North of Scotland Planning Group Annual Event

NORTH OF SCOTLAND PLANNING GROUP

North of Scotland Planning Group Annual Event

Regional Futures: horizon scanning and the

implications for regional working

21st September 2011

North of Scotland Planning Group is a collaboration between NHS Grampian, NHS Highland, NHS Orkney, NHS Shetland, NHS Tayside and NHS Western Isles

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Foreword

For the first time in three years, the North of Scotland Planning Group (NoSPG) hosted an event aimed at

determining how regional partners should best concentrate their efforts, working collaboratively for the

benefit of the people of the North.

In December 2010, NoSPG asked the North of Scotland Public Network (NoSPHN) to identify the key factors

that would have the biggest impact on the future provision of services across the North of Scotland. Over

the next few months, NoSPHN colleagues developed a picture of the future from national and international

research and the views of a number of stakeholders and this work was presented at the NoSPG event in

Nairn in September 2011.

72 delegates attended the event, including the Chairs of four of the North Boards, the Chief Executives of

two Boards and a number of Non-Executive and Executive Directors from all Boards. Clinical Leaders from

across the region, together with regional and service managers were also at the event, supported by

NoSPHN members and representatives of the North Deanery of NHS Education for Scotland, RRHEAL,

Scottish Centre for Telehealth and Telecare and the Healthcare Strategy Directorate of Scottish Government

Health Department. Through the support of the NoS Bridging Service, 13 delegates, over five sites were

able to attend the event by video-conferencing for all or at least part of the day.

This report summarises the outputs from the day, making recommendations to NoSPG and to the

collaborating NHS Boards, on the key themes emerging from the day and some proposed actions for

consideration by the NoSPG and NoSPG Chairs Group on the 30th November 2011.

A copy of this report and all presentations will also be available to view on the NoSPG web site at:

www.nospg.nhsscotland.com.

Finally, we wish to extend our thanks to all of you who contributed to the day, whether by presenting,

supporting or participating. Without all of you, no event would be successful!

Ian Kinniburgh Richard Carey Chair, North of Scotland Chairs and Chief

Executives Group / Chair, NHS Shetland

Chair, North of Scotland Planning Group /

Chief Executive, NHS Grampian


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Regional Futures: horizon scanning and the implications for regional working

The 2011 NoSPG event was chaired by Ian Kinniburgh, Chair of NHS Shetland and Chair of the North of

Scotland Chairs and Chief Executives Group. Pip Farman, Network Coordinator and Dr Sarah Taylor, Clinical

Lead for the North of Scotland Public Health Network (NoSPHN) set the scene and provided a wider context

for horizon scanning, before Mrs Farman outlined the cross cutting themes that had emerged from the

stakeholder feedback from the North of Scotland workstreams. The focus for the rest of the day was on

discussing whether colleagues agreed with the assessment and what further action was required.

Welcome and Background

Mr Kinniburgh reminded colleagues that the North of Scotland Planning Group (NoSPG) is collaboration

between six NHS Boards: NHS Grampian, NHS Highland, NHS Orkney, NHS Shetland, NHS Tayside and NHS

Western Isles. Mr Richard Carey, Chief Executive of NHS Grampian is the current Chair of the NoSPG

Executive and Mr Kinniburgh chairs the NoS Chairs and Chief Executives Group. NHS Boards work together

to ensure access to the full range of modern health services for their wider populations. Regional planning

includes both service and workforce planning and the current workplan focuses on 8 regional clinical

planning groups.

The North of Scotland Public Health Network (NoSPHN) is Public Health collaboration between NHS

Grampian, NHS Highland, NHS Orkney, NHS Shetland and NHS Western Isles. The Network aims to link

groups of public health and health improvement professionals across the North, who work in a coordinated

manner to contribute to improving health and reducing inequalities, thus maximising our shared resources.

A key focus for NoSPHN is supoprting the work of NoSPG.

NoSPG asked the North of Scotland Public Network (NoSPHN) to identify the key factors that would have the

biggest impact on the future provision of services across the North of Scotland, and therefore inform what

Boards should be planning on a North of Scotland basis. The programme for the day aimed to share the

findings of the horizon scanning work and facilitate discussion at a strategic level on these implications, with

a view to agreeing what might be the next steps.


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The big issues…

At the start of the day, participants were asked to identify the three issues that they thought were likely to

have the biggest impact on healthcare in the future. The following table summarises the responses:

Finance 22

Demography 18

Workforce 12

Technology 11

Patient/Public Expectations 6

Networks/Integration/Partnerships 6

Medicines 5

Care of Elderly/Chronic Conditions 4

Health Improvement/Community Engagement 3

Climate Change 3

Obesity 2

Rural issues 2

‘Other’ 12

What we have done so far

Mrs Farman said that the focus of the day would be on the big picture, collating and building on work that

has been undertaken within individual Boards. The presentations would give a general understanding of the

burden of disease, potential changes in demography, changes in epidemiological needs, inevitabilities of

demand, scope for the greatest gain, technology change and national policy change.

Mrs Farman outlined that a project steering group had overseen a review of Board documentation, a review

of demography, a literature review and consultation with the Clinical Leads and Managers involved in the

NoS workstreams. She added that this work was not primary horizon scanning but a high level overview of

what was available. She noted that there are a variety of approaches to horizon scanning, with as many

views on what horizon scanning can and cannot do.

Horizon scanning should be seen as distinct from forward planning and implementation; trend analysis; or

scenario planning. The working definition of horizon scanning used by NoSPHN was based on the

Department for the Environment, Food and Rural Affairs (Defra)1:

“Horizon scanning is the act of gathering published insights and predictions (threats, opportunities

and likely future developments) that may point us towards affirming or amending existing

trends and developments as well as identifying new and emerging trends and developments

(including those which are novel and unexpected) which are on the margins of our current thinking,

1 Defra http://horizonscanning.defra.gov.uk/default.aspx?menu=menu&module=About


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but which will impact on our services and plans in the future and enable us to identify further

information/research requirements.”

Essentially, the focus was on trying to understand “how will the future be different?”

A number of sources and types of information are available, which are continually being added to, including:

International Futures Forum, Foresight (UK Government), Scottish Medicines Consortium, National Horizon

Scanning Centre, and Health Improvement Scotland. Topic or clinically specific information is also available

from NHS Knowledge Network, Health Observatories, NHS Evidence and Scottish Government policies. NHS

24 and the Scottish Health Protection Review are also undertaking specific work on horizon scanning.

Having assessed the information available, Mrs Farman highlighted a useful analogy: the submarine outlook,

where even if the threats/issues are spotted, there is a need to think about how receptive we are to them,

how the impact is assessed and how they are dealt with (for example, do we dive, bomb, ignore, or call in

other troops?).

How will the future be different?

Dr Sarah Taylor, Clinical Lead, NoSPHN and Director of Public Health and Planning in NHS Shetland said that

although the current focus of regional planning has been on technical specialist services, for example,

medical and technical innovation (therapeutics, diagnostics, genetics, immunology), there is a body of

literature on the wider context and horizon scanning on the social sciences, economics, environment,

political and social context. Horizon scanning on public health and on health services had also been

included, which would be picked up in the workshops.

Dr Taylor presented a world view – global horizons, which identify a number of big issues, for example:

• Planetary viability: climate change; increase in travel abroad leading to an increase in some

diseases, for example, Legionnaires disease; and global issues such as impact on fishing and food

industries.

• Resource balance: energy costs, dependence on fossil fuels and renewables; trade.

• Human stewardship: governance (global and health services) and wealth (inequalities).

• Human quality: community, demographics, social capital and the changing nature of communities,

the role of corporate business, food politics, oil wars, travel and communications, and the resultant

demand on services.

Dr Taylor highlighted that the Intergovernmental Panel on climate change (scientific consensus) predicts

that average global temperatures have already risen and are likely to rise even further over next 20-80

years. In the UK, models predict a mean annual rise in UK temperatures of between 2.5 degrees and 3


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degrees by the end of the century. Predictions for Scotland show a small rise in average temperature but

with greater variation across seasons, drier summers and much wetter winters. With global population

increases, climate changes are also linked to sustainability, as a decreasing area of land is required to

support more people in terms of living space, food, water and energy requirements. Global effects and

extreme weather events are more likely, which has an impact on food supply and distribution, infrastructure

damage, insurance costs, population migration and war or unrest. Heat waves could have more direct

health related consequences, for example, the quality and quantity of drinking water, increases in heat

related deaths, sun burn and skin cancer. Inward population migration, as a result of population pressures

elsewhere, could lead to an increase in food poisoning and insect borne diseases such as Lyme disease2.

Public Health: Horizon scanning on health raises a range of future definitions which tend to move away

from the World Health Organisation (WHO) definition of health which is seen as “unattainable for most of

the people most of the time” to thinking in the future definition of “what it takes to make life worth living”

and “the ability to adapt and self manage in the face of social, physical and emotional changes” or resilience.

Public Health horizons include ecological public health, the pursuit of efficiencies, disinvestment and

increasing cost-effective responses, assets-based/co-production approaches.

Dr Taylor went on to explain the lessons of history used to shape the future, the four waves of public health

thinking:

Wave 1: industrial revolution – Chadwick, ‘Great Public Works’, co-operative societies, modern police force, health

visitors, rational social order and discrediting miasmic theories of disease.

