commissioned some research around the demographic changes within the SEAT region.

The South East Educational Forum brings together service and educational providers sponsored a third regional learning event in 2007 and delegates had an opportunity to hear case studies relating to innovation, challenges and solutions in workforce development. NHS Lothian contributed with its programme called In Search of Cultural Change – Signposting the Lothian Way.

The Regional Nursing Workload and Workforce Planning Programme NHS Lothian continues to play a key role in this activity. The aim is to have the tools, methodologies, systems and local infrastructures developed and implemented to allow NHS Boards to take full ownership for the delivery, utilisation and ongoing monitoring of the key recommendations of the Workload/Workforce Planning Project and the Nationally Co-ordinated Nurse Bank Arrangements.

Regional Allied Health Professionals (AHP) Workload and Workforce Planning Project has completed the scoping for an AHP bank and its recommendations are currently out for consultation.

A Regional Healthcare Scientists Workforce Group has been established to ensure a consistent response to the national workforce survey and review the impact of the implementation of Agenda for Change and Modernising Medical Careers.

The Regional ACT (Additional Costs of Teaching) Group is chaired by NHS Lothian’s Medical Director and the group has agreed three-year core funding from 2007/8 for General Practice, Public Health and the ACT office. The Regional ACT Group is considering performance management of ACT funding. NHS Lothian, Lanarkshire, Tayside, and Fife, have either appointed or are in the process of appointing Directors of Medical Education and are considering the necessary clinical infrastructure to support high quality undergraduate and postgraduate teaching in clinical units.

35

Agenda Item 4: Shifting the balance of care towards primary and community care

4.1 Primary Care Modernisation Strategy

4.2 Mental health services

4.3 Management of long term conditions

4.4 Pharmacy

4.5 Prescribing

4.6 Optical and dental services

4.7 CHP development

4.8 Anticipatory care

NHS Lothian Annual Review 2008 Agenda Item 4

4: Shifting the balance of care towards primary and community care

Key Points • NHS Lothian has embarked on a five-year Primary Care Modernisation Strategy (2007-2012), which aims to shift the balance of care towards primary and community care and treat people closer to home

• We are developing community-based alternatives to hospital admission with a particular focus on helping people to manage long-term conditions and on anticipatory care

• Mental health and wellbeing remains a priority and many exciting initiatives were developed throughout the year, including a planned service for veterans and new partnerships

• We are making progress on HEAT target areas of suicide reduction, reducing hospital admissions and cutting anti-depressant prescribing

• Community pharmacies are an important part of the primary care team and all Lothian pharmacies are delivering the Minor Ailments Service and Public Health elements of the new pharmacy contract.

• NHS Lothian is a leader in prescribing, with the lowest primary care prescribing costs per patient per year in Scotland and an admired joint formulary (which has now been adopted elsewhere in the UK)

• The Lothian Ophthalmology Managed Clinical and Care Network is taking the lead in initiatives to shift the balance of care into the community

• NHS Lothian has met the target on the dental health of 11-year-olds three years ahead of schedule and has seen an increase in the number of NHS dentists.

• Community Health (and Care) Partnerships continue to develop and 42% of NHS Lothian healthcare expenditure now takes place CH(C)Ps, the primary care organisation and Royal Edinburgh Associated Services

• NHS Lothian is working closely with local councils. For example West Lothian has the largest telecare programme in Europe.

1 NHS Lothian Annual Review 2008 Agenda Item 4

2 NHS Lothian Annual Review 2008 Agenda Item 4

4.1 Primary Care Modernisation Strategy

The Primary Care Modernisation Strategy is Lothian’s five year vehicle (2007 – 2012) for delivering a number of key strategic goals. • Shifting the balance of care from acute to primary and community care • Provision of care in communities closer to patients’ homes • Demand management • Reduction of emergency hospital admissions and readmissions • Development of supported self care for long term conditions

It provides Lothian with a framework for taking these priorities forward. Lothian aspires to increase the proportion of healthcare activity delivered in the community and much of the activity led by CH(C)Ps in 2007/8 has been concerned with establishing services, recruitment and training. The full impact and benefits of the investment in revised models of care will begin to be realised in 2008/9.

The focus continues to be that articulated in Better Health, Better Care: specifically a move from episodic hospital-based care to continuous care based in the community and with a particular emphasis on anticipatory care. This is further supported by the ongoing implementation of the new contractual arrangements for independent contractors - GPs, dentists, community pharmacists and optometrists - and identification and exploration of the opportunities presented.

Access and inequalities are being addressed through initiatives such as the Keep Well project, which targets hard-to-reach communities and individuals. Significant progress has been made in addressing inequities, particularly relating to access to services. The lessons learned are being assessed with a view to wider roll-out during 2008/9. More generally, work has been done to improve responsiveness by extending the opening hours of GP surgeries. This has been complemented by increasing the availability of the evening and night nursing services available to support people in their own homes. Work is also underway between CH(C)Ps and local authorities to develop improved out-of-hours social care services to help manage crises.

Work continues in refining data collection and analysis. SPARRA (Scottish Patients At Risk of Readmission and Admission) remains an important tool but is increasingly being used in combination with practice-derived data to identify patients with unmet need relating to long term conditions and in particular those at risk of admission. Work is also underway to develop more sensitive markers to show the impact of interventions. In 2008/9 SPARRA and other primary care related data will be incorporated in MIDAS, Lothian’s IT System for performance management. This work will inform and support the local management team to deliver performance levels to achieve HEAT targets including locally set stretch targets in line with the NHS Lothian LDP.

Key to shifting the balance of care is a reduction in referrals and admissions to hospital and this involves developing community based alternatives.

3 NHS Lothian Annual Review 2008 Agenda Item 4

Ambulatory care sensitive conditions will be targeted in 2008/9. In the last quarter of 2007/8 the CH(C)Ps were demonstrating either a slowing in the rate of growth of acute admissions or, in one case, a reduction. As the benefits of the investments in community services in 2007/8 have an impact in 2008/9 it is anticipated that there will be a further slowing of the growth in emergency admissions and ultimately a reversal. For specific examples of interventions see section 4.3 Management of Long Term Conditions. These fit well with the HEAT targets to reduce admissions associated with certain specific chronic diagnoses and to reduce admissions and readmissions in people over 65.

Example In north-west Edinburgh the Section 17c Admission Prevention Project audited all admissions from their practices to establish whether the admissions could have been prevented and what facilities would have been necessary to allow the patients concerned to be managed in the community. This demonstrated that although most admissions were appropriate, alternative strategies would have been available had there been more community based services. This information is being used to inform community based developments.

Similarly, work taken forward in East Lothian in 2006/7, as part of the Lean in Lothian programme, demonstrated that an appropriately resourced and functioning day hospital can be used to offer same or next day assessment of older people, keeping them in their own locales thus offering alternatives to admission and avoiding inpatient episodes.

Falls are another area of great concern and much activity. It is known that falls result in significant morbidity and mortality in the elderly and many are associated with hospital admissions. Prevention of falls featured in the action plans of all four CH(C)Ps and in 2008/9 the intention is to link the various strands of work from the CHPs with established activity involving the acute sector and allied health professionals.

4 NHS Lothian Annual Review 2008 Agenda Item 4

4.2 Mental Health Services

Mental Health and Wellbeing remains a priority for Lothian.

Our focus on social inclusion of vulnerable communities continues with: • The first Deaf Counselling Service which provides free one to one counselling in British Sign Language (without interpreter) by British Association of Counselling and Psychotherapy accredited staff to people who are deaf, deafened, hard of hearing or deaf-blind and live in Lothian. A CPN and Occupational Therapist work with Deaf Action to provide specialist mental health assessment and treatment. • Introducing a guided self-help pilot for people who have suffered childhood sexual abuse. • Working with the Scottish Government Mental Health Division and the Ministry of Defence to set up Scotland’s first one stop shop for veterans. Called First Point, it aims (in the words of one of veterans involved in its design) “to offer help and assistance in a veteran’s life, no matter what the need may be”. A one-stop-shop, First Point will offer support and advice to former members of the armed forces, including reservists. The project will provide access to local clinical networks and to advice and support on issues including housing, education opportunities and employment.

We have also created some new partnerships including: • The Charlie Waller Memorial Trust - We will be recruiting the first CWMT Trainer post in Scotland. This pilot post will work with further and higher educational institutes across Lothian to raise awareness of mental health and wellbeing in student populations • Department of Trade and Industry – Knowledge Transfer Partnership (KTP) - A UK wide programme to encourage business / knowledge base collaborations. The project – known as ACTIVATE – will redesign mental health vocational rehabilitation services in Edinburgh • Lothian Alliance Against Depression (LAAD) – A partnership with University of Edinburgh, Depression Alliance Scotland and European Alliance Against Depression. LAAD work continues with further advertising campaign in 2008, and specific workstreams on older people and children and young people • ARTFUL – Mental Health and The Arts - We are working with the Scottish Storytelling Centre to use story telling with different client groups.

HEAT Target H5 Reduce suicide rate between 2002 and 2013 by 20%, supported by 50% of key frontline staff in mental health and substance misuse services, primary care, and accident and emergency being educated and trained in using suicide assessment tools/ suicide prevention training programmes by 2010

2002 is the baseline for the 20% reduction in ten years. In 2002 there were 129 deaths in Lothian (16.6 per 100,000). The trajectory anticipates a figure

5 NHS Lothian Annual Review 2008 Agenda Item 4

of around 104 completed suicides in 2010; equal to a rate of 14.1 per 100,000. Lothian has a suicide rate slightly less than the Scottish average and is currently two years ahead of target with 116 deaths in 2005 (14.6 per 100,000).

Our local projects and Choose Life activities are key to the ongoing reduction in the suicide rate. NHS Lothian as a whole is in step with the trajectory in relation to the reduction in the suicide rate.

The 50% training target was introduced in April 2008. This equates to just over 3,300 key frontline staff across NHS Lothian.

A comprehensive programme for awareness raising, education and training has been developed. This programme builds on the tiered model that was developed for the Mental Health Act Training and Education Programme. Starting in June 2008, the programme will be delivered by a network of trainers with a range of skills and experience and will utilise different media including e-learning and film. Training for Trainers courses will be delivered for NHS Lothian staff in September and October and this will further increase our training capacity. Public awareness will be raised further during International Suicide Prevention Awareness Week in September 2008. This will include initiatives to support those affected by suicide.

HEAT Target T3. Reduce the annual rate of increase of defined daily dose per capita of anti- depressants to zero by 2009/10, and put in place the required support framework to achieve a 10% reduction in future years.

This target was refined and from April 2008 it is now measured as the number of Defined Daily Dose (DDDs) per capita. We have subsequently recast our trajectory and will be monitoring this at a practice based level.

Lothian has a model of stepped/matched care for people experiencing anxiety and depression. This model is being implemented in partnership with social care and the voluntary sector across Lothian. The Lothian Integrated Care Pathway for depression to be piloted during July–October 2008 will provide consistent care pathways for people presenting with depression across Lothian, meeting the QIS standards.

Case study A range of alternatives to prescribing anti-depressants for patients with mild depression are being implemented across Lothian. These social prescribing initiatives include:

• Book prescribing – GP provides prescription for client to borrow recommended and approved books on condition from local libraries • Exercise prescribing – GP provides prescription to council leisure facilities, which can include a “buddy” to attend and motivate client • Peer support and befriending – e.g. services run by Health in Mind

6 NHS Lothian Annual Review 2008 Agenda Item 4

• Welfare advice – clinics being introduced to wards at Royal Edinburgh Hospital in partnership with Citizens Advice Bureau • Counselling - range of voluntary sector providers receive funding from health service to provide counselling including Crossreach (Post natal depression), PF Counselling and health in mind • Brief solution focused therapies – six week interventions delivered by clinical associates • Drop in advice clinics - evening classes on how to recognise and deal with stress. Done in a lecture style in partnership with Stevenson College, Edinburgh, there is no need to register or be referred • Positive psychology – CDs using relaxation techniques, widely prescribed by GPs in Edinburgh • Guided self-help – using manuals supported by face to face contact • Education and training - Education sessions for primary care teams, which focus on the range of alternatives that are available within the practice’s locality, including those services provided by the voluntary sector will be rolled out from September 2008 and includes the Integrated Care Pathway for Depression.

Heat Target T4 Reduce the number of readmissions (within one year for those that have had a psychiatric hospital admission of over 7 days by 10% by the end of December 2009).

Implementation of a range of redesign projects and developments outlined in Lothian’s Joint Mental Health and Wellbeing Strategy 2005-2010 have enabled a further shift in the balance of care through providing alternatives to admission. We are set to deliver a major strategic change in terms of a reduction to 150 acute admission beds on two sites by summer 2009 from our baseline position in February 2005 of 216 beds on four sites.

The success of these developments has seen Lothian achieve the level of readmissions ahead of the target date. Excellent progress has been reported in this measure with the number of psychiatric re-admissions declining from 623 for the quarter ending June 2006 to 581 for the quarter to September 2006. This exceeds the overall target of a reduction to 671 by December 2009.

Consequently Lothian had agreed to stretch this target by ensuring there are no more than 671 psychiatric readmissions by December 2009 – a 20%, rather than a 10% reduction from the December 2004 baseline. Community services will be further enhanced to help deliver this stretched target.

Further service modelling and redesign work has undertaken as part of the Royal Edinburgh Campus Re-provisioning review. The non-financial option appraisal process has involved the participation of a wide range of stakeholders at the four care group specific two-part workshops which were held to agree and weight benefit criteria which was then used to score the

7 NHS Lothian Annual Review 2008 Agenda Item 4 short list of site options for each care group. Completion of the outline business case is a priority action for 2008/9.

