Shaping Services for the Future - NHS Forth Valley Services for the Future ... following sections...

of 48

Shaping Services for the Future

Clinical Services Review A Case for Change

of 48

1. Executive Summary ......................................................................................................................... 4

2. Introduction .................................................................................................................................... 9

3. Current situation and Forecast ..................................................................................................... 10

3.1 Demographics ....................................................................................................................... 10

3.2 Birth Rates ............................................................................................................................. 12

3.3 Dependency ratio .................................................................................................................. 13

3.4 Migration, Equality & Diversity ............................................................................................. 14

3.5 Forth Valley Characteristics .................................................................................................. 15

4. Challenges and Forecast ............................................................................................................... 16

4.1 Disease .................................................................................................................................. 16

4.2 Conditions ............................................................................................................................. 18

4.3 Activity (Hospital & GPs) ....................................................................................................... 19

4.4 Variation ................................................................................................................................ 24

5. Risk Factors ................................................................................................................................... 26

5.1 Deprivation............................................................................................................................ 26

5.2 Housing ................................................................................................................................. 26

5.3 Employment .......................................................................................................................... 26

5.4 Behavioural Risk Factors ....................................................................................................... 27

5.5 Multiple risk factors .............................................................................................................. 27

6. Financial Landscape ...................................................................................................................... 29

7. Health Service Workforce ............................................................................................................. 30

7.1 Current Situation and Forecast ............................................................................................. 30

7.2 Factors influencing the shape of the Workforce .................................................................. 31

8. A Potential New Model of Care .................................................................................................... 32

8.1 Integrated anticipatory care ................................................................................................. 32

8.2 Self‐Management .................................................................................................................. 34

9. CSR Model ..................................................................................................................................... 36

10. Conclusion ................................................................................................................................. 37

11. References ................................................................................................................................ 38

12. APPENDICES .............................................................................................................................. 39

12.1 APPENDIX A ‐ Note of Caution regarding Use of Data in the Case for Change ..................... 39

12.2 APPENDIX B ‐ Self‐Reported General Health ........................................................................ 40

12.3 APPENDIX C ‐ Components of migration mid‐ 2012 to mid‐2013 ........................................ 41

12.4 APPENDIX D ‐ Comparison of costs and other parameters 2013/14 .................................... 42

12.5 APPENDIX E ‐ Estimated number of patient contacts in Scotland ........................................ 43

of 48

12.6 APPENDIX F – Estimated Population Attributable Risk Fraction (PAF) ................................. 44

for Major Diseases – High Income Nations ........................................................................................... 44

12.7 APPENDIX G ‐ Model for a Person ......................................................................................... 45

12.8 Appendix H ‐ Risk Factor Strategies ...................................................................................... 46

12.9 APPENDIX I ‐ Engagement Model – ‘Interpersonal Improvement work’ .............................. 47

12.10 APPENDIX J ‐ Information Support to CSR ........................................................................ 48

of 48

1. Executive Summary

Aim and expected Benefits ‐ The Clinical Services Review (CSR) aims to identify what is needed in order to meet the needs of an ageing population, manage increasing demand for health services and deliver more care at home or in local communities so patients can retain their independence, supported by family and friends. Once there is greater clarity about the challenges, needs and cross‐cutting themes, the CSR will produce recommendations addressing the current and forecasted challenges NHS Forth Valley (NHS FV) is facing. The CSR aims to do this by engaging with stakeholders, including patients and front‐line staff, in order to get insight into what change may be possible in practical terms. Findings from the eight different CSR work streams will form the basis for NHS FV healthcare strategy 2015‐2020. This paper will set out the case for change as well as further inform the development of the final report based on the findings of the eight work‐streams. Context Financial and workforce constraints, now and in the future, suggest that the pressure to reconfigure services will continue to grow (Imison et al., 2014, p. 7; see section 6 & 7 in this document). NHS FV is facing challenges and constraints of high demand and scarce resources. Currently, people have less family and informal social support. We have an ageing population and people are living longer, which simultaneously brings a rise in people in middle and older age with co‐morbidities. Therefore, the traditional health service structure needs to change to put the patient in the centre, which aligns with the Scottish Government’s 2020 Vision. A shift in balance, from hospital centred care to community centred care and from disjointed care towards integrated care amongst others, is needed. Furthermore, various reports indicate that ‘high levels of public resources are devoted annually to alleviating social problems and tackling ‘failure demand’ (Christie, 2011). Person‐Centred The Healthcare Quality strategy states ‘person‐centred’ as a key quality dimension, where person‐centred means providing care that is responsive to individual personal preferences, needs and values and assuring that patient values guide all clinical decisions (Scottish Government, 2010). The former resonates with the proposition of more generic approaches around patient problems (Lunt, 2013, p. 17). The vision for Healthcare in Scotland is that, by 2020, everyone is able to live longer, healthier lives at home, or in a homely setting (Scottish Government, 2011). Patients and Public should be regarded as key assets and as part of the solution in a spirit of true partnership rather than a service driven paternalistic approach, without compromising the quality of care. Current Situation & Challenges People are living longer and healthier, despite an increase in the prevalence of Long Term Conditions (LTCs) ‐ due to a combination of new treatments and better and earlier diagnosis. The population of Forth Valley is growing in size, ageing and increasing in complexity and in the multiplicity of health problems, such that demand is exceeding the capacity of the current model. For example, at the moment the system is struggling with bed capacity and patient flow, which is forecast to increase in the next decades (Scottish Government, 2012). The following sections illustrate these challenges and give an insight into the sort of information and data analysis which is informing the work of the eight CSR work streams.

Demographics Figure 1 demonstrates the life expectancy at birth, divided by gender, between 2000 and 2012, for Clackmannanshire, Falkirk, Stirling; Forth Valley overall; and Scotland. The chart indicates that life expectancy at birth is increasing and that Forth Valley’s life expectancy is higher than that of Scotland.

of 48

2000‐2 2005‐7 2010‐12 2000‐2 2005‐7 2010‐12

Males Females

Clackmannanshire 73.4 74.1 77.0 78.2 79.5 80.6

Falkirk 73.6 74.9 76.9 78.6 79.5 80.6

Stirling 75.2 76.9 78.4 79.6 80.9 81.9

Forth Valley 74.0 75.4 77.4 78.8 79.9 81.0

Scotland 73.3 74.9 76.6 78.8 79.7 80.8

Figure 1. Life Expectancy at Birth. Figure 2 demonstrates the ageing population trend in Forth Valley, in 2015 and 2035. This will have implications for the health care system in its current form, which will be elaborated upon in the sections diseases and activity.

Figure 2. Population Charts NHS Forth Valley.

Diseases/Conditions Figure 3 demonstrates the estimates of the proportion of the population in Forth Valley, with various numbers of long term conditions, which is forecasted to increase between 2014 and 2034 (Figure 4).

Figure 3. Estimated number of people with various numbers of long‐term conditions – 2014.

‐20000‐10000 0 1000020000

0 to 4 years

15 to 19 years

30 to 34 years

45 to 49 years

60 to 64 years

75 to 79 years

90+

2015

‐20000‐10000 0 1000020000

0 to 4 years

15 to 19 years

30 to 34 years

45 to 49 years

60 to 64 years

75 to 79 years

90+

2035

0

5000

10000

15000

20000

25000

0‐4

5‐9

10‐14

15‐19

20‐24

25‐29

30‐34

35‐39

40‐44

45‐49

50‐54

55‐59

60‐64

65‐69

70‐74

75‐79

80‐84

85+

0 disorders

1 disorder

2 disorders

3 disorders

4 disorders

5 disorders

6 disorders

7 disorders

8 or more disorders

of 48

Figure 4. Estimated number of people with various numbers of long‐term conditions – 2034. The co‐morbidities demonstrated in Figure 3 and 4 bring both financial as well as person‐centred challenges (Christie, 2011). Patients with complex conditions are currently making multiple trips to hospital clinics to see a range of uncoordinated specialist services. The proposed way forward is looking at developing new pathways and guidelines away from the current disease specific models to more generic approaches focused on the holistic needs of patients (Lunt, 2013, p. 17). The latter ties in with the Scottish Government’s 2020 Vision and the values of designing the services around the patient, for example to make sure that patients do not need to go unnecessarily to 5 different, disjointed, specialists for the 5 conditions they have. Activity The majority of occupied beds within NHS FV is non‐elective. Figure 5 represents the emergency admissions, which demonstrates that the rate of activity is lower than the average emergency admissions for Scotland. However, given the projected increase in 65+ years, FV is facing a challenge regarding emergency bed capacity, illustrated in Figure 6.

Figure 5. Emergency Inpatient Stays NHS Forth Valley 2009‐2013. The potential impact of an increasing population of over 65s on emergency bed numbers is presented in Figure 6. Considering the potential impact of the ageing population on emergency bed

0

5000

10000

15000

20000

250000 disorders

1 disorder

2 disorders

3 disorders

4 disorders

5 disorders

0

20

40

60

80

100

120

2008 2009 2010 2011 2012 2013 2014Crude Rate per 1000 population

Financial Year Commencing

Emergency Inpatient Stays

Scotland

FV

of 48

demand, the current model seems unsustainable. Moreover, Figure 7 demonstrates an estimated potential increase of approximate 55% in demand for bed numbers by 2035, within Forth Valley.