Wave 2: Boer War recruits – science in medicine, engineering, development of hospitals, concept of the

‘expert’, Koch, Pasteur, germ-based theories of disease.

Wave 3: health as results of conditions of everyday life – NHS, social housing, welfare – role of politicians as key

figures – Beveridge.

Wave 4: post-industrial society – service industries replace manufacturing, knowledge economy, consumer choice,

reducing risk, systems thinking, levelling up to tackle increasing inequalities.

Dr Taylor explained that the effect of each wave was cumulative and interactive, each gaining prominence

when the previous one fails to solve the problems of the day. Current thinking is that the time is right for a

new wave of public health thinking – a 5th wave.

Health Services: Dr Taylor highlighted that in 1948, the NHS accounted for 3% of GDP. In 2002, Wanless3

projected that health spending would rise to 10% of GDP by 2020, assuming the maximisation of public

health interventions. Recently published figures suggest that the currently the UK spends 9% of GDP on

health. The body of horizon scanning evidence sees this increasing spend as both inevitable, and

paradoxically unsustainable. She went on to say that drivers were much of what the horizon scanning

literature describes in terms of impact going forward. These were described as demography, patterns of

2Somerville M (2010) “NHS Highland Director of Public Health Report, 2010” 3 “Securing our future health: taking a long term view – the Wanless report”, January 2002, Department of Health. www.dh.gov.uk


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disease, medical activity, technology and drugs, and workforce change. Dr Taylor, referring to the Christie

Commission report4, said that many felt that it did not provide the answers, although there were elements

that would suggest support for innovative future work. She suggested that there was now a need to move

identify a radically different approach and suggested that the 3rd horizon concept model, replicated below,

identified by the International Futures Forum might offer a way for organisations to innovate, whilst keeping

the current system going.

International Futures Forum Three Horizon Model5

IFF Three Horizon Model

increasing

synchronous

failure

Innovation to try

and keep things

going

Radically new ideas

with better fit to new

environment new context for

useful old ways

less

disruptive

change

new paradigm

fits and takes off

innovation

shifts

allegiance

TIME

THE TURBULENT TRANSITION

HORIZON 1

HORIZON 2

HORIZON 3

VIABILITY

radically

different

operating

environment

NOW

www.internationalfuturesforum.com

Dr Taylor questioned whether the Christie report went far enough, commenting that it did not give neat

structural solutions but that it included a range of possible solutions, though not framed in easily accessible

language. The question perhaps was: how do we interpret this body of horizon scanning evidence and use

Christie to move us into the 3rd horizon? She added that examples of success could be seen in the assets-

based approaches of Cormac Russell and Alaska6.

Dr Taylor said that there was no easy technical fix, and that what was required was a culture change.

Dr Taylor then went on to share some of the data that may inform thinking in the workshops:

Demography:

4 “Commission on the Future of Public Services” June 2011 www.publicservicescommission.org APS Group Scotland DPPAS 11647 (06/11) (2011) 5 International Futures Forum Three Horizon Model www.internationalfuturesforum.com/ 6 www.southcentralfoundation.com


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• North of Scotland Boards are predicted to go through significant changes in population

demographics over the coming 25 years and this will impact the way public services are delivered in

the future;

• Population increase are driven largely by people living longer - all areas projected to have an

increasingly elderly population;

• North of Scotland - 72% anticipated increase in the population aged 65 and over by 2033 (GROS);

• Population projections do have limitations. Projections are calculated on particular assumptions:

fertility, mortality and in and out migration rates. Social and economic factors are not included and

can influence population change in a big way.

Living longer – in sickness and in health: Dr Taylor noted that life expectancy is on the increase, as is

healthy life expectancy, but the gap between the two is not closing, indicating that the burden of chronic ill-

health in later life continues and is shifting to an older age group. Premature mortality is falling.

Disease trends: Increasing disease trends were summarised and decreasing rates of ischaemic heart

disease and smoking were identified. Other conditions flagged in the horizon scanning that were not

sourced in detail are musculoskeletal and immunological conditions, and non alcohol related liver disease.

Dr Taylor noted in particular that Obesity, Alcohol and Smoking were key to tackling many other conditions.

Impact of health behaviours and health interventions on demand and cost of NHS Services in

the North of Scotland:

Data had been extrapolated by colleagues from NHS Tayside from a paper7 by Dr Harry Burns, Chief Medical

Officer for Scotland. The paper was submitted to the Scottish Government Finance Committee – Inquiry into

preventative spending (2011).

• Around a third of hypertension and nearly half of type 2 diabetes is due to obesity.

• Over 43,350 bed days in non psychiatric hospitals in 2007/08 were associated with alcohol related

illness at a cost to the NoS of around £21.4 million.

• Over 25,500 ambulance journeys and 76,500 A&E visits were also alcohol related.

• Alcohol costs NHS in the NoS were at least £68.9 million per annum.

• 82% of lung cancer and 86% of COPD is smoking related – as are 50% of gastric ulcers.

• The cost of smoking related disease to NHS in the NoS was estimated at over £85.7 million in

2007/08.

• Obesity related illness cost NHS in NoS £48.7 million in 2007/08 and rates of obesity continue to rise

(SG estimates likely to double by 2030).

7 Burns H (2011) Paper submitted to Scottish Government Finance Committee Inquiry into preventative spending

http://www.scottish.parliament.uk/s3/committees/finance/inquiries/preventative/cmo.pdf


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• Long-term care is estimated to cost £2.8 billion in the NoS, and is forecast to rise to £3.8 billion in

the NoS by 2040.

In a bottom-up costing approach (programme budgeting) for three risk factors, smoking, obesity and

excessive alcohol consumption, Health Analytical Services analysed NHS activity and expenditure related

directly to the secondary prevention of these risk factors as well as costs associated with diseases directly

resulting from the presence of the risk factors. The analysis indicated that significant cost savings for NHS

Scotland could be made by investing in preventative measures to reduce the future incidence of these risk

factors.

Preventative spend will also contribute to increasing healthy life expectancy and reducing the cost of health

care for older people. Long-term care is estimated to cost £11 billion currently (£2.8 billion in the North of

Scotland), and is forecast to rise to £15 billion by 2040 (£3.8 billion in NoS). Preventative activity which

delays or reduces the incidence of conditions in older people or helps them manage these conditions

differently could produce very substantial cost savings. Key recommendations from the Finance Committee

enquiry were to focus on work in early years and also to prepare for demography change. There is a case

for doing things differently.

Cross cutting themes from literature review and/or workstreams

Mrs Farman said that NoSPG workstreams had been asked to provide evidence/views regarding trends and

horizons relating to cancer, cardiac services, oral health and dentistry, child and maternal health (including

specialist children’s services, CAMHS and neonatal services), obesity, workforce, IT and the drug and

therapeutics collaborative. NoSPHN then specifically sought further information in areas of work highlighted

by the literature review including NHS facilities and also mental health. Mrs Farman highlighted that all the

evidence gathered to support the work had been made available to participants via the NoSPG website and

thanked all of the NoSPG workstreams for their contribution to the work. The key issues were:

Demographics: had been highlighted in all the submissions.

Risk factor impacts: had been indicated in cancer, cardiac and some of the child health submissions.

Impact of improvements in health: Oral health has been successful in improving oral health, for

example, since 1972 over one million Scottish adults now have their own teeth. The trend is due to continue

although has led to an increasing demand for more complex and costly treatments, for example, implants

following on from plastic dentures, which would have been the norm and much easier to maintain.

Focus on earlier diagnosis (diagnostics/impacts): there was a noted increased focus on earlier

diagnosis, which has led to the ‘Detecting cancer early’ action plan, and home testing kits for cardiac and


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other conditions, and is increasing the likelihood of referral. This is noted to have a profound impact on

existing services and the need to invest and redesign to achieve anticipated levels of improvement. Two

issues were related to this, the new technologies and/or facilities needed to do this and the increasing

number of people being identified as requiring treatment, with consequent impact on all Boards, but

particularly island Boards, where patients potentially have to travel to access diagnostic services. Some of

the literature questions, however, whether the right people are being targeted noting that inequalities are

increasing. The ongoing Well North programme has focussed on targeting public health interventions but

such programmes may also lead to increasing patient expectations that the NHS can cure everything,

creating increased dependency and as Dr Taylor had previously questioned whether this is always

appropriate?

Inequalities: It is widely recognised in the literature that inequalities in health persist however there was a

variation in recognition of inequalities across the workstreams.

Increase in prevalence of conditions and complexity of conditions: for example, for children who

might not previously have survived as long.

Increase in complexity of and demand for interventions: as we understand conditions better and as

people live longer, whether that be trends in survival of low birth weight babies with greater health and

social care needs, or of people surviving cancer who previously would have died, the complexity of

conditions is increasing, and in turn, the demand for interventions is increasing.

Primary / secondary care tensions: had been highlighted, whether that was shifts toward integrated

models of working or the sustainability of services.

Workforce: Some would describe the current financial challenges as minor, when seen in the context of the

workforce challenge. Key issues include the projected reduction (4.5% by 2033) of those within the working

age population, as the population ages, with a subsequent reduction in tax revenue; Reducing numbers

working within the public sector; Reduced opportunities for specialist staff; recruitment and retention

challenges and the impact of public sector policy change and reforms. Christie, for example, proposes that

public sector services should be integrated, outcome focussed, with a focus on prevention. This will require

changes in culture and more in the education requirements necessary to meet these challenges.