Other priorities for 2008/0 include:

• Mental Health Assessment Service (MHAS)- in January 2008, an interim MHAS was introduced during the out-of-hours periods i.e. from 6pm to 8am and at weekends at the Royal Infirmary of Edinburgh (RIE) providing a service to A&E, the Combined Assessment Area (CAA) and Lothian Unscheduled Care Service (LUCS). This provided a service for 97 patients in January and contributed to the delivery of the maximum 4 hour wait in A&E target. The intention now is to complete the implementation of MHAS, which will initially operate 24 hours per day from the Royal Edinburgh Hospital (REH) replacing the Psychiatric Emergency Team (PET) and during the out-of-hours period at the RIE (with Liaison Psychiatry and mental health nursing continuing to operate during normal working hours). An operational policy has been drawn up and an audit tool introduced • Establishing two intensive home treatment teams in Edinburgh that operates 24/7 and provides post-midnight support to clients from East and Midlothian • Specialist Mental Health Services (Regional) - Enhanced Community Forensic Mental Health Team, which will provide clinical input to MAPPA across Lothian • Eating disorders – An option appraisal for regional inpatient care is underway with partner Boards – Fife, Forth Valley and Borders

Supporting service users and carers Examples • Peer Support - NHS Lothian, in partnership with Penumbra and the Scottish Recovery Network, have established an innovative project, Plan 2 Change, which employs people who have lived with experience of mental health problems as peer support specialists. This project has received extended funding. • NHS Lothian Board area – East Lothian and Edinburgh are one of the three national pilot sites (as per Delivering for Mental Health commitment 2) for peer support workers in mental health services. • Oor Mad History - Lothian has a long history of service user involvement supported by collective advocacy. NHS Lothian has funded a two year project “Oor Mad History” which will chronicle, archive and produce materials and artefacts regarding the 20 year history of service user involvement across Lothian. This will culminate in a celebration of 20 years in 2010, hopefully with permanent art exhibitions, installation and archives. • Recovery Across Lothian Network will host its 2nd Annual Seminar in December. The Network continues to flourish with increasing numbers of people with experience of recovery being involved in delivering education and training initiatives.

8 NHS Lothian Annual Review 2008 Agenda Item 4

Strategy investments

As part of implementing our five-year Lothian Mental Health and Well Being Strategy 2005-2010, to date a total of £8.725m has been committed for investments in a range of service areas. This will make a significant contribution towards meeting targets and delivering our commitments to the recommendations outlined in Delivering for Mental Health.

9 NHS Lothian Annual Review 2008 Agenda Item 4

10 NHS Lothian Annual Review 2008 Agenda Item 4

4.3 Management of long-term conditions

The prevalence of long-term conditions (LTCs) continues to rise and, given the demographic of Lothian’s population, will continue to do so. As a group of conditions they are of great importance and their management impinges directly on several HEAT Targets

• NHS Boards will achieve agreed reductions in the rates of attendance at A&E, from 2006/7 to 2010/11; • By 2008/9, we will reduce the proportion of older people (aged 65+) who are admitted as an emergency inpatient twice or more times in a single year by 20% compared with 2004/5 and reduce, by 10%, emergency inpatient bed days for people aged 65 and over by 2008. • To achieve agreed reductions in the rates of hospital admissions and bed days of patients with primary diagnosis of Chronic Obstructive Pulmonary Disease, Asthma, Diabetes or Coronary Heart Disease, from 2006/7 to 2010/11. • NHS Lothian has set a number of stretch targets within the 2008/09 LDP including reduction in acute admissions. • Improvement in the quality of healthcare experience. • Increase the level of older people with complex care needs receiving care at home.

The management of LTCs is the focus of much activity associated with the Primary Care Modernisation Strategy (Section 4.1 of this document). It is accepted that improving LTC management will improve the health and well- being of many people and will also reduce demands on secondary care and hospitals. Much of the rise in unscheduled activity in acute hospitals is associated with exacerbations of LTCs.

All CH(C)Ps are engaged in programmes designed to identify and assess people with LTCs and, where appropriate, put in place care packages supported by case management. The developments funded in 2007/8 have only begun to impact in the last quarter of the year and it is anticipated that significantly more impact will be seen in 2008/9.

While reduction in demand on secondary care - in particular reduction in admissions and readmissions - remain priorities for 2008/9 there will be an increasing focus on the development of supported self management. This was identified as a priority in Better Health, Better Care. Lothian has engaged with a number of patients and carers groups and the Long Term Conditions Alliance Scotland to advance this agenda. Working with the Thistle Foundation, East Lothian CHP commissioned self management programmes for patients with COPD (Chronic Obstructive Pulmonary Disease 0and heart failure as well as a programme looking at the generic issues associated with LTCs. These were well received by patients and are being evaluated against outcomes such as patient satisfaction but also usage of healthcare resources.

11 NHS Lothian Annual Review 2008 Agenda Item 4

COPD is a good example of how Lothian is tackling LTCs. COPD is a common respiratory condition associated with considerable morbidity and mortality and it features in the top three diagnoses of patients identified using the SPARRA tool. Nationally it is a marker condition of the CHP LTC Toolkit and features in the Scottish Enhanced Services Programme. Locally it has been prioritised by all four CH(C)Ps. Patients are being identified, their diagnosis is being confirmed by spirometry, their therapy is being optimised and personal management plans, including aspects of self management, are being put in place. Community based services are being developed, including pulmonary rehabilitation across Lothian.

Case study During 2007/08 East Lothian CHP, in collaboration with the Met Office, offered its COPD patients weather warnings and management advice. Early feedback from the evaluation suggests that this was successful in preventing exacerbations and admissions. In Edinburgh the physician assistant is offering an assessment service and a rapid response physiotherapy service has been set up to deal with exacerbations. Case study The CH(C)P and University Hospitals Division have jointly funded rapid access respiratory outpatient clinic slots to prevent admissions. In West Lothian the hospital respiratory service is more closely linking with the CHCP service, with the respiratory specialist nurse doing sessions for both. COPD is one of the conditions being monitored as part of Lothian’s large Telehealth project launched in May 2008. Eventually this will see 400 Lothian patients with LTCs having access to home-based tele-monitoring and management. Much of the work relating to COPD has been co-ordinated through Lothian’s Respiratory Healthcare Group. An exciting joint venture involving NHS Lothian and ABPI Scotland (Association of the British Pharmaceutical Industry) means that funding has been made available to establish a formal Respiratory (COPD) MCN for Lothian.

The combined impact of these various initiatives is that • more patients and their carers are better informed about their condition • there are fewer acute exacerbations • exacerbations are identified and treated earlier • exacerbations are shorter and less severe • fewer patients are admitted to hospital and • those that are have shorter lengths of stay.

If the early success of these interventions is sustained similar models will be developed for more conditions.

12 NHS Lothian Annual Review 2008 Agenda Item 4

4.4 Pharmacy

National guidance around the community pharmacy contract has been adopted and the Minor Ailments Service (MAS) and the Public Health Service (PHS) elements of the community pharmacy contract are being provided from all 180 pharmacies.

The Minor Ailments Service - allows patients, who do not pay for prescriptions, greater access to medicines to treat minor conditions by allowing these to be supplied at a cost to the NHS but not the patient, when appropriate, in response to symptoms without the need for a GP appointment. Latest available figures (from October to December 2007) show that during this quarter there were 72,465 patients registered for the service and 28,002 items were supplied through MAS at a total ingredient cost of £53,652.07. This equates to an average cost per item of £1.92. The supply of simple remedies for minor conditions through this service reduces the impact of these conditions on the Lothian Unscheduled Care Service (LUCS) when pharmacies are open.

The National Patient Group Direction (PGD) for urgent supply of repeat medicines and appliances - is another new way in which care can be provided for the patient in the pharmacy during the out-of-hours period. In NHS Lothian from October to December 2007 a total of 2,132 items were prescribed and dispensed in the pharmacy using Community Pharmacy Urgent Supply (CPUS) forms. This means the patient received ongoing supplies of repeat medication direct from the pharmacy rather than potentially requiring a prescription or a consultation from LUCS or missing doses.

Case study Chlamydia patients’ partners A pilot running in Lothian since the beginning of December 2007 is looking at the treatment of the partners of patients diagnosed and treated for the sexually transmitted infection Chlamydia. The treated patients are issued with vouchers to give to their partners and the partners have the option of consulting their GP, going to a family planning clinic, attending the Genito- Urinary Medicine (GUM) Clinic or taking the voucher to a participating pharmacy. The pharmacy provides a confidential service using a PGD to supply treatment where appropriate. The level of uptake of the pharmacy service is encouraging and will alleviate pressures on the other services.

Stop Smoking Services These have started to be delivered through community pharmacies since the beginning of December 2007. This service provides smoking cessation products, such as nicotine patches, and one to one support from the pharmacy for 12 weeks. Uptake has been very encouraging and the hours of access to this service seem to meet patient need. Anecdotally, there would appear to be a good number of patients accessing this service on Saturdays when other agencies are closed. There are still only a small number of pharmacies delivering this service due to IT difficulties with the multiple

13 NHS Lothian Annual Review 2008 Agenda Item 4 pharmacies but this is being worked round with the piloting of a paper system which will be introduced to all pharmacies during the summer to increase the numbers participating. Latest data shows the numbers to have set a quit date through pharmacy services are 206 since January 2008. In addition, to increase awareness of the services, an advertising campaign will be launched during 2008/9.

14 NHS Lothian Annual Review 2008 Agenda Item 4

4.5 Prescribing in Primary Care

High quality and cost-effective prescribing in Primary Care

NHS Lothian continues to have an excellent track record in primary care with the lowest cost per patient per annum (£149) in Scotland. Generic prescribing rates are very high at over 82%. It has been estimated that if NHS Lothian prescribed at the same level as the Scottish average this would have resulted in additional prescribing costs of £28.1 million in 2007/8 for Lothian Health Board.

The Medicines Management Team an annual report ‘Prescribing Pressures in Primary Care’ provides a summary of primary care performance. The report is also used to inform planning for prescribing expenditure for the forthcoming year.

Support for Prescribers in Primary Care Good practice High quality and cost-effective prescribing is underpinned by the Lothian Joint Formulary (LJF). The LJF (www.ljf.scot.nhs.uk) continues to be developed, supported and promoted in Lothian. It is recognised as one of the most developed formularies in Scotland and is now also in used in a number of Primary Care Trusts in England. The impact on prescribing patterns in several therapeutic areas has already been demonstrated. The LJF encourages safe, effective and economic prescribing in Lothian and should be considered the gold standard of local prescribing. The Lothian Joint Formulary provides a robust mechanism for the introduction of new medicines as well as a means to support the integration of the latest clinical evidence and guidelines (e.g. QIS, SIGN and NICE) into clinical practice.

A wide range of systems and processes have been developed to support prescribers (including GPs, nurses and other non-medical prescribers) in primary care. These include a web based formulary, electronic prescribing systems, a range of prescribing guidelines, over 60 Shared Care Protocols, regular newsletters [Lothian Prescribing Bulletin] and training packages for prescribers.

Investing in primary care prescribing

NHS Lothian invested £51,000 in Primary Care Development Scheme projects in 2007 to encourage innovation and prescribing efficiencies. Funding was given to a wide range of projects at practice, Local Health Partnership (LHP) and CHP levels.

Prescribing efficiencies

Following on from the Audit Scotland report ‘Supporting prescribing in general practice - a progress report’, published in June 2003, work has continued across Lothian to address issues raised in the report. Expenditure on a range

15 NHS Lothian Annual Review 2008 Agenda Item 4 of medicines forms part of the reporting mechanism for Building A Better Scotland (BABS) (efficient Government programme initiative). A number of prescribing initiatives, based on recommendations contained in the report, continue to be taken forward across NHS Lothian.

BABS outlined the national action plan required to enable NHS Boards across Scotland to meet the objective of demonstrating identified savings from a range of areas over the period 2005 to 2008. Lothian is required to generate £2.8 million savings from primary care prescribing over these three years. Lothian has demonstrated savings of £12.1 million up to June 2007.

Introduction of new drugs and the Scottish Medicines Consortium

Established local processes support the introduction of new drugs into clinical practice in Lothian following advice from the SMC. The Lothian Formulary Committee, in consultation with local clinicians, assesses each SMC recommendation. The Formulary Committee then makes a recommendation on whether the drug should be added to the LJF or not.

16 NHS Lothian Annual Review 2008 Agenda Item 4

4.6 Optical and Dental Services

Optical services

Lothian Ophthalmology Managed Clinical and Care Network

Ophthalmology MCCN in Lothian provided the lead in many collaborative initiatives over the recent years to help shift the balance of care towards primary and community. For example, Lothian Orthoptic Optometry Partnership Scheme is well received by the patients. It has also reduced the number of visits needed by patients and reduced significantly waiting times at the eye department, which was historically the first port of call for all referrals.

The Contact Lens Service provided in the community for the last few years by specialist optometrists has kept patients in the community with certain corneal disease without the need to attend the eye department until late stages when surgical intervention is needed. This also reduces the burden on the secondary eye care service.

Implementation of Community Eye Care Services Review is currently progressing for both children and adults with visual impairment. This enables patients with visual impairment to be assessed on a multi-agency basis in appropriate local settings, where possible. Supported by making available low vision aids (e.g. hand magnifiers) at locations close to where patients live without the need to travel to eye departments. The multi-agency approach allows people with visual impairment to be identified at an early stage for the social work department and education authorities to provide appropriate support, thereby improving speed of access for these services.

NHS Lothian was able to meet the patient’s journey from the referral for cataracts to the actual surgery within 18 weeks for all people in Lothian. Due to collaborative working and redesigning the eye care services (community optometrists, GPs and the eye surgeons) we were able to meet the expected target. Further initiatives are at the planning stage for us to move forward with initiatives such as community glaucoma care, managing external eye diseases through optometry taking into account of the new General Ophthalmic Services contract in Scotland.

Dental services

NHS Lothian has achieved the 2010 target for dental health of 11 year olds three years early. Data for 2006/7 NDIP (National Dental Inspection Programme) of Primary 7 children shows that 66% are free of tooth decay experience. Childsmile (nursery children tooth brushing) coverage has increased to 88% and number of participating nurseries participating has increased to 89% of nursery schools.

17 NHS Lothian Annual Review 2008 Agenda Item 4

The number of NHS dentists working in Lothian (GDS, CDS and HDS, excluding double- and triple-counting) by headcount has increased from 466 in 2005 to 496 in 2007. We achieved the H2 HEAT target with 81.6% of – three to five year olds registered in December 2007, three years early. In addition, at a clinical level, there is increasing specialisation within primary dental care as evidenced by the senior and specialist dental practitioners now working in the salaried services. To ensure there is a ready supply of new specialists for primary care, the Edinburgh Dental Institute – part of the medical faculty at the University of Edinburgh – has introduced a flexible Masters programme in primary dental care which is proving to be very popular.

18 NHS Lothian Annual Review 2008 Agenda Item 4

4.7 CH(C)P development

Lothian CHPs and CHCP have continued to develop their role as key parts of the NHS Lothian system taking a leading role in a number of areas including: • Hosting services • Joint work with councils • Organisational changes and • Developing local plans to meet Scottish Government and NHS Lothian priorities.