Figure 6. Ageing population and the potential impact on emergency bed capacity (Source: Scottish Government, 2012, p. 9).

Figure 7. Bed days per 1.000 persons aged 65+ in Forth Valley with the present model.

Variation – The data presented in the Case for Change document largely shows Forth Valley in comparison to Scotland. However, there is also great variation in health and health service practice within Forth Valley. Some of this is due to socio‐ economic factors, some of which are amenable to focussed interventions and health promotion; others are less explicable on patient need and more related to individual professional practice whether in primary or secondary care. Local data suggests that there can be a two or three fold variation between very similar practices and that some consultants have consistently greater admission numbers and lengths of stay for similar conditions for example. Increased available capacity, improved health and added value are possible, if variation is addressed.

2,569 2,6343,043

3,6984,140

4,652

0

1,000

2,000

3,000

4,000

5,000

2014 2015 2020 2025 2030 2035

The rate (bed days per 1,000 persons aged 65+ in Forth Valley) if we do nothing

of 48

Risk Factors Risk factors can be described as personal attributes which may be environmental, behavioural or clinical. The risk factors mentioned in this section relate to factors that can influence health, such as deprivation, housing, employment and behavioural risk factors. They are important to keep in mind, because when minimised, the prevalence and complexity of disease could be prevented to some extent. We need to take a person‐centred approach to lowering risk factors, helping to motivate people to modify behaviour.

Financial Landscape NHS FV has been operating in a challenging financial environment. Forecast is that, without any intervention, the divergence between funding and cost will increase. Areas of significant cost growth are ‘prescribing’, ‘staffing costs’, ‘technology’ and ‘demography’. In addition, NHS FV is required to deliver efficiency savings of 3%. This will be achieved through real cash savings and using resources more effectively. Human Resources Landscape In common with other Health Boards, NHS FV faces many challenges in relation to the delivery of ongoing, affordable health care within even tighter financial parameters. Changes to pension and national insurance arrangements along with the challenges of pay, prices, prescribing, achieving and sustaining targets, technology advances, demographic impact and the changes as we implement Health and Social Care Integration will place a much higher risk on the system from 2015 onwards. In order to address these challenges, we remain committed to the continuous development of our workforce through their skills and competencies and to our annual programme of workforce planning. A Potential New Model of Care The traditional model is unsustainable and new models and approaches are being addressed. These new models and approaches focus on prevention, integrated anticipatory care and self‐care. By approaching clinical care through eight work streams a framework is provided to view and organise/categorise the information needed to make appropriate and practical possible recommendations for future models of care in Forth Valley. Conclusion The current situation as outlined above demonstrates that the current model of care is unsustainable. People are living longer, are more likely to have multiple long‐term conditions, and have less family and informal social support. The traditional health service structure needs to change to put the patient in the centre, which aligns with the Scottish Government’s 2020 vision. Various reports reiterate the need to move towards community‐based care and a more generic approach to patient care. The CSR will produce recommendations responding to the challenges NHS FV is facing and provides an opportunity to be innovative and forward thinking. The process is person centred and engages a variety of stakeholders, staff, patients and carers. NHS FV will aim to continue to provide safe, high quality and effective healthcare, tailored to meet the needs of patients and their families.

of 48

2. Introduction The reconfiguration of clinical services has attracted public and political controversy over the life of the NHS. Financial and workforce constraints, now and in the future, suggest that the current model is unsustainable and that the pressure to reconfigure services will continue to grow. (Imison et al., 2014). NHS FV is facing similar challenges as other boards, which have been indicated to be unsustainable (Christie, 2011). NHS Forth Valley (NHS FV) is facing the challenge of high demand and scarce resources. Currently, people have less family and informal social support. We have an ageing population and people are living longer. This brings a rise in the number of people in middle and older age groups with co‐morbidities. Furthermore, various reports indicate that ‘high levels of public resources are devoted annually to alleviating social problems, related to individuals and families who are trapped in cycles of ill health, unemployment and poverty, the costs of what has been called ‘failure demand’ (Christie, 2011). The National Community Planning Group, for example, has estimated that dealing with negative demand absorbs over 40% of local public service spending (Christie, 2011). Therefore, the traditional health service structure needs to change to be able to respond to the rising demand and put the patient/person back in the centre. A shift in balance, from hospital centred care to community centred care and from disjointed care towards integrated care amongst others, is needed, which aligns with the Christie Report and the 2020 Vision (Naylor, Alderwick & Honeyman, 2015; Scottish Government, 2013; Christie, 2011). Person‐centeredness is key in any future redesign. The Christie report states the following principles to inform reform processes: empowering individuals and communities by involving them in the design and delivery of services they use; improve outcomes through integration of service provision; prioritisation of the prevention of negative outcomes; and reducing duplication and sharing service in order to improve efficiency (Christie, 2011, p. vi). The 2020 Vision is set out by the Scottish Government and entails ‘that by 2020 everyone is able to live longer healthier lives at home, or in a homely setting. Scotland will have a healthcare system where we have integrated health and social care, a focus on prevention, anticipation and supported self‐management. When hospital treatment is required, and cannot be provided in a community setting, day case treatment will be the norm. Whatever the setting, care will be provided to the highest standards for quality and safety, with the person at the centre of all decisions. There will be a focus on ensuring that people get back into their home or community environment as soon as appropriate, with minimal risk of re‐admission’ (Scottish Government, 2013, p. 3). The Clinical Services Review (CSR) aims to identify what is needed in Forth Valley in order to meet the needs of a rapidly ageing population, manage increasing demand for health services and deliver more care at home or in local communities so patients can retain their independence, surrounded by family and friends. Once the needs are identified, the CSR will produce recommendations addressing the current and forecasted challenges Forth Valley are facing. The CSR aims to do this by engaging with people, including patients, carers and front‐line staff, to understand what change may be possible in practical terms. The CSR is being taken forward by eight individual work streams, namely emergency and out‐of‐hours care; routine care planned appointments, operations and treatment; mental health and learning disability services; long term health conditions and multiple morbidity; cancer care; care for frail older people and end of life care; care for women and children; clinical support services and infrastructure. The findings emerging from the eight individual work streams will form the basis for NHS FV healthcare strategy 2015‐2020. This document will demonstrate the case for change for Forth Valley by outlining Forth Valley’s current situation, challenges and forecasts. Preventable risk factors are illustrated. A potential new model of care is outlined, with a focus on integrated anticipatory care and self‐management. Finally, further information is provided for the individual work‐streams on how the CSR could be approached and how recommendations may be structured, followed by concluding remarks.

of 48

3. Current situation and Forecast People are living longer and healthier, despite an increase in the prevalence of Long Term Conditions (LTCs) ‐ due to a combination of better and earlier diagnosis and new treatments. The population of Forth Valley is ageing, growing in size; and an increase in complexity and multiplicity of health problems is developing. Consequently the demand is exceeding supply within the present model. For example, at the moment the system is struggling with bed capacity and patient flow, which is forecasted to increase in the next decades (Scottish Government, 2012), if the system does not change. The following sections illustrate these challenges with charts. Furthermore, some Forth Valley specific characteristics will be outlined.

3.1 Demographics The number of people in the population forms the basis for planning health services; the more people the more services are likely to be required. The population of Forth Valley is changing more significantly than the Scottish average. Currently, Forth Valley has a population of approximate 300,000 and will rise to nearly 308,000 by 2019 (2.3% increase), compared to a 2% increase in Scotland.

Figure 8. NHS Forth Valley Area. The distribution of the population of Forth Valley is 17% in Clackmannanshire council, 52.5% in Falkirk council and 30.5% in Stirling council. There is some variation in population trends between areas in Forth Valley. For example, although the overall population is expected to increase, the relative population of Clackmannanshire is expected to be lower in 2035 than it is now. The estimated population distribution in 2035 is 15.4% in Clackmannanshire, 52.6% in Falkirk and 32.0% in Stirling, which is presented in Figure 9.

2014 2035

Clackmannanshire 17.0% 15.4%

Falkirk 52.5% 52.6%

Stirling 30.5% 32.0%

Forth Valley 100% 100%

Figure 9. Population Distribution Forth Valley 2014 & 2035.