Drug and therapeutics – costs of new and more complex systemic anti-cancer agents, for example,

Herceptin, Rutuximab and the increasing range of targeted therapies. Differences in policy between England

and Scotland make it possible for patients in England to receive funding for non-NICE approved drugs,

creating significant policy conflicts on how cancer is managed UK wide; managing capacity requirements and

increasing the trend towards treatments at home.


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Technology: may be defined as any intervention that may be used to promote health, to prevent, diagnose

or treat disease or for rehabilitation or long term care, including pharmaceuticals, devices, medical and

surgical procedures and organisational systems used in healthcare (International Network of Agencies for

Health Technology Assessment)8. Many systems are in place to look at new technologies, for example, the

Scottish Health Technologies Group (SHTG), but these groups tend to focus on those interventions we

anticipate will impact in next 2-3 years. For the NHS, much of the evidence points to us better using

existing technology for example, the current information platforms, telehealth and telecare, remote

monitoring, use of the internet for information exchange and highlights the impact of new technologies, for

example insulin pumps which may have a major impact. It was noted that new technology also has an

impact on facilities.

IT/eHealth: all submissions mentioned the need for better connectivity, however, it has been suggested

that even the basics are not in place, for example, websites are not maintained or used to their maximum

potential, and information sharing.

National policy impacts: for example, changes to immigration policy, which would have an impact on the

number of children seeking care and their needs.

Finance: the current economic climate had been sited in the majority of submissions.

Patient and public expectations: many of the submissions and the horizon scanning work had noted

increasing public expectations of the NHS and demand for increasing choices for treatment.

Long Term Conditions: managing chronic conditions was a cross cutting theme that was evident from the

literature review but was less evident from the individual workstreams. Key issues related to the need for

complex care and self-management, integrated working, HR issues were seen as critical (for example,

culture and practice), partnerships and the need to consider end of life issues. The Kerr report9 in 2005 had

predicted this and said that these changes in themselves make the current models of care unsustainable –

and Mrs Farman asked delegates to consider whether we have moved on enough since 2005? Population

ageing means that we will be faced with an unprecedented number of people who have many things wrong

with them all at once – these people are frail and they challenge how healthcare needs to be delivered.

Real horizons: the horizon scanning work had highlighted that genetics (identifying genes to aid treatment

or genes responsible for certain behaviours) and stem cell research were likely to have significant impacts in

the future, although some had noted that these were not issues of the future but were with us now, but that

the NHS was currently unprepared for them.

8 International Network of Agencies for Health Technology Assessment INAHTA www.inahta.org/Home/ 9 (2005) “Building a Health Service fit for the future: A National Framework for Service Change in the NHS in Scotland” May 2005,

Scottish Government, Edinburgh ISBN 0755946693 http://www.scotland.gov.uk/Publications/2005/05/23141307/13104


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Mrs Farman said that common issues had been identified across the work streams, however she questioned

how NoSPG should best think about and address these in the future, set against the range of challenges, not

least financial, and against competing pressures and service demands? How should NoSPG make

judgements about the relative impacts, importance and impacts of for example indications for cancer

compared to new approaches to management of cardiac patients? Considering the statistics for premature

deaths for men and women, less than 20% and 9% respectively die early due to Ischemic Heart Disease,

but 35% of men and 94% of women die prematurely from cancer – where should Boards invest?

Discussion

Prof Needham asked Dr Taylor what the 5th wave of public health might look like?

Dr Taylor said that it was not easy and that if we knew, we would be doing it already. She added that some

things give us clues, for example, the body of evidence on assets-based approach and co-production. The

challenge was in transferring small scale programmes to the larger scale. Prompted by Mr Watson, further

discussion highlighted the benefits of and the need to engage and work with communities if we were to

move into the 5th wave.

Dr Bashford asked that given the IFF three horizon model, and the need for a viable and sustainable new

paradigm, whether it was possible without explicit rationing?

Dr Taylor noted that she felt that explicit rationing was about managing in the current system but noted that

spend on healthcare did not directly correlate with improved outcomes. Referring to the literature, Dr Taylor

said that some other countries spend less than Scotland on healthcare, yet appear to have better outcomes.

Dr Taylor quoted examples from Alaska10, where they had constructed different systems and changed health

significantly, therefore lowering spend. The answer is yes, it is possible.

Dr Dijkhuizen noted a frustration with the local practices that might stifle innovation and highlighted how use

of, for example, SMS texting might be widely and effectively used but may not be supported locally and

asked the question as to where responsibility for this lay?

Workshop 1: Will the future be different?

A series of parallel workshops followed to allow delegates the opportunity to discuss the issues arising from

the earlier presentations, focussing on the themes emerging from the horizon scanning, including: Global

Issues, Health Services, Health Definition and Public Health, Medical Innovation, and Technical Innovation,

and explore examples through a case study from the evidence submitted. Each of the groups was asked to

consider the following questions:

10 www.southcentralfoundation.com


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• Worrying developments in regard to the theme / case study;

• Positives/opportunities in relation to the theme; and

• How might the themed issues present or impact on a NoS basis? (e.g. impact on population,

patients, services, clinicians, managers).

Groups were asked to summarise the discussion by highlighting the three most pressing challenges

emerging from that theme. The flip chart sheets for each group are noted in Appendix 2.

Group 1: Global issues

Facilitator: Dr Sarah Taylor, Clinical Lead, NoSPHN

Dr Taylor provided the group with a more detailed explanation of some of the global issues identified in the

earlier presentation. Phil Mackie from the Scottish Public Health Network (ScotPHN) then gave a short

presentation on obesity to highlight some of the specific issues from a clinical perspective.

Dr Mackie compared the prevalence of obesity in Scotland with that of the USA, noting that US trend data on

obesity levels amongst adults suggests that Scotland is around 10-15 years behind the US, in terms of

obesity prevalence. The levels in Scotland, in 2003, (22.9%) were similar to USA levels in 1991 (23.2%).

Current estimates for the North of Scotland indicate that 17,000 people are morbidly obese (BMI>40) and

that this is predicted to rise to 25,000 by 2030.

Those who are obese may face accelerated pathologies resulting in an increased risk of a range of diseases,

both physical and psychological. This will in turn have direct consequences on health services and will

require increased resources committed to management of obesity related disease, direct management of

obesity (obesity reduction, weight reduction, and weight management), and indirect facility costs for obese

patient care.

Dr Mackie also discussed some examples of obesity system maps which have been designed as a conceptual

representation of the causal interdependencies of obesity in a whole systems approach which can be used to

develop interventions. These are explained in detail by the Government Office for Science.11

The group discussed whether there was a role for the health service in influencing some of the global issues,

for example, the cost of food and the avoidance of waste. It was agreed that it would be easier to get

agreement at regional level for a collective effort, however, there was a debate as to how the NHS would or

could drive change and whether the organisation was actually fit to do this. This may require a change in the

11 Tackling Obesities: Future Choices – Building the Obesity System Map www.bis.gov.uk/assets/bispartners/foresight/docs/obesity/12.pdf


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way that the organisation works, including a cultural shift. More radical thought was required and for this to

happen and people should be allowed to take risks and we should allow them to (possibly) fail.

The three most pressing challenges agreed by the group were the need for:

1. Radical transformational change (risk taking);

2. Practical local action;

3. Leadership.

Group 2: Health Services – structures, models and finance

Facilitator: Dr Annie Ingram, Director of Regional Planning & Workforce Development

Dr Ingram introduced the workshop by referring to three quotes from the horizon scanning literature to

highlight the issues.

“Look out. Better yet, look outward.

“There is growing evidence that the current health systems of nations around the world will be

unsustainable if unchanged over the next 15 years. Globally, healthcare is threatened by a

confluence of powerful trends – increasing demand, rising costs, uneven quality, misaligned

incentives. If ignored, they will overwhelm health systems, creating massive financial burdens for

individual countries and devastating health problems for the individuals who live in them.” 12

Dr Ingram said that spending in the NHS over the last 60 years had increased on average by 4% per annum

and that there had never been a sustained period of zero growth since the NHS was established in 1948, not

even during economic downturn. She noted that “In the last 12 years, spending on healthcare has more

than doubled from c£50bn in 1998 to over £120bn in 2010…”13 The factors driving the increase have been

staffing costs, an ageing population, changing patterns of disease and an increase in medical activity, and an

increased investment in drugs, technology, IT, buildings and premises. She went on to say that “With zero

growth from 2011/12, productivity will need to increase by 6% per year just to mark time…”

Dr Ingram posed the following question to the group:

‘How can we provide universal healthcare according to need, free at the point of delivery, meeting

contemporary patterns of illness and other public expectation, as part of an integrated approach that

sustains healthy, fulfilled lives at a fraction of the cost?” 14

12 “Healthcast 2020: Creating a sustainable future” Price Waterhouse Coopers Health Research Institute (2005) 13 Hannah M (2010) “Costing and Arm and a Leg: A plea for radical thinking to halt the slow decline and eventual collapse of the NHS”

International Futures Forum ISBN 978-1-905658-08-4 www.internationallfuturesforum.com/ 14 Hannah M (2010) “Costing and Arm and a Leg: A plea for radical thinking to halt the slow decline and eventual collapse of the NHS”

International Futures Forum ISBN 978-1-905658-08-4 www.internationalfuturesforum.com/


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Dr Malcolm Metcalfe then gave a short presentation on cardiac services, to highlight some of the issues from

the perspective of clinical services. Referring to all cause mortality in the UK between 1981 and 2011, data

suggests that the number of people dying from cancer continues to increase, despite significant and

increasing investment, whereas the number of deaths from cardiovascular disease is reducing, with no

evidence that the trend has bottomed out. The number of people living with cardiovascular disease as a long

term condition is increasing and Dr Metcalfe challenged workshop participants to consider where scarce

resources would be better spent, when 1 in 2 men and 1 in 3 women in Scotland will suffer myocardial

Infarct before they die.