Hosting: All CH(C)Ps have taken responsibility for hosting individual services that provide Lothian wide and regional services previously managed by the Primary Care Organisation. These include learning disability, rehabilitation, dental, sexual health, health promotion, substance misuse, primary care out- of-hours services. Almost 50% of NHS Lothian healthcare expenditure now takes place with CHCP/CHPs/REAS (Royal Edinburgh Associated Services)/PCO.

Joint work: Edinburgh CHP and West Lothian CHCP are part of joint organisational arrangements with councils and have jointly appointed directors. East and Midlothian CHP also work very closely with the two Councils. Examples of significant joint work include:

In West Lothian CHCP: • The CHCP is mainstreaming telehealth/telecare as part of its models of care that provide a more customer-focused service within a robust business case. West Lothian has the largest telecare programme in Europe (over 4,300 people) and funding has been secured from the National Telecare Development Programme to finance a roll-out of lifestyle monitoring systems along with an expansion of individual telecare packages as part of the home safety service. Technology will be installed in 400 homes on a pan-Lothian basis as part of the management of long-term conditions. The project has started and installation will be completed by November 2008 for the first 400 homes. • Extensive work has been carried out to produce a West Lothian joint premises (primary care) strategy which outlines a 10-year strategy and a framework for future investment in community health and social care facilities. The strategy was agreed in principle at the CHCP Board meeting in February 2008. Re-provisioning of West Calder Health Centre has been agreed. Work has started on site to build Fauldhouse Partnership Centre. • Joint induction for all new CHCP staff is held on a regular basis. A number of valuable joint training opportunities have been developed e.g. Management Development programme, over 800 NHS/council staff jointly trained on eCare and C-Me information sharing systems. • West Lothian CHCP has consistently been at the top of the national delayed discharge performance tables with a zero return being reported on a regular basis.

19 NHS Lothian Annual Review 2008 Agenda Item 4

In Edinburgh CHP: • Developing joint premises with approval of business cases for Westerhailes Healthy Living Centre, securing funding for a similar centre in Firhill and the start of work on a new joint equipment store. • Implementing the joint capacity plan for older people with the opening of two new 60-bed care homes, work started on a third and planning underway for a fourth, the extension of provision of complex packages for older people at home and investment in community nursing to support older people. • Establishing a joint planning group for Mental Health to develop and implement an Edinburgh Mental Health plan across all agencies. • The CHP chairs the newly established Adult Protection Committee. • Piloting Getting It Right for Every Child (GIRFEC) in partnership with the Council in the same areas as the pathfinder sites for Review of Nursing in the Community.

In East Lothian and Midlothian CHP: • Significant joint initiatives were achieved during 2007/8 in Midlothian with the development of a number of co-located, combined health and social care community teams for Substance Misuse, Mental Health, and Rapid Response. • In 2007/8 Midlothian CHP were the first health, social care and voluntary sector partnership to implement the Lothian Mental Health strategy which shifted the balance of care by reducing its acute psychiatric beds by over 60% and establishing a comprehensive network of round the clock community care. • Both East and Midlothian CHPs and Councils achieved their targets of zero delayed discharges for patients waiting over six weeks or in short stay settings.

Organisational changes: Edinburgh CHP was established as a single CHP on 1st April 2007. The change has proved successful. East and Midlothian CHP management teams came together in February 2008 in order to maximise the efficiency of the NHS across the two areas.

Local plans: the CHPs/CHCP have worked to develop local plans to support NHS Lothian and Scottish Government strategies. Examples include:

• Mental Health: each CH(C)P has a local joint implementation plan which has driven significant changes in service including the provision of home treatment services in Midlothian and West Lothian and the development of similar plans for East Lothian and Edinburgh. • Long-term conditions: each CH(C)P has a local plan for the implementation of programmes designed to identify and assess people with LTCs and, where appropriate, put in place care packages supported by case management. CH(C)Ps have created lead nurses for this role. • Premises: each CH(C)P has also agreed premises development priorities and strategies and significant developments and refurbishments of premises have been initiated in 2007/8 including Haddington, Bonnyrigg

20 NHS Lothian Annual Review 2008 Agenda Item 4

Community Dental Facility, Dalkeith, West Calder, Westerhailes, Firhill, Lauriston Place, and Muirhouse. • Shifting the balance of care: there has been significant work under the long term conditions programme. In addition, Edinburgh CHP implemented the vasectomy redesign programme to move 1,200 procedures into primary care. Planning began to extend the musculoskeletal assessment clinic in primary care and to establish a partnership with Dermatology and Plastic Surgery to remove more “lumps and bumps” in primary care.

21 NHS Lothian Annual Review 2008 Agenda Item 4

22 NHS Lothian Annual Review 2008 Agenda Item 4

4.8 Anticipatory care

Anticipatory care is about promoting wellness and foreseeing and dealing with problems at the earliest opportunity. It will have benefits for all concerned - patients, carers and providers – and is key to the delivery of shifting the balance of care. Activity in 2007/8 has largely been concerned with establishing the necessary baselines, services and infrastructure. In 2008/9 the benefits of the approach will become apparent.

Anticipatory care is being taken forward under a number of banners – the Primary Care Modernisation Strategy (Section 4.1 of this document), Keep Well, the Scottish Enhanced Services Programme and (Management of) Long Term Conditions Section 4.3). Using SPARRA and other tools at-risk patients have been identified and the most complex are being case managed by specialist community nurses and AHPs. This approach is optimising therapy, and managing exacerbations thus reducing admissions and other demands on acute care. Residents of care homes have been specifically targeted as a Local Enhanced Service. Out-of-hours, the Lothian Unscheduled Care Service will also contribute in the form of planned review contacts and visits for people whose conditions may be unstable or at risk of deteriorating.

The activity and benefits associated with anticipatory care link closely with those outlined in the management of Long Term Conditions (Section 4.3 of this document)

23

Agenda Item 5: Access to services and waiting times

5.1 Waiting times and progress towards 18 week referral to treatment

5.2 Diagnostic waits

5.3 Cancer waits

5.4 A&E waits

5.5 Access to primary care

5.6 Access to NHS dental services

5.7 Delayed discharges

NHS Lothian Annual Review 2008 Agenda Item 5

5: Access

Key Points: • NHS Lothian has met all waiting times targets, many ahead of schedule, and is making progress towards the 18-week referral to treatment standard

• Initiatives including the roll-out of PACS (Picture Archiving and Communications System) are improving efficiency, helping clinicians and improving the patient experience

• NHS Lothian is using technology to improve care, for example, a telehealth project which monitors people in their own homes

• Compliance with cancer waiting targets improved dramatically during 2007, from 80.4% in the first quarter to (provisionally) 95.6 at the beginning of 2008.

• More than half the GP practices in Lothian have signed up to (50%) or expressed willingness (6%) to provide extended hours access.

• Targets on delayed discharge have been met or exceeded and work continues to improve this further

1 NHS Lothian Annual Review 2008 Agenda Item 5

2 NHS Lothian Annual Review 2008 Agenda Item 5

5.1 Waiting times and progress towards 18 weeks referral to treatment

A range of waiting time standards came into force during 2007/8. All have been achieved through a combination of investment and redesign with significant effort from all the staff involved. From January 2008 implementation of ‘New Ways of Defining and Measuring Waiting Times’ introduces a significant change in how NHS Scotland collects and defines waiting times, and also how waiting lists are clinically and administratively managed.

Inpatients

NHS Lothian maintained the 18 week standard for inpatients during 2007/8, which was first achieved in December 2006, a year ahead of the national requirement. Work has now started on reducing waiting times further in 2008/9 towards the delivery of an 18-week referral to treatment pathway by 2011. Following discussion with the Access Support Team, NHS Lothian anticipates achievement of a 12 week maximum wait for inpatients by March 2009.

Within planning discussions for 2008/9, funding of £17m has been allocated to address waiting times including for those groups outside of national guarantees.

Outpatients

NHS Lothian achieved the 18 week maximum wait for outpatients in December 2007. In December 2006 there were 3,469 waiting.

As with inpatients, NHS Lothian aspires to reduce the maximum wait further in 2008/9, lowering the longest wait to 12 weeks by March 2009, to support achievement of an 18 week referral to treatment pathway by 2011.

A priority has been placed to bring those patients waiting for an outpatient consultant from referral from neither a GP nor dentist into parity with those covered by the guarantee.

Hip fracture

NHS Lothian has maintained at least the 98% standard for admission to theatre within 24 safe operating hours since November 2007, a month earlier than the target date.

3 NHS Lothian Annual Review 2008 Agenda Item 5

100

80

60

% of patients of % 40

20

0

6 6 6 6 6 7 7 7 7 7 7 8 8 8 -0 -0 -0 -0 -0 0 -0 -0 -0 -0 -0 0 -0 -0 r n g t c - r n g t c - r n p u u c e eb p u u c e eb p u A J A O D F A J A O D F A J

% operated on within 24 safe hours Trajectory

Coronary Heart Disease

A target 16 week maximum wait came into force at the end of 2007 for patients requiring cardiac intervention. Working closely with other boards within SEAT and also with the Golden Jubilee National Hospital, NHS Lothian successfully met this target and has maintained these standards,

Cataract

The target 18 week maximum wait for cataract pathway was broken into two elements – a standard of 11 weeks for outpatients and 7 weeks for inpatients.

This standard was met at the end of 2007 with the support of the Eyecare Collaborative.

18 weeks referral to treatment (RTT) standard

A standard of 18 weeks from referral to treatment has been set for 2011. Attainment of this standard will require both investment and redesign of services. Following discussions with the Access Support Team, approximately £17m has been provided to support the transition to an 18 week pathway. This sum, coupled with investment from NHS Lothian’s planning discussions for the present year, will support the delivery of a 12 week maximum for outpatients and inpatients and a six week maximum for key diagnostic tests by March 2009. This is one year ahead of the standard outlined in the Scottish Government 18-week policy document.

The SGHD Improvement and Support Team have selected NHS Lothian as the partner body for the 18-week collaborative programme. NHS Lothian’s adoption of Lean techniques positions the board ideally for the redesign work

4 NHS Lothian Annual Review 2008 Agenda Item 5 required to deliver an 18-week journey. Pathways must be redesigned so that patients move quickly through the process with delays eliminated from the system. The strength of the Lean approach in reducing delay has been demonstrated repeatedly in the Kaizens run as part of Lean in Lothian.

Work undertaken by the Planned Care Collaborative has also set the foundation for 18-weeks RTT. Lothian’s redesign exercises increased levels of admissions on the day of surgery in orthopaedics and in urology introduced pathways into out patient referral management that supports the shift to day cases for prostate patients. Similarly the groundwork undertaken by other collaboratives in Diagnostics, Eyecare and Unscheduled Care will support the development towards 18-weeks RTT pathway.

5 NHS Lothian Annual Review 2008 Agenda Item 5

6 NHS Lothian Annual Review 2008 Agenda Item 5

5.2 Diagnostic waits

Access to eight key diagnostic tests has been speeded up. NHS Lothian delivered the target of a maximum nine-week wait in July 2007 - five months ahead of the planned delivery date. In addition we have made significant progress in developing a single system approach to the management of patients.

Additional capacity across all the diagnostic tests is now in place and is improving performance. This provides capacity to ensure the improvement to waiting times is sustainable. Work is progressing to reduce the waiting time for the eight key tests further. The plan will include some short-term measures to manage the backlog supported by capacity to ensure the improvement is sustainable.

Significant benefit has been delivered from implementing systematic service redesign across the diagnostic tests. Lean thinking techniques will be applied to MRI processes in 2008. NHS Lothian is planning to replace one MRI at RIE during 2008 and a mobile unit will be utilised to ensure capacity is sustained throughout this period.

NHS Lothian has also delivered improvement in waiting times for urgent patients, including patients on a cancer pathway. Cancer patients receive diagnostic tests within two weeks and any urgent patients are seen within 48 hours.

Work is progressing to ensure NHS Lothian can achieve and maintain the outpatient and diagnostic pathway waiting time target of 18 weeks. This will involve increasing the number of patients going straight to test and improving direct GP access. NHS Lothian is also exploring a physiotherapy-led back pain service with direct access to MRI.

7 NHS Lothian Annual Review 2008 Agenda Item 5

8 NHS Lothian Annual Review 2008 Agenda Item 5

5.3 Cancer waits

Over the four quarters of 2007, NHS Lothian has improved compliance with the headline 62-day target from 80.4% in quarter one 2007 to 94.5% in quarter four 2007. Provisional data for quarter one 2008 shows a further improvement to 95.6%.

Q1 Jan–Mar Q2 Apr–Jun Q3 Jul–Sep Q4 Oct–Dec

07 07 07 07 All Cancers 80.4% 85.1% 89.5% 94.5% Breast 86.9% 95.0% 96.3% 97.3% Colorectal 58.7% 64.9% 76.8% 90.5% Lung 88.3% 92.6% 95.1% 94.9% Ovarian 83.3% 100.0% 100.0% 100.0% Melanoma 81.8% 87.0% 100.0% 100.0% Lymphoma 88.2% 90.9% 85.0% 93.8% Urological 58.1% 71.8% 80.1% 91.4% Upper GI 92.9% 81.5% 81.0% 92.0% Head & Neck 88.9% 95.5% 93.8% 95.5%

The higher volume tumour groups are lung, breast, colorectal and urology. Of these, performance in breast and lung has improved and is now showing clear signs of stability at target performance levels. In breast cancer, poor performance in the first quarter of 2007 was associated with a longer wait at that time for new patient clinic. Management and clinical focus is now in place in the lung service with Positron Emission Tomography (PET) access available locally at the Western General Hospital and also pilot work is underway to improve the diagnostic pathway. Challenges in lung remain with surgical patients and those switching between a surgical and oncological treatment plan, often late in the 62-day pathway, following further diagnostic and staging investigations. Following the Breast Unit Kaizen event in March 2007, taken forward as part of the ‘Lean in Lothian’ programme, the Breast Unit introduced a one-stop breast new patient clinic in January 2008. The model of service and design for the new one-stop clinic was tested for several weeks before full implementation. The trial included a survey of patient and staff experience and both were very positive.

Case studies Colorectal cancer performance has improved significantly in the last two quarters of 2007. The Colorectal Kaizen events in 2007 have also clearly supported the significant performance improvement that colorectal has shown against the 62-day target. The Colorectal Pathway Kaizen events to date have resulted in better integration of overall information flow and have provided a platform upon which further pathway and service improvement work can be delivered.

