Tour de Finance by Jeff Ace

This summer, unlike the many thousands of fellow Welsh folk heading south to France for one of our regular appearances in a major football tournament, I decided to head west, then east, then sort of north east. Together with our Finance Director, Katy Lewis, I recently undertook a tour of the region to try to talk directly to as many staff as possible about the challenges we were facing and to hear first hand their experiences and ideas for improvement.

In three days we travelled over 400 miles, met over 400 staff and heard from nurses, AHPs, domestics, GPs, consultants and others on issues ranging as wide as the region itself. At a number of the meetings, it was great to see social work staff in attendance, reflecting our ever closer working relationships.

I asked Katy to open each session with a presentation on the financial situation – my thinking being that pretty much anything I then said would come as light relief. The 2016/17 numbers are grim and substantially worse than anything we’ve faced up until now. In summary, we estimate our costs will increase by around £16.5M in the year (largely driven by drug cost increases and pay / price inflation) whilst the increase in our allocation for health services is around £3.6M. The gap between these figures of about £13M (or 5%ish of our running costs) will have to be found from efficiency savings. This would be a tough ask at the best of times but, as most of you will be well aware, it comes after four years of delivering large annual efficiency savings targets.
And of course the financial problem does not sit in isolation. In each of the discussions across the region we heard of pressures caused by difficulties in attracting staff or by increased service demand driven by an ageing population. At times it felt as though we were describing a perfect storm of crises in money, recruitment and demography that threatened to overwhelm us as surely as Storm Frank had submerged parts of Dumfries.

But just as the pub in this picture was open for business only two days later (it felt longer), things often brightened up pretty quickly in a lot of our discussions. The staff that we met were keen to highlight potential solutions, things that could change services for the better and stand up to our triple challenge.
We’re going to write up the key points raised and create a plan for delivery but some of the common themes were;

• The right I.T. can transform the way teams work, but we need to make it connect faster and more reliably across the region.
• We need to get far better at sharing appropriate information between health, social work and third sector colleagues.
• We need to be quicker at admitting that some vacancies won’t be filled and to redesign and retrain teams to provide services differently.
• Local teams need to be empowered to make locally appropriate decisions and as much resource as possible needs to be devolved to operational levels.
• Coordinated support to teams around improvement techniques and methodologies would be helpful.
• We need to work more closely with carers and families.
• We need to celebrate team successes and better spread their ideas and learning.

It’s also important to remember that we’re not on our own in trying to work our way through the financial, demographic and recruitment problems. In our meetings we highlighted some of the huge amount of work ongoing at national and regional level at the moment to try to identify high quality and more sustainable models of service delivery across Scotland. Two particular strands of work have the potential to help us transform the landscape;

• The National Clinical Strategy (written by Angus Cameron, our Medical Director) sets out a clear direction for closer working between Health Boards aimed at improving safety and effectiveness of care within their wider region.
• The Chief Medical Officer’s work on ‘Realistic Medicine’ points to how genuinely person centred care can lead to better patent outcomes whilst reducing waste and unnecessary expenditure.

So, both locally and nationally, there are grounds for cautious optimism that we can come through these uniquely challenging times in a way that allows our teams to continue to deliver excellent health and care services for our population. It is clear though that to succeed in this, the pace of change around redesign of service models and ways of working will have to be dramatic. Whilst there’ll be a few giant leaps (it’s just over a year until we receive the keys to our new acute hospital…) most of this change will be smaller scale and driven by the local teams that we talked with on our regional tour. Our success will depend on how well we support these teams and ensure they have the skills and confidence to adapt their services in ways that allow us to deal with the financial, demographic and recruitment complexities.
Thanks to everyone who came along to speak to us on our tour.

Jeff Ace is the Chief Executive Officer for NHS Dumfries and Galloway

Change…. Didn’t we do that program already? by Neil Kelly

“The Only Thing That Is Constant Is Change -”
― Heraclitus

How often have we now heard that the challenges we face can only be resolved through transformational change?  It seems we are in a constant state of flux with management structure changes, team developments, policy statements and strategy.  So does it feel as though these changes are transformational? Although we have this feeling of constant reorganisation I suspect we are all still inherently conservative and hope that if everyone else changes then we can keep our own ‘show on the road’.  Our natural anxiety of change being disruptive helps us to keep our heads down and hope that the process will pass us by and things will settle down as they so often have in the past. This defence mechanism has served us well in until now but is about to be found wanting. In Primary Care (as in the whole of the public sector care giving service) we face the ‘perfect storm’ of even increasing demand, a dependence culture generated by our desire to ‘do good’, a crisis of man power with unfilled posts for GPs other clinical staff and especially carers and significant financial pressures which continue having already ‘trimmed all the fat’ over the last 4 years.

It trying to deal with the’ impending dooms day scenario’ we have been doing multiple tests of change, PDSA cycles and participating in all the latest Scottish Government and Health Board initiatives in an attempt to reshape what we do.  We have gathered a lot of information about how good some of these initiatives have proved to be.  However now we seem stuck.  How do we convert all this ‘learning’ into the transformational change we all desire? Certainly our approaches until now do not seem to have delivered for us.