Figure 1populatiareas. Twithin Sbased ca

Area

Clackm

Falkirk

Stirling

Forth V

Scotlan

Figure 12014). The anngreater up to 2020% incslightly aged 85demons

Figure 1 Figure 1age catemany yoand 199the firstimplyingmight be

10 illustratesion resides ihe highest aScotland. Theare.

mannanshire

g

Valley

nd

10. Percent o

nual increasethan in 2014030. Howevecrease by 20beyond 20355 years or abtrated in Fig

1. Populatio

10 presents fegory either oung people 91) illustrate t chart. Theg a decreasee more depe

s the spreadn Other Urbnd only percese Figures c

Large UrbaAreas

3

of population

e in total po4. The year oer, for the o020 compare5. By 2020 tbove. These gure 11.

n prediction,

four charts, iside of a ceand fewer oan increase

e last chart e in people tendent. A sim

d of the poban Areas ancentage of Rcould inform

an Other Urban Areas

0

0

0

0

34.5

n in each 6‐f

opulation ofon year increver 65 year ed to 2014 ahe populationumbers ar

, Scotland, 1

illustrating thentral spine. older people e in older pe(2031) illusto support tmilar trend i

pulation witnd the lowesRemote Rura discussion r

AcceSmaTow

39.8

89.6

53.3

73.2

35.1

fold Urban/R

f Forth Valleease for the tolds the proand a 50% ion of over 6e in line wit

911, 1951, 1

he number (The first chwho need to

eople and a dstrates fewethe increaseis apparent f

thin FV, whet percentagel resides in Sregarding pr

essible ll

wns

RemSmaTow

46.2

2

13.1

9.1

9.3

Rural categor

ey is such thtotal populaoportionate ncrease by 25 year olds wth the ageing

1991 & 2031

(percentage)hart (1911) iso be looked decrease in r younger p in elderly pfor Forth Va

ere the maje (2.3%) resiStirling (4.9%racticalities r

mote all wns

AcceRura

0

0

0

0

3.4

ry (Source: S

hat by 2030 tion is estimincrease is f2030. The %will be aboug population

(NHS Forth V

) of males ans pyramid shafter. The foyounger peopeople and people, wholley. Figure 1

Page

ority (73.2%ides in Remo%), comparedregarding co

ssible l

RemRura

14

8.3

28.7

15.4

11.7

Scottish Gove

it will be amated at aroufar greater, n% growth wiut 62,000, wn across Sco

Valley, 2012)

nd females inhaped and ilollowing chaople, compamore older

om at the sa12 demonstr

e 11 of 48

%) of the ote Rural d to 2.3% mmunity

mote al

0

0

4.9

2.3

6.1

ernment,

bout 7% und 0.4% namely a ll reduce ith 7,600 tland, as

).

n a given lustrates rts (1951 ared with r people, me time rates the

of 48

ageing population trend in Forth Valley, in 2015 and 2035, with a broadening and flattening at the top, indicating the relative increase in those in the greatest age groups. Males are demonstrated on the left and females on the right of the spine. Consequently, this will have implications for the health care system in its current form, which will be elaborated upon in the sections diseases and activity.

Figure 12. Population Charts NHS Forth Valley. Increased longevity is one reason for the estimated increase in the size and age of our population. Forth Valley’s life expectancy at birth has been rising and is higher than Scotland’s average and is higher for females than for males. Figure 13 demonstrates the life expectancy at birth, divided by gender, between 2000 and 2012, for respectively Clackmannanshire, Falkirk and Stirling; Forth Valley overall; and Scotland. Variation within Forth Valley is apparent, where Clackmannanshire has the lowest life expectancy and Stirling the highest.

2000‐2 2005‐7 2010‐12 2000‐2 2005‐7 2010‐12

Males Females

Clackmannanshire 73.4 74.1 77.0 78.2 79.5 80.6

Falkirk 73.6 74.9 76.9 78.6 79.5 80.6

Stirling 75.2 76.9 78.4 79.6 80.9 81.9

Forth Valley 74.0 75.4 77.4 78.8 79.9 81.0

Scotland 73.3 74.9 76.6 78.8 79.7 80.8

Figure 13. Life Expectancy at Birth.

Healthy Life Expectancy for Forth Valley residents (1999‐2003 data) is 68.7. Healthy Life Expectancy is different from life expectancy, as the former entails the ‘number of years that a person can expect to live in "full health" by taking into account years lived in less than full health due to disease and/or injury’ (WHO, 2015). Further information regarding self‐reported general health is outlined in Appendix B.

3.2 Birth Rates The number of births per year in Forth Valley is expected to rise, with a peak in 2026, followed by a fall in 2035. This is illustrated in Figure 14 and 15, which gives some insight into future trends.

Year 2015 2020 2025 2030 2035

Births 3232 3317 3373 3387 3355

Figure 14. Births within Forth Valley (Source: NRS population projections).

‐20000‐10000 0 1000020000

0 to 4 years

15 to 19 years

30 to 34 years

45 to 49 years

60 to 64 years

75 to 79 years

90+

2015

‐20000‐10000 0 1000020000

0 to 4 years

15 to 19 years

30 to 34 years

45 to 49 years

60 to 64 years

75 to 79 years

90+

2035

of 48

Figure 15. Births within Forth Valley (Source: NRS population projections).

3.3 Dependency ratio The dependency ratio is a measure of the proportion of the population seen as economically ‘dependant’ upon the working age population. The definition generally used in Scotland is: ‘those aged under 16 or of state pensionable age, per 100 working age population’. There is an overall increase in dependency ratio to 2035, with some dips, largely explained by changes in pensionable age, as illustrated in Figure 16 and 17.

Forth Valley 2014 2015 2020 2025 2030 2035

Dependency ratio 63.13 63.77 56.98 60.52 62.33 67.97

Figure 16. Forth Valley Dependency Ratio 2014‐2035. The trend gives a further indication of demographic change and the related health, social and economic implications. However, it does not take account of working age people who are not working, which can be a further significant factor for the local system (see section 4).

Figure 17. Forth Valley Dependency Ratio 2012‐ 2037.

3220

3240

3260

3280

3300

3320

3340

3360

3380

3400

2010 2015 2020 2025 2030 2035 2040

Births

Births

0

10

20

30

40

50

60

70

80

2010 2015 2020 2025 2030 2035 2040

Forth Valley Dependency Ratio

of 48

3.4 Migration, Equality & Diversity This section will give an overview of the population living in Forth Valley, which can have implications for the type of care needed. It will outline migration towards Forth Valley, disability and ethnicity. National Records of Scotland (NRS) consistently describe migration as the most difficult aspect of modelling population projections, as there tends to be great uncertainty. The best data on historical migration comes from the mid‐year estimates, and within that ‘components of migration’ produced by NRS (most recent data presented in Appendix C). Net migration for Forth Valley area tends to be relatively low. NHS FV might expect about 500 extra residents per year as a result of migration (already factored in to population projections). The estimated increase in population for 2014‐15 was about 1300, roughly 40% of that increase could be due to migration from within Scotland and the rest of the UK. In terms of disabilities, Figure 18 illustrates that the majority of Forth Valley (80.7%) are not limited in their day‐to‐day activities, however 10.1% is limited a little and 9.2% of the population is limited a lot. Day-to-day activities limited a lot 27,492 (9.2%)

Day-to-day activities limited a little 29,964 (10.1%)

Day-to-day activities not limited 240,180 (80.7%)

Total 297,636

Figure 18. Long Terms Health Problem or Disability within FV. According to the 2011 Census, the majority of the population of Forth Valley consider themselves ‘white – Scottish’ or ‘white – other British’. Of the minority ethnic groups, about 1.4% of the population are ‘white – other white’, and 1.6% 'Asian, Asian Scottish or Asian British', illustrated in Figure 19. A full overview can be found in NHS FV Equality Delivery Progress Report & Clinical Services Review. Having an overview of the population’s ethnicity can be of added value as it gives insight into the genetic predisposition to disease as well as indicate prevalence of language or cultural barriers.

White: Scottish 261844

White: Other British 20560

White: Irish 2014

White: Gypsy/Traveller 281

White: Polish 2157

White: Other White 4219

Mixed or multiple ethnic groups 785

Asian, Asian Scottish or Asian British: Total 4671

African: Total 480

Caribbean or Black: Total 221

Other ethnic groups: Total 447

Figure19. Ethnicity overview Forth Valley (Source: NRS, Census, 2011).

of 48

Figure 20 illustrates that the majority of Forth Valley is married, followed by people who are single.

Single (never married or never registered a same‐sex civil partnership)

78,287

Married 118,678

In a registered same‐sex civil partnership 341

Separated (but still legally married or still legally in a same‐sex civil partnership)

7 959

Divorced or formerly in a same‐sex civil partnership which is now legally dissolved

20,240

Widowed or surviving partner from a same‐sex civil partnership

18,399

All People over 16 years 243,904

Figure 20. Marriage or civil partnership within FV.

3.5 Forth Valley Characteristics Forth Valley is situated in the heart of Scotland in the central belt in between two large health boards with teaching hospitals, Glasgow in the West and Edinburgh in the East. Forth Valley has links with both health boards. Most of the population lives in large or small towns, with a small minority living in remote rural locations in the North West of the Stirling Council area. Also of note, Forth Valley has three prisons, greatly surpassing what might be expected for its population size. These are: HMP & YOI Cornton Vale (Young Offenders Institute and Women's Prison); HMP Glenochil; and HMYOI Polmont (Young Offenders Institute). There is one acute hospital – Forth Valley Royal Hospital, situated in Larbert; and four Community Hospitals situated at Bo’ness, Clackmannanshire, Falkirk and Stirling. For regional planning purposes, its central location means that NHS Forth Valley works with both SEAT (South East and Tayside region) and the West of Scotland region. Figure 21 illustrates where the total operating cost are spent across the hospital sector, community sector and family health sector, in comparison with Scotland, Lanarkshire and Fife. It illustrates that Forth Valley spends significantly less per head in the community sector, namely £283 compared to Scotland (£329), Lanarkshire (£350) and Fife (£298). Appendix D contains further detail.