9 NHS Lothian Annual Review 2008 Agenda Item 5

Urology performance has improved, particularly over the last two quarters of 2007. The challenges for urology are associated mainly with capacity planning and development in laparoscopic treatment (prostatectomy in particular) and TURBT (transurethral resection of bladder tumour) waits.

Of the remaining tumour groups, ovarian, head & neck and melanoma (skin) are relatively stable, achieving good performance. Variations in performance in lymphoma and upper gastrointestinal (GI) cancers are mainly attributable to the complex entry points in to the system and circuitous / tertiary service pathways. This makes patient tracking and associated performance management challenging for the specialties involved. Following feedback to clinical director to highlight bottlenecks in the ENT service, management action plans are being taken forward to avoid diagnostic delay or transfer delays to haematology. In upper GI, endoscopy remains the largest single issue and work is underway to improve the management of patients to endoscopy lists.

10 NHS Lothian Annual Review 2008 Agenda Item 5

5.4 A&E waits

In Scotland’s busiest A&E, since the end of December 2007, NHS Lothian has maintained the 98% standard in Accident and Emergency Departments and other areas covered by the four-hour standard from arrival to discharge or admission.

A&E quarterly activity - annual comparison.

Quarter to March 2007 RIE WGH SJH RHSC Lothian Activity 24,760 8,084 10,422 8,011 51,277 No: within 4-hour target 20,152 6,979 9,331 7,970 44,432 No: of 4-hour Breaches 4,608 1,105 1,091 41 6,845 % in Dept less than 4 hours 81% 86% 90% 99% 87%

Quarter to March 2008 Activity 25,513 8,415 11,166 8,319 53,413 No: within 4-hour target 24,790 8,233 11,042 8,240 52,305 No: of 4-hour Breaches 723 182 124 79 1,108 % in Dept less than 4 hours 97% 98% 99% 99% 98%

This also represents a significant reduction in waiting times against three years ago. Then one third of patients waited longer than four hours, with 12 hour waits experienced by some.

11 NHS Lothian Annual Review 2008 Agenda Item 5

12 NHS Lothian Annual Review 2008 Agenda Item 5

5.5 Access to primary care

Scottish Enhanced Services Programme 2007–2009

• Investment of £60k is earmarked to pilot extended hours. • Early discussions on pilot proposals have taken place with three practices.

Proposed objective: To increase access to the working population by extending opening hours beyond 8am and 6pm (Monday to Friday) for routine, booked appointments.

Evaluation of the proposal will include: • Assessing patient up-take of extended opening appointments. • Determining whether patients were additional to system. • Assessing whether new arrangements restricted access to different groups of patients. • Assessing benefits/ costs to the practice, such as organisational factors, acceptability to staff and additional costs.

New Extended Hours access for GP Practices – PCA(M)(2008)4

Proposals • As part of the changes to the Primary Medical Services Contract announced (PCA (M) (2008)2), practices offered the opportunity to provide a Directed Enhanced Service (DES) for extended hours access for patients. • Arrangements to be additional to existing day time services, weekday evenings, weekly mornings and Saturday mornings. Typically minimum blocks of 1.5 hours (6/7 consultations) for weekday evenings and Saturday mornings, and 1 hour for weekday mornings. • Practices who participate will be paid £2.95 per patient on their list, funding provided nationally: £9.5m across Scotland of new money and £6.5m across Scotland from the previous 48 hour access DES. • New Access arrangements within core hours (8am – 6pm) - recycling 58.5 QOF points: practices require to provide 48 hour access for patients, the ability to pre-book appointments at least 2 days ahead, and practice achievement assessed via patient satisfaction questionnaire based on 2 new QOF indicators. • Expression of interest invitations were sent out to all GP practices in Lothian in April asking if they wished to submit a bid to provide the new Extended Hours Access DES: indicate what arrangements they propose for the service, with any rationale/patient information for their choice.

13 NHS Lothian Annual Review 2008 Agenda Item 5

Table below shows the position as at 18 July 2008 of NHS Lothian practices’ position on extended hours.

No: of Practices % of total Contractually signed 64 50 Expressed willingness 7 6 Indicated will not provide 54 43 No decision 0 0 Total 125 100

The PCCO/CH(C)Ps are developing a monitoring framework to capture information from GP practices about the services they have provided. It will include a practice monitoring return to provide updates and agreed time period for reporting on the views of patients and also an assessment of potential impact of the extended hours services on OOHs, NHS 24 and A&E attendances. This monitoring framework will be agreed with the Local Medical Committee. It is anticipated that the monitoring exercise will take place in the autumn, and the results will be used to inform future arrangements for extended hours access.

14 NHS Lothian Annual Review 2008 Agenda Item 5

5.6 Access to NHS Dental Services

Workforce

Routine data collected by ISD Scotland shows that there were 496 dentists working in the NHS Lothian area in September 2007, up by 8% from 460 at September 2003. A total of seven dental practices received access grants in Lothian. There were additional surgeries added to four practices and three totally new practices were established.

NHS Dental Capitation Registration – Under 18 Year 98/99 99/00 00/01 01/02 02/03 03/04 04/05 05/06 06/07 (to March) Scotland 63.4% 65.9% 64.9% 65.2% 66.1% 65.9% 66% 67% 67.2% Lothian 67% 70.1% 69.8% 69.6% 70.7% 70.5% 71% 71% 71.2%

Working closely with our general dental practitioner colleagues, in December 2007 NHS Lothian had increased the number of children registered with an NHS dentist. Lothian has over three quarters (75.5%) of r children registered with an NHS dentist, significantly above the Scottish average figure of 71.7%.

15 NHS Lothian Annual Review 2008 Agenda Item 5

16 NHS Lothian Annual Review 2008 Agenda Item 5

5.7 Delayed discharges

In 2007/8, both national targets to have zero patients delayed in short stay and over six weeks categories were met. Additionally a locally agreed target to have no more than 66 patients delayed overall was exceeded with a total of 50 patients delayed overall at the April 2008 census.

Following a series of discussions across the Lothian Delayed Discharge Partnership, broad agreement has been reached to roll forward the main elements of the 2007/8 spending programme into 2008/9.

Each member of the partnership has agreed to maintain the zero standards for the numbers of patients delayed in the short stay, six weeks plus and one year plus categories.

The partnership considered a series of options to reduce further the local target of 66 delays overall. It concluded that maintaining the zero standards posed a significant challenge, and as a result, it agreed to maintain the level of the local target in 2008/9 at 66 for the overall delays.

The partnership has agreed a number of actions designed to improve its overall performance including;

• Earlier allocation and completion of social care assessments • Making the moving on process more effective • Monitoring and managing overall performance through the National Community Care Outcomes Framework and linking this to Single Outcome Agreements.

17

Agenda Item 6: Service change and redesign

6.1 Sites and services vision

6.2 Improving Care – Investing in Change (ICIC)

6.3 Lean in Lothian

6.4 Patient Focus and Public Involvement

6.5 Carer Information Strategy

NHS Lothian Annual Review 2008 Agenda Item 6

6: Service change and redesign

Key Points • NHS Lothian’s major modernising programme, Improving Care, Investing in Change, continues and is delivering improvements

• “Master-planning” work has started to look at how NHS Lothian can best use its three adult acute hospital sites

• Ongoing work will ensure that, where appropriate, older people will be treated at or near home, rather than in hospital

• Plans for a new Musselburgh Primary Care Centre and Midlothian Community Hospital are making progress

• The Lean in Lothian programme pilot evaluated positively in 2007 and the approach is helping NHS Lothian meet targets and improve services for patients

• Patient Focus and Public Involvement is a priority for NHS Lothian and progress is being made in developing Public Partnership Forums

• The multi-agency Lothian Carer Information Strategy, drawn up in extensive consultation with carers, has been endorsed

1 NHS Lothian Annual Review 2008 Agenda Item 6

2 NHS Lothian Annual Review 2008 Agenda Item 6

6.1 Sites and Services Vision

In mid 2006 NHS Lothian developed a high level vision, building on the ICIC programme of strategic direction, of possible future delivery models for major hospital based services, which was presented as part of the 2005/6 Annual Review.

This vision is based on shifting services from hospital to community based delivery (including community hospitals and community treatment centres) wherever safe and practical to do so. Those services that need to be on a major hospital site would be focused on the three acute sites in Lothian, with consequent clinical synergies, optimal use of expensive infrastructure and economies of scale.

This overall vision has now been developed into a number of proposed new projects including the reprovision of: specialist rehabilitation services; older people’s assessment services for South Edinburgh and Midlothian; and neurosciences for adults alongside children’s services. These projects will be developed alongside the existing projects for acute services, older people, mental health, children and community hospital services already within ICIC.

A key aspect to progress this work is the development of master plans for the future use of the three acute sites at RIE, WGH and St John’s. This work is underway for WGH and incorporates the plans for reprovision of the Royal Victoria Hospital, which now has OBC approval, subject to confirmation of master plan acceptance, expected October 2008. Master planning for RIE is also underway, incorporating plans for the development of a new Edinburgh children’s hospital. This work has to be aligned to the overall master plan for the Bioquarter development, and is at an advanced stage. Master planning for St John’s at Livingston will incorporate phase 2 of the short stay elective surgical centre. Following the development of phase 1, investment of £3.358 in a new endoscopy facility is now underway.

The following specific actions have been undertaken to date: • Analysis of space utilisation audit of major sites • Development of an Initial Agreement for Neurosciences Service replacement adjacent to the proposed new Children’s Hospital • Conclusion of option appraisal of colorectal services.

Further work remains to be concluded to inform our overall sites and services vision including: • Progressing work on critical care and Regional Infectious Diseases services, which is due to report later this year. • Confirmation of impact of revised models of care for adult mental health and older people’s services mental health, being undertaken as part of Royal Edinburgh Hospital business case development.

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• Final outcomes of the exercise assessing the feasibility of rezoning of acute medical admissions in Lothian which includes transport infrastructure solutions involving local authority and other partners.

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6.2 Improving Care- Investing in Change (ICIC) – Service Modernisation

Improving Care, Investing in Change (ICIC) is our ambitious, far-reaching programme of modernisation, affecting services involving more than half (54%) of NHS Lothian’s 28,000 workforce. ICIC was approved by the then Scottish Executive in 2005 following extensive public consultation. Its four main strands are:

• Better acute care in Lothian (BACiL) • Mental health and wellbeing • Older people’s services • RHSC reprovision project (added in 2006)

Better Acute Care in Lothian

At the heart of BACiL is the goal of making the best possible use of all three of our main adult acute teaching hospitals – St John’s, the Royal Infirmary of Edinburgh and the Western General Hospital, further developing them as centres of excellence.

During 2007/8 the following has been achieved:

• Cardiology service reconfiguration was implemented in July 2007. A review of its outcomes in early 2008 confirmed achievement of significant improvements in providing uniform access to cardiology services across Lothian, with continued local delivery of consultant led services across five sites. • An extensive review of sustainability of colorectal services on the WGH site was undertaken. Through redesign work, including lean projects and development of new staffing models, it was confirmed in November 2007 that the service would be best delivered at WGH, where co-location with oncology and other services achieve maximum clinical synergy and patient benefit. • Significant work has progressed on rezoning with a public involvement session in February 2008. This highlighted the importance to the public of robust and timely transport links to St John’s Hospital and equally the need for enhanced social work links across local authority areas. • A group of clinicians and managers are progressing to develop a new model of service delivery for critical care services. The focus of the development is on a shorter-term option to address the challenges of meeting the European Working Time Directive for trainee doctors with a longer-term plan to ensure the sustainability of three adult critical care units in Lothian. • Reviews of the Ophthalmology and Regional Infectious Diseases Unit are underway. • With the introduction of the Hospital at Night service on the WGH site in 2005 followed by that on the RIE and St John’s site in 2006, the focus has

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moved to the need to develop a similar system of overnight medical cover for Liberton, Royal Victoria, Astley Ainslie and Roodlands Hospitals. Phase 1 of the development of the short stay elective surgical centre (SSESC) at St John’s Hospital is the creation of additional endoscopy space. This work will start in June 2008 with completion in February 2009. This will be followed by a phase 2 development which is planned to achieve completion of the SSESC by 2010.

Mental health and wellbeing

Substantial progress has been made on the implementation of the mental health strategy and the shift of care from hospital to community across all four Lothian joint planning partnerships. This includes: the introduction of enhanced community mental health services in Midlothian, with the consequent closure of isolated and unsatisfactory acute mental health inpatient facilities at Rosslynlee Hospital in May 2007.

Further details of the achievements in mental health services are included in agenda item four.

The Older People’s service element of ICIC has seen progress in the following areas:

• Review of orthopaedic pathways, across acute and rehabilitation services, to ensure a quality experience for older people, with a project manager now in place to implement changes. • A whole systems approach to delivering services for older people is under development in Edinburgh. Particular focus will be the development of community based solutions to ensure older people do not stay in hospital longer than is necessary. • Four Joint Capacity Plans for Older People have made progress in the CHC(C)P and local authority areas across Lothian. These plans identify the range and capacity of accommodation and services required to meet the future needs of older people. • The Royal Victoria Hospital outline business case for the reprovision of medicine services to the Western General Hospital site was submitted and approved by the Scottish Government in June 2008. Development of the full business case is now underway and this project will be completed by May 2012.

Major capital projects

Further achievements during 2007/8 in relation to the capital projects to support ICIC delivery include:

• Submission of Musselburgh Primary Care Centre OBC to Scottish Government in December 2007. This project has been agreed to proceed, and work is progressing, while formal approval is expected from the Scottish Government when section 75 agreements are finalised between the site owners and East Lothian Council Planning Department.

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• Development of RHSCE OBC, working closely with colleagues in NHS Greater Glasgow and Clyde and with SEAT regional NHS Board partners to meet future specialist health care needs of children locally, regionally and nationally. This OBC was submitted to the Scottish Government in July 2008. • Midlothian Community Hospital review of OBC approved by Scottish Government in August 2006. The project has now progressed and testing for Public Private Partnership (PPP), including key stage review at final invitation to negotiate stage, and final bid evaluated March 08.

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6.3 Lean in Lothian - Process Improvement Programme

The Lean in Lothian Programme was established in 2006. GE Healthcare was appointed to support NHS Lothian to develop its capacity and capability to take forward the significant service redesign needed to deliver top quality health services to our population and deliver on targets for health, efficiency, access and treatment (HEAT).