At the core of what we do as a service are the people who are toiling every day to provide the care demanded and recognising the pressures trying to work harder, faster and smarter.  We are literally ‘sweating our assets’. The eternal busy-ness has resulted in silo working and fragmentation of teams.  So we now need to pick up our bits of learning, coordinate our approach to care, re-establish our community based teams and begin a very different sort of relationship with the communities we serve. In Annandale and Eskdale we will establish in the first instance 4 community groupings of health and social care staff with third sector and independent service providers. These groups will work closely with public health teams to better understand the needs, prioritise and plan services more in tune to those needs and negotiate amongst themselves how this can best be achieved.  In other words everyone involved will take a bit more responsibility for what they do.  The users of the service will be encouraged and enabled to care more for themselves, family members will take a bigger role and everyone involved will be geared to working towards those aims.

So how do we make this happen?  We need to invest in and support collective leadership and ownership, allow much more autonomous decision making and allow the team to monitor its own success. This is a change in approach which is just beginning and will be challenging and uncomfortable at times.  It may feel like just another ‘dip in the change water’ but this time it really needs to transform what we do.  This is applicable to everyone and this time there will be nowhere to hide.

“No man ever steps in the same river twice, for it’s not the same river and he’s not the same man.”
― Heraclitus

Dr Neil Kelly is a GP in Annan.

Time to prepare for our new hospital by Chris Isles

This has been a busy month for the NHS. England has narrowly avoided a 24 hour strike by junior doctors, the difficulties experienced by the Queen Elizabeth Hospital in Glasgow have been laid bare on national television for all to see and Question Time debated passionately whether the NHS would fail this winter. Locally, Katy Lewis, our finance director, told a packed audience at our Wednesday Clinical Meeting of the financial difficulties faced by our Health Board while Ewan Bell, Associate Medical Director, wrote a blog about Prioritising Health Care and the chairman of our Medical Staff Committee drew our attention to Audit Scotland’s report on the state of the NHS in Scotland 2015.

Did I hear/listen to/read them all correctly? Can it really be true that the fifth largest economy in the world cannot afford to provide safe, high quality, emergency health care that is free at the point of delivery? 

Let’s start locally. Unless I am very much mistaken we have two major challenges in the run up to our new hospital opening in December 2017. We desperately need to avoid the scenes in Glasgow of ambulances queuing outside A&E and trolleys stacking inside A&E and equally we need to ensure that there is sufficient social care for our frail elderly patients when they go home from hospital. The challenge is likely to be greater for Dumfries and Galloway which has the second highest proportion of people in Scotland who are aged 75+ and living alone.

Katy Lewis spoke of the need for transformative change (aka doing things differently). Who could possibly disagree? If we carry on as we are doing now then the tidal wave of unscheduled medical admissions will cause our new hospital to silt up on the day it opens.  This is the conclusion I have drawn after analysing data provided by our own Health Intelligence Unit (the figure below shows the medical unit is sailing perilously close to 100% bed occupancy) and it is the nightmare scenario we must all be dreading. It should surely be concentrating everyone’s minds. If we get this wrong it won’t just be the local newspaper that will have a field day.

As it happens we have been working on ways of doing things differently and have identified two possible solutions: Ambulatory Emergency Care (which does what it says on the tin) and Comprehensive Geriatric Assessment (see below for definition). We must also ensure that we staff the new Combined Assessment Unit adequately. Both AEC and CGA will require investment if they are to be part of the organisation’s response to an impending beds crisis.     Other hospitals in Scotland have already embraced AEC and CGA and there is published evidence to support the view that these examples of transformative change will reduce bed occupancy. Has anyone come up with a better idea?

Equally if we are to keep that new hospital flowing we must invest in patient transport and community support services, particularly social care teams, providers of equipment, community nurses and carers.   The unintended consequence of preventive medicine is that we have more frail elderly people to look after than ever before. Their numbers appear to be increasing as the number of carers available to look after them decreases.  It can surely come as no surprise to learn that carers are in short supply when some are only paid £6.70 per hour (even less than this when we don’t pay mileage or travel time between visits). Compare this to a consultant physician on £36-44 per hour and the eye watering sums of up to £120 per hour we spend on some of our locums. The enormous difference between carer and locum salaries simply has to be addressed.  

Audit Scotland say that ‘significant pressures on the NHS are affecting its ability to make progress with long-term plans to change how services are delivered.’ The title of Katy Lewis’ presentation was ‘Austerity or Bust’.  Ewan Bell wants us to acknowledge that ‘we can’t continue to provide the current range of interventions and services, if we want a sustainable NHS for the future.’ I personally believe that the 5^th largest economy in the world could afford to provide high quality emergency care as well as batteries for hearing aids and palliative chemotherapy for the frail elderly (if that is what they really want), but if I am wrong then surely the batteries and the chemo must go.

Chris Isles is a ‘semi-retired’ Consultant Physician

Comprehensive Geriatric Assessment: ‘a multidimensional and usually interdisciplinary diagnostic process designed to determine a frail older person’s medical conditions, mental health, functional capacity and social circumstances. The purpose is to plan and carry out a holistic plan for treatment, rehabilitation support and long term follow up.’