Dr Metcalfe presented some basic cardiovascular disease statistics noting that the prevalence of IHD was

6%, with a high prevalence in the elderly, suggesting that as the population ages the number of people

living with IHD would grow; hypertension 11% 1 in 10 people have high blood pressure but do we refer the

right people into secondary care; Atrial fibrillation (AF) at 1.1% is poorly diagnosed and treated in the

population; heart failure 2% or 1 in 50, yet management of heart failure is not included in the QOF for GPs;

and palpitation 100% - everyone at some time has palpitation. Many are referred into cardiac services, even

though there is nothing wrong. Do we need better education?

Dr Metcalfe went on to say that primary prevention and improving existing therapies may be the way

forward. He also highlighted the debate around high technology versus low technology approaches, noting

that clinicians want technology, whilst public health advocates a more low tech approach. Whilst no one

approach is right, a balance is required and prioritisation should concentrate on identifying where the

greatest benefits can be achieved. He added that funding primary prevention gave value for money. Services

should aim to ensure that all patients with IHD are identified and appropriately treated; the detection rate

for heart failure should be improved and Atrial Fibrillation should be treated optimally in primary care

through investment in more heart failure nurses.

Looking to the future, Dr Metcalfe indicated that new developments such as Warfarin substitutes (for limited

groups due to cost), the Polypill, more effective treatment of AF (AVCs, PVI, devices), more effective

treatment of coronary heart failure (new drugs; devices for the 15% with LBBB), TAVI and CT calcium

scoring and angiography should be considered.

Dr Ingram then opened discussion to the group.

There was a discussion around the utility approach adopted, in that it comes down to value for money based

on evidence. It was noted however that it is difficult to stop doing some things to concentrate on others.

The group discussed the success of the policy to prevent smoking in public places and whilst members

recognised the need to debate individual freedoms versus Government policy, suggested that a similar


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approach should be adopted towards the food industry. The group suggested that society is being

manipulated by the food industry and this needed to be tackled if the obesity epidemic is to be addressed.

The need for an integrated approach to technology was agreed and the group considered that there needed

to be an open conversation to inform public expectation, rather than rely on the influence of the media to

drive policy decisions, for example, if services are not safe, there should be an open dialogue about the need

and evidence for change. Risk needed to be measured against benefit and informed decisions about risk

should be made.

In relation to the health service, the group discussed changing demographics which could increase resource

implications, increasing activity in the community, the potential to reduce very expensive lengths of stay in

hospital, and public expectation.

Finance was also discussed, and the group suggested the need to find the best health benefit and invest in

that. The example of Cuban health services was debated as only doing the most effective things because

that is all that they can afford. This related to the efficiency and productivity agenda; however, to gain the

benefits, there is a need to make difficult decisions, which may be unpopular.

The most pressing themes identified by the group were:

1. Public perceptions.

2. Getting the right balance of risk.

3. Impact of demographics on how service is delivered.

4. Early intervention and transition through services.

5. Redesigning the plane without it costing any more, and possibly less.

Group 3: Health definition and Public Health

Facilitator: Dr Margaret Somerville, Director of Public Health, NHS Highland

Following a brief discussion on the event introductory presentations and the Three Horizons model, Dr

Somerville opened the discussion by asking whether we could determine what the future will be and could

we influence the next wave?

Reacting to change: It was noted that generally speaking, the NHS does things by evolution and not

revolution and we are often poor at effecting change. The NHS needs to get better at reacting to what is

happening outwith the NHS and in society generally.


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Communication & Technology: In addition, communication methods and technology are changing (with

texting now not as effective a means of communicating). We are often poor at articulating change outwith

professional boundaries and care boundaries.

Patient Choice: What is sustainable for the future given the ageing population and the potential

requirements for specialist care? NHS communication systems do not currently keep up with the fast

changing pace of society and we need to get better at engaging with the public locally in order that they can

be involved in effecting changes to services in the future. In addition, we will need to deliver according to

patients’ expectations and therefore we need greater dialogue with patients, but it was also noted that they

have a personal responsibility to manage their health issues.

Dr Somerville then provided a short presentation looking at the drivers that have effected change in years

gone by, for example, the World Health Organisation Ottawa Charter (1986), Health Council of the

Netherlands 2009 and it was debated whether we are now entering a 5th wave of public health thinking.

Dr Bisset, Regional Clinical Lead for Child Health provided a perspective from the current child health work

stream. He said that it is recognised by Public Health nationally that investing in child and maternal health

in the early years of life pays benefits in health and in the criminal justice system in 20+ year’s time. The

question was whether funding should be diverted away from acute services and more put towards education

of families. The current challenge in Child Health services is the ability to sustain services in the longer-

term. Drivers in this are:

• Managing Medical Careers – government decision to reduce the numbers of doctors in training.

Acute services will probably need to be provided by expensive Consultant staff.

• Immigration – due to change in government policy, it is not now possible to rely on doctors from the

Commonwealth countries to fill recruitment gaps, which had previously been the case.

• Workforce – the paediatric workforce is largely female – resulting breaks in service e.g. maternity

leave, child rearing, which adds added pressure.

• North of Scotland Secondary Care Services Review – this report is due in October and it may suggest

that Health Board boundaries should be ‘thrown away’? This would certainly reduce barriers to

providing services across the North.

• Community Child Health – there are fewer doctors in training in this area, which has an even higher

proportion of women than general paediatrics. There will be a need to re-design services due as the

current cohort of Associate Specialist and Staff Grade doctors retire over the next 10 years.

• Transport – this could be a major issue in the future - there will be a requirement to move patients

around more when specialist care is increasingly delivered on a regional basis.

• Training of junior doctors – in future it will not be possible or practical to have all fully trained

doctors as specialists in secondary/tertiary care; however the current system of training does not

lend itself to a different model. There will still be doctors needed in Primary Care with a special


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interest in paediatrics. Presently doctors decide to take career breaks from their training when they

don’t want to go where they are sent in Scotland and the training programme therefore takes longer

to complete. An idea has been put forward that perhaps FY1s should be sent to Highland first

during the early states of their general training.

The impact of investment in Early Years and Health Inequalities: the biggest impact on health in future will

be related to the wealth of the population and the state of the economy. There is a lot of evidence to show

that early input will pay dividends with the outcomes in mental health in later years of life.

The Chief Medical Officer has been doing a lot of work recently on inequalities and focussing on getting the

wealth distribution right in the country. There will be a greater requirement in future to measure equity of

access to services more effectively – risk factors will include, alcohol, smoking, food, obesity. Evidence was

given of a Family Nurse pilot project, being carried out in Tayside and Lothian, where engagement with

vulnerable groups is getting the message across through education. There are similar projects in the US and

England.

Access to Patient Information & Patient Expectations: It was agreed that this is such a challenging issue for

all as Health Boards often use different IT systems, which make working operationally very difficult and

these can cause massive barriers. Data protection on the use of patient information was also stated as a

barrier. It was suggested that perhaps the breaking down of Health Board boundaries should be

investigated further. In NHS Highland, for example, there is a move towards a Health and Social Care

model, with a number of services being led by Highland council on behalf of both organisations. It was

noted, however, that presently Local Authorities have no access to NHS IT systems, despite having to carry

out joint assessments on patients. It was felt that the public expectation is that clinicians, wherever they

work on a given day, have access to all their patient information, which is not always possible. It was noted

by all that younger generations are now much more open about sharing information. It was agreed that it

may be difficult to manage patient expectations in future and it was questioned as to the best means of

communicating with the public, e.g. new technologies, charities, community groups. It was felt that we

should be thinking about ‘relationships’ across communities as well as the rights and responsibilities of the

individuals. Evidence from cardiac rehab: exercise classes in communities, activities in community centres.

In closing the workshop, the following three most pressing challenges were noted:

1. A Whole Public Sector Response (Health, Local Authorities, and Police) was required. It was agreed

that agencies need to come together in communicating with the public and there is a requirement

for a decision to be made on whether there should be a single funding stream for all. Added to this,

political decisions need to be taken into account.


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2. Training versus workforce versus service needs - needs joined up thinking; getting the balance right;

personal versus service; specialisation versus generalist medical staff; re-branding - sectors versus

services; and role development (ANNPs, AHPs).

3. Communication, including: information sharing, community engagement, rights and responsibilities

versus expectations, identifying North of Scotland communities, and managing and balancing

expectations.

Group 4: Medical innovation

Facilitator: Sharon Pfleger, Consultant in Pharmaceutical Public Health, NHS Highland

Mrs Pfleger set the scene by highlighting that an ageing population will raise the question of what will we die

of at aged 90? Dementia may be a bigger problem by this time. Healthy life expectancy may not improve,

so how do we reduce the gap? How do we sustain the workforce skill? How will services be rationalised?