In April 2007 the pilot phase was evaluated as highly successful and its continuation and further progress towards becoming a mainstream approach for service redesign in Lothian was supported.

The year two programme has continued to focus on the delivery of specific projects, linked to our strategic objectives. These have supported improved services for patients and on the development of skills and capacity to utilise the tools and techniques of improvement science across our staff at all levels.

Development of skills and capacity

During this year, the programme has developed 62 key staff, including three further partnership representatives to be change champions, through participation in training in Lean, CAP and Workout. Additionally 110 staff have attended awareness training, and 11 senior leaders have been trained as project sponsors.

Lothian now has a total of 98 staff who have been trained in one or all of the improvement methods and are being supported to use these skills to benefit patients. In addition a further 230 staff have participated in the projects, and two further full time improvement leads have been mentored to increase our pool of experienced individuals able to lead major projects across the organisation.

We also made progress towards developing our own capacity to deliver training in the toolkit, with two trainers co-delivering workout training with GE colleagues.

Delivery of improvement projects

Fourteen projects have been delivered this year with a range of areas addressed including mental health, substance abuse, laboratory processes and hospital decontamination and sterile supplies, as well as further projects in acute service departments. Further work has been taken forward to build on improvements already achieved: in breast services (follow up), colorectal (diagnosis to treatment) and discharge processes (medicine).

Once again, the projects have delivered significant immediate impact on staff and patient experience in terms of improved efficiency, greater equity of response and improved reliability. Improved resource utilisation has resulted from reductions in DNA’s, better targeting of staff time to delivering direct

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care, reduced waiting times, faster turnaround time for test results and essential equipment.

Sustainability of Phase 1 improvements

A review of projects undertaken during the pilot phase has confirmed that there has been no loss of momentum on the improvements achieved during 2006/7. Reduced waiting times in CT and colonoscopy, more timely transfer from acute to post acute care and more patient focused services in breast services and medicine of elderly in East Lothian have been established and sustained.

Sharing of learning

The outcomes of the programme have been shared with NHS Scotland at the Lean in Lothian conference in November 2007, attended by over 200 delegates from across Scotland and addressed by the Cabinet Secretary for Health and Wellbeing. There have also been a number of presentations to meetings and conferences, and posters displays on the outcomes at local, national and international conferences.

Year three of the programme will see the delivery of further projects in a wide range of areas to support delivery of our stretched HEAT targets. For example, the programme will play a key role in the transformation of services to achieve the national target of an 18 week maximum pathway from referral to treatment for all acute sector referrals. Partnership with GE Healthcare will continue, with focus this year in developing full internal Lothian capacity to deliver Lean in Lothian training. GE colleagues will also lead projects in two specific areas within Children’s and Cancer services. The programme will also link closely to Patient Safety, Compassionate Care and other quality improvement work underway in Lothian. NHS Lothian aims to perform at the level of the best in Scotland, and to be among the top 25 healthcare organisations internationally, and the adoption of lean thinking is one of the tools to achieve this objective.

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6.4 Patient Focus and Public Involvement

Patient Focus and Public Involvement (PFPI) governance Patient Focus and Public Involvement (PFPI) policy documents and activity are reported to the PFPI Management Group, which was set up in April 2006, meeting bi-monthly. The group also receives reports on progress on the key PFPI activities agreed with the Scottish Health Council (SHC). It comprises lead staff for PFPI, representation from clinical governance, members of the public, local authority and Scottish Health Council representation.

The Healthcare Governance and Risk Management Committee, which is a sub-committee of NHS Lothian Board, receives half yearly reports on progress on NHS Lothian’s PFPI Action Plan, together with any PFPI policy papers and a progress report on key PFPI actions.

Progress made with the development of Public Partnership Forums NHS Lothian set up a Public Partnership Forum (PPF) in each CH(C)P during 2006: East Lothian, Midlothian, West Lothian and North and South Edinburgh. In 2006 the PPFs together with their respective CH(C)Ps agreed working agreements. During 2007/8 they have moved to publicising the organisations, increasing membership and seeking to influence the delivery of services, some to a greater extent than others. In late 2007 the South Edinburgh PPF was suspended and was independently reviewed. The outcome reported to the Edinburgh CHP in June 2008. An action plan for re- establishment has been agreed and is being implemented.

The method of recording membership to reflect a stratified approach has been agreed with the SHC and a baseline established. This recognises that some people are individual members, while many are members of voluntary organisations and community groups, which allows for wider dialogue. While East Lothian, Midlothian, North Edinburgh and West Lothian PPFs have representatives on various groups of the CH(C) Ps, three of the PPFs have actively participated in projects or in raising issues including:

Examples • Midlothian PPF engaged with the Dalkeith Medical Centre Re-design Group, Midlothian Community Hospital Project and participated in the design of a waste medicine campaign. • North Edinburgh PPF raised concerns about toenail maintenance and support, resulting in piloting of a nail care service. The forum has also raised concerns following the re-organisation of mental health service provision in NW Edinburgh. • West Lothian PPF fed back concerns about the number of services increasingly based in Craigshill and pressed for the Mental Health Rehabilitation and Recovery Re-design Project, which they and West Lothian Mental Health Forum had been involved with. This will be brought back to the CHCP Committee for an update.

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What has worked well in progressing PFPI To achieve a systematic approach across NHS Lothian to clinical governance, each directorate (including CH (C)Ps) in 2006 were required to set up Quality Improvement Teams to produce a Quality Improvement Programme (QIP). The aim of the QIP is to improve the patient experience of our services. Each programme has been asked to demonstrate evidence that patient experience feedback has influenced the design, delivery, responsiveness and person centeredness of improvements in care. This programme is now in its second year and teams have shown an increase in achieving the PFPI indicator, 79% compared to 63%. In 2007/9 guidance on equality and diversity, Rapid Impact Assessment (RIA), was issued to teams to assist in understanding the importance of assessing the impact of policies and/or actions on the diverse communities that use NHS Lothian services.

Some of the PPFs have begun to achieve a difference for the communities they serve. Engagement in the early stages of service planning/redesign is also more systematically applied across NHS Lothian.

Where further work is required As noted above dissemination of guidance on Rapid Impact Assessment has taken place, but will need to be supported further to ensure greater understanding of its importance. Several actions from 2007/8 have just begun, so will carry over to 2008/9: surveys on the patient experience of hospital discharge and 48 hour access to primary care and development of the Advocacy Action Plan.

While some PPFs have begun to show the difference they are making for their communities, a key action for 2008/9 will be that all PPFs are able to provide such evidence. NHS Lothian, through the CH(C)Ps, will work in partnership to support all PPFs to raise issues from their communities, in all their diversity, and also to ensure they participate in the early development of planning and service redesign both at CH(C)P and pan-Lothian level.

The PFPI Action Plan 2005/8 has expired and a further plan will be developed as part of an Involving People Improving the Patient Experience Strategy, which will also seek to ensure NHS Lothian is able to meet the requirements of Better Health, Better Care – Action Plan.

How public/patients have been supported to be involved and the difference it has made There have been a number of strategies and service redesigns, which have involved patients, carers and the public during 2007/8 including: the Royal Hospital for Sick Children Re-provision, the Royal Edinburgh Hospital Campus Review, the Joint Lothian Learning Disability Strategy Review and the Joint Lothian Physical and Complex Disability Strategy. Their involvement has resulted in development of the respective plans and strategies. Methods to support people to participate have included information in plain English, going out to communities, reimbursement of travel expenses and provision of transport. Guidance to staff based on the National Standards for Community

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Engagement is issued when public/patients join committees/groups. After workshops, participants are invited to complete evaluation forms to help NHS Lothian learn whether people have been able to participate.

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6.5 Carer Information Strategy

NHS Lothian Healthcare Governance and Risk Management Committee endorsed the multi-agency Lothian’s Carer Information Strategy. The strategy has undergone an extensive engagement and involvement process to ensure it reflects the needs of carers. The Strategic Development Groups for Carers across the four partnership areas continue to assist and contribute to the further development of the Strategy and materials. Generic training for NHS Lothian staff has also been developed. Resources are devolved to CH(C)Ps to assist collaboration with council and local carer forum groups to address and prioritise local needs. The strategy details are available at www.nhslothian.scot.nhs.uk.

NHS Lothian is providing a lead in the following areas:

• Development of information materials and marketing/communications strategy • Training specifications being developed for staff and carers • Spending plan and priorities for Lothian in conjunction with local authorities, voluntary carer agencies and carer representation • In June 2008 during Carers week proposed spending plans were highlighted to demonstrate NHS Lothian and partners’ commitment to carers following submission of the strategy to Scottish Government.

Investments committed for the strategy for 2008/9 is £136k rising to £408k in the following year.

Lothian’s carer population is similar to that of Scotland at around 9% with the exception of Midlothian, which is slightly higher at 10.9%.

The table below shows the number of carers in the population for Scotland and Lothian categorised by unpaid time commitments.

Carer Commitment Unpaid hours 1 –19 20-49 50+ per week Scotland 305,610 60,294 115,675 Lothian 47,483 7,992 15,565 Edinburgh 26,999 3,977 7,900 East Lothian 5,874 1,026 1,930 Midlothian 5,236 1,014 1,939 West Lothian 9,374 1,978 3,794

Carer Population; source 2001 Census, General Registry Office

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Agenda Item 7: Improving treatment for patients

7.1 Enabling and supporting patients to be partners in their care

7.2 Making healthcare safer

7.3 HAI and infection control

7.4 Modernising services through better use of technology

7.5 Spreading best practice

NHS Lothian Annual Review 2008 Agenda Item 7

7: Improving treatment for patients

Key Points • NHS Lothian is committed to supporting its staff to provide person-centred care

• We have both overarching (e.g. Lean in Lothian) and specific programmes to develop staff and improve patients care, such as Connect in Care, which provides resources to help staff improve the quality of care for older people

• We are committed to improving the patient experience and are using approaches such as the Patient Experience Action Team (PEAT) which make action plans based on the patient view

• Management of risk, patient safety, quality and clinical governance continue to evolve and improve within NHS Lothian

• Minimising healthcare associated infection (HAI) and improving infection control continues to be a priority for NHS Lothian. Examples of action in 2007 include a pilot project, which started in November, to reduce clostridium difficile rates.

• We are improving care through better use of technology, including increased use of CHI (patient identifier), PACS, e-referrals and TrakHealth, the single patient administration and A&E system which is now working across the acute sector.

• We are committed to developing our workforce and our organisation through a variety of initiatives, including The Lothian Way, which helps staff work in a patient-centred way

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7.1 Enabling and Supporting Patients to be Partners in their Care

Leadership in Compassionate Care

NHS Lothian has many initiatives aimed at building staff capacity, capability and commitment to person-centred care. These are embedded in our organisational development framework, The Lothian Way and seek to ensure that staff are supported, involved and valued which in turn helps them to support, involve and respect the people who use our services. Our Lean in Lothian programme, the pursuit of Investors in People award and Healthy Working Lives are all examples of this. Specific programmes which have a particular focus on older people include Connect in Care, Leading in to the Future and Leadership in Compassionate Care. At the core of all these developments, is a drive to provide care based on values and a rights-based approach. This includes participation in treatment and care, and respect for the individual, including their cultural and religious background. NHS Lothian is also making use of the 10 Essential Shared Capabilities (an education and training programme) within mental health and we are leading work on their use in non mental health settings.

Case study Connect in Care is a collaborative national project, funded by NHS Education for Scotland, which includes NHS Lothian and Edinburgh, Ulster and Napier Universities. The project aims to create a network supporting learning and practice development in the care of older people. The project engages frontline clinical staff that supports person-centred care by using online resources and action learning. The ultimate purpose of Connect in Care is to improve the quality and experience of care for older people in Scotland.

Leading in to the Future is a newly developed person-centred leadership programme aimed at older people care. It utilises the Senses Framework which focuses on relationships as central to the delivery of person centered care. The framework suggests that the best care involves the creation of a set of senses or experiences, for older people, for family caregivers and for staff working with them. The Sense Framework has been shown to resonate with older people, their families and staff in a range of care environment (Nolan et al 2006)

The set of senses are: security; continuity; belonging; purpose; achievement and significance.

The Leadership in Compassionate Care Project is now well into its first year of the three-year project. This partnership between NHS Lothian and Napier University aims to ensure patients receive the compassionate, person centred care they expect and deserve. The project has four strands and during this first year progress has been made in each.

Beacon ward strand: The team (Lead Nurse and four Senior Nurses) are gathering and analysing information from the four Beacon Wards (centres of

3 NHS Lothian Annual Review 2008 Agenda Item 7 excellence) leading to the development of a working understanding of compassionate, person centred care.

Supporting development of leadership skills in compassionate, person centred care: Eighteen nurses representing 13 wards have recently taken up development opportunities to lead compassionate and person-centred practice development initiatives within their wards.

Supporting newly qualified nurses during their first year in practice: With the aim of facilitating the transition from student to that of a confident staff nurse, a number of supportive activities have been introduced. These include regular study days which incorporate engagement with NHS Education Scotland’s Flying Start programme and opportunities for reflecting and sharing their experiences. To date 55 nurses have attended two of these study days.

Embedding compassionate, person-centred care in the undergraduate nursing curriculum at Napier University: This strand will actively focus on understanding, identifying and promoting compassionate care, and related themes, within all aspects of teaching and learning within the school.

NHS Lothian has appointed a post in partnership with Edinburgh University to maximise the exchange of knowledge between current values based projects and to support the development of further initiatives. All of the projects are supportive of embedding the Lothian Way in practice.

Patient Environment and Monitoring Team

As part of NHS Lothian’s commitment to improve the patient experience, the Patient Environment and Monitoring Team have used the Patient Experience Action Team (PEAT) system at 20 healthcare sites during the year. The PEAT process has recently been extended to Nursing and Ward Management matters on 4 UHD sites with nursing colleagues joining the team. These Assessments and the resulting Action Plans are made “through the patient’s eyes” and each of the assessments has involved a patient or public representative. Therefore it is not possible to make a year on year comparison.

However PEAT Assessments generate a score for the environment, food and food service, and meeting patients needs. Of the areas surveyed 98.5% were in the acceptable, good or excellent categories. Inevitably there is scope for improvement in some areas targeted by the local PEAT team. Arising out of the multi-disciplinary PEAT team reports, 490 actions have either been completed or are in process of completion.

Every ward or department will be the subject of a combined PEAT and Nursing Assessment over the next two years.