Scotland Forth Valley

Lanark‐shire Fife

Board Operating Costs

Total operating costs £10451M £501M £974M £604M

per head £1962 £1673 £1702 £1646

‐‐ Hospital sector (Acute & Community) £5945M £267M £479M £319M

per head £1115 £892 £837 £869

‐‐ Community sector £1750M £84M £201M £109M

per head £329 £283 £350 £298

‐‐ Family health sector £2404M £130M £258M £159M

per head £451 £437 £451 £434

‐‐ Resource transfer (to local authority) £350M £18M £36M £16M

per head £65 £62 £63 £45 Figure 21. Comparison of total costs & hospital, community, family health and resource transfer. Scotland, Forth Valley, Lanarkshire and Fife.

of 48

4. Challenges and Forecast

4.1 Disease Forecasting disease prevalence can provide information regarding where resources and level of resources might be needed in the future or where preventative interventions could reduce disease. There are a range of factors which influence the prevalence of disease. These are:

Age ‐ in general most conditions are age‐related. Even if other risk factors are decreasing the effect of demographic change can be overwhelming.

Genes – most diseases have at least some genetic component.

Environment – physical and social.

Deprivation – even accounting for differences in behaviour, most diseases are deprivation related. This may be mediated through stress (the socio‐psycho‐neuro‐immuno‐pathological pathway).

Health related behaviours.

Underlying mental wellbeing/ resilience/ self‐efficacy / confidence / motivation.

Real engagement with life in general and personal wellbeing in particular.

Options for intervention and organisation of this. It is easy to assume that disease trends will continue. However the trends could change to some extent when the modifiable factors are being modified. To apply a crude method consisting of application of age‐specific prevalence rates to population projections gives the forecast demonstrated in Figure 22, 23 and 24, respectively for Diabetes, Ischaemic Heart Disease (IHD) and Stroke. The Figures show an increase in the forecasted prevalence of disease. The assumption has been made that the age‐specific prevalence remains constant.

Figure 22. Estimated number of individuals in Forth Valley with Diabetes.

0

5000

10000

15000

20000

2010 2015 2020 2025 2030 2035 2040Number of individual aged 15+

Diabetes

Diabetes

of 48

Figure 23 Estimated number of individuals in Forth Valley with Ischaemic Heart Disease.

Figure 24. Estimated number of individuals in Forth Valley with Stroke. Figure 25 shows disease prevalence rates for self‐reported long term conditions, such as cardio‐vascular disease, stroke, COPD and diabetes, from the Scottish Health Survey, with an overall higher reported percentage for Forth Valley than Scotland.

Item Forth Valley Scotland

Cardio‐vascular disease 15.9% 14.9%

Stroke 2.9% 2.7%

COPD 4.1% 3.8%

Diabetes 5.3% 5.2%

Figure 25. Self‐ Reported Long Term Conditions (source: Scottish Health Survey, 2008‐11).

0

5000

10000

15000

20000

25000

2010 2015 2020 2025 2030 2035 2040

Number of individual aged 15+

IHD

IHD

0

2000

4000

6000

8000

10000

12000

2010 2020 2030 2040

Number of individual aged 15+

Stroke

Stroke

4.2 CIn light conditiomore lopopulatiincreaseValley.

Figure 2

Figure 2

0

10

20

30

40

50

60

70

80

90

100

Patients (%)

0

5000

10000

15000

20000

25000

Conditionsof an agei

ons (also refng term conion in Forthe between 20

26. Estimated

27. Estimated

0

0

0

0

0

0

0‐4

5‐9

10‐14

s ng populatiferred to as nditions as th Valley with014 (Figure 2

d number of

d number of p

10‐14

15‐19

20‐24

25‐29

on, Forth V multiple‐mhey age. Figuh various nu27) and 203

conditions p

people with

Age grou

30‐34

35‐39

40‐44

Valley is facorbidities). ure 27 demoumbers of lo34 (Figure 28

resent by ag

various num

up (years)

45‐49

50‐54

55‐59

6064

cing more pFigure 26 donstrates theong term co8), based on

ge group.

mbers of cond

60‐64

65‐69

70‐74

75‐79

people with emonstratese estimates onditions, whthe forecast

ditions – 201

7579

80‐84

85+

Page

multiple los that patieof the numbhich is forect population

4.

1 disorde

2 disorder3 disorder4 disorder5 disorder6 disorder7 disorder

0 disord

1 disord

2 disord

3 disord

4 disord

5 disord

6 disord

7 disord

8 or mo

e 18 of 48

ong term nts have er of the casted to of Forth

er

rs

rs

rs

rs

rs

rs

ders

der

ders

ders

ders

ders

ders

ders

ore disorders

of 48

Figure 28. Estimated number of people with various numbers of conditions – 2034. The multiple morbidities demonstrated in Figure 27 and 28 bring both person‐centred as well as financial challenges (Christie, 2011). Patients with multiple complex long term conditions are currently making multiple trips to hospital clinics to see a range of uncoordinated specialist services. A proposed way forward could be to look at developing new pathways and guidelines away from the current disease specific models to generic approaches focused on the holistic needs of patients (Lunt, 2013, p. 17). The latter ties in with the 2020 Vision and the values of designing the services around the patient. For example, we need to make sure that patients do not have to unnecessarily attend five different, disjointed, specialists for the five different conditions that they have. Although there is a focus on people over 65 years of age, it needs to be noted that there is significant burden of disease in our population under 65 years of age and that there is a significant % of our population that are termed frail and pre‐frail. Moreover, one in our people will, at some point in their lives, experience a mental health problem.

4.3 Activity (Hospital & GPs) As mentioned in section 3, Scotland and NHS Forth Valley are faced with an ageing and growing population. Consequently, there is an impact on activity in hospital and in primary care. Activity which is directly for the benefit of clients or patients consists of assessment and intervention. Assessment, for example, includes clinical examination, history taking, laboratory tests, X‐rays, amongst others. Intervention includes provision for basic physical and emotional needs, support and motivation to change behaviour or knowledge and skills, and treatment (medicines or surgical intervention). Figure 29 demonstrates the self‐reported attendance at NHS Facilities, which indicates that on average people attend their GP approximately 5 times per year and approximately 10% report an in‐patient stay. Unfortunately activity data may not have this level of detail, for example ‘GP consultation’ indicates that the patient has attended, however detail of the event is not known.

Item Response Forth Valley Scotland

GP consultations Est. no./ yr / person 5.5 5.9

Hospital attendance OP in last year 37% 37%

IP in last year 10% 11%

Figure 29. Self‐reported attendance at NHS Facilities – Scottish Health Survey, 2008‐11.

0

5000

10000

15000

20000

250000 disorders1 disorder

2 disorders3 disorders4 disorders5 disorders6 disorders7 disorders

of 48

Hospital Activity Currently, within Forth Valley the number of occupied emergency beds (514) is significantly higher than the number of occupied elective beds (46) within 2013/2014. Figure 30 demonstrates the division of occupied beds either elective or non‐elective broken down by specialty.

Figure 30. Forth Valley: occupied beds by specialty (Source: Civil Eyes Research Ltd. 2014). Nationwide, Figure 31 demonstrates the potential impact of an increasing population of over 65 year olds on demand for emergency bed numbers.

Figure 31. Demographic change for population aged 65+ Scotland, Potential impact on emergency bed numbers 2007‐2031 (Source: Scottish Government, 2012, p. 9). Figure 32 estimates approximate 55% increase in bed capacity for over 65 year olds by 2035, within Forth Valley. Considering the potential impact of the ageing population on emergency bed capacity, the current model deems unsustainable.

of 48

Figure 32. Bed days per 1.000 persons aged 65+ in Forth Valley with the present model. A comparison in hospital activity of NHS FV with Scotland is presented in Figures 33, 34, 35 and 36. The types of hospital activity presented are emergency admission, elective admission (e.g. for a surgical procedure), or day‐case (e.g. for a surgical procedure). The first graph, Figure 33, represents all 3 combined. The data has been extrapolated from ISD on continuous stays in hospital and has been divided by the estimated total population for that year to give an estimated rate per 1000 population. For each disease presented, the rate of activity seems lower in Forth Valley than for Scotland as a whole, especially for day case. However, this does not imply that the challenges are less significant for NHS FV. Furthermore, an increase in activity might not be explicitly visually apparent, but even with declining numbers per 1000 population, with an increasing population, activity will go up.

Figure 33. Hospital activity including emergency admission, elective admission and day‐case. Forth Valley compared with Scotland, between 2009 and 2013.