No one wants to make this decision centrally.

Drivers and challenges for future use of medicines: Pharmaceutical companies contribute substantially to

the country’s GDP and the government are not keen to change this. It is an expensive investment to get a

drug on the market. This process is driven by the pharmaceutical companies rather than the needs of

population. The expanding knowledge of gene mutations and the development of biomarkers to label cells

more accurately is helping to drive the development of targeted therapies. The culture within society is to

maintain life at all costs. Would it be worth while to pursue this even if it did not have much of an effect?

Public expectation is such that money should not be a consideration in end of life treatment. It is the

responsibility of the Scottish Government to initiate discussions to promote a change in attitude and culture.

Long term conditions and lifestyle illness will lead to more expense in patient treatment. Obesity, smoking

and alcohol misuse will lead to a long-term issue of non-communicable disease. Access to medicines is

available to all people but it may not be backed by their specific Health Board. The opportunity cost of what

will not be delivered to allow the supply a particular drug must be considered. This process is time

consuming and is in danger of becoming more frequent. New models of delivery will impact on the

availability of drugs with capitation via community pharmacy.

Mr Gent, NOSCAN manager presented the cancer perspective, highlighting issues including increased access;

targeted treatments, which are generally safer with less systemic side effects; the population is fitter and

older; there are more treatment options; improvements have been made in side effect management; there

are more oral and short-infusional options; homecare options; Telemedicine & Telehealth improvements;

and Improvements in supporting locally delivered services.

Mr Gent summarised the issues:


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• Surgery still best option for cure (over 90% of curative treatment is surgical);

• Rapid development of targeted therapies has improved survival and outcomes in many tumour

groups;

• More targeted radiotherapy has the potential to improve outcomes and prevent collateral damage;

• Treatment interventions in some groups have increased by 100% e.g. adjuvant colorectal;

• 300% increase in drug costs across the North over the past 15 years; and

• High cost of drug development (Herceptin cost $200m) drives the high pricing during patency

period.

He said that the worrying developments in regard to this theme were public expectation and attitude fuelled

by pharmaceutical companies, the required cultural change, and a suggestion that we should invest in the

existing resource/workforce but change the way in which services are delivered, by reducing administration

processes, duplication and waste.

Positive opportunities were noted as:

• Improved two way communication.

• Is innovation being held back by being risk averse?

• Technology improvements will provide opportunities for change as long as technical issues and

barriers to cross boundary working and are removed.

• Horizon scanning should be identifying what we need for the future and developments should not be

driven by pharmaceutical companies’ priorities.

The impact on a NoS basis: Changes within cancer detection and treatment will require collaborative

working to ensure service provision but service may not be local for every patient.

The three most pressing challenges highlighted by the group were:

1. The workforce will need to be flexible to be able to deliver innovation with the possibility of

specialists sitting centrally and generalists peripherally.

2. A change in attitude towards end of life care and knowing when oncological interventions will add no

additional benefit.

3. Economic factors are leaving the NHS unable to direct what is needed for the future. We are

reactive to change instead of leading the direction of change. It is essential to balance the drivers

for change and maintain some control to be able to achieve a sustainable service.

Group 5: Technical innovation

Facilitator: Dr Roelf Dijkhuizen, Medical Director, NHS Grampian


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Dr Dijkhuizen suggested that through technology it would be possible to improve access for patients to

health services without the patient necessarily having to move from their home environment. He suggested

that through existing technology, it was possible to provide the first responders with appropriate information

to better manage initial patient contacts and through use of IT based systems for imaging and video-

conferencing, it is currently possible to provide advice to local hospitals minimise the number of unnecessary

transfers.

Future services should harness communication technology to limit referrals into larger centres and services

should be encouraged to use technology to take expertise to the patient, through VC consultations and use

modern approaches, for example use of mobile phone technology to interact with patients.

Mrs Hazel Archer, Technical Lead for the Scottish Centre for Telehealth and Telecare at NHS 24 updated the

group of progress being made towards a national video conferencing network. She reported that the pilot

programme with the North had been completed successfully with approximately 500 devices now

registered. Rollout of the service has now started throughout Scotland with every health board agreeing to

take part and adopt communication standards.

She also discussed some of the ongoing work of the SCTT including the DALLAS programme (Development

of Assisted Lifestyle Living at Scale), the introduction of a Digital TV service for health information and

telehealth developments such as Paediatric Unscheduled Care.

The three most pressing challenges highlighted by the group were:

1. Need to identify what patients and population want;

2. Patient outcomes and benefits; and

3. Gather evidence of technological advances already in place and decide which are regional

priorities to implement.

Group 6: Videoconference group – Health Services

Facilitator: Prof Gillian Needham, Post Graduate Dean (North), NES & Dr Lesley Wilkie, DPH NHS Grampian

Mr David Kerr presented data from the General Registrar Office Scotland (GROS).

The group discussed how to move from an informative to a formative approach and then towards a

transformative - take information, respond to it, and do cleverer things with it.

A number of issues were raised around this GROS data relevant to North of Scotland endeavour: what is the

nature of our population now and in the future; and how does this understanding challenge equity; how will


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the population needs differ in the future; what is ever increasing life expectancy telling us in the context of a

health life expectancy, living longer healthier; does seeing demographics as a problem change the

paradigm?

The three most pressing issues as agreed by the group were:

1. Changing from risk minimisation to informed risk management;

2. Community empowerment (informative / formative / transformative); and

3. Inequality is unacceptable.

Afternoon session - Back to the Future

Dr Taylor opened the afternoon session by highlighting reflections on the horizon scanning process, what we

might do next and summarising the feedback on the most pressing issues emerging from the discussions in

the morning.

Horizon scanning: the process

Dr Taylor suggested that horizon scanning is an uncertain science, which is complex, technically and in

terms of time, and subjective, for example, to social or clinical perspectives. She said that although there

was a huge body of work available, there was scope for doing more but questioned whether this was

wanted. She went on to summarise what had been found to date, including:

• Demography;

• Sustainability (environment, services, economy);

• Burden of disease (circulatory diseases, cancer, obesity, lack of wellbeing);

• Smoking, alcohol;

• Cross cutting issues;

• New technologies;

• Drugs; and

• New issues.

Although there may be nothing here that was not already known, Dr Taylor asked how receptive delegates

were to the threats/issues highlighted and asked how best we might assess the impact and what we might

then do about them?

Dr Taylor introduced the concept of ‘Redesigning the Plane whilst Flying it’ an IFF analogy which suggested

we had to keep the plane flying (the work of the NHS) whilst redesigning it.


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Dr Taylor asked so what might we do next and posed some questions which she suggested should be

explored in the second workshop of the day:

• Are delegates convinced of the need for change?

• What are the challenges of thinking like this?

• Should we dive, bomb or ignore the issues?

• How to keep the plane flying?

• What are we doing already that is heading in the right direction (asset based approaches, integrated

services)?

• How can we take the best of what we already know and find the space for innovation and

transformation?

• What opportunities does the future hold (e.g. demography?)

• What is our ‘tipping point15?

• What needs to change?

• Do we need a new set of rules by which to operate by?

• Do we need new tools/ processes (e.g. more horizon scanning, set of questions we need to ask,

scenario planning)?

• How resilient are we?

Delegates then broke up into different mixed groups for the second workshop.

Workshop 2: How might we redesign the plane whilst flying it?

The aim of this workshop was to explore how to ‘keep the plane flying but redesign at the same time’ and

was based on the three horizon model highlighted in Dr Taylor’s earlier presentation. Groups were asked to

discuss:

• Whether members agreed there was a need to change – and where this might be nationally,

regionally, locally etc.

• What do we need to keep doing / what needs to stay?

• What needs to change?

• What might need innovating (and how do we create the opportunity for this)?

• What might be some of the new rules we operate by?

15 The Tipping Point: How Little Things Can Make a Big Difference (ISBN 0-316-31696-2) is a book by Malcolm Gladwell, first published by Little Brown in 2000.


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• What does this mean for NoSPG?

Groups were also asked to prepare questions for the panel debate in the final session.

Feedback from each of the groups is highlighted in Appendix 3 but key issues are summarised here:

1. Whether members agree there is a need to change – and where this might be nationally/

regionally/ locally etc.

• There was unanimous agreement across the groups for the need for significant change as we could

not sustain current services. Do nothing was not an option. We need to work together to make

efficiencies and take advantage of economies of scale.

• Shift the balance of care from specialist services to primary care, but not shift the balance of

resource.

• Different political agendas at national and local levels, results in conflict.

• Whole systems approach required.

• Think collectively about disinvestment.

2. What do we need to keep doing / what needs to stay?

• Collaborative working.

• Multidisciplinary working.

• Leadership at all levels, including clinical leadership.

• Working through community planning partnerships, although they need to be more productive.

3. What needs to change?

• Need to manage public expectations, but also need to educate the public.

• Culture change, however the big question was: are people prepared for the challenge and the effort

that it will require?

• Expectation that managers and leaders have the solutions, however in reality, they may not have

the required skills for the change required.

• Technology: need standards; refresh of equipment; training; and technical support.

• eHealth/IT – need for integrated systems across Boards and thereafter with all partners involved in

patient care, for example, local authority and voluntary sector.

• Public to be more aware of the issues in healthcare.

• ‘We know best’ attitude – involve communities.