There are only four types of people in the world….. by Lindsay Sim & Sharron McGonigle

‘There are only four types of people in the world…….those who have been Carers, those who are currently Carers, those who will be Carers and those who will need Carers.’

In this current climate of integration, it would bode us well to remember the above statement. Dumfries & Galloway Carers Centre has historically always promoted and encouraged partnership working but now it’s something that we have all been directed to achieve together under the Scottish Government Health & Social Care Integration Policy.

Are you letting your patients and their Carers know about the services that you yourself may need someday or are you assuming that someone else has done it? Don’t you want to be the person who lets a Carer know about the services they could access so that it can make a huge difference to their life? In order to give the Carer the smoothest journey throughout their caring role (which is likely to be us all at some point in our lives) we need to be aware of the issues Carers face and try and work together to make their journey have as smooth a road as possible.

If a referral is made to the Hospital Carers Support Project at the very beginning of a Carers journey, for example a stroke diagnosis, a cancer diagnosis, newborn baby with a disability, long term condition, brain haemorrhage (and the list goes on) it has been proven that the Carer feels supported, listened to and most importantly identified as a Carer who needs supported throughout their journey. Early intervention can mean a lesser impact of a caring role upon someone’s life with the correct support.

Carers have vital information to offer health professionals about the person they care for; they know the person inside out so this is more than beneficial to the professional involved as the Carer has firsthand knowledge on how the person they care for functions on a daily basis. Carers need advice on how to cope in the future, need help to access different services or simply want to know about progress and the outlook for the future. The advantage of sharing information with Carers is crucial in acknowledging the important role they carry out.

Carers have a large part to play in helping their cared for recover and ensuring their continued health. To do this, Carers need access to the right level of information. The Hospital Carers Support Project’s Coordinators frequently speak with Carers reporting that they feel cut off from the care of an individual to whom they have provided considerable support. The Carer is continuing to duplicate the care you administered once they get home after discharge. The Carer continuing what you have been doing in the hospital is vital in preventing re-admission. Many Carers also discover our Project for themselves by chance and tell us that no-one directed them to our service for support.

Why is it, when we have so much good policy and practice to help us support Carers through their journey, that some Carers still feel unrecognised and state that they feel they are not treated as partners? Identifying and referring a Carer to the Hospital Carers Support Project early on in their caring role means the Carer can access the following support….

• Instant access to support whilst their cared for person is still in hospital
• Information and advice
• A listening ear
• Assistance to have a voice in their cared for person’s discharge from hospital
• Advocacy
• Benefits advice
• Training and education
• Access to address their own health and wellbeing
• Accessing a Carers Support Plan which looks at their caring role now and plans for the future
• Funding and grants to access a break from their caring role
• Activities and groups where they can meet up with other Carers
• Access to counselling

If Carers and the people they support are informed, involved and supported throughout their caring journey, the likelihood of good outcomes rises, risk of re-admission falls and the financial and emotional costs this incurs can be avoided. Thinking about all the other services out there that are available to Carers is vital in giving the Carer the support they need. Don’t wait until you are a Carer yourself before realising that it can be a difficult, isolating, heavily impacting and frustrating role before remembering all the people you could have pointed in the right direction.

 

Did you know that the Hospital Carers Support Project, part of the wider Dumfries & Galloway Carers Centre has been based within Dumfries & Galloway Royal Infirmary for the last 14 years? We have supported over 1500 Carers with issues ranging from debt management, housing problems, applying for funding, arranging counselling; applying for benefits, accompanying a Carer to a hospice with their terminally ill child, liaising with ward staff, sorting out accommodation, listening when no-one else has, the list is endless. There is no problem that we won’t at least try and find out the answer to when trying to make the Carers journey more seamless but to achieve this we just need you to let us know who we can help……….

If we all work together – it will all come together.

 

Lindsay Sim & Sharron McGonigle

Hospital Carers Support Coordinators

Hospital Carers Support Project (part of the wider Dumfries & Galloway Carers Centre)

Support & Advice Centre

Dumfries & Galloway Royal Infirmary

Tel: 01387 241384 #33384

email: dgcarers@nhs.net

 

 

 

 

Mental Health Change Programme by Ian Hancock

Government policy, changing demographics, epidemiology, health inequalities and increasing public expectations services, requires NHS Scotland to flex and bend to meet healthcare needs of the Scottish public.

The challenges faced by NHS Dumfries and Galloway Mental Health Service Directorate are no different from the national perspective, and have required innovative thinking which have seen the development of better ways of working.

The demographic changes facing Scotland are well documented, with the number of people in Scotland aged over 65 projected to increase by 22% by 2020, and by 63% by 2035. The over 75 population is predicted to increase by 23% and 82% over the same period and the over 85 population will increase by 39% by 2020 and 147% by 2035. Our current service will need to adapt to meet the healthcare needs of this growing population

We all recognise the benefits of keeping people at home, or within a homely setting, as close to their family, friends and local community. The Mental Health Service works closely with patients, carers, statutory and third sector colleagues to provide services that, wherever possible, prevent unnecessary hospital admission. There are, however, times when admission to a hospital is necessary and with this in mind, we have been developing our services over a number of years, and have seen a huge shift from hospital based care to community settings. We need to capitalise on our previous successes and have identified ways in which we plan to move ahead over the coming years.

