Shaping Up For the Future

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Shaping Up For the Future

• Isles Workshops
• December 2007

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Introductions
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Purpose of Tonight

• Brief overview of CSSP recommendations and
  savings identified to date
• Feedback the themes from the pre consultation
  meetings in September
• To get further ideas and community feedback on
  the emerging options

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Why NHS Orkney 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  layers of new service but not stopping out of
  date ones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. NHS Orkney must be
  proactive and plan for change with communities

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The Bottom Line.

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

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Why Should NHS Orkney Bother?

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

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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 NHS Orkney to balance its 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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CSSP Recommendations

• CSSP has made recommendations, following
  engagement with staff, for improving service and
  reducing costs in the following areas
• Hospital
• Pharmacy
• Support Services
• Income Generation
• Primary Care

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Summary of Savings
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Hospital Recommendations

• Create a unit where all emergency patients coming
  into the hospital will be seen, treated and then
  either sent home, transferred to a ward or,
  transferred to the mainland
• The unit will be situated between the male and
  female wards and will be used as the base for the
  primary care out of hours doctor and Minor Injury
  Service
• Invest in Day Surgery Services so that more day
  cases will be carried out reducing the need for
  patients to stay in hospital overnight
• Improve the pre-assessment arrangements so that
  patients do not need to come into hospital the
  night before surgery as well as to ensure
  patients are as fit for surgery as possible

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Hospital Recommendations

• Invest in physiotherapy services by providing
  additional staff to see patients before they are
  referred to the orthopaedic consultant so only
  those requiring a Consultant Orthopaedic Surgeon
  are referred on
• Appoint a third consultant surgeon
• Integrate the current inpatient rehabilitation
  service on to the acute wards and provide a new
  allied health care professional area in one of
  the day rooms
• Re-configure the current rehabilitation team to
  enable more community rehabilitation outreach
• Move to managing the two acute wards as one
  nursing team
• Retain Piper Ward to be used as an overflow area

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Pharmacy Recommendations

• NHS Orkney currently spends 3.2m on medicines in
  the community. Have identified three ways to
  reduce this spend-
• Introducing a preferred medicine list
  (implemented)
• Going out to tender for wholesale buying
  (implemented)
• Introducing a buying scheme that allows all the
  dispensing GPs to join together to buy their
  medicines, which reduces the total cost (under
  discussion with GPs)

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Support Service Reviews

• Looked at all of the support services (estates,
  finance, health promotion) looking at ways of
  doing them differently
• Focus on core job of providing health care to the
  people of Orkney
• Joining up with OIC to reduce management and
  service costs
• Reduce the number of people employed
• Starting at the top by reducing number of
  management roles

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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

• NHS Orkney get 4.4m from Government to provide
  GP services and it costs up 5.4m.
• Funded on a per head basis
• Based on 2005 / 2006 data it costs an average of
  235,000 per annum to keep a GP on the inner and
  northern isles
• 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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Pre Consultation What You Said and How NHS
Orkney Have Responded
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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.

• NHS Orkney have received comments by phone,
  email, letters 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 NHS Orkney Have Heard

• The clear community preference is to retain all
  the existing GP services. NHS Orkney does not
  believe that it can meet this in all cases but
  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 NHS Orkney Have Heard

• Genuine belief that there is more Government
  money available for services and that NHS Orkney
  just needs to ask more forcefully
• Belief that better use could be made of GPs who
  serve smaller populations without removing them
  for islands
• Lack of trust and confidence in NHS Orkneys
  desire to listen to and work with communities to
  find the right solutions 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 NHS Orkney have done

• Revised the options to include ideas coming out
  of the sessions
• Auditing the air ambulance data
• Shared a break down of headline isles costs
• Changed the criteria that are being used to judge
  options by
• Plan to start working with each island to more
  clearly understand the unique factors that we
  need to take into account to tailor options
• Have a greater recognition that GP services to
  the isles will never be financially viable and
  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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Criteria That Will Be Used To Assess Options

• Is the option safe?
• Does the option meet the broad clinical needs of
  the community?
• Is the option proportionate in terms of the size
  of the population?
• Is there safe and reliable transport to support
  the option
• 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 move towards less
  single handed GPs?

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Emerging Options

• No change
• Providing a visiting GP service / twinning
• Resident GPs funded from other sources
• Isles GP working on mainland or other isles as
  part of their work
• Isles GPs being part of other practices
• Delegating a budget to the community
• Increased governance arrangements
• The options are not exclusive and there is the
  opportunity to respond to the needs of individual
  communities

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No Change

• Retain existing Primary Care Services
• Under this option there would be no change to the
  existing services on Hoy, Shapinsay, Rousay,
  Westray, Stronsay, Sanday and North Ronaldsay

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Providing Visiting Service from Mainland /
Twinning with another island

• Create more financially viable GP practices by
  sharing a GP across two or more isles (similar to
  Westray and Papa Westray)
• 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

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Access Money from Outside NHS to Support GP
services

• Recognised that GP does not simply fulfil 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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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 and or First Responders backed up by
  guaranteed phone and or video conference link
  into on call GP on mainland Orkney

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Maintain resident GP but make them part of other
practices

• GP remains resident on island
• Practice would be merged with another practice

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Delegate Community Budget to Community

• NHS Orkney delegates healthcare budget to
  individual communities to design and commission
  their own primary care services

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Strengthening Governance Arrangements

• Strengthen existing governance arrangements to
  respond to political concerns about single handed
  practices
• Could include recruiting more stable relief cover
  such as regular locums and associates, creating
  more formal networks, creating peer review,
  rotation and strengthening GP appraisal systems
• clinical accountability

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Primary Care Next Steps

• Working at individual island community level to
  look at options for each island
• Identify transport requirements for each option
• Any proposals other than the status quo are
  major service changes and must go through a
  statutory consultation process
• Very likely that the Cabinet Secretary for Health
  will ask an Independent Scrutiny panel to review
  the Primary Care options to ensure that all
  options have been taken into account
• NHS Orkney welcomes this because its such an
  important issue but it does means the timetable
  will change
• Start a 3 month Independent Scrutiny process in
  March 2008
• Start formal consultation in June 2008
• Scottish Health Council review and approve
  consultation work between Sept 2008 and December
  2008
• Board makes final decision on changes early 2009
• Cabinet Secretary grants approval for changes mid
  2009

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Thank you for attending