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7.2 Making Healthcare Safer

Quality issues, clinical governance, risk management and patient safety.

Risk management Over the past 12 months risk management, at both a strategic and operational level, has continued to evolve and improve. The NHS Lothian framework for risk management has moved from an implementation to monitoring stage and it underpins the Scottish Patient Safety Programme.

Key areas that have supported this have been:

Risk registers The registers are in place at all levels in the organisation. The Corporate Risk register is continually reviewed by NHS Lothian’s Executive Management Team and NHS Lothian Healthcare Governance and Risk Management Committee to provide assurance to the Board.

Case study Incident Reporting A revised NHS Lothian Incident Management Policy and supporting Operational Procedure is being implemented and provides a single system approach to risk management. The method of dissemination of information on incidents and lessons learned has been improved by using newly designed templates for incident reports, This facilitates the production of a standard reports at local operational levels that can be aggregated to corporate level to support the process of learning lessons.

Training An e-learning risk management package has been developed and is being used by Lothian staff for basic risk management training. This award winning elearning tool is now being used by number of health boards across Scotland.

Scottish Patient Safety Programme Significant progress has been made building on existing clinical governance, risk management and quality improvement structures and processes.

Although challenging, particularly in terms of timescale, the pre-work for the first learning session in January 2008 was completed on time and key learning points included: • Enthusiasm, ownership and commitment from clinician and mangers • Multi-disciplinary and Pan-Lothian teamwork • IHI tools useful especially the testing of current systems and processes • Valuable insights for all involved • Indentifying good practice and structures already in place

...and key challenges • Time, resources and communication

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• Difficulty in obtaining reliable data from all three sites from which to select samples.

These will be tackled by building safety work into normal care process and normal job planning e.g. safety briefing part of routine ward handover. SPSP has become an effective driver for enhancement of quality and availability of relevant data from routine data sources. We are also simplifying and increasing integration of analysis by using Datix for all types of incident reporting and MIDAS for routine activity and surveillance figures.

NHS Lothian was well represented at the first SPSP learning event with 50 participants attending over the 3 days. Frontline teams are in place for each of the four initial work streams and comprise an operational director sponsor, an operational, clinical team lead and a multidisciplinary team. The fifth workstream - Leadership Patient Safety Walkrounds - has begun. Regular reporting timescales all continue to be met and involvement from staff at all levels continues to spread.

Frontline teams have welcomed the establishment of a monthly ‘Team Lothian’ meeting, led by the Medical Director, rotating round the three main sites. This facilitates regular updating, sharing and monitoring on a less formal basis.

Communication throughout the organisation is also seen as key to success and engagement with regular briefings are included in the Clinical Governance newsletter as part of the CGST monthly briefing which is disseminated widely.

NHS QIS Clinical Governance and Risk Management Standards A high level action plan, supported by detailed operational plans, which have a lead executive director named for each sub-section.

A number of key pieces of work are supporting progress against these standards including: • A new integrated strategy for Quality Improvement which, following wide consultation during the first quarter of 2008, will be submitted to the Board in September 2008. • Monitoring of Risk Management policies, Incident reporting and review of risk registers. • Communication strategy approved by the Board in March 2008 • Continued roll out of integrated Risk Management Information System throughout NHS Lothian. • Demonstrable improvements in business continuity planning in CH(C)Ps and Acute Division. • Equality and Diversity Steering Group established and the requirement for Equality and Diversity Impact Assessments on all policies.

Quality Improvement Teams and Programmes Updated guidance on the content of the Quality Improvement Programme was issued to all QITs emphasising safe, effective, and person-centred care and

6 NHS Lothian Annual Review 2008 Agenda Item 7 the need to integrate PFPI and equality and diversity throughout all improvement work. New requirements included: • Work related to reducing medication events, pressure sores, falls and MRSA, which will greatly assist with future stages of the Scottish Patient Safety Programme (SPSP) • Active work on relevant NHS QIS standards, including Food, Fluid and Nutrition. • Audit against relevant guidelines and ability to show evidence of acting upon audit results.

The QI programmes are firmly embedded in the responsibilities of management teams with continued leadership from senior management and clinicians. The transition of the Primary and Community specialist services into hosting arrangements within the CH(C)Ps has successfully incorporated their quality improvement work.

There is clear commitment to maintaining and continuing to develop these arrangements so that a robust mechanism exists to focus on quality improvement and patient safety in a way which is integral to existing management arrangements. These structures will be critical to achieving the aims and objectives of the SPSP and embedding improvements into routine clinical practice.

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7.3 HAI and Infection Control

Healthcare Associated Infection (HAI)

HAI continues to be a key priority area for NHS Lothian and key actions over the past year have included:

• Infection Control Policies and Procedures Manual: Available on both intranet and internet for staff use. The manual is undergoing a programme of review and will be updated in September 2008. • In line with HDL (2005)8 the Head of Service Infection Control (Infection Control Manager) was appointed and took up post November 2007. Attempts to recruit the Nurse Consultant HAI have been unsuccessful and the job description has been revised. • Scottish Patient Safety Programme includes activities to reduce HAI in critical care and general surgery. Infection control team provides support in the pilot clinical areas with additional data and education programmes. • Surveillance of HAI: National HAI surveillance requirements as outlined in HDL (2006)38 are being met. Infection rates for hip arthroplasty (0.78%) and caesarean section (2.9%) are below the national average (1.64%; 8.24% respectively). NHS Lothian’s surveillance system for HAI provides monthly reports enabling prompt action on any issues arising. Enhanced surveillance of Meticillin Resistant Staphylococcus Aureus (MRSA), Meticillin Sensitive Staphylococcus Aureus (MSSA) bacteraemia and Clostridium difficile takes place. Infection rates are monitored through the local Quality Improvement Team. Root cause analysis for Staphylococcus Aureus bacteraemia is being carried out in partnership with infection control and clinical staff. A reduction of 11.24% (in MRSA/MSSA) has been achieved against the Health & Efficiency and Access & Treatment (HEAT) target of 40% by 2010. Equating to a reduction in numbers from 498 in 2005/6 to 442 in 2007/8 and target being 299 by 2009/10. Case Study • A pilot project began in November to reduce Clostridium difficile rates within NHS Lothian. Care bundles (a collection of interventions applicable to the management of Clostridium difficile, such as reviewing anti-microbial prescribing and environmental cleaning), are being piloted in several areas within the Western General Hospital and the Royal Victoria Hospital. The results of the pilot will be used to guide practice in other clinical areas within NHS Lothian. • Education: NHS Lothian now has over 670 Cleanliness Champions. HAI is now incorporated in both induction and mandatory training programme. The infection control team delivered three study days on HAI in 2007/9, which were positively evaluated and a further three will be provided 2008/9. • Decontamination: Upgrade plans for the decontamination facilities in the Oncology Unit have been submitted to Health Protection Scotland. Phase 1 of the managed services PCAT action plans, which identifies priority areas, has now been sent to the Scottish Government for review. Phase 2

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and 3 action plans, which identify medium and low-level priorities, are progressing well. • Funding for the centralised compliant decontamination facility and additional treatment room to accommodate the increased endoscopy service at St John’s has been agreed. • Code of Practice for the Local Management of Hygiene and Healthcare Associated Infection is now incorporated into the annual work plans for infection control and surveillance. The HAI audit tool has been integrated into clinical areas within the University Hospital Division and the implementation into Community Health Partnership inpatient facilities has commenced. • Cleaning Services: National monitoring and audit requirements for cleaning services as outlined in HDL (2005)50 are being met. The national quarterly reports demonstrate continued improvement with average compliance remaining above 95%. The audits are being validated through peer review, including Infection Control Nurses and public representative. • National Hand Hygiene Campaign: Local campaigns and publicity drives have been progressed with audit results highlighting improved compliance by medical and nursing staff groups.

Reduction Plan 2008-2009 of Healthcare Associated Infection

Details are contained in our 2008/9 Local Delivery Plan. The key elements of how this will be achieved include:

• Develop and collate an evidence base against HAI Quality Improvement Standards in preparation for audit 2009. • Integration of the Scottish Patient Safety Programme initiatives with infection control activities including the introduction of surgical site infection surveillance within general surgery pilot areas. • Enhanced surveillance, root cause analysis, rapid feedback to clinical areas and Quality Improvement Teams on progress against HEAT target to reduce Staphylococcus Aureus bacteraemia by 40%. • Review the effectiveness of the Clostridium difficile care bundles pilot project and expand the successful components into other clinical areas within NHS Lothian. • Promote and improve hand hygiene and decontamination (alcohol hand rubs) to achieve 90% compliance by November 2008. • Implement Healthcare Associated Infection Audit across NHS Lothian • Monitor to ensure cleaning standards above 90% for National Cleaning Specifications • Deliver mandatory and additional multidisciplinary education programmes • Development of patient information leaflets in consultation with patients.

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7.4 Modernising Services through better use of technology e-Health including CHI utilisation

NHS Lothian CHI (the unique patient identifier) utilisation continued to increase during 2007/8. The HEAT target for laboratory requesting of 97% was met in February 2008 and increased to 98% in March 2008. This is a significant improvement from April 2007 when it was just over 75%.

Sustainability monitoring continued for the acute and community sectors with many areas meeting the government target of 97% for the use of CHI on a number of monitored patient communications. Further improvement will be achieved through increased use of electronic referrals for example in the acute hospitals on radiology requesting, final discharge letters and immediate discharge letters.

SCI Store – Clinical Repository

SCI Store continues to grow in the number of users using the system and the number of laboratory results and radiology reports being added and viewed. The number of results viewed on SCI Store has peaked. The introduction of TRAK has enabled clinicians to access their required results and work is underway with the Unisoft Endoscopy system to allow reports to be placed into SCI Store.

User Type 2005/06 2006/07 2007/2008 GP Practices 884 1,412 1,741 Secondary Care 93 497 1,162 Total 977 1,909 2,903

Development at a national level continues to enable GP systems to upload results from SCI Store into the patient record and it is anticipated that the new version of GPASS software (the system used by most GPs across Scotland but which is to be replaced) will be rolled out 2008.

The overall improvement in the use of CHI throughout the organisation has supported the improvement in data quality within SCI Store for the matching of results/reports to the correct patient.

The overall aim is to increase the clinical content of SCI Store to include clinical letters and copies of referrals enabling these to be available to a number of clinicians across NHS Lothian. A national guidance around this highly sensitive area involving patient record confidentiality and information sharing is being developed. The focus for 2008/9 will be to increase the overall clinical content of SCI Store. e-Referrals

11 NHS Lothian Annual Review 2008 Agenda Item 7

NHS Lothian has seen an increase in the use of SCI Gateway for electronic referrals by GPs using GPASS. Those practices that use other computer systems, EMIS, Vision and Ascribe, have now signed off this functionality nationally and will start implementing electronic referral.

The number of eReferrals being received throughout NHS Lothian continues to increase as shown below:

Apr Aug Mar Apr 2006 2007 2008 2008 Total no. of eReferrals 2422 9290 10,101 12,776 Total no. of Referrals 16,144 12,797 11,628 13,060 eReferrals as % of Total Referrals 15% 74% 87% 97%

Services within acute division are now able to accept eReferrals with the exception of obstetrics referral, which is currently being re-designed. Community AHP services such as physiotherapy, podiatry, speech and language are also using SCI Gateway for the receiving of eReferrals.

• 106 GPASS practices using eReferrals. • 2 non GPASS practice uses eReferrals.

In March 2008, 56% of practices were generating electronic referrals for 90% of their referrals in line with the national target (90%). The most recent figures have shown a continued increase by the GP practices with 73% of practices are using eReferrals for more than 90% of their referrals. The national target has been revised with new definitions and a target of 95% by December 2008.

Mental Health Services for adults and elderly are currently being implemented for 2008/9 and there is a migration of SCI Gateway into the business as usual environment.

An e-triage pilot project is underway to establish the next stage of managing referrals on-line within UHD and to support the 18 week target.

TrakHealth

Patient Administration System (PAS) and A&E functionality were implemented at the RHSC and St John’s sites, replacing the existing systems and giving University Hospitals Division a single PAS and A&E system across its four hospitals and associated sites. Currently all A&E discharge letters, over 50% for inpatient and 50% of outpatient clinical letters are produced via TrakHealth and are therefore available for clinical staff to access as part of the TrakHealth patient record.

Significant work undertaken to upgrade the Patient Administration module will support the introduction of the New Ways of managing waiting lists.

Radiology department systems have also been enhanced at the WGH and RHSCE sites to meet the requirements of the RIE service. Radiology clinical

12 NHS Lothian Annual Review 2008 Agenda Item 7 reports for all three of these sites are now available on TrakHealth for clinical staff and are also sent to GPs via SCI. In addition, implementation of the PACS will enable clinical staff to access radiological images via the TrakHealth patient record.

An interface with the local NHS Lothian/Borders CHI was implemented to support registration of new patients from CHI. This interface will be extended to include national CHI during 2008/9.

Ongoing development of the TrakHealth including release of new software will enhance the system functionality. The enhancements include: maternity functionality, strategic deliverables such as support for incremental discharge and provision of a platform for further integration of AHP/Community information.

Picture Archiving Communications System (PACS)

Lothian signed up an Access Agreement, to the nationally negotiated PACS solution at the end of July 2007. Carestream is the supplier selected to provide all future PACS systems within Scotland, with each PACS instance communicating through a centralised national store to provide a joined up patient imaging record across Scotland. At present there are 24 sites feeding the national archive.

The Lothian PACS went live at the Royal Infirmary of Edinburgh and Lauriston and Liberton hospitals in November 2007 achieving a near film-less image status by March 2008. It also went live at WGH in January 2008 and RHSCE, Chalmers Hospital and the primary care sites at Roodlands, Leith, and Astley Ainslie in May 2008. St John’s will also go live by summer 2008. The active Lothian wide PACS system has been achieved on time and within budget in a period of less than 12 months.

More than 2,000 users have been trained in the use of PACS allowing secure access to PACS nationally. The PACS implementation has received a positive response from clinicians and has transformed their ways of working, enabling access to patient images on demand. The WGH and RIE are experiencing the benefits of being able to view images across Scotland, providing valuable information to facilitate cross Health Board consultations and admissions in a timely manner. Patients also benefit because their images are immediately available.