The Mental Health Service Directorate comprises of four large component service teams (Mental Health, Learning Disability, Substance Misuse and Psychology) and within these teams there are a range of individuals from different professional backgrounds (nurses, AHPs, administrative staff, HCSW, Medical Staff, Psychology, and workforce business partners from Workforce Directorate, Finance). We have 2 in patient units based in Midpark, and in Darataigh in Stranraer, and have numerous community bases across all 4 localities

Over the next few years, the Mental Health Directorate will continue to strive to provide care that aligns with contemporary healthcare policy and legislation, and do this in a collaborative way with our stakeholders. In order for us to ensure appropriate services are being delivered, and that will meet the health needs of the general public of Dumfries and Galloway, we will continue to focus on a number of specific areas.

We will consider ways in which our inpatient beds are configured and consider opportunities to improve individual’s experience of in patient care, whilst developing inpatient services in line with our changing demographics. Services will be based on patient need rather than age.

We will support and evaluate the current 24/7Crisis Assessment and Treatment Pilot Service (CATS), based in the Out of Hours/Accident and Emergency Unit

We will develop our IDEAS (Interventions for Dementia, Education, Assessment & Support ) Service, a team designed to enhance skills in statutory and non statutory services specifically for individuals with a diagnosis of dementia.

We will develop a model of care that takes into account the challenges associated with our more remote and rural areas.

We will develop services which provide early interventions for people with memory problems, and develop Health Care Support Workers to work with families living with dementia.

This is an exciting time with significant challenges to face. We think, however, that we can offer a modern and effective service, within budget, but that such successes will inevitably rely on continuing to build strong working relationships with our service users, carers, and families, colleagues from all health and social care settings, and third sector partners.

Ian Hancock is the General Manager for the Mental Health, Learning Disability, Substance Misuse and Psychological Services Directorate

Leadership in a rewarding, complex and demanding world by Paul Gray (@PAG1962)

The people we serve – the people who live in Scotland, and visitors too – have high expectations of us. And so they should. We operate in a complex and demanding environment, but NHS Scotland is a successful organisation, delivering to high standards of timeliness and quality, and always seeking to improve. The people I meet work day and night, every day of the year, to deliver compassionate care, and whole range of ancillary and supporting services from health science to finance to laundry. And the rewards of speaking to someone whom we have been able to help, who expresses their thanks and wants to emphasise how much they appreciate the care they have received, can’t really be quantified.

Some facts and figures might help. What are we actually delivering each year, with a workforce of over 150,000, and a budget of £12bn, serving a population of 5,295,000?

• Over 24 million GP and practice nurse consultations
• Over 450,000 acute day case procedures
• Over 1 million acute inpatient procedures
• Over 1.6 million A&E attendances
• Over 4.6 million outpatient attendances

And we have over 4.7 million patients registered with an NHS dentist, and real progress on improving oral health in children through the Childsmile programme. Pharmacy is developing too, with services being introduced including Minor Ailment Service (MAS), Public Health Service (PHS), Acute Medication Service (AMS) and Chronic Medication Service (CMS).

We’ve also made considerable and measurable progress on patient safety through the internationally recognised Scottish Patient Safety Programme. Our most recent data show a 16.1% reduction in Hospital Standardised Mortality Ratios since the implementation of the Scottish Patient Safety Programme in 2008; and cases of C.Diff in patients aged 65 and over are at their lowest level since monitoring began.

We are integrating health and social care, so that more people can be supported to stay at home, or in a homely setting – some of whom might be quite unwell, with complex conditions. That means different ways of working, with a range of partner organisations, while maintaining our focus on safe, person centred, effective care. And Sir Lewis Ritchie is leading a review of Primary Care out of hours services, which I am sure will offer some important recommendations on the way we structure and provide unscheduled care. The demographic trends we face are well known to us – we do have an aging population, with increasingly complex health conditions; and there is clear evidence that people generally have better outcomes, and are happier, when they can be cared for at home. Indeed, it’s worth remembering that although there is clearly pressure on General Practice, 87% of patients say that the overall care provided by their GP surgery is good or excellent.

When people do need to come to hospital, we work hard to treat them within the standards we have set, whether that’s to see and treat 95% of people within 4 hours of attending an Emergency Department, or to deliver treatment within our 12 week Treatment Time Guarantee. We’ve made considerable progress on getting to the 95% A&E target across Scotland and I’m grateful for that – but I do know that there are peaks in demand, and that patients are tending to present with more serious and complex conditions. And I know that some specialties are finding recruitment tough, which adds to pressure, but we should also remember that 89% of Scottish inpatients say overall care and treatment was good or excellent – which is highest figure since surveying inpatients began in 2010.

We continue to look critically at ourselves, through a combination of internal assessment and governance, and external assessment through Healthcare Improvement Scotland, and Health Environment Inspections. We don’t pretend that we always get it right, and when we don’t, we act systematically to understand the issues and to implement the changes we need to make with purpose and commitment. And we learn too from reports from elsewhere, like the recent report on maternity and neonatal services in Morecambe Bay, to which our Chief Medical Officer, Catherine Calderwood, contributed, and earlier reports such as those on Mid Staffordshire, including the report “A promise to learn – a commitment to act” to which our National Clinical Director for Healthcare Quality, Jason Leitch, also contributed.