• Change of mindset – new drugs are no different from new services.

• Focus on patient pathway.

• Training of medical staff in remote and rural areas – require generalists with decision support and

specialist advice from larger centres.


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4. What might need innovating (and how do we create the opportunity for this)?

• The relationship with the population we serve needs re-invigorating.

• View the ageing population as an opportunity rather than a problem.

• If the solution is revolutionary rather than evolutionary, it is too difficult.

• Embrace digital economy and eHealth and adopt a risk management approach.

• Empower clinical excellence to drive down variation.

5. What might be some of the new rules we operate by?

• Need for partnership with the voluntary sector as well and public and private bodies.

• Need for engagement of wider population.

• Take a patient centred approach and do the right thing.

• Sharing information seamlessly.

6. What does this mean for NoSPG?

• It is selfish not to work regionally, and we cannot leave the island Boards to provide all their own

services.

• If regionally, no added value can be demonstrated, then the item should not be on the workplan.

• Pick areas that we are working on already across region and work on the variation – choose big

hitters.

• Joint decision on interventions required so as to avoid creeping developments.

• Sharing of good practice.

• More emphasis on eHealth.

• Reviewing the limiting rules.

The big 3…

Participants were asked to re-evaluate, either individually or as a group, what they thought the three big

issues were that would have the biggest impact on healthcare in the future. Not all groups completed this

task but for those that did, there was some commonality between the groups and the identified issues, in no

particular order were identified as:

• Public expectation

• Demographics

• Technology / eHealth / IT infrastructure

• Management & leadership of risk

• Prioritisation and rationing

• Professionalism/medicalisation of everything/regulation

• Workforce and training

• Access to healthcare – what is practical and necessary; what could be redesigned; optimisation of specialist care

• Partnership/integrated approach


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There were similarities with the list generated at the beginning of the day but with some new issues

emerging which reflected the wide ranging discussion in the workshops. Significantly ‘finance’ was not

highlighted at the end of the day.

Panel Debate

Mr Kinniburgh chaired the session and introduced the panel, which consisted of:

Mr Ian Kinniburgh, Chair, NoS Chairs & Chief Executives;

Mr Richard Carey, Chair, NoSPG;

Dr Roelf Dijkhuizen, Chair, NoS Medical Directors;

Dr Sarah Taylor, Clinical Lead, NoSPHN;

Mrs Rhoda Walker, Chair, NoS Nurse Directors; and

Dr Annie Ingram, Director of Regional Planning & Workforce Development.

Firstly, Mr Kinniburgh asked each member of the panel to summarise their thoughts on the day and to share

what key message they would take away from the event.

Generally, the panel noted that substantial change was required and that there was willingness for that

change. The challenge would be in the need to oblige people and for delegates to go back into their NHS

Boards and communicate these messages. There was a demonstrated need and benefit to be seen from

regional working and being better at it.

Mr Kinniburgh then fielded questions from each of the workshops:

Q How do we have a conversation with the public as equals, both regionally and locally, in the context

of national conversations?

A There is a need to articulate the case for change within the health service and to continue to work

on a strategic narrative, which will be much more specific about the changes that are happening.

There is a need to make use of connections already in place within Boards and to be much more

active at engaging with the public. The challenge was to do this on a regional basis, given the

particular geography and issues within the North of Scotland.

Q Why not let the system collapse to initiate the change quicker?

A The panel concluded that the system may well collapse if there is no change, however, if it did, we

would be failing patients.


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Q What is the panels’ view of management of risk: political consequences and fall out of

disinvestment; over regulation e.g. sharing patient information between organisations and

professions?

A Well managed risk is an opportunity and there is a need to take more risk on a collaborative basis

between Boards. There is a need to convince at Board level and through clinical planning groups

that regional planning is worthwhile and can reduce inequalities. Chairs, Executive Teams and NoS

Clinical Leads to take this message out into Boards. Regarding the transfer of information, there is a

need to work together, within legislation, and to ask the information commissioner how they can

help to do this legally and in a transparent way.

Disinvestment is difficult, as some, for example, Warfarin, TAVI or insulin pumps are not really

disinvestment and there is a need to think of a managed introduction rather than just not funding.

Continuous dialogue with clinicians regarding what works best and what should be stopped will allow

us to manage the introduction of something else that works. It was suggested that in terms of

public engagement, there is a need to start new thinking about choices, for example, quality of life

versus extension of life. End of life treatment and care should be a public conversation in terms of

how much and where to spend. It may be easier to this collectively as a region.

This is a risk worth taking, to disinvest at a regional level and trust partner Boards to undertake

services on our behalf. We need to think about what is right for the patient in the long run. We

need to be more receptive to working together.

Q Do we need to look at the needs of the population, not only health needs, but also social and

economic needs?

A Influences are inter-related therefore we need to think in a more integrated way without being

distracted by unnecessary change. Need for transformational thinking. Demonstrate through

success that that collaboration is effective.

Q How do we create the energy to change? How can NoSPG contribute? What is the role of NoSPG in

generating change, particularly cultural?

A Need to work very hard on hearts and minds and get a group of critical people that feel the same

about issues and the changes that need to be effected. Need to establish meaningful collaboration

with Local Authorities and the voluntary sector. Leaders need to remove barriers and obstacles to

change. Learn from the number of pilots underway. Want forgiveness when make mistakes

occasionally (risk taking). It’s not just energy, but persistence that is required, the ability not to give

up and to believe what we are doing is the right thing.

Q Is there an appetite to work collaboratively at Board level? (This question was directed to NHS

Board Chairs)


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A Mr Watson, NHS Tayside said yes, the will is there to work regionally for specific issues.

Mr Scott, NHS Orkney said that he had always been a fan of regional working and that there was a

definite energy to take this forward.

Mr Galbraith, NHS Western Isles said that as a relative newcomer to health, he could see that there

had been a huge amount of work done by Dr Ingram over the years, and that regional working was

becoming more important.

Mr Kinniburgh said that he had been sceptical early on but was now convinced and committed to

make this work. He added that some provocative views had been expressed throughout that day

but that this was worth fighting for.

A full list of questions submitted for the panel, but which were not addressed, are included at Appendix 4.

Closing remarks

Mr Carey thanked Dr Taylor and Mrs Farman for the significant work that had been undertaken on horizon

scanning, for the stimulating presentation and a good start to the day. He also thanked Dr Ingram and her

team and all those who had contributed for the planning of the day which had led to a successful event. Mr

Carey said that although regional collaboration was fragile, the challenge was for all to make the case for

collaborative working. He cited CAMHS and Medium Secure as current examples that show that it can work.

He added that the feedback from the event would be discussed at the next NoSPG and NoSPG Chairs event

and incorporated into the NoSPG workplan, for example, eHealth.

Evaluation

Delegates were asked to compete an evaluation form (the results of which are given in Appendix 5). To date

41% of delegates have returned the questionnaire.

In summary the key reflections on the event were:

• The majority of participants felt the aims of the event had been achieved although the objective to

discuss next steps was thought to have been only partially achieved, but with a recognition that this

was probably not achievable at the event.

• As a result of the event, just under half of all respondents noted an intention to change practice or

follow up on some of the themes discussed during the day.

• One of the key messages that many delegates took away from the event related to the need for

collaboration to tackle the issues highlighted.

The majority of delegates were happy with the planning for/arrangements for the event.


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Appendix 1

Attendees

Forename Surname Title Organisation

Paul Allen Head of ICT Services NHS Grampian

John Angus Non Executive Member NHS Tayside

Hazel Archer Service Development Manager NHS24

Bruce Archibald Service Planning Lead for Oral Health & Dentistry NHS Grampian

Ian Bashford Medical Director NHS Highland

Michael Bisset Regional Clinical Lead - Child Health NoSPG

Emily Burt Specialist Trainee in Public Health Medicine NHS Grampian

Richard Carey Chief Executive NHS Grampian

Chal Chute Management Trainee Scottish Ambulance Service

Phil Crockett Clinical Lead - Eating Disorders NoSPG

Wendy Croll National Network Manager - MSN for Children's Cancer NoSPG

Roelf Dijkhuizen Medical Director NHS Grampian

Carolyn Duncan Child Health Network Manager NoSPG

Jillian Evans Head of Health Intelligence NHS Grampian

Michael Evans Non-Executive Director NHS Highland

Pip Farman Coordinator NoSPHN

Neil Galbraith Chair NHS Western Isles

Marie Gardiner Clinical Facilitator - Neonatal Services NoSPG

Elaine Garman Public Health Programmes Director NHS Highland

Peter Gent Manager NOSCAN

Sandra Hay Corporate Services Manager NoSPG

Annie Ingram Director of Regional Planning & Workforce Development NoSPG

Nikolaus Kau Clinical Lead - Neonatal Services NoSPG

Linda Keenan MCN Manager - Eating Disorders NoSPG

Peter King Clinical Lead NOSCAN

Ian Kinniburgh Chair NHS Shetland

Martin Kirkpatrick Clinical Lead - Paediatric Neurology NoSPG

Heather Knox Director of Regional Planning West of Scotland

Phil Mackie Public Health Specialist ScotPHN

John McAnaw Head of Pharmacy NHS24

Gillian McCreath Non-Executive Director / Chair, SE Highland CHP NHS Highland

Neil McLachlan MCN Manager NOSCAN

Malcolm Metcalfe Clinical Lead - Cardiac Services NoSPG

Ken Mitchell Programme Manager - Acute Services and Workforce NoSPG

Sara Murray Project Support Officer, MSN for Children's Cancer NoSPG

Gary Newbigging Programme Manager, Primary Care Redesign (Aberdeen City) NHS Grampian

