NHS Orkney Shaping Up For the Future

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NHS OrkneyShaping Up For the Future

• Community Seminar
• Saturday 3rd November 2007

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Iain Crozier Chief Executive Officer NHS Orkney
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Introductions

• Iain Crozier (CEO)
• John Rodwell (Community General Manager)
• Rhoda Walker (Nursing Director)
• Fiona Smith (Project Manager)
• Jean Aim (Consultation and Communication)
• Community Reference Group
• Scottish Health Council
• Members of NHSO Board

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Purpose of Today

• Provide a short overview of why we are looking at
  our services and what we are doing
• Feedback the themes for the pre consultation
  meetings in September
• Follow up from those meetings by providing
  information on how Primary Services are provided
  in other areas of NHS Scotland
• To share ideas for the latest thinking on ideas
  for the future provision of Primary Care Services
• To get further ideas and feedback on the latest
  thinking

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Creating Sustainable Services What is it and
why are we doing it?
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National Context

• Main Policy Driver is the Kerr Report
  Delivering for Health
• Reaffirmed by new Administration with an SNP
  stamp
• Better Health, Better Care - New health by end of
  2007
• No fundamental policy shifts expected Example
  whole patient journey waiting time of 18 weeks
• Specific element of KR is Remote and Rural Health
  Services
• Huge drivers for change

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Local Context

• Service deficits Childrens Services/Mental
  Health/Diabetes
• Evidenced by various reports, e.g. Quality
  Improvement Scotland
• Financial deficit - 3.8m
• More than 10 of budget
• Need for clinical and financial recovery
• Another significant driver for change

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Characteristics of NHS Orkney

• NHS Orkney smallest NHS Board in Scotland
• Population of 20,000 geographically dispersed
• Annual budget of circa 35m
• Compared with NHS Glasgow and Clyde - 2bn
• Many health priorities are the same or greater
  (LTCs)
• Targets are the same
• Legal compliance is the same
• Overhead costs are the same
• Consequence is very limited flexibility

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NHS Funding

• Funding for NHSS is via Arbuthnott Formula
• NHS Orkney is currently 0.4m below target
• Stringent efforts made to get extra funding
  continuous process
• Very successful with one off initiative funding
• SEHD aware we have expensive and inappropriate
  care models
• Until we resolve that there will be no additional
  recurring funding

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Political Context

• No major policy shifts expected
• More demanding efficiency targets
• Next Spending Review will add to financial
  pressures
• We want to keep health decisions within Orkney
• Crucial that we maintain control of our own
  destiny
• Therefore we must resolve our problems together
• Creating Sustainable Services Project is key to
  our future

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Orkneys Changing Health Needs Are At The Heart
of The Change

• Carried out Health Needs Assessments on the 8
  things which use up 80 of our resources (heart
  problems, cancer, diabetes, mental health,
  respiratory problems, digestive diseases,
  neurological diseases and muscular skeletal
  problems)
• Looked at how many people suffer from them now
  and how many will by 2016
• Helps us understand how we need to plan and
  change services

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Why we are doing it?

• Health services in UK cant continue the way that
  they are-
• An increased older population
• A reduced working population
• Long term conditions (diabetes, heart problems
  etc) are becoming the main challenge (MaryHill)
• Changing expectations from patients for more
  personalised care, delivered closer to home
• Current services arent affordable, building up
  layers of new service but not stopping out of
  date ones
• More people, with more complex problems, wanting
  a higher level of service and less people and
  less money to provide it

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Big Changes by 2016

• Most caused by changing age profile and long life
  expectancy in Orkney
• 185 more people will have cardio vascular
  diseases (24 increase)
• By 2020 we will be dealing with 128 more cancer
  cases per year
• 15 rise in cases of diabetes (115 more cases)
  resulting in more need for services like dialysis
  
• 15 rise in dementia suffers
• 262 more new osteoporosis and 1200 more serious
  back pain cases resulting in more need for physio
  services
• Cant just hope that existing services will
  stretch, tried that before. We must be proactive
  and plan for change with our communities

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The Bottom Line.