13 NHS Lothian Annual Review 2008 Agenda Item 7

14 NHS Lothian Annual Review 2008 Agenda Item 7

7.5 Spreading best practice

The Board Development Plan is the overarching organisational PDP (personal development plan) whereby all actions are associated with enhancing the experience of patients through engaging and growing our staff. It includes our commitments to:

• Support the delivery of safe and effective patient and client services • Demonstrate efficiency and value for money • Follow best practice • Maximise the talent and skill of our workforce • Work in partnership with our staff, the community health and social care colleagues on areas of common purpose

The “Lothian Way” enables us to put our patients first so that their experience with us is second to none. We want staff to feel good about being part of an organisation striving to do this, and to work in a person-centred way, in partnership, with integrity, being innovative and accepting accountability.

Revising the Lothian Learning Plan enables us to realise key deliverable themes of access, flexibility and blended learning, increasingly supported and underpinned by electronic environments.

Corporate and professional induction, our mandatory lifelong learning journey introduction, is encouraging safe and effective working in NHS Lothian

The Leadership and Management Development Framework enables us to ensure our managers and leaders have the opportunity to develop their skills and knowledge, to work together in partnership, crossing organisational boundaries, learning from each other in order to build and lead effective multi- disciplinary and multi-agency teams. The framework takes managers from continuing policy awareness and engagement of staff governance (including the communication and assertion skills necessary to challenge behaviours) through to advanced organisational influencing and networking skills.

Appraisal, PDP, performance management – This a key component underpinning our responsibility, authority and accountability for doing what we say we will do, and preparing us to do it safely, effectively and efficiently within our means and role parameters.

Advancing roles & Lothian-wide career framework commits us, in accordance with national workforce development strategy, to enabling our staff to do things well, do things better, do better things.

Enhanced workforce reporting allows us to manage systems and processes to maximise our workforce potential.

15 NHS Lothian Annual Review 2008 Agenda Item 7

The Knowledge and Skills Framework commits us to articulating clearly the knowledge and skills which underpin the majority of roles in our organisation, and to providing the options, means and portfolio to ensure job delivery, satisfaction and progression.

The CPPD agenda – specifically in relation to the redesigned model of clinical supervision training and implementation in mental health, the implementation of all of the capability frameworks but particularly those with a focus on values based practice and relationship-centred care which engage staff in working with patients, clients and each other in ways that foster and embody the Lothian Way and therefore promote attendance. Other projects which focus on values-based care include Compassionate Care and Person-Centred Leadership, and work in relation to national strategies such as Rights, Relationships and Recovery, the report of the review of mental health nursing.

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Agenda Item 8: Finance, Efficiency and Workforce

8.1 Financial performance and planning

8.2 Efficiency savings and efficient government targets

8.3 Workforce and efficiency

8.4 Aligning workforce, financial and delivery plans

NHS Lothian Annual Review 2008 Agenda Item 8

8: Finance, efficiency and workforce

Key Points • NHS Lothian will achieve its three financial targets in 2007/8 (subject to external audit) and will, for the third year running, achieve the largest efficiency gain (£26.7m) of any Health Board in Scotland.

• Major capital projects throughout the year included a multi-million pound investment in e-health and £6.6 million on replacement medical equipment

• NHS Lothian is keen to see implementation of the new NHS resource allocation formula and is keen to achieve the share of resource recommended under it

• Although committed to financial balance, NHS Lothian is particularly aware that population growth is increasing demand on services, particularly maternity, A&E and growing GP patient lists.

• NHS Lothian is reducing spend on agency staff, is improving staff sickness rates and has reduced staff turnover

• Pay modernisation continues to be implemented and is bringing benefits to patients

• Key workforce challenges remain, including compliance with the European Working Time Regulation, which will see a further reduction in trainee doctor hours. Work has already started to find new models of care to comply with the regulation by the end of this year (eight months ahead of the August 2009 deadline)

1 NHS Lothian Annual Review 2008 Agenda Item 8

2 NHS Lothian Annual Review 2008 Agenda Item 8

8.1 Financial performance and planning

Financial performance

2007/8 overview

Subject to external audit, NHS Lothian will achieve its three financial targets in 2007/8 and will for the third year running achieve the largest efficiency gain (£26.7m) of any Health Board in Scotland.

Revenue Outturn

NHS Lothian is reporting a £0.3m surplus against its revenue resource limit for 2007/8. This is after adjusting for a further £2m advance brokerage repayment agreed with the SGHD, with a total of £7m having been repaid in year of which, £2m has been repaid earlier than planned.

NHS Lothian has continued to focus on reducing the level of non-recurring funding to support recurring expenditure over the years. A target of £13m has been delivered in year which represents circa 1% of the overall allocation. This is a significant reduction from previous financial years (£44m in 2003/4, £25.6m in 2005/6). A target of £11.6m has been set for 2008/9 with further reductions to £6m in future years.

Capital Outturn

NHS Lothian is reporting a £0.3m surplus against its capital allocation of approximately £40m for 2007/8. No disposals have concluded in year which would augment the availability of capital resources.

The major capital projects undertaken during the year include:

• £6.6m invested in medical equipment replacement throughout NHS Lothian, of which £4.4m was funded as part of the national investment plan with a further £2.2m locally prioritised. • £1.6m invested in equipment to improve cancer services. • £3m invested in diagnostic equipment to assist in delivery of the waiting times targets and a further £900k development in radiotherapy equipment. • £1.2m spend as part of 5 year investment programme to address the recommendations of the Disability Discrimination Act • To support the delivery of the e-Health strategy a further £3.2m has been invested in local prioritised proposals and additional £1m has been invested in replacement PCs to enhance the local hardware infrastructure. • £3m has been jointly invested with Midlothian Council to advance the provision of a 60 bedded nursing home for elderly patients • £1.2m invested with West Lothian Council to modernise the Community infrastructure focused specifically on Learning Disability Services. • £3.6m support for City of Edinburgh Council to assist in the development of additional care homes.

3 NHS Lothian Annual Review 2008 Agenda Item 8

NHS Lothian has entered into partnership with the University of Edinburgh, City of Edinburgh Council, Scottish Enterprise and Alexandria Estates Inc to develop a high quality biosciences park adjacent to the Royal Infirmary of Edinburgh. Approval will be sought from SGHD in 2008/9 to enable NHS Lothian to invest directly in this enterprise and fully share in the benefits so that they can be reinvested in NHS services.

Financial summary

NHS Lothian, subject to audit, has achieved its financial targets in 2007/8 of operating within its revenue and capital resource limits. This has been achieved with around £13m of non-recurrent support to fund recurrent revenue expenditure.

At the end of 2007/8 NHS Lothian was around £11m below Arbuthnott parity (the share of NHS resources which it should receive under the national allocation formula, but which is being gradually implemented). The 2008/9 financial settlement has allocated an additional £3m to NHS Lothian in respect of the move to Arbuthnott parity, reducing the overall gap to £8m.

During 2007/8 NHS Lothian has successfully lobbied for implementation of the NRAC (National Resource Allocation Committee) report in full. The Cabinet Secretary approved the outcome of the NRAC report and this has increased the gap by a further £47m to £55m. The continued focus for NHS Lothian is to accelerate the movement to full parity over as short a timescale as possible. NHS Lothian is experiencing serious population growth-related problems in respect of maternity services, A&E attendances and increasing list sizes within primary care services.

NHS Lothian is fully committed to continuing to achieve financial balance in respect of services provided to the Lothian population and beyond whilst also achieving key quality and activity targets.

4 NHS Lothian Annual Review 2008 Agenda Item 8

8.2 Efficiency savings and efficient Government targets

Efficiency targets

For the third year running NHS Lothian will deliver the best efficiency savings of any Health Board in Scotland. The performance in the last three years is reflective of the benefits of the Lothian single system approach.

The 2007/8 efficiency delivery of £26m was achieved through a combination of pay modernisation benefit realisation, service redesign, efficient Government targets and local initiatives. Delivery is made up of a combination of £24.2m of efficiency schemes and £2.5m of generated in year flexibility to offset cost pressures.

Efficiency delivery plans have been agreed and are in place for the 1st of April 2008.

Prescribing efficiencies

Efficient Government programme initiative Building a Better Scotland outlined NHS Lothian savings target of £2.8m from a range of areas over the period 2005-2008. Lothian demonstrated savings of £12.1m up to June 2007. Further details discussed in the section on Prescribing in Primary Care within agenda item 4.

Agency nursing savings

The target set for the reduction of agency nursing supply in 2007/8 was the second year of a three year plan to reduce utilisation by 30% year on year. (In 2006/7 the target was not fully achieved, with only 47,792 hours of 100,000 hours target attained.)

In 2007/8 the target reduction in agency nursing was 155,000 hours compared to the baseline of 2005/6. The target was overachieved, with a reduction in hours of 217,130 hours. Against a target for agency usage of not exceeding 145,032 hours the actual usage was 82,902 hours, over-achieving the target by 62,130 hours.

YEAR Agency Spend Agency Use Agency Target (£m) (Hours) (Hours) 2004/5 10.2 416,262 2005/6 7.7 296,675 Baseline 2006/7 4.5 245,300 200,000 2007/8 1.8 82,903 140,000

There has been a reduction in agency spend, to £1.82m in 2007/8, from £4.5m in 2006/7.

5 NHS Lothian Annual Review 2008 Agenda Item 8

There has been an overall reduction in supplementary staffing usage of 10% in 2007/8 over 2006/7. Overall a reduction in spend of £1.1m on supplementary staffing has been achieved in 2007/8 over 2006/7.

Supply from bank sources has increased with expenditure increasing to £18.915m from £16.230m in 2006/7. The Staff Bank office achieved a recurring efficiency savings exceeding £40k.

A consolidated target for 2008/9 has been agreed, which requires a further reduction in the overall supplementary staffing usage of 4% (46,416 hours) over targets set for 2007/8. The consolidated target enables growth in bank usage if agency continues to over-achieve the reductions required by local targets.

There are recognised challenges in meeting a further reduction in overall supplementary staffing usage. • Robust demand management in relation to the underlying reasons for supplementary staffing is required • Local management of the nursing establishments including appropriate monitoring of built in allowances for predictable absence • Prospective planning to meet activity for other targets, such as waiting times • Specific difficulties in complex care provision and theatres where agency supply has prevailed over a lengthy historic period.

Sickness absence

All NHS Scotland Boards are required to achieve the Efficient Government Staff Sickness Absence Target of 4% by 31 March 2009. In terms of progress towards the target during 2007/8, the figures have been moving in the right direction. Sickness absence within NHS Lothian as at 31 March 2008 was 4.6%. For the year to date from April 2007 to the end of March 2008 the average percentage was 4.9%. This compares favourably to last year when the figures were above 5%.

Significant work has been ongoing in relation to sickness absence including:

• A number of local training programmes were undertaken to support first line managers and ward managers to ensure they understood the Promoting Attendance Policy and their role within that. • A Traffic Light system has been rolled out appropriately across the organisation. The tool provides a structured approach to managing sickness absence and ensures appropriate interventions happen in a timely manner. Four absences and over are classed as Red and need attention, heading towards four absences is Amber and needs to be watched and Green is where there are no difficulties. • Hotspots of absence were also investigated and all absence cases discussed in depth to ensure the appropriate action is being taken.

6 NHS Lothian Annual Review 2008 Agenda Item 8

• The Promoting Attendance Policy was included in the Policy Awareness Raising Sessions and skill development in absence management is included in the Induction to Management Programme. • Other leave polices such as Carers, Special Leave etc were promoted during the year to ensure that leave is properly classified and does not inflate absence levels. • The HR system, PWA Empower has been rolled out to all managers and this will give them readily available access to absence information.

In addition, an integrated organisational strategy operates to create the environment intended to engage staff, reduce stress, manage workload and motivate, thus promoting attendance. These include:

For 2008/9 a Sickness Absence Action Plan is being developed. This is based on the NHS Scotland Best Practice Guidance on Sickness produced through SWISS and also a Lothian Partnership Forum workshop on absence management. This will include greater availability of absence information at a local level, further training particularly for middle managers, and the introduction of Sickness Absence Co-ordinators to support line managers in absence management. Also the establishment of a partnership Expert Group will provide advice and guidance on absence management, share good practice and develop further practical guidance for managers.

All work towards the achievement of the sickness absence target is undertaken on a partnership basis with staff side colleagues and regularly features on the Lothian partnership forum and staff governance committee agenda.

7 NHS Lothian Annual Review 2008 Agenda Item 8

8 NHS Lothian Annual Review 2008 Agenda Item 8

8.3 Workforce issues, including workforce planning

Human Resources Strategy

NHS Lothian published its Human Resources Strategy in November 2005. The strategy was developed to provide a meaningful and practical framework to support change; to enable the most effective use of organisational processes and resources; including links to productivity targets that provides an environment in which staff can realise their potential and feel valued. Progress against the objectives contained within the strategy has continued during 2007/8 and some of the key achievements during 2007/8 are outlined below.

The existing HR Strategy ends during 2008 and work has already commenced on developing its successor. The next generation, 2008-2012 HR & OD (organisational development) Strategy is currently being scoped, with plans for engagement and investment developed and agreed via our local due processes during the summer and early autumn of 2008, with formal approval sought at the November 2008 formal NHS Lothian Board meeting. It is anticipated the areas of focus will encompass Living Values, Engaging Leadership and Delivering Quality, building on work to date, and creating a culture and focus with our staff that makes us well placed to deliver on the Better Health, Better Care commitments and opportunities.

Recruitment and retention • An On-line Recruitment facility is now being used in NHS Lothian. This allows the e-transfer of applicant detail to the recruiting manager’s desktop. • A co-ordinated recruitment calendar is established to ensure recruitment is connected to workforce and service imperatives. • An enhanced redeployment provision ensures the ability to manage organisational change and workforce redesign. • Promotion of e-access for all staff to vacancy information at a variety of e- learning suites across NHS Lothian and local authority libraries and Job Centre+ search facilities. • Key networking partnerships established to ensure diversity across our workforce. This currently includes ‘Women Onto Work’, Job Centre+, Lauder College, Linknet, Healthcare Academy, South Edinburgh Partnership, Capital City Partnership, Into-Work and West Lothian Council. • MMC Recruitment - the management of surgical specialty recruitment on behalf of NES. We have processed some 2,100 applicants resulting in the appointment of 400 Specialty Training Registrars. • In accordance with the More Chances, More Choices policy, our JET (Jobs Education & Training) pilot has been recognised as an innovation in support of reducing the number of teenagers leaving school ‘Not in Education Employment or Training’. • LEP (Local Employment Partnership Agreement) Employment partnership with Job Cente+ Plus, which in summary commits us to offering work trials of 3 week durations; offering a target number of places for disadvantaged

9 NHS Lothian Annual Review 2008 Agenda Item 8

jobless people to take up work experience, work placement or employment initiatives that lead to jobs; working with Job Centre+ and partners on the design of pre-employment training; encouragement of NHS Lothian staff in the provision of one to one mentoring for potential recruits to help prepare them for work, and providing facilities to hold seminars with Job Centre+ to introduce potential recruits to work • In 2008 our development plans include a review of our recruitment process to ensure service continues to deliver fully effective governance compliant entry to the organisation, and the launch of the revised single system recruitment policy to ensure delivery of PIN compliant Pre and Post employment vetting.