Pam Nicoll RRHEAL Programme Director NES

Mark Parsons Lead Pharmacist NOSCAN

Robbie Pearson Acting Deputy Director - Health and Healthcare Improvement Scottish Government

Murray Petrie Vice Chair NHS Tayside

Sharon Pfleger Consultant in Pharmaceutical Public Health NHS Highland

David Pfleger ADTC Chair NHS Grampian

Jane Reid Associate Director of AHP NHS Tayside

Ralph Roberts Chief Executive NHS Shetland

Marthinus Roos Medical Director NHS Orkney

John Ross Scott Chair NHS Orkney

Caroline Selkirk Deputy Chief Executive NHS Tayside

Graeme Smith Project Director/Head of Service Development NHS Grampian

Margaret Somerville Director of Public Health NHS Highland

David Steel Programme Director - Communications & Info Management, NSD NHS NSS

Neil Strachan Programme Manager - Child Health & CAMHS NoSPG


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Sarah Taylor Director of Public Health & Planning NHS Shetland

Susan Vaughan Epidemiologist NHS Highland

Rhoda Walker Director of AHP and Nursing NHS Orkney

Sandy Watson Chair NHS Tayside

Susan Webb Deputy Director of Public Health NHS Grampian

Milne Weir General Manager (North) Scottish Ambulance Service

Tom White Clinical Lead - Secure Care NoSPG

Barbara Wilson Service Manager - Secure Care NoSPG

By videoconference

Forename Surname Title Organisation

Ken Black Consultant in Public Health Medicine NHS Orkney

Kathleen Carolan Director of Nursing NHS Shetland

David Kerr Health Intelligence Lead NHS Shetland

Susan Laidlaw Chair of Area Clinical Forum NHS Shetland

Suzanne Lawrence Non Executive Member NHS Orkney

Martin Malcolm Health Intelligence Lead NHS Western Isles

Liz Middleton Non Executive Member NHS Orkney

Gillian Needham Postgraduate Dean (North) NES

Christopher Nicolson ADTC Chair NHS Shetland

Andrew Russell Medical Director NHS Tayside

Jill Vickerman Acting Director, Health and Healthcare Improvement Scottish Government

Catriona Waddington Non Executive Board Member NHS Shetland

Lesley Wilkie Director of Public Health & Planning NHS Grampian


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Appendix 2

Workshop 1 – flipchart summaries by group Task:

• General discussion/observations on the presentation / highlight further questions • What information have we missed / can participants add to (need to take account of or look for)? • Worrying developments in the situation and positives/opportunites? • How might these issues present in the NoS? • Most pressing challenges in relation to Groups theme? (3)

Group 1 (Global / Obesity)

• Cost/price of food – Does it make a difference? • Avoiding waste • Need small scale changes to start building things/move in the right direction • Where is health services role to influence this? • Collective effort of north collective voice/slightly easier to get agreement at regional level • Look at whole picture of weight e.g. obesity/activity levels/low weight • How will NHS drive the change - is organisation fit to actually do this? Change the way the organisation

work? • Local solution to global problem – really powerful • What helps/hinders transitional changes? • Can we build evidence base/knowledge base to make best decisions • Allow innovation along side • Allow people to take risks and allow them to (possibly) fail • Practice what you preach • Cultural shift • More radical • How do we achieve this? • Economic growth is not sustainable • Identify and voice – get closer with local authorities • Opportunities – pursue this and how we achieve this Group 2 (Health Services / cardiac) • Worrying • Rationing – not got courage to stop doing • Not debated personal responsibility. • Food industry needs curtailed • Implications of state intervention and policy levy • Population debate – not enough engagement national and local • Rules and bureaucracy – constrain us • Info governance • What is the priority? Risk vs. benefit • Risk management v risk averse • Allow risk • Contracts • Who are they?

Group 3 (public health and health definition / child health)

See discussion above: no flipchart notes available.

Group 4 (Medical innovation / cancer) Requirement to change? Yes


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• Need feedback from patients • Public resistance to change – some examples of this • Lack of engagement with public (text, Facebook, etc) • Issue of quality vs cost • Political resistance to debate • Articulate through the media • Managing public expectation • Behavioural change in workforce • How we communicate to/ with communities? • SMS texting (inequality – old, remote) • Risk averse/ strangling innovation • Remote technological barriers • Be more directive about horizon scanning • Early diagnostics – is it all gold? • New models of care – use the technology with lower skilled staff e.g. ECG’s • Community involvement • Carer/clinician motives/corporacy • Ambulance accessibility • Collaboration/sharing • Detection/targeting Not there/worrying? • Prevention effectiveness • Shifting the curve re longer life – cause of death

- health service provisions • Person centred • More co-morbidity • Workforce: expensive resource; how do we change delivery • Community resilience – sustainability • Collective decision making • Public attitude/culture change Group 5 (Technology Innovation / NHS24 work)

• Sustainability • Communication • Improve patient pathway • Regional linking of/to specialists Opportunities • Telehealth clinics/ consultations • Support patients in community • Take expertise to patient instead of patients to expertise • When there are limited social networks, can use technology to support – benefits for promoting health • Health protection/promotion messages • Can use technology to change culture or improve access • “Advertising” messages to target • Need to identify what patients and population want Patient outcomes/benefits • Who do we need to target • How do we then contact – methods need to reflect their chosen communication ‘tools’ • How can technology help us establish personal contact/communication Consultations; clinic appointments - Telehealth clinics


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Horizon scanning • Need to move forward on the things we have already identified could make the difference • Different systems for different people or situations • Flexibility is important • Improved interfaces so systems link • Video conferencing pilot complete and about to be rolled out across Scotland • Developing shared service model • Developing guidelines/principles • DALLAS • Access to technology & broadband • Options for digital TV systems – vc - licences– each board can have from NHS 24 • Training and support for those using • Recognise risks of social isolation and how to develop ‘welbeing’ links • What needs to be done – Now and future • What infrastructure is need to make the ‘now’ things happen in sustainable way • Need to learn from current work underway in various Boards – IT need to advise e.g. SMS on specific

priorities (medication, appointments etc) • Collate • Integrate what works well? • Implement • Use local media for key messages NoSPG • Gather evidence of what technology advances in place are targeted at patient services / improvements • Decide which are a regional priority and implement • How can we learn what peoples priorities are

• How can we then use technology • Have we asked our public what they want – health (personal) – communication methods – services

• Can we use technology to inform us on services e.g. patient need/want and ongoing conversations • Need to find solutions to concerns about information and clinical governance • System needs to drive the technology not the technology drive the system


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Appendix 3

Workshop 2 – flip chart sheet summaries

Task: • Do we need to change? • What needs to stay / do we need to keep doing? • What needs to change? • What needs innovating? • What might be the new rules? Groups to conclude by: • Participants to identify again 3 issues likely to have the biggest impact on healthcare (individually and

then collectively) in future considering presentations and workshops. • Participants to generate a set of questions to bring to panel session after the break (is there an appetite

to do more work, if so what needs to happen, challenges, NoS perspectives?) Group 1 Need to change • Technology need (investment?) to get right

• Standards required • Refresh equipment • Reliability – kit/user • Support availability/ access to • Decision support/advice skills development • Super users in local area - every locality with equip

• Highland 6,500 trained Doc hours for travel – use to invest in technology • No capacity individually to keep running while redesigning – need to work together • Focus on patient pathway – change/enhanced/technology to support • Cross discipline working - integration • Local generalists with specialist advice via VC • Chief Exec’s to mandate use of technology • Be prepared to fail – radical risk taking • Central software development team • Current systems/tools not being used effectively • What are we using technology for? • What staffing R&R areas? Change – what? When? • Doc 11yrs to train • How get Generalists? With access to specialist • Medicine – extend core training from 2yrs to 4yrs • How is NHS informing education providers? • Clarity of vision – 10yrs? • If you wait for the answer, you will never find it, so start training differently • Need workforce planning across all professions – define the problem • Avoid reactive responses to work out solutions - transactional approach • NHS weak at working with external agencies - barriers include organisational structures • Pressures of demand failures • Asset based approach – a tool Group 2

No flip chart notes available.