So what does this mean for leadership in the face of complexity and increasing demand? What does it mean for leadership when often the external narrative – whether in print, broadcast or social media – focuses on problems, and gives less recognition to the things that are going well or improving? I offer the following suggestions. It’s drawn from my own experience of the things that have worked for me, so in that sense it’s personal. But I hope that it prompts you to think and reflect, or to have a conversation with someone. If it did, that would be great.

• Ask yourself if you can describe what you do, and the outcomes you need to achieve, simply and clearly in a few sentences. If you can do that, it helps you and those around you to understand how they fit in to this complex world.
• Remind yourselves and those around you of what we do well. Take time to recognise success and to praise a job well done.
•  Build on what we have – almost all of the people I meet are proud of what they do, and want to do it better.
•  Remember that leadership is about proactive actions, not job titles. Some of the best examples of leadership I have seen include:
•  the porter who realised that a patient was upset, spoke to her about how she was feeling, made the staff on the ward aware, and got her a cup of tea. In her words, “He turned my day right round”;
• the receptionist who realised from the questions asked by visitors that the signage somewhere in the hospital was misleading, went and found the misleading sign, wrote out some better wording and gave it to her colleagues in Estates.
•  Be open to feedback. Seek it out – and don’t be afraid to reflect on what you hear. Don’t be afraid of external scrutiny either. It can be tough, even painful at times, but better to learn, improve and grow than to stagnate and provide a service that is less good than it could be, or to put patients at risk.
•  Learn all the time. Encourage and support others to learn. Learn from the best, as well as learning from what went wrong.
•  Have honest conversations. Don’t let issues fester until they create a real problem. Prepare for these conversations. Good conversations don’t often happen by accident.
•  If there is an issue or a problem, describe it specifically, and think carefully about the best way to tackle it. Ask yourself if there’s a contribution you could make to the solution.
•  Uphold the core values of the NHS. If you see or experience inappropriate behaviour, such as bullying or discrimination, speak up, or seek help to address the issue. Don’t let it slide, or suffer in silence.
•  Think about what the complexity and demands mean for the people in your teams. Acknowledge the situation when things are difficult, or the going is tough. People appreciate honesty, and see through hyperbole.
•  Ask people for their ideas about how best to tackle problems. They will have some amazing ideas – I promise you!
•  Leaders take advice and ask for help. They know that they don’t know everything. They recognise and value that expertise that others have. So don’t become isolated, especially when times are tough.
•  Involve others in decisions – especially in decisions that are about them, or affect them in some way.
•  If you’re wrong, say so, and apologise. Be transparent. It’s not weakness to admit a fault or a mistake.
•  Understand the people who work with you, for you and around you – including people who work in different organisations, who might have a different governance context, face a different set of pressures or demands, and use different language from that used in the NHS. They will appreciate that, and if you understand people and their motivations, it’s far easier to be influential. People are far more likely to listen to you if they know that you understand their perspective.
•  Be someone who offers more often than they ask.
•  Be someone who gives credit to others, and doesn’t seek it for themselves.
•  Be persistent and methodical – if something is right, don’t be deflected by setbacks and criticism. If you have considered a course of action carefully, listened to advice, and considered the evidence, follow it through. In a complex world, people value leaders who keep a steady course, and don’t chop and change every day. However, if the context or the evidence changes, review your course of action. Persistence in the face of adversity is good leadership. Dogged pursuit of an outmoded idea isn’t.
•  Look after yourself. Build and develop networks of people you can consult and talk to when the going gets tough. Take time off, and take a bit of exercise. Make time for family, friends, and things you enjoy outside work. Easy to say, I know – but we do need to restore our energy and keep our perspective. We give our best when we are at our best.

And finally – a big thank you from me. I am both proud and humbled to be associated with NHS Scotland. I am proud of the work we do, and of the people who do it. We have a great privilege to serve patients, their families and their carers, and a strong and shared commitment to do it well.

 

Paul Gray is Chief Executive Officer for NHS Scotland and Director General Health and Social Care, Scottish Government.

 

Resistance is futile by Euan MacLeod

Assimilation or Integration?

For those of you familiar with Star Trek you will immediately recognize the Borg phrase Resistance is futile. The full version is “We are the Borg. Lower your shields and surrender your ships. We will add your biological and technological distinctiveness to our own. Your culture will adapt to service us. Resistance is futile.”^[.

Is that how it feels for you as we undergo a period of change and is Integration a bit like the equation below?

 

The rule for integration is provided

Well what can the Borg add to this?

I decided to research this a bit more and see if the Borg approach to other species was just as simple as taking them over and those species who were assimilated losing identity and just becoming part of a big machine.

The Borg operates toward the fulfilment of one goal “achieving perfection”, they exhibit a rapid adaptability to any situation or threat, and they have an ability to continue functioning after what may seem a devastating or even fatal blow.

So what is the goal of Integration, I think most of us would agree that it is designed primarily to improve the delivery of high quality compassionate care by enabling all involved in delivering that care to function more collectively.