Learning and development • Comprehensive review and redesign of corporate induction and strengthening of the blended learning components to facilitate easier electronic access. • Redesign and implementation of a blended Mandatory Update Programme for clinical staff • Re-accreditation as an awarding centre for ILM accredited management development programmes and sustaining investment in Leadership and Management development • Investment in training supporting key policy initiatives such as equality and diversity, child protection, PoVA (Protection of Vulnerable Adults) • Investment and attracting funding into the Healthcare Academy for piloting new assistant roles, comprehensive SVQ award structure, and overseeing the HCA Regulation Pilot initiative • Undertaken a Readiness Assessment survey for the Investors in People Standard, with a view to securing full organisational recognition by late 2009 • Providing and continuing to evolve the CPPD supporting frameworks for professional practice and values-based initiatives.

Organisational development • Delivered ‘Single-System’ organisational change programme 2005-2008 across all Corporate Services. • Smooth and risk contained transition of leadership and service delivery from the former Primary Care Organisation (PCO) to Community Health ( and Care) Partnerships and Royal Edinburgh and Associated Services teams • “Lean” collaboration with General Electric (GE), National Education Scotland (NES) and NHS Lothian (NHSL); pilot commissioned and commenced September 2006, evaluation May 2007, National Conference November 2007 and second phase annual report July 2008. • Focused and targeted people and organisational development work with key clinical management teams in University Hospitals, CHP/CHCP and Royal Edinburgh and related services to support achievement of Delivery Plan objectives and Improving Care, Investing in Change work streams.

10 NHS Lothian Annual Review 2008 Agenda Item 8

• Pilot(s) with ethical and accredited providers of coaching development models for front line staff and OD practitioners, to inform next generation HR & OD Strategy for 2008-2012. • Scanscot hosted visit with Swedish network sharing learning and experiences across older people’s services in health and social care.

Partnership and employee relations • Further Human Resource policies developed and implemented; available across the organisation through policy manuals and intranets; • HR policy awareness sessions in place for managers and staff side representatives to raise awareness of new policies; • People Management in Practice training programmes developed and delivered on a modular basis, covering employment policies and their practical application • Supported a number of organisational change and modernisation programmes in partnership, e.g. BACiL, RVH and RHSC outline business cases • Area and Local Partnership Fora firmly embedded contributions towards targets and revised HR & OD strategy engaged.

Working environment • NHS Lothian Health and Safety Management Systems issued, with new manual and detailed implementation plan.

Workforce planning

• Roll out of the PWA/Empower Human Resources system to all line managers was completed, delivered on-time and within budget; • NHS Lothian reported its third annual workforce plan in April 2007. This outlined the progress made against the 2007/8 action plans, an assessment of the key local and regional workforce drivers such as population demography. The plan also included the workforce projections for all staff groups for the next 3-10 years resulting from a ‘bottom-up’ process involving CMTs and CHPs. Highlights from report for the year 2007/8 include: o Overall increase of 1.8% in the workforce, with 4.6% in Medical and 5.4% in Registered Nursing. o Overtime costs have reduced by c£1.4m, 20%. o Expenditure on banding payments for training grade medical staff has reduced by c£1.6m. o Use of agency staff has reduced by c50% for registered nursing and 97% for non-registered, there has also been a reduction of 97.8wte in the overall usage for Band and Agency combined. o The number of leavers from NHS Lothian has decreased by 7.6% o Sickness absence is down 0.05% according to SWISS the lowest of any of the large teaching boards. • Substantial input and support from NHS Lothian to Regional and National Workforce Planning priorities

11 NHS Lothian Annual Review 2008 Agenda Item 8

• Joined up service, financial and workforce planning within ICIC in-line with national workforce planning guidance

During 2008/9 the workforce planning team will be involved in a national development programme aimed at developing workforce planning capability and competence within workforce planners. As part of this programme a range of materials and tools are being developed to enable cascading of this programme through local management teams. A workforce planning web site will be developed during the next 12 months to host some of these resources and access to a wide range of workforce information.

Workforce planning for 2008/9 has been focused on redesign of services with a significant number of more junior medical posts now not being filled by suitable candidates. The MMC transition phase has been shorter than originally predicted but the preparatory work on redesign undertaken in previous years means that solutions can be implemented without delay. NHS Lothian is anticipating using a number of career grade doctors based on a new specialty contract, an increase in nurse practitioners where these are available, and the use of physician assistants, particularly in surgical specialties.

The added pressure of the European Working Time Regulation for August 2009 means that service redesign is an integral and necessary part of plans for out-of-hours medical cover. NHS Lothian is looking at models of care that use fewer trainee doctors and more career grade staff for OOH on-call support.

The greatest challenge for the service in the next 12 months is the delivery of trainee doctor rotas that will be compliant with EWTR. In Lothian a steering group is overseeing the individual directorates which have been charged with ensuring compliance by the end of the calendar year 2008. The models of care in different areas will be different, some involving different grades of medical staff and some non-medical health care professionals.

Pay Modernisation: benefits realisation

Pay Modernisation is a key issue for NHS Lothian and the Pay Modernisation Board oversees the process and ensures that the benefits of the financial investment made are fully realised. During 2007/8 significant benefits were identified from the investment in pay modernisation and this has been reflected in our Pay Modernisation Benefits Delivery Plan. Work in relation to Agenda for Change and the GMS (General Medical Services) contract has continued as well as some work on the other contracts of Community Pharmacy Contract, General Dental Services and General Ophthalmic Services.

Pay Modernisation Benefits Delivery Plan NHS Lothian has so far invested £70m in the pay modernisation programmes. The Pay Modernisation Benefits Delivery Forward Plan for 2007/8 identified a benefit of £6.3m, full year effect to be achieved by 31st March 2008. This

12 NHS Lothian Annual Review 2008 Agenda Item 8 included £4.1m efficiency, £750k Cost Avoidance, £1.3m Reinvestment and £40km Patient Benefit. An end of year report on the Pay Modernisation Plan for 2007/8 is currently being developed in line with the SGHD guidance and will also include a report on the progress with implementation of KSF during 2007/8 as this was included, in line with the guidance as part of the Pay Modernisation Benefits Delivery Plan for 2007/8.

During 2008/9 it is planned to combine the work of the Pay Modernisation Board and the Workforce Planning Group into a single Board given the very close links between each of the agendas.

General Medical Services Contract During 2007/8 the overall spend on GMS was £114m, which included £13m of NHS Lothian support plus historical HCH (Hospital and Community Health Services) funding of £3m. Practices in Lothian achieved an average of 989/1000 points (99%) for 2007/8 in the Quality and Outcome Framework up from 979/1000 points (98%) in 2006/7. Twenty two out of 125 practices achieved the full 1,000 points and 45 achieved 999 points and higher. The total spend on QOF in 2007/9 was £20.2m.

During 2007/8 the SGHD offered additional new Enhanced Services (ES) through the Scottish Enhanced Services Programme (SESP), where Boards chose from a basket of nine national options and one local option to commission new services with GP Practices. NHS Lothian prioritised three national ES and one local ES: • COPD/Pulmonary Rehabilitation/ Anticipatory Care – joint proposal with GP Practices and CH(C)Ps • Services for Adults with Learning Disabilities – practice based service • Cancer and Urgent Referral Audit – practice based service • Child Health and Wellbeing – local option

In addition NHS Lothian proposed piloting in 2008/9: • Flexible GP Appointments – replaced by new Extended Hours Enhanced Service • Learning Disability Health Checks • Falls Prevention and Bone Health

The SGHD provided £2.705m over 18-month period (01 October 2007 – 31 March 2009), with £900k provide in 2007/8.

Agenda for Change As at the end of March 2008 there were 1,200 staff still remunerated on the Whitley grades. Of this total, approx 1,000 have been processed for assimilation with Agenda for Change (AfC) but it has not been possible to pay the individuals on the new ranges as they have had a second job since October 2004 for which the job description has still to be matched. This leaves a balance of 200 to be assimilated.

13 NHS Lothian Annual Review 2008 Agenda Item 8

There are currently 34 posts identified as a mismatch which will require local evaluation. These posts cover approximately 50 staff. This number is substantially lower than initially had been anticipated.

In terms of arrears, within NHS Lothian this has been done on an ongoing basis and to date all staff who have been assimilated have received their arrears of pay.

In terms of leavers we have contacted to date those leavers where we have a matched post outcome. Individuals are asked to provide up to date contact and bank details and on receipt of this information any appropriate payments are made.

In terms of reviews, 3,346 have been submitted to date. A process has been agreed with the staff side organisations and our first reviews commenced in December 2007. All individuals will be eligible for an informal review in the first instance and a review panel of management and staff side representatives has been established. A number of staff side representatives have also been provided with additional facilities time in order to support their members through the review process.

In terms of KSF (Knowledge and Skills Framework) work is progressing in agreeing the relevant post outlines for each role within the organisation, approximately 600 post outlines. A KSF Action Plan for 2008/9 has been developed to ensure the HEAT Target at the end of March 2009 is achieved.

Discussions have also commenced about the mainstreaming of AfC work into core duties and responsibilities. The ongoing staffing to support AfC for the future has been agreed and identified. A process is also currently being developed as to how job evaluation will be managed in the future.

14 NHS Lothian Annual Review 2008 Agenda Item 8

8.4 Aligning workforce, financial and delivery planning

Local Delivery Plan 2008/9

NHS Board Local Delivery Plan provides a framework to align workforce, financial and delivery planning processes. The NHS Lothian Local Delivery Plan (LDP) for 2008/09 was signed off by the Scottish Government following detailed discussions between key officers from both organisations. The Board of NHS Lothian ratified the LDP at its meeting on 23 April 2008.

In addition to completing the HEAT Trajectories in line with the Scottish Government guidance, Lothian has taken the opportunity to “stretch” a number of these targets to further improve the healthcare services to the Lothian population.

Underpinning the overall LDP, the four CH(C)Ps, along with each of the Clinical Management Teams within the University Hospitals Division, have produced business plans which set out the contribution that they will make in ensuring the overall delivery by NHS Lothian of the 2008/9 HEAT trajectories.

The Scottish Government Health Department has confirmed that NHS Lothian is to assume an additional £5 million being available in the latter four years of the Financial Plan (£3m additional in 2008/9). This is the amount available from the revised funding formula recently developed by the National Resource Allocation Committee.

During 2008/9, monthly performance assessment by the Scottish Government will continue, to measure progress made against the delivery of the financial plan and the HEAT trajectories.

15

Agenda Item 9: Local service issues

9.1 St John’s campus visioning

9.2 MMC repatriation of funding from NES

9.3 Capital support for Lothian large schemes

NHS Lothian Annual Review 2008 Agenda Item 9

9: Local service issues

9.1 St John’s Campus Visioning

On 9th May 2008, a visioning workshop was held at St John’s Hospital, at which three key service areas were reviewed in relation to patient acuity and the most appropriate physical location on the St John’s Hospital campus: • Redesign of front door services • Development of the Elective Short Stay Surgical Centre • Development of a Head and Neck Centre

From this event the following actions are taking these projects forward: • Design consultants have been instructed to undertake the detailed modelling of the Elective Short Stay Surgical Centre, and the full business case for this project will move to formal approval by August 2008 • A remit for the working group to plan the Head and Neck Centre, chaired by the Director of Acute Services is being developed and the group will hold its first meeting In September • A remit for the redesign of front door services and the alignment of the management of acutely ill patients has been agreed and work on this is progressing.

These further developments build on projects already funded and underway at St John’s hospital including: • Investment of £3.358m in additional endoscopy suite, including decontamination facilities, which forms phase 1 of the elective short stay surgical development. • Investment of £0.5m in specialist dental facilities and dental training support.

1 NHS Lothian Annual Review 2008 Agenda Item 9

2 NHS Lothian Annual Review 2008 Agenda Item 9

9.2 MMC repatriation of funding from NES

NHS Lothian has invested £1m recurrently each year since 2006/07 for local solution in response to reduction in junior doctor’s hours. These changes are being driven by requirements to meet the European Working Time Directive and changes planned through Modernising Medical Careers. NHS Lothian will work constructively with NHS Education Scotland to ensure that, as trainee numbers begin to reduce, that resources will be reinvested in alternatively means of service delivery including new consultants, specialty grade doctors, and other healthcare professionals. This will be reflected in annual workforce plans built up from directorates as predicted doctors in training numbers alter each year.

3 NHS Lothian Annual Review 2008 Agenda Item 9

4 NHS Lothian Annual Review 2008 Agenda Item 9

9.3 Capital support for Lothian large schemes

The Strategic Capital Plan identifies potential capital investments of £900m over the next 10 years. At a macro level the sources of funds available indicate that £725m of Scottish Government capital is projected to be available together with an estimate of £185m for capital receipts. The final component is the value of schemes, which will be funded from PFI or its successor the Scottish Futures Trust (SFT). From a review of the proposed schemes it is evident that in excess of £500m will require to be tested against the SFT, due to the size of the capital schemes. NHS Lothian will be keen to ensure that it receives a fair proportion of capital funding available from the Scottish Government.

The Outline Business Case for the Royal Hospital for Sick Children went to SGHD CIG on 1 July 2008 and the final approval is awaited. NHS Lothian has committed significant capital funds with additional capital support of £48.5m required from the Scottish Government to build "a new, fit for purpose, Children and Young People’s (C&YP’s) Hospital in Edinburgh providing a local service for Lothian, a regional service to the South East of Scotland and a National service for a few specialist services."

The new publicly procured building estimated at £148m will be based at Little France and has extensive financial and non-financial support from all key partners including regional boards within the South East of Scotland region, University of Edinburgh and charitable organisations; Non NHS partners are providing combined capital funds of circa. £38m.

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