2,569 2,6343,043

3,6984,140

4,652

0

1,000

2,000

3,000

4,000

5,000

2014 2015 2020 2025 2030 2035

The rate (bed days per 1,000 persons aged 65+ in Forth Valley) if we do

nothing

0

50

100

150

200

250

2008 2009 2010 2011 2012 2013 2014

Crude Rate per 1000 population


All continuous stays

Scotland

FV

of 48

Figure 34. Emergency Inpatient Stays. Forth Valley compared with Scotland, between 2009 and 2013.

Figure 35. Elective Inpatient stay. Forth Valley compared with Scotland, between 2009 and 2013.

Figure 36. Day‐case stay. Forth Valley compared with Scotland, between 2009 and 2013.

0

20

40

60

80

100

120

2008 2009 2010 2011 2012 2013 2014

Crude Rate per 1000 population


Emergency Inpatient Stays

Scotland

FV

0

5

10

15

20

25

30

35

40

2008 2009 2010 2011 2012 2013 2014

Crude rate per 1000 population


Elective Inpatient Stays

Scotland

FV

0102030405060708090

2008 2009 2010 2011 2012 2013 2014Crude rate per 1000 population


Day case stays

Scotland

FV

of 48

General Practice Activity The above demonstrates an increase in hospital activity. An increase in GP activity can be seen as well. ISD produced Practice Team Information to give an estimate of primary care activity across Scotland. This can be applied pro rata to NHS FV, which demonstrates a statistically significant increase in total activity between 2003/4 and 2012/13, illustrated in Figure 37 (More detail can be found in Appendix E). However, there is no detailed information for Forth Valley specifically.

Figure 37. Estimated number (millions) of patient contacts in Scotland.

0

5

10

15

20

25

30

GP & PN combined

General Practitioner

Practice Nurse

Estimated number (millions) of patient contacts in Scotland

of 48

4.4 Variation The data presented in the Case for Change document largely shows Forth Valley in comparison to Scotland. However, there is also great variation in health and health service practice within Forth Valley. Variation entails that there are differences. For example, Figure 38 shows great variation, as Grangemouth Town Centre has over a 1000 rate of all cancers, whereas High Bonny Bridge and Greenhill have a rate under 500. Figures 38 and 39 illustrate variation across Forth Valley regarding Disability Living Allowance (DLW) claimants, varying from under 2000 to over 15000; and Rate of all cancers varying from under 500 to over a 1000. When variation is related to deprivation, it is termed health inequalities.

Figure 38. DLA Claimants per 100,000. Figure 39. Rate of all cancers combined.

0 10000 20000

Logie

Dunblane East

Bridge of Allan

Western Villages

Brightons, Reddingmuirhead …

Dunblane West

Stirling Town Centre

Antonshill

Menstrie

Carron

Merchiston and New Carron …

Shieldhill

Bantaskin

Wallace

Kinneil

Alva

Stenhousemuir East

Tillicoultry

Alloa West

Maddiston and Rumford

Grahamston

Blackness, Carriden and …

Tullibody South

Bowhouse

Banknock and Haggs

Carse and Grangemouth Old …

Fankerton, Stoneywood and …

Bonnybridge

Alloa North

Hallglen and Glen Village

Falkirk Town Centre and …

Sauchie

Fishcross, Devon Village and …

Bannockburn

Fallin

Alloa South and East

Camelon East

DLA claimants per 100,000 : 2012Q04

0 500 1000 1500

High Bonnybridge and Greenhill

Wallace

Shieldhill

Merchiston and New Carron Village

Hallglen and Glen Village

Alloa North

Lochgreen, Lionthorn and …

Sauchenford

Tullibody North and Glenochil

Carronshore

Blackness, Carriden and …

Laurieston and Westquarter

Western Villages

Banknock and Haggs

Middlefield

Teith Valley

Antonshill

Dunblane West

Bannockburn

Douglas

Alva

Highland

Fankerton, Stoneywood and …

Blane Valley

Clackmannan, Kennet and …

Alloa West

Dollar and Muckhart

Bonnybridge

Newtown

Redding

Torbrex

Fishcross, Devon Village and …

Dunipace

Tamfourhill

Bantaskin

Callander

Grangemouth Town Centre

Rate of all cancers combined ‐persons per 100,000 : 2005‐2009

of 48

Regarding GP referrals and Admission, there is great variation in primary care. This relates to a wide range of list sizes, and variation in referral and admissions to hospital as illustrated in Figures 40 and 41. In terms of clinical practice similar variation exists between practitioners and specialties in secondary care.

Figure 40. GP Practice Consultant‐Led Referrals (all specialties), 2013/14.

Figure 41. GP Practice Emergency Hospital Admissions (all specialties), 2013/14. Some of the variation is due to socio‐economic factors, some of which are amenable to focussed interventions and health promotion; others less explicable on patient need and more related to individual professional practice whether in primary or secondary care. Local data suggests that there can be a two or three fold variation between very similar practices and that some consultants have consistently greater admission numbers and lengths of stay for similar conditions. Increased available capacity, improved health and added value are possible, if variation is addressed. Furthermore, it is important to acknowledge the health inequalities and take them into consideration in the CSR, as it is a priority area for improvement noted in the 2020 Vision.

0

100

200

300

400

500

600

700

Rate per 1000 GP List size

GP Practice Consultant‐Led Referrals (All Specialties), 2013/14

Rate per 1000 GP List sizeNote: SCI Gateway data only

0

20

40

60

80

100

120

140

Rate per 1000 GP List size

GP Practice Emergency Hospital Admissions (All Specialties), 2013/14

Rate per 1000 GP List Size

of 48

5. Risk Factors Risk factors can be described as personal attributes which may be environmental, behavioural or clinical. The risk factors mentioned in this section relate to factors that can influence health, such as deprivation, housing, employment and behavioural risk factors. They are important to keep in mind, because when minimised, the prevalence and complexity of disease could be prevented to some extent. A person‐centred approach seems needed in order to lower risk factors and help motivate people to modify behaviour.

5.1 Deprivation Deprivation is a risk factor for the vast majority of conditions. Based on the proportion of data zones within the 15% most deprived in Scotland, Clackmannanshire has a much higher rate of deprivation than Falkirk or Stirling, as illustrated in Figure 42.

2004 2006 2009 2012

Clackmannanshire 15.60% 23.40% 18.80% 21.90%

Falkirk 7.10% 9.60% 8.60% 9.10%

Stirling 5.50% 6.40% 6.40% 6.40%

Figure 42. Proportion of data zones found in 15% most deprived (Source: SIMD 2012).

5.2 Housing Housing may be considered a determinant of health. The level of overcrowding has decreased significantly since the inception of the NHS in 1948. Average occupancy in Forth Valley was 3.5 in 1951 decreasing to 2.25 currently. The decrease in household size leads to an increase of the risk of loneliness and isolation. Figure 43 indicates that more than 40,000 people in Forth Valley live alone. Moreover, inadequate housing causes or contributes to many preventable diseases and injuries, including respiratory, nervous system and cardiovascular diseases and cancer (King’s Fund, 2014).

Occupied dwellings Number of people in Household (census 2011)

One Two Three Four Five Six Seven Eight +

128984 40587 45520 20674 16068 4816 984 234 101

100% 31.47% 35.29% 16.03% 12.46% 3.73% 0.76% 0.18% 0.08%

Figure 43. Household size (Source: Census , 2011).

5.3 Employment Unemployment is another risk factor, as it can affect mental health of individuals and add costs to the healthcare system. Figure 44 shows employment Figures for the 3 Forth Valley Council areas and Scotland as a whole for the last 5 years available. It demonstrates some fluctuation, however in general Forth Valley’s employment rates are broadly similar to Scotland as a whole, with Clackmannanshire generally lower than average, Stirling about average, and Falkirk higher than average.

2009 2010 2011 2012 2013

Clackmannanshire 69.45% 76.08% 65.60% 65.50% 66.11%

Falkirk 72.60% 71.65% 72.00% 72.90% 73.47%

Stirling 72.99% 69.55% 71.10% 67.30% 71.23%

Scotland 71.93% 70.95% 70.70% 70.60% 71.00%

Figure 44. Employment Figures Forth Valley and Scotland. (Source: Scottish Government Employment data).

of 48

5.4 Behavioural Risk Factors Behavioural Risk Factors refer to individual behaviours that have a negative impact on health. Figure 45 gives the estimated prevalence of various risk factors from the Scottish Health Survey. It demonstrates behavioural risk factors such as alcohol use, cigarette smoking, fruit and vegetable intake and physical activity. Forth Valley’s estimated prevalence of behavioural risk factors is similar to the national behavioural risk factors.