Resistance to the changes that integration brings may develop unless people think that they will make a powerful positive difference to patient care. We will also I think need to feel that changes will enable us to do our jobs better and maintain, strengthen and develop the key working relationships that high quality compassionate care is based on. To be able to operate compassionately is a key relational aspect to our character as human beings.

 

The strength of the Borg collective is a pervasive collective consciousness that enables all the drones to feel what the other drones are experiencing, in the collective each individual is given constant supervision and guidance, being part of the collective consciousness offers advantages to the individual drones. Does being part of something bigger benefit you in delivering compassionate care and what are those key relationships that help you achieve that goal?

 

The Borg are more interested in assimilating technology than people and they don’t assimilate any old species only those who might add to their overall goal of progress towards a more efficient way and achieving perfection. At times the outcomes and progress we are chasing seem more about productivity, efficiency and cost effectiveness, and perhaps less explicitly so about high quality compassionate care.

Pursuing high quality compassionate care should deliver productivity and efficiency so perhaps assimilating those aspects of how we all do our work into a collective approach that delivers high quality compassionate care will be helpful.

 

So assimilation or integration or is it a bit of both

Looking up definitions of these we find it most commonly is applied to questions of immigration, culture and identity

Questions about culture and identity are fundamental as we go through this process, how we react to that will to some extent define whether we experience assimilation or feel that we have become integrated into a bigger whole that displays parts of our unique culture and contribution in fulfilling our goal.

The Borg operates on a basis of collaboration and this is built on mutual altruism, mutual concern and mutual support which are focused on achieving their goal. Can we do the same?

Euan McLeod is a Senior Project Officer for the National Bed Planning Toolkit

Winter is coming (but that’s OK) by @JeffAce3

I might be tempting fate here, but I’m in an unusually bold mood and I’m just going to go for it… it’s time to declare winter 2014/15 officially over.

Despite living here through the last fifteen of them, I’m still a little in awe of Scottish winters with their frozen lochs and snowfalls into April. I grew up in South Wales (which, for those of you who haven’t been there, has a broadly Mediterranean type climate…) and the adjustment to more northerly weather takes a long time. Indeed, the Ospreys rugby team’s narrow miss of the league title this season is largely accredited to our failure to wear thick enough vests during the trips to Edinburgh and Glasgow.

A typical midwinter scene at Torbay, Swansea.

Sadly, it’s hard to mention ‘winter’ in an NHS context without immediately adding ‘pressure’. Locally, this was a record breaking year in terms of winter admissions to hospital and patient activity through primary and community services, a fact which is quite staggering when you think that the previous two winters have also broken records.

 

 

We’ve experienced all the usual difficulties of Norovirus and Flu outbreaks amidst this record activity and it’s to the enormous credit of staff that we’ve maintained extremely high performance levels. For example, the 95% 4 hour wait target in A&E has proved impossible to achieve across much of the UK; our teams not only delivered it, but improved on previous years’ performance. This is much more than an impressive set of statistics; this was a major contribution to good patient experience and safety.

 

 

There are lots of other examples of the huge efforts of staff in improving services throughout the pressures of winter. We’ll be reviewing a range of such information at our NHS Board public meeting in June, so I’d expect forthcoming media reporting to be even more heavily dominated than usual by praise for our teams and their achievements…

We should take pride in these achievements but I’d also like to reflect on how this level and quality of service can be built on as we begin the winter planning for 2015/16. The ‘winter pressure’ this year has fallen squarely on teams of staff dealing with unprecedented gaps in staffing due to well publicised recruitment problems. We have succeeded for our patients this winter frankly because many clinical and support teams have worked harder and longer than ever before. I can make this statement knowing it applies right across our system, from the primary care teams coping with GP vacancies, to the cottage hospital staff managing record levels of occupancy, through to our acute teams juggling rotas around consultant and other doctor vacancies. This is a great reflection on the ethos of our teams, but it can’t surely be the basis of our long term planning; it can’t be our ambition to ask individuals and teams simply to work harder year after year to deal with rising patient activity.

It’s certainly not my ambition and I instead want us to be seen as the outstanding place to work and to develop your career in Scotland. That has to mean relieving some of this pressure on individuals and teams to allow them to focus on continuing to improve our patient experience rather than simply ‘fire-fighting’ a relentlessly rising workload. In years gone by this would have been quite a simple process; a (often young, Welsh) manager would put together some demand and capacity analysis, demonstrate the imbalance and cost out the required extra capacity in a bid to the Health Board. The Board would then consider this in the context of other priorities and, more often than not, commit a proportion of its growth monies to fix the problem. Life’s now a lot more complicated. In the next few years this ‘growth’ funding barely keeps pace with health inflation and even where money is available, we’ve no longer a guarantee that we can recruit to traditional roles.

But whilst previous solutions may no longer be as effective, I think we can still allow in some cautious springtime optimism that a more sustainable future is achievable.