• This isnt an Orkney issue, its a national issue
• We are feeling it sooner because we have more
  older people
• We are feeling it harder because our finances are
  already tight
• No change isnt an option
• Started our Creating Sustainable Services project
  to tackle these problems in a planned and
  thoughtful way

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Creating Sustainable Services Programme Aims

• Creating a clear understanding of what services
  NHS Orkney can and will provide. These services
  must be appropriate, safe and sustainable and
  enable us to balance our budget. This will
  involve making choices as a community about what
  we want
• Communicate a clear understanding of services to
  all stakeholders (including staff, mainland and
  island communities, GPs, Scottish Ambulance
  Service and Health Department)
• Saving Financial 3m - 4m of ongoing savings

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How we are doing it
Support Services Reviews
Hospital Services redesign
Primary Care redesign
Pharmacy
FIRM FOUNDATIONS
Management Information
Performance Management
Income Generation
EMT Restructure
PM Tools
Leadership
HNA
Service Reviews
Budget Controls
Governance
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Support Service Reviews

• Looking at all of the support services (estates,
  finance, health promotion) looking at ways of
  doing them differently
• Focus on our core job of providing health care to
  the people of Orkney
• Joining up with OIC
• Contracting services out to private sector
• Stopping support services
• Reduce the number of people that we employ
• Starting at the top by reducing number of
  management roles

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Pharmacy

• Changing the way we pay GPs for prescribing and
  dispensing
• Working with Doctors to agree a recommended
  medicine list cheapest but most clinically
  effective drugs
• Looking at how we source drugs

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Hospital

• Increasing day surgery rates to reduce overnight
  stays
• Reducing predictable emergency admissions
• Looking at what services could be brought back
  from Aberdeen
• Looking at how we provide casualty and minor
  injuries services

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Primary Care

• Primary Care is everything that isnt done in the
  hospital
• 2 types of GP practices, ones run by NHS Orkney
  and ones that are run by private contractors

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Practices

• Board Run
• Scapa
• Heilendi
• Shapinsay
• Sanday
• Rousay (currently)

• Contractors
• St Margaret's Hope
• Skerryvore
• Dounby
• Evie
• Stromness
• Hoy
• North Ronaldsay
• Stronsay
• Eday
• Westray

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Primary Care

• We get 4.4m from Government to provide GP
  services and it costs up 5.4m.
• We are funded on a per head basis
• Based on 2005 / 2006 data it costs 235,000 per
  annum to keep a GP on the inner and northern
• Limited choice of male or female GPs
• In some smaller locations could be harder for GPs
  to stay up to date because they are not seeing
  the variety that colleagues with larger numbers
  of patients would see
• Increasingly hard to recruit to island practices

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Why Should We Bother?

• Taking control of the situation and putting a
  stop to moving from one crisis to the next
• Facing the fact that we are not going to get
  money from SEHD in short term therefore we need
  to find our own solutions
• Need to solve our own problems for our own
  community or it will be done to us
• Committed to doing our part in making Orkney a
  thriving and sustainable community

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Experience Outside Orkney

• What happens is Shetland and Western Isles?
• Community Councillors perspective Fair Isle
• What are first responders?

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Fair Isles Experience Fiona Mitchell, Community
Councillor, Fair Isle, Shetland
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What are first responders and how are they used?
June Gordon, Area Manager Scottish Ambulance
Service
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Pre Consultation What Your Said and How We Have
Responded

• Fiona Smith, Shaping Up Project Leader, NHS
  Orkney

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Reminder of the Process

• Carried out 8 focus groups in September 2007 to
  identify concerns and ideas
• Focus groups took place on every island with a
  resident GP
• Independently run by VAO
• Used random sampling to select a group of people
  who represented the age and gender profile of the
  community (criticism, ve, part of a wider
  process)
• 152 people attended - 62 turnout rate (NR /
  Westray)
• Reports for each island were issued shortly after
  the meeting

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In addition.

• We have received comments by phone, email,
  letter and at the sessions from -
• MSP
• Stronsay Development Trust (formal and informal)
• Hoy Development Trust
• Westray Community Council
• Rousay Residents
• Hoy Residents
• Sanday residents
• Westray residents
• Isles GPs and nurses
• Individual councillors

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What We Have Heard

• The clear community preference is to retain all
  the existing GP services. We do not believe that
  we can meet this in all cases but we want to work
  with communities to find some middle ground
• The need for NHS Orkney to recognise that the
  role of GPs in the isles is not simply a narrow
  medical issue but seen as key to the economic and
  social sustainability of islands
• The need to recognise that solutions need to
  tailored to the individual needs of individual
  isles communities
• Lack of confidence in the air ambulance response
  time
• Lack of transparent performance data to allow the
  community to judge the success of the air
  ambulance response times