Alcohol use None 13% 13%

Hazardous 24% 23%

Within g/lines 42% 43%

Problem drinking indicators 2+ 13% 12%

Cigarette smoking Current 25% 25%

Fruit and veg. intake None 11% 9%

5+ 22% 22%

Physical activity As recommended 39% 38%

BMI 30+ 24.8% 27.4%

Figure 45. Estimated Prevalence of main risk factors to the health of the Population of Forth Valley (Source: Scottish Health Survey, 2008‐11)

5.5 Multiple risk factors Risk factors can co‐exist and have can have an adverse impact on health as demonstrated in Figure 46. For example, it suggests that about 40% of the burden of all non‐communicable disease could be prevented if modifiable risk factors were eliminated and for certain conditions this proportion is more than half: Ischaemic heart disease (about 90%), stroke (about 80%), COPD (about 70%) and lung cancer (at least 80%). The percentage of ‘contributing Risk Factors and their population attributable risk fractions (PAFs)’ is the percentage that would disappear should the risk factor be totally absent. The percentages per PAF in this table can add up to more than 100% because they are not independent (e.g. improving diet could reduce the impact of heart disease, but could also reduce other risk factors for heart disease, such as raised cholesterol or high blood pressure). Appendix F provides a more detailed overview.

Disease Contributing Risk Factors and their PAFs Joint PAF for these risk factors and this disease

Ischaemic heart disease

High blood pressure (58%), high cholesterol (63%), high BMI (33%), low fruit and veg, (28%), physical inactivity (22%), tobacco (22%), alcohol (0.2%)

89‐93%

Depression Alcohol (3%), childhood sexual abuse 4%) 7%

Stroke High blood pressure (72%), high cholesterol (27%), high BMI (23%), low fruit and veg.(12%), physical inactivity (9%), tobacco (22%)

81‐86%

Alcohol use disorders

Alcohol (100%), childhood sexual abuse (3%) 100%

All non‐communicable diseases

Multiple risks 41%

All causes Top 20 risks 39%

Figure 46. Estimated Population Attributable Risk Fraction for some major diseases – High Income Nations (Source: Global Burden of Disease study – published in The Lancet; Appendix F)

of 48

Regarding the population of Scotland, Figure 47 gives an estimate of the proportion of the population of Scotland with various numbers of risk factors (from the main seven: poor diet, insufficient physical activity, smoking, excessive alcohol use, obesity, high blood pressure, high cholesterol). Less than 3% have none of these risk factors and nearly half the population has three or more risk factors present.

Number of Risk Factors Present

% Population (est.) Cumulative %

7 0.08% 0.08%

6 0.5% 0.6%

5 3.8% 4.4%

4 15.6% 20.0%

3 29.5% 49.4%

2 32.9% 83.3%

1 15.0% 97.3%

0 2.7% 100%

Figure 47. Multiple Risk Factors present (source: “Is Scotland Living Dangerously?”analysis of SHeS, 2004) Following the above, it is apparent that risk factors are important to be kept in mind, as they can lead to adverse events. Simultaneously, when risk factors are eliminated disease could, to some extent, be prevented. Figure 48 illustrates the inter‐relationships and complexity between risk factors and disease. Reducing risk factors needs to be person‐centred, with motivation to modify behaviour.

Figure 48. Inter‐relationship between major diseases and risk factors

Poor Diet

Physicalinactivity

Tobacco

Alcohol

Overweight

High BloodPressure

HighCholesterol

CHD

Stroke

Lung cancer

Colorectalcancer

Depression

Diabetes

Asthma

COPD

Kidneydisease Oral disease

Osteoporosis

Osteoarthritis

6. Fin

FinanciaIn recenenvironmyears, an

1

2

3

4

5

6

7£m

Figure 4 Areas of

Figure 5

In additrequiremreal cashthat mois that p

ancial Lan

al Landscapent years NHSment. Lookind the diverg

NHS FV

0

100

200

300

400

500

600

700

2014/1

49. NHS FV: P

f anticipated

Prescribing –

Staffing cost

Technology –

Demography

50)

50 Illustrative tion NHS FVment will conh savings, wre can be aclans must be

ndscape

e – Within ExS Forth Valling ahead, Figence betwe

V: Projec

15 2015

Funding U

Project Costs

significant g

– growth in n

ts ‐ increase

– developm

y – changing

e Cost Curves

V is requiredntinue for thwhere costs ahieved frome delivered w

xisting Resouey has, as oigure 49 illuseen funding a

ted Cost

/16 201

plift

versus Fund

growth in cos

new drug the

s to employe

ments in Med

g demands an

s of Acute, Ca

d to deliver he foreseeabare reduced the same lewithin existin

urces other Boardsstrates the aand costs, w

ts vs. Fun

16/17 20

Expenditur

ding.

sts include:

erapies and c

ers National

ical equipme

nd utilisatio

are of The El

efficiency sble future. Thin real time,evel of resoung resources

s, been opeanticipated fuwithout any in

nding

017/18

re

changing dru

Insurance an

ent and Infor

n of resourc

lderly, Menta

savings of 3his will be ac, and by usinrce. The ove.

erating in a unding and cntervention.

2018/19

ug indication

nd Superann

rmation Tech

e of an agein

al Health and

3%, and it ishieved throung resourceserall financia

Page

challenging costs over th

ns

nuation cont

hnology

ng populatio

d Community

s assumed ugh a combins more effecl strategy for

e 29 of 48

financial he next 5

ributions

n (Figure

y.

that this nation of ctively so r the CSR

of 48

7. Health Service Workforce

In common with other Health Boards, NHS FV faces many challenges in relation to the delivery of ongoing, affordable health care within tight financial parameters. Changes to pension and national insurance arrangements along with the challenges of pay, prices, prescribing, achieving and sustaining targets, technology advances, demographic impact and the changes as we implement Health and Social Care Integration will place a much higher risk on the system from 2015 onwards. In order to address these challenges, we remain committed to the continuous development of our workforce through their skills and competencies and to our annual programme of workforce planning.

7.1 Current Situation and Forecast Currently NHS FV has an ageing and predominantly female workforce, the demographic of our staff and local communities requires that NHS FV deliver innovative, proactive workforce solutions. Over 80% of our workforce lives within the Forth Valley area. Although the total working age population of Forth Valley (adults aged 16‐64) will remain fairly constant over the next 20 years at about 182,000, it is important to recognise that the percentage over age 50 will increase from 36% to 41.7% by 2025. Overall 19% of our current workforce is aged 55+ and 6.48% aged 60+. There is a need to specify the size of the challenge, especially regarding Hospital doctors and GPs. NHS FV will build on our proactive recruitment strategy and aim to create innovative solutions for areas where there are hard to fill posts, for example within certain specialities including paediatrics, ophthalmology and within primary and community care. In addition we will develop a local workforce of skilled nurse endoscopists and create multi‐disciplinary and multi‐agency recruitment solutions. Figure 51 illustrates the comparative age profiles of staff currently working in NHS FV and by 2020 (assuming the workforce is unchanged during this time), demonstrating a significant increase in the 55+ workforce from 19% in 2015 to 37.62% in 2020. We also need to value the maturing workforce and look at alternatives to current ways of working to deliver sustainable services.

Figure 51. Percentage of Staff by Age Group, 2015 and 2020.

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

35.00%

40.00%

16‐19 20‐24 25‐29 30‐34 35‐39 40‐44 45‐49 50‐54 55‐59 60‐64 65+ % aged 55+

% aged 60+

% 2015 Age Group % 2020 Predicted Age Group

of 48

Figure 52 shows the overall age profile of staff who left employment in NHS FV in 2012/13, 2013/14 and the current year to date. The highest percentage of leavers is in the age band 25‐29. Approximately 25% of all leavers each year are aged 55+, as illustrated in Figure 52. Considering that by 2020 over a third (37.62%) of the workforce will be 55+, resilience challenges and redesign opportunities become apparent.

Figure 52. Percentage of Leavers by Age Group and Financial Year.

7.2 Factors influencing the shape of the Workforce A wide range of factors are influencing and will continue to influence the shape of the workforce in the coming years. Some of these factors have already driven changes in the shape of service delivery. In determining the nature of the workforce looking forward it is important to have a clear vision of how services will provide high quality care to the population of Forth Valley in the future. There are a number of major external factors that influence future provision:

Demographic and societal changes Rising expectations Health informatics and telemedicine New medical technologies Increasing costs of health service provision National Strategic Direction – Health and Social Care Integration Changes anticipated in training programmes Demographics of the current workforce Recruitment and retention issues.

To deliver effective healthcare in this changing environment, we will require a confident, flexible, trained workforce able to work in multidisciplinary teams providing anticipatory, planned and unplanned care. Health and Social Care Integration will create opportunities for change and improvement, much of this is emergent. Other national direction include for example the focus of 24/7 provision, which is translated in practice to seven day working. Changes anticipated in training programmes relates for example to encouraging more generalist experience and expertise, and to the development of enhanced roles. Moreover, our demographic challenges can and are being addressed through leadership development and succession planning.

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

Leavers 2012/13

Leavers 2013/14

Leavers 2014/15 (to date)

of 48

8. A Potential New Model of Care

The previous sections have addressed the changing demographics, current and forecasted challenges as well as risk factors. Combined with the key messages from the Christie report and the 2020 Vision, a shift from the traditional healthcare system to a new model of care seems required. It could be suggested that the population will need to become an equal partner in healthcare, such that NHS FV provides enabling support, rather than a ‘service’, and the assets of people themselves are recognised and valued, without compromising the quality of care. This section will look at elements of a potential new model of care, namely integrated anticipatory care and self‐management.