Health and Adult Social Care integration is one of the reasons to believe the future could look significantly different. First the injection of pragmatism; integration doesn’t magic up one more GP, social worker or care worker, doesn’t add a pound to our stretched budgets or endow our managers with (even) greater wisdom. It does, however, give us the first real opportunity to pool our resources and expertise in each of the region’s natural localities and try to create local models of health and care that are more effective at managing complex conditions in home or community settings. We now have a bank of evidence from the Putting You First change programme of the impact of small scale redesigns, integration allows us to take the best of these and implement them at a scale that could make a fundamental difference to flows of patients and to the quality of experience of those patients. This will be a difficult process of enormous change to many clinical practices and pathways, but it seems to me that it offers promise of genuine sustainability of service quality as an alternative to a future of perpetual winter pressures. Our integration scheme is the most ambitious in Scotland, has been approved by both Board and Council and we go live on 1 April 2016 after a period of ‘shadow’ running this year.

Similarly, the ‘Change Programme’ (part of the suite of work around the new acute build) gives us a once in a generation chance to examine every aspect of our organisation of acute workload. We know that come 2017/18 we’ll have the finest DGH facility in Europe, the contract’s signed and the diggers are on site. We need now to ensure that services in the hospital from acute receiving to theatres to outpatient reviews are reorganised in a way that gives staff the very best opportunity to deliver high quality care and act as the best advert for recruitment of top class staff. This isn’t quick fix work, but again offers us an opportunity for improvement that we’d be foolish to miss.

I don’t want to put a rose tinted perspective on what are the most challenging times in health services I’ve seen in my career. I also appreciate that engaging in such major redesign programmes is particularly difficult when faced with increased demands of the day (and night) job. But I do think these programmes are our best strategy, and that locally we have a unique opportunity to create a future that feels a bit more balanced, and winters that feel a little more fun.

Jeff Ace is Chief Executive Officer for NHS Dumfries and Galloway

 

“I Dinnae dae change” by Stephanie Mottram

As Clinical & Service Change Programme Manager for NHS Dumfries & Galloway, having responsibility for delivery of an extensive two year programme of “on the ground” changes, I would like to share something with you as we start out on our journey of change.

I am not going to go into any detail on why we need to change as we all know the demands on our health services will continue to grow, we all know that we have a responsibility for own health and the health of our family, we all know that resources are scarce. Yet, last week, a member of staff enlightened me to the fact that they “dinnae dae change”

That got me thinking, what if none of us “did change” what would that actually mean.

We are in an enviable position in Dumfries & Galloway as we are about to embark upon building a new state of the art hospital, designed for optimal benefits for our patients and our staff. The new hospital will be ready to take its first patient at the end of 2017. We are also about to integrate Health & Social Care which will bring great opportunities. Very exciting times for us indeed.

However, lets take a sneaky peak at what the future may look like if we all stood still ….

 

Nothing was altered, nothing was done differently…..

• Services continue to be scheduled based on a traditional working week (Monday – Friday – 9 am to 5 pm)
• Patients continue to be admitted to an acute hospital as there are no alternatives available in the community setting
• No new roles developed, appropriate skill-mix introduced, or integration of teams.
• Technology was ignored

The result would be mayhem, with the likelihood that the new hospital would be doomed to failure before it even opened its doors and our community services saturated. This does not mean for one minute that our staff would not be working extremely hard to provide high quality services in the future but they would be very much up against it if we all stood still and didn’t do change.

Our team have been talking to staff to find out what change means to them and encouragingly we have had comments ranging from

“I fully Support Change”    

“I find change exciting”

“We need change to survive”

“It’s necessary”

“I am just no techy!!!” 

Here at NHS Dumfries & Galloway, the Clinical & Service Change Programme Team will continue to build upon the great foundations that already are in place, working closely with staff, listening, supporting and facilitating the necessary change.

Change is challenging, it is hard work, but it will be worth it!!

Look out for further information coming shortly and we will keep you posted as to how it is all going….

Stephanie Mottram is Clinical & Service Change Programme Manager for NHS Dumfries & Galloway

Learn from Yesterday, Live for Today, Hope for Tomorrow by Vicki Freeman

When Albert Einstein was asked his New Year’s resolution he, now famously, said “Learn from Yesterday, Live for Today, Hope for Tomorrow”.

It’s a new year and, as we move from the last few weeks of the 4 year ‘Putting You First’ (PYF) change programme towards the integration of health and social care, it feels like a good time to ‘learn from yesterday’.

It is nigh on impossible to pick up any national strategy, policy document or guidance on health and social care without coming across the phrase transforming health and social care services.

Here in Dumfries and Galloway, PYF has set us off on this journey of transformation; four years of developing

• New ways of working
• New thinking and
• New partnerships between Communities, Carers, the Third and Independent Sectors, Dumfries and Galloway Council and NHS Dumfries and Galloway.

Transformational Change

There are good past examples of where we have successfully delivered transformational level change in Dumfries and Galloway, however, the scale at which transformational change is required in health and social care today is unprecedented. It is complex, requires a significant level of commitment and resource to achieve and takes time to deliver.

Impacts of transformational changes are often long term and non-linear. This means it is challenging to evaluate and demonstrate impact. However, an increasing focus on demonstrating ‘outcomes’ in the future rather than inputs and outputs and the achievement of short term goals will help to address this.

Partnership Working
PYF worked around a key principle of broad partnership working enabling a truly ‘whole systems approach’ between health, social care, housing, the independent sector, the third sector and communities.