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What We Have Heard

• Genuine belief that there is more Government
  money available for services and that NHS Orkney
  just needs to ask more forcefully (Arbuthnott,
  lack of equality across isles, latest review good
  news and bad news)
• Belief that we could make better use of GPs who
  serve smaller populations without removing them
  for islands
• Lack of trust and confidence in NHS Orkney desire
  to listen to and work with communities to find
  the right solutions (knew we had a problem, work
  at community level)
• Desire to understand more about the roles of
  nurses, paramedics and first responders
• Desire to understand why the services are so
  expensive / a belief that NHS Orkney was not
  presenting the real costs

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What we have done

• Revised the options to include ideas coming out
  of the sessions (John will coverstill open)
• Auditing the air ambulance data (3 way tally)
• Share a break down of headline isles costs
  (cover)
• Changed the criteria that we are using to judge
  options by (cover)
• Plan to start working with each island to more
  clearly understand the unique factors that we
  need to take into account to tailor options (e.g.
  Hoy)
• Greater recognition that GP services to the isles
  will never be financially viable and that we will
  need to accept, to some extent, that they will
  cost more

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Headline cost of GP Services

• Based on 07/08 figures, just including headline
  cost categories, not all costs (housing, enhances
  services)
• 14,000 on IT
• 127,000 on upkeep and running of surgeries
• 614,000 on Locums and Associate, or which
  20,000 is accommodation and 9,000 is car hire
  and ferry costs
• 1,000,000 payment to GPs. This is not salaries,
  this is payments made to their business from
  which they have to meet a wide range of business
  costs such as employing staff etc
• Cant break down by island (income, DPA v FOI)

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Draft Criteria That Will Be Used To Assess Options

• Is the option safe?
• Is the option proportionate in terms of the size
  of the population?
• Does the option make the GP services more
  financially viable?
• Does the option make the recruitment of GPs
  easier in the future?
• Is the option sensitive to the wider economic and
  social needs of the community?
• Does the option move towards a more modern team
  based approach to primary care?
• Does the option allow NHSO to meet its governance
  requirements?

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Emerging Options For Isles Primary care

• John Rodwell
• Community Health Partnership General Manager, NHS
  Orkney

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Emerging Options

• Visiting GP service
• Twinning islands
• Access funding from elsewhere to pay for GPs
• Maintain resident GPs but make better use of them
  outside their island
• The options are not exclusive and there is the
  opportunity to respond to the needs of individual
  communities

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Visiting GP Services Only

• No resident GP on any isles other mainland Orkney
• GP services provided by visiting GP, with number
  of surgeries determined by population size and
  need
• Immediate response to emergencies provided by a
  resident nurse and / or first responder team
  backed up by guaranteed phone and or video
  conference link into on call GP on mainland
  Orkney

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Advantages and Disadvantages

• Enables cost reduction of around 1m
• Overcomes predicted future recruitment problems

• Does not respond to most of the needs of most
  island communities

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Twinning Smaller and Larger Isles (Current
Situation in Westray and Papay)

• Create more financially viable GP practices by
  sharing a GP across two or more isles
• GP to be resident on the island with the largest
  population and providing a visiting service to
  others
• Nurse resident on smaller island
• Immediate response to emergencies provided by a
  resident nurse backed up by guaranteed phone and
  or video conference link into on call GP on
  mainland Orkney
• e.g. Westray and Papay)

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Advantages and Disadvantages

• Enables cost reduction
• Enables some islands to maintain a resident GP
• Enables community to have known GP
• May help recruitment by offering larger therefore
  more financially viable practice sizes

• Does not respond to all the needs of all the
  communities

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Access Money from Outside NHS to Support GP
services

• Recognised that GP does not simply for fill a
  narrow medical role but has a role in the social
  and economic viability of the community
• Retain existing set up with NHS Orkney funding
  part of GP costs on a per head basis
• Seek alternative funding to top up the funding
  to pay for the current set up

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Advantages and Disadvantages

• Enables cost reduction
• Tried and tested in other remote and rural areas
  outside UK

• Requires other agencies to commit to funding
• Does not ease recruitment problems

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Retain Existing GP set up but make more use of
GPs outside their island

• GP remains resident on island
• GP provides other services to NHS Orkney (e.g.
  working in the hospital)
• Emergency cover provided in their absence by
  nurse backed up by guaranteed phone and or video
  conference link into on call GP on mainland
  Orkney

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Advantages and Disadvantages

• May enable some small cost reduction
• Enables some islands to maintain a resident GP

• Does not deliver the level of savings required to
  make services sustainable
• Assumes that isles GP skills and experience match
  the medical roles that need to be carried out on
  mainland

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Thank You For Attending