8.1 Integrated anticipatory care A potential new model could require greater emphasis on partnership with patients, families and carers that allow the development of anticipatory care planning and ways of working where patients feel enabled to be responsible for and are appropriately informed about aspects of their care management (NHS FV Integrated Healthcare Strategy, 2011). However, anticipatory care is not solely focused on when patients are diagnosed, but can intervene at a much earlier stage and could contribute to disease prevention. A clearer understanding of the meaning of Integrated anticipatory care will emerge from the CSR. Figure 53 illustrates that all help/ intervention is on a spectrum from general / low tech / preventative to more specialist / high tech / curative. Furthermore, it is illustrated that in effect all interventions are preventative, it seems a matter of degree. Awareness and buy‐in from a variety of stakeholders into this model would be necessary in order to move towards ‘integrated anticipatory care’.

of 48

Figure 53. MODEL FOR INTEGRATED ANTICIPATORY CARE.

'Life circumstances' (socio‐economic factors, the physical environment)

Health‐related behaviours (smoking, the use of alcohol and other substances, diet, physical

activity)

Clinical risk factors (such as high blood pressure, obesity, high cholesterol and

impaired glucose metabolism)

Diseases (heart disease, stroke, cancer, mental illness etc.)

Consequences of diseases (health problems ‐ physical, psychological and social functioning,

pain)

Identification

Intervention

Identification

Intervention

Identification

Intervention

Identification

Intervention

Economic and Social Regeneration, Social inclusion

Health Improvement/ Health Promotion

Chronic disease management

Preventing avoidable admission

Early detection of disease / screening

Disease Prevention

Integrated Anticipatory care

of 48

8.2 Self-Management Self‐management can be part of a potential new model of care (Christie, 2011). The following factors have been identified as important in ‘self‐management’: o 'User involvement' and 'Client Choice' o Capabilities ‐ Knowledge, skills, attitudes, motivation o Risks (identify, understand, manage – all involved) o Environmental factors o Assessment o Record keeping o Access to services o Access to resources o Responsibilities Previous work on self‐management has focussed on the individual and is consequently person‐centred. However this approach also recognises the contribution of others. There are a range of contributors – the individual, family and friends, professionals – providing a range of assessment and intervention support. Therefore, person‐centred collaborative care may be a better term. The self‐care toolkit ‘my support plan’ may be a good starting point. Whatever approach is adopted, there is great scope for improvement and development. The key thing is that people are bought‐in to this approach and apply the principles. A clearer understanding of the meaning of self‐management will become clear throughout the CSR. Figure 54 illustrates a framework produced for the Healthy Stirling Partnership on healthy ageing and builds on the model of the person (Appendix G).

Attributes/ domains/ dimensions/ resources Change in Circumstances (attributes, resources

the

environmen

t)

and

Meaning

of

the

experience

Adaptation or protection through

resilience

Support from: The individual, Family, Friends/

peers, Services, Businesses, Third sector

Being: ICFH

physical b ‐ body functions s ‐ body structures

psychological (b ‐ body functions )

spiritual (?)

Becoming:

personal growth d ‐ activities and participation

leisure d ‐ activities and participation

practical d ‐ activities and participation

Belonging:

social d ‐ activities and participation

community e ‐ environmental factors

ecological e ‐ environmental factors

Figure 54. Framework on healthy ageing. An example of how self‐management can be organised is illustrated in Figure 56, produced by the self‐care subgroup of the Long Term Conditions Collaborative in Forth Valley.

FFigure 56. Organis

People withmore Long

C di ised Self‐Care Mod

h one or g Term i

Technologies

del.

Suppo

Guidelines

Staff

Informatio

rt

Carers

LearningDevelopm

Knowl

Aware

Skills

Attitud

n

Toolkit

Peers

g and ment:

edge

eness

des

Employers

Culture

Support

a

Improvemanag

Community

= Capability and Capacity

ed Self‐ement

335

36

9. CSR Model

To deliver activity NHS FV requires a combination of workforce (with attributes of knowledge and skills), facilities/ materials and equipment, and intangibles (information, processed, pathways). The CSR will collate recommendations from each of the eight individual work streams and it may be helpful to consider them against these three elements. Figure 57 illustrates the process on how the identified gaps and recommendations from the eight individual work streams might be categorised, which then leads to the next steps, namely prioritisation, development of NHS FV Healthcare strategy 2015‐2020 and the implementation of the recommendations. Figure 57. CSR Model – Next steps for Work stream Outputs.

Workforce: Number – type Knowledge skills attitude etc.

Intangibles: Processes, Guidelines, Pathways

Facilities Materials Equipment

Gaps Identified / Recommendations from Workstreams

NHS FORTH VALLEY

Prioritisation through MCDM, engaging with all stakeholders

Development of Healthcare strategy

Implementation

37

10. Conclusion

The current situation as outlined above suggests that the current model of care is unsustainable. People are living longer, and are more likely to have multiple long‐term conditions, and less family and informal social support. Simultaneously, NHS FV has contemporary and forecasted workforce challenges and is operating within a financial challenging environment. The traditional hospital focused health service structure needs to change to put the patient in the centre, and align with the 2020 Vision. Various reports suggest a need to move towards community‐based care and a more generic approach to patient care. The CSR will produce recommendations responding to the challenges NHS FV is facing and provides an opportunity to be innovative and forward thinking. The process is person centred and engages a variety of stakeholders, staff, patients and carers. NHS FV will aim to continue to provide safe, high quality and effective healthcare, tailored to meet the needs of patients and their families.

38

11. References

Christie, C. (2011). Commission on the future delivery of public services. Available at: http://www.scotland.gov.uk/resource/doc/352649/0118638.pdf Civil Eyes (2014). NHS Forth Valley – Bed Modelling analysis & update for 2013/14. Civil eyes

Research LTD. Imison, C., Sonola, L. Honeyman, M., & Ross, S. (2014). The Reconfiguration of clinical services

(November) King’s Fund. http://www.kingsfund.org.uk/sites/files/kf/field/field_publication_summary/Reconfiguration‐of‐clinical‐services‐kings‐fund‐nov‐2014.pdf

King’s Fund, (2014). Housing. http://www.kingsfund.org.uk/time‐to‐think‐differently/trends/broader‐determinants‐health/housing‐conditions‐and‐home‐ownership Naylor, C., Alderwick, H., & Honeyman, M. (2015). Acute hospitals and integrated care – from

hospitals to health systems. (March) King’s Fund. Retrieved from http://www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/acute‐hospitals‐and‐integrated‐care‐march‐2015.pdf

Scottish Government (2010). The Healthcare Quality Strategy. Retrieved from

http://www.scotland.gov.uk/Resource/0039/00398674.pdf Scottish Government (2011). 2020 Vision. Retrieved from

http://www.scotland.gov.uk/Topics/Health/Policy/2020‐Vision Scottish Government. (2012) The Reshaping Care for Older People: A Programme for Change 2011‐

2021. Retrieved from http://www.scotland.gov.uk/Topics/Health/Support‐Social‐Care/Support/Older‐People/Reshaping‐Care

Scottish Government (2014). Scottish Government Urban/Rural Classification 2013‐2014.

November. Retrieved from http://www.gov.scot/Resource/0046/00464780.pdf WHO (2015). Health Status Statistics: Mortality. Retrieved from

http://www.who.int/healthinfo/statistics/indhale/en/

39

12. APPENDICES

12.1 APPENDIX A - Note of Caution regarding Use of Data in the Case for Change

In using data it is important to consider there validity, which depends on the source, what the original intention was when they were generated, general reliability and validity etc.

Population projections are based on modelling, using data from the census, modified to take into account various factors.

Population projections tend to be inappropriately precise – down to single Figures for single year of age – and are forecasts rather than predictions.

Prevalence data often comes from a sample (e.g. through a survey) with the assumption that it is sufficiently representative

Activity data relate to activity and any extrapolation to disease needs to be carried out with caution.

Benchmarking is comparison with different areas’ healthcare arrangements and again requires caution that the areas being compared are sufficiently alike.

‘Synthesis’ is applying data from one source to another to give an estimate – e.g. applying prevalence data to population projections (also known as spreadsheet modelling). It is important to be aware of the assumptions and caveats etc. with this kind of forecasting.