“The experience of partners working together across all sectors through PYF has created a real momentum. Providers involved in meetings and tests of change have experienced a real difference for them personally – they say they are better informed, feel more engaged and, best of all, have become to feel more like real partners, rather than just contractors. Where individuals from different sectors have worked closely together the change has been even more dramatic – attitudes have changed and partners have realised that they ARE BOTH working to create better outcomes for older people.” (Sue Newberry Scottish Care Associate)

Culture
Acknowledging and accepting the different cultures that exist within each sector is important. It helps develop our understanding of each other and respect each other’s values and beliefs. This cultural diversity can bring new and different perspectives to thinking providing us with a more multi-dimensional overview.

“There is no doubt that the work in the Annan Pathfinder project has improved our understanding of the challenges we face as a team and helped us to use the different skills and approaches to better serve the individual we are caring for. This change in attitude and culture can only be built from the groups of individuals in these teams working more closely together to realise the assets we have within each and every community.  These more integrated teams are the key to a different, more person centred approach to care which emphasises the responsibilities of the individual and the community.” (Dr Neil Kelly)

Leadership
Whilst the continued support of the PYF Programme Board, Locality Groups, Work Streams and Enablers has been vital to the success of this change programme, what has been achieved has been as a result of everyone acknowledging and embracing their own unique leadership role within their particular areas of expertise and interest.

“We need to encourage ideas from all levels of the organisation and provide people with the opportunities, support and “permission” to take their ideas forward. Recognizing the unique contribution that every person plays in delivering improvements is key to success, and critical to the continued development of services, teams and individuals.” (Linda McKechnie, Service Development Manager)

Working Co-productively with Communities
New ways of working together with communities was a key element of successfully delivering change at community level.

“Encouraging people and communities to take ownership of services and assessing their own health and care needs empowers people. It supports people to understand the processes involved in planning and the constraints and demands placed (on) services.  I think people like to do rather than be done to.  Community integration, participation and planning  as well as inspiring, collective and future thinking leadership are key for any future and successful integration in my eyes” (Suzanne McGarva, Pathfinder Evaluation Programme Lead)

Emergent Themes
All of the tests of change that have been undertaken have quite naturally fallen under one or the other of these four themes.

• Developing Communities/Community Resilience
• Optimising Technology as an Enabler
• Integrated Ways of Working
• Preventative and Anticipatory (Proactive) Approaches

“As we move towards health and social care integration, it is important that we consider the 4 themes and the tests within each of them. The learning from these provide a helpful source of information that could contribute to the development of the Health and Social Care Locality Plans with a particular focus on supporting the delivery of the 9 national integration outcomes.”      (Mark Sindall, PYF Programme Manager)

What other people had to say about some of the work developing under these 4 themes

Developing Communities/Community Resilience
“Time bank has given individuals a chance in their own communities, contributing to new skills, enhancing their social networks and community engagement and therefore having a positive feeling of self-worth.” (Action for Children)

“Time Banking makes me feel I’m still able to offer something even though I’m in my 70’s” (Time banker)

“Makes an awful difference having the (Hard of Hearing) service, I don’t know what I would do. I don’t drive; I just wouldn’t wear my hearing aids”. (Service User)

“Fantastic piece of work (Single Point of Contact Initiative – Falls Pathway) with real benefits for patient’s going forward.” (Scottish Ambulance Service)

Optimising Technology as an Enabler
“Feel more confident. Was having trouble sleeping before (telecare) installation but happy there’s a backup in place and it is a lot more comfortable at home now” (Service User)

Integrated Ways of Working
“I have certainly made use of the ideas team on the end of the phone when I have not
been sure of how to manage residents’ behaviour. I have personally found that very useful to get support when I’ve needed it” (Care Home staff member)

“If we did not get the timely and co-ordinated support from the health and social care hub, we would really have struggled to manage at home.” (Service User)

Preventative and Anticipatory (Proactive) Approaches
“It’s good to know that there are people looking out for you and your health as people like myself are sometimes too busy looking after everyone else and tend to forget about ourselves.” (Carer)
“‘I was suffering with anxiety and unable to concentrate. I was desperate and unable to cope….my life is better, much better now” (Carer)

“I am able to live in my own home which means the world to me”

“Through this discussion (Forward Looking Care Planning) my family is now aware of what I do and don’t want to happen to me”

“Once the nurse had visited, adaptations happened very quickly and we had been waiting months for this” (Forward Looking Care)

Hope for Tomorrow
Are we facing complex and challenging times ahead? – Certainly, but there is hope for tomorrow. As well as all of the learning from PYF, there are many other opportunities on the horizon that we can capitalise on to support us to achieve the level of transformation of health and social care in Dumfries and Galloway that will deliver long term sustainability.
“Innovations in technology and treatments offer opportunities to change the way in which care is delivered.” (Royal College of GPs Report – November 2014)

The integration of health and social care is another opportunity for us to further develop new models of holistic, person-centred, seamless, team-based care and support for people with chronic, multi-morbid conditions; focussed on improving outcomes and working to support every person in Dumfries and Galloway to achieve what matters to them.

To see some of the PYF work in action, please click on the link below

Vicky Freeman is Acting Head of Strategic Planning at NHS Dumfries and Galloway