40

12.2 APPENDIX B - Self-Reported General Health

Self‐Reported General Health (SHeS)


Self‐assessed health Very good 36% 36%

Very bad 1% 2%

Long‐term conditions Limiting LTC 27% 27%

Non‐limiting LTC 16% 16%

No LTC 58% 58%

Any LTC 42% 42%

WEMWBS Mean score 49.7 49.9

Life satisfaction Mean score 7.7 7.6

Carer Provides regular 11% 12%

Natural teeth None 11% 11%

20 or more 71% 72%

(Source: Scottish Health Survey, 2008‐2011)

Self‐Reported Long Term Conditions – Scottish Health Survey


Cardio‐vascular disease Yes 15.9% 14.9%

Stroke Yes 2.9% 2.7%

COPD Yes 4.1% 3.8%

Diabetes Yes 5.3% 5.2%

(Source: Scottish Health Survey, 2008‐11)

41

12.3 APPENDIX C - Components of migration mid- 2012 to mid-2013

Net‐migration Total Within Scotland Rest of UK Overseas

Clackmannanshire ‐64 ‐82 50 ‐32

Falkirk 357 390 102 ‐135

Stirling 276 109 215 ‐48

Forth Valley 569 417 367 ‐215

In‐migration Total Within Scotland Rest of UK Overseas

Clackmannanshire 1603 1186 339 78

Falkirk 4047 3150 667 230

Stirling 5061 3351 1024 686

Forth Valley 9188 6164 2030 994

Out‐migration Total Within Scotland Rest of UK Overseas

Clackmannanshire 1667 1268 289 110

Falkirk 3690 2760 565 365

Stirling 4785 3242 809 734

Forth Valley 8619 5747 1663 1209 (Source: National Records of Scotland (NRS))

42

12.4 APPENDIX D - Comparison of costs and other parameters 2013/14

Scotland Forth Valley

Lanark‐shire Fife

Board Operating Costs

Total operating costs £10451M £501M £974M £604M

per head £1962 £1673 £1702 £1646

‐‐ Hospital sector (Acute & Community) £5945M £267M £479M £319M

per head £1115 £892 £837 £869

‐‐ Community sector £1750M £84M £201M £109M

per head £329 £283 £350 £298

‐‐ Family health sector £2404M £130M £258M £159M

per head £451 £437 £451 £434

‐‐ Resource transfer (to local authority) £350M £18M £36M £16M

per head £65 £62 £63 £45

Hospital sector ‐ patient statistics

Number of beds 22553 1030 2088 1303

per head 0.004233 0.003437 0.003648 0.0035

53

Inpatient activity exc long stay specialties (cases) 1112597 55071 118480 65131

‐‐ cost per case £2691 £2243 £2073 £2347

‐‐ cost of inpatient surgery £3105 £3047 £2520 £2196

‐‐ cost of intensive care £8127 £6967 £8024 £8082

Long stay inpatient activity (weeks) 242978 16165 22291 16126

‐‐ cost per week £2701 £2229 £2029 £2636

Daycases 502857 9463 58894 28818

‐‐ cost per case £873 £981 £806 £740

Day patients 517279 26403 31614 56852

‐‐ cost per attend £204 £188 £228 £186

Attendances at outpatient clinics 6000154 347437 479661 327710

‐‐ cost per attend £126 £151 £117 £134

Attendances at A&E 1670337 76831 205249 78005

‐‐ cost per attend £107 £152 £95 £115

Hospital sector ‐ services

Theatres

Number of theatres 367 15 27 19

Theatres per head 6.89E‐05 5.01E‐05 4.72E‐05 5.18E‐

05

Community ‐ services

‐‐ District nursing £163M £10M £17 £10M

‐‐ cost per head of population £31 £34 £30 £28

‐‐ Community midwifery £38M £1.7M £3.0M £2.6M


‐‐ Community dentistry £39M £1.8M £4.6M £3.1M


43

12.5 APPENDIX E - Estimated number of patient contacts in Scotland

GP & PN combined

General Practitioner

Practice Nurse

Year Number Confidence interval

Number Confidence interval

Number Confidence interval

2003/04 21.712 (20.858‐22.566) 15.626

(14.938‐16.315) 6.086

(5.580‐6.591)

2004/05 22.088 (21.259‐22.917) 15.671

(14.994‐16.348) 6.417

(5.939‐6.895)

2005/06 22.590 (21.705‐23.475) 15.762

(15.054‐16.471) 6.827

(6.297‐7.358)

2006/07 22.911 (21.953‐23.870) 15.988

(15.207‐16.769) 6.923

(6.367‐7.479)

2007/08 22.142 (21.070‐23.215) 15.752

(14.991‐16.513) 6.391

(5.635‐7.146)

2008/09 23.213 (22.302‐24.124) 16.379

(15.687‐17.071) 6.834

(6.241‐7.427)

2009/10 24.131 (23.249‐25.013) 16.704

(16.069‐17.338) 7.427

(6.814‐8.041)

2010/11 23.454 (22.546‐24.362) 16.199

(15.574‐16.823) 7.255

(6.596‐7.914)

2011/12 24.079 (23.111‐25.047) 16.470

(15.763‐17.177) 7.609

(6.948‐8.270)

2012/13 24.203 (23.213‐25.194) 16.236

(15.499‐16.973) 7.967

(7.306‐8.629)

Estimated number (millions) of patient contacts in Scotland – GP, PN and GP&PN combined.

44

12.6 APPENDIX F – Estimated Population Attributable Risk Fraction (PAF) for Major Diseases – High Income Nations

Disease % burden of all disease

Contributing Risk Factors and their PAFs

Joint PAF for these risk factors and this disease

Ischaemic heart disease 9.4% High blood pressure (58%), high cholesterol (63%), high BMI (33%), low fruit and veg, (28%), physical inactivity (22%), tobacco (22%), alcohol (0.2%)

89‐93%

Depression 7.2% Alcohol (3%), childhood sexual abuse (4%)

7%

Stroke 6.0% High blood pressure (72%), high cholesterol (27%), high BMI (23%), low fruit and veg.(12%), physical inactivity (9%), tobacco (22%)

81‐86%

Alcohol use disorders 3.5% Alcohol (100%), childhood sexual abuse (3%)

100%

COPD 3.2% Tobacco (69%), indoor smoke from solid fuels (2%)

71%

Road traffic accidents 2.5% Alcohol (38%), illicit drugs (4%), occupational risk factors for injuries (4%)

45%

Osteoarthritis 2.5% High BMI (21%), tobacco (10%) 28%

Lung cancer 2.4% Tobacco (85%), low fruit and veg. (11%)

86%

All non‐communicable diseases

78.2% Multiple risks 41%

All causes 100% Top 20 risks 39%

Communicable, maternal, perinatal and nutritional conditions

9.0% Multiple risks 24%

(Source: Global Burden of Disease study – published in The Lancet)

45

12.7 APPENDIX G - Model for a Person

Sensation

Emotion

Skills

Values

Perception

Spirituality

Attitudes

Creativity

Connectedness

Beliefs

Behaviour

Knowledge

Identity

Physical and Social Environment

BODY

SOUL

Memory

Imagination

MIND

12.8 A

Risk fac

Mental intellige

Determ

Behavio

Clinical

Appendix H

ctor

wellbeing/ence/ self‐e

minants of he

oural risk fa

Alcohol use

Tobacco us

Physical Ac

Diet and Nu

risk factors

Obesity and

High blood

High choles

H - Risk Fa

/ resilience/efficacy

ealth

ctors:

e

se

ctivity

utrition

s

d overweigh

pressure

sterol

actor Stra

/ emotional

ht

ategies

Strategy

Person‐cWorkfor

CommunOutcom

Forth Varevised s

Let’s ma

Diet andwork

Child an

Clinical g

Clinical g

y

centred strarce develop

nity Plannine Agreemen

alley Alcohostrategy, To

ake Forth Va

d nutrition s

d Adult Hea

guidelines p

guidelines p

ategy ment

ng Partnershnts

ol and Drug obacco Actio

alley More A

services, com

althy Weigh

plus link to o

plus link to o

hips’ (CPP) S

Partnershipon Group

Active

mmunity fo

ht programm

other strate

other strate

46

Single

p –

ood

mes

egies

egies

47

12.9 APPENDIX I - Engagement Model – ‘Interpersonal Improvement work’

Inter-personal Improvement work’ - process:

Identify

Engage

Involve

Positive Intention

Attention

Dialogue

Understanding ‐ meaning

Appreciation/ Awareness

Co‐production of an ontological/

epistemological framework

Identify……

Rapport Communication

(all types)

‘Assets’

Shift in: Beliefs Values attitudes

Trust

Possibilities

Options

Action

Holistic model of wellbeing

Problem structuring and

‘accommodation’

Goal setting

Feedback

Relaxation

48

12.10 APPENDIX J - Information Support to CSR

Further information is available on: V:\Clinical Services Review Current sub‐folders are:

Briefing Papers

Engagement

Health Information Files

IRF information (Integrated Resource Framework)

Meeting & Action Notes

Other HBs Strategic Plans and Papers

Population Data

Published Staff Updates

Scoping Documents

Work in Progress Files Within the Briefing Paper folder:

End of Life briefing paper

Frail Older People briefing paper

Long Term Condition/ Multiple Morbidity paper

CSR information briefing sheet on population

Key facts for Elaine vanHegan

Routine Care Inpatient and Daycase spreadsheet

Routine Care Outpatient Attendances spreadsheet

Routine Care Outpatient Referrals spreadsheet

Shaping Services for the Future - NHS Forth Valley Services for the Future ... following sections...

Documents

Transcript of Shaping Services for the Future - NHS Forth Valley Services for the Future ... following sections...