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Group 3 Do we require change? • Change culture presently but needs to be sustainable • Is there a corporate energy across the system • Is there one plane or several, depending on different services • Do we need air traffic control • All of us need to do the best at all times • Who is the pilot – need for leadership • Patients need to be at the forefront of all of this - ? passengers or pilots • ? NHS - only – need to take on Local Authority • ? just patients – needs to be whole population • Need to understand our complex patients better and provide services for them Public Health influence • Good experience smoking policy need to develop to other areas • As clinicians increase we focused on patients – control to take into account full population • Need to get balance right in relation to prevention need to involve other agencies • Influence areas already progressing • Certain things we can’t influence at this level – global • Work together to make efficiencies and economy of scale • How do we use NoS planning to influence above • Collectively clear recognition that this works best • Can we afford the best in everything • How do we move to Horizon Scanning 3? • Efficiency will not deliver this quick enough • High quality HS globally cost least • Do we understand the variation across the region • Way to get change in the health service is to influence the clinicians • If this is all not affordable that is a different argument: best use of resources • The system will generate savings decrease workforce pension arrangement • How do we use this to create a new model that is sustainable – opportunity to look at this regionally if we

don’t – we will lose it? • Do we need to be more honest with the public – re finance – budget management • Need to think about population as a whole • Tackle 40% failure demand • Early years – influence • Local impact • Working practices – heavily regulated now and not fit for purpose • Empower clinical excellence to drive down the variations • General agreement for a need to make changes • MCNs – in some areas have provided little gain. Dependant on individuals within MCNs • Pick areas that we are working on already across region and work on the variation – choose some big

hitters • Difficult decisions around what we should provide – to free up funding to allow investment in new

treatments • Need joint decision on interventions or they will creep in. • Need to get a degree of control and balance back into the system. • New drugs are no different from new services – need to change our thinking around what is implemented. • Need to manage public expectations • Need to educate public • Work together – committed to work together


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Group 4

What might be the new rules? • Take a patient centred focus and do the right thing • Partnership and leadership • Sharing information seamlessly (multi-agency) What needs innovating? • Digital/ehealth embracement – Telehealth care • Adopt a risk management approach to ehealth What needs to change? • Controlled/phased approach to change • Anticipating change and innovation and being more prospective • Being more bold about clinical prioritisation • Prioritise health benefit • More proactive and accepting of reaching ‘end of life’ What needs to stay / what do we need to keep doing? • Boards working in partnership • Working in clinical teams • Multidisciplinary care • Current redesign efforts to deal with pressure points • Clinical leadership What does this mean for NoSPG? • More emphasis on eHealth • Reviewing the limiting rules 3 big issues

1. eHealth 2. addressing our demographic pressures 3. access to healthcare: what is practical and necessary; what could be redesigned; optimisation of

specialist care - in partnership

VC group:

No flip chart notes available


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Appendix 4

Panel Questions

Group 1

1. How do we influence strategically, the development of a generalist clinical workforce? 2. Why don’t we just fix the IT problem? 3. Why not let the system collapse to initiate the change quicker? Group 2 1. What is the panel’s view of management of risk: political consequences and fall out of disinvestment;

over regulation e.g. sharing patient information between organisations and professions? 2. Disinvestment regionally – may be going to do things differently or in an alternative or non appropriate

location. Group 3 1. Is there an appetite to work collaboratively at Board level? 2. Will we continue to be supported at Government level, given the changes on a political level? 3. Will there be one Health Board across Scotland? 4. Do we need to look at the needs of the population, not only health needs, but also social and economic

needs? 5. We need some control over the technology so it takes us in the direction we need to go. Group 4

1. The group acknowledged a requirement to change – how do we do this better and in partnership? 2. How do we engage the public better about the need for change? 3. Can we overcome political obstacles to progress meaningful changes? Group 5 1. What will the plane crash look like? (problem trying to solve) 2. What is the vision for the future? (outcomes we are trying to achieve) 3. Can the panel identify quick wins to take us forward? (build on what works) 4. How do we create the energy to generate change? 5. How can NoSPG contribute? What is the role of NoSPG in generating change – particularly culture? 6. Benchmarking best practice; coordinating input at community level Group 6 – VC group

1. How do we have a conversation with the public as equals both regionally and locally in context of

national conversations? 2. Rural issues are not just regional issues but are also national 3. Are we good enough at learning from elsewhere, e.g. Equally Well for all assets approach? 4. Can we learn from models currently around an enablement and partnership approach in a service for

elderly people (ie. all of us some day) 5. Sometimes we will gain from turning questions on their head, i.e. Take from patients viewpoints of

needing certain skills to promote rehabilitation in a remote setting rather than dealing with problem of too few physiotherapy staff


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Appendix 5

NoSPG 2011 Event - evaluation

NoSPG asked the North of Scotland Public Health Network to detail the key factors that would have the biggest impacts on the provision of services in the North of Scotland in the future and therefore the implications for planning on a North of Scotland basis. The programme for the day aimed to enable a sharing of the findings and strategic discussions on the implications for the North of Scotland with a view to agreeing what might be next steps. Participants were invited to complete a short evaluation form to help us in our planning for future events. These were available at the end of the day and emailed to those delegates on VC. A total of 72 people attended the event, held in the Newton Hotel, Nairn, including a number of colleagues from Grampian, Shetland, Orkney, Western Isles, NES and Scottish Government, linking via video-conference, for all or at least part of the day. Thirty (30) questionnaires were returned, representing a response rate of 41.7%. All of the respondents had attended the event in person. Did the event achieve its aims?

Respondents were asked if the event achieved its aims to: 1. Share the findings of the NoS Horizon Scanning Work?

Of those who answered this question, 25 (83.3%) thought that this had been achieved, and 4 (13.3%) thought that this was partially achieved.

2. Enable opportunities to discuss the findings and their implications?

Of those who answered the question, 23 (76.7%) thought that this had been achieved, 5 (16.7%) thought that this was partially achieved, and 1 (3.3%) thought that this had not been achieved.

3. Discuss/agree what the next steps might be?

Of those who answered the question, 12 (40%) thought that this had been achieved and 13 (43.3%) thought that this had partially been achieved.

Those who thought that the aims were not achieved were asked to comment on what was missing. Comments received were:

• Not enough solutions/next steps/practical implementations agreed. • It is such a broad area, which was acknowledged at the beginning of the event, perhaps it

would be useful to revisit at a later date. • Examples of radical thinking to stimulate ideas.

NORTH OF SCOTLAND PLANNING GROUP


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• Big agenda, but yes I believe so. • Probably too high level. • If the aim was to find a role for horizon planning – no; if the aim was collaborative planning – I

hope so. • What happens next i.e. who will take notice of this – what will regional planning do – for it to

make any difference, individual Boards also need to be aware? • More concrete outputs would have been good. • Very explicit focus on next steps.

Workshops

Which workshop did you attend?

Workshop 1 Workshop 2

No. % No. %

1. Global issues 5 16.7 Group 1 4 13.3

2. Health Services 6 20.0 Group 2 6 20.0

3. Health Definition & Public Health 4 13.3 Group 3 6 20.0

4. Medical Innovation 8 26.7 Group 4 8 26.7

5. Technical Innovation 8 26.7 Group 5 5 16.7

6. Health Services (VC) 0 0.0 Group 6 (VC) 0 0.0

Do you intend to change practice / follow anything up as a result of the event?

Fifteen respondents (50%) answered this question. One respondent said that they did not intend to change anything and fourteen said they would. Responses included:

• eHealth: including IT infrastructure, intelligence gathering via Facebook; • Horizon scanning; • Workforce planning; • Regional working: challenge commitment to regional working, develop more regional working,

revisit regional solutions and link more closely with NoSPG; • Discuss how to support innovation and change across the region; • Increase focus on balanced risks; • Consider how to engage in discussion with communities around future; • Include North of Scotland/National work explicitly in team members’ objectives; • Promote discussion with Board and Executives; • Continue down the trade we are already on, heartened by the terror of today’s discussion.

What is the key message that you took away from the event?

There was a strong focus in the feedback on collaboration:

• Regional collaboration is going to be even more important in future in finding solutions to the challenges we face.

• We need regional. • Shared views and vision for future working is an increasingly challenging environment. • Need to work more collaboratively across the region; can learn so much from other services which

are not directly related to my service; it was encouraging to learn that other services face very similar challenges.

• Need to do less but do it really well, better to work in partnership to increase access to what we have got.

• Regional working is essential. • Collaboration. • There is definitely commitment to seek regional solutions. • We need to get on with it, trust each other and effectively collaborate and deliver for patients. • Importance of networking and collaboration. • Collaborative working needs to continue and we need to step up the pace.

Further issues:


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• It is difficult but we need to get a shared sense of direction; there are many clinicians still working in an ill-health service!

• Organisational risk; info governance responsiveness. • The need to consider changing the way services function with greater integration with other public

services. • Very similar issues in the variety of specialties. • North has very specific issues particularly around workforce and technology. • Think local or regional and make some difference or effect some change, even if small. • Need to take steps to move forward but accept level of uncertainty. • Realisation of the importance of community engagement and of having the public signed up to the

direction of travel is beginning to dawn. A great deal of work required here. • Needs to be more strategic partnership working to meet the needs of patients and public and link

with whole public sector. Overall arrangements

Overall, respondents were happy with the pre-event information, venue & catering and technology/facilities. The challenge for next year is to build on what has been achieved.

Pre event information

26 of the 30 respondents (86.7%) who answered this question rated the information as good or excellent. One (3.3%) was unsure. Venue & Catering 86.7% (26) of respondents rated the venue and catering arrangements as excellent or good. One thought this was poor and one thought that it was very poor. Technology

Twenty four (24) of the 30 respondents (80%) who answered this question rated the facilities as excellent or good. One was unsure.

Overall, did the event meet your expectations?

Nine respondents (30%) said they strongly agreed; 14 (46.7%) agreed and 3 (10%) were unsure.

Please add any other comments you feel will help us plan future events.

• A very successful event, well organised. Well done! Circulate presentations by email please. • Pleased to see collective commitment of Chairs/Chair of NoSPG to advance regional planning. • Panel discussion good idea but didn’t work. • Whilst interesting, the panel session went on a little too long. • I hope horizon scanning is not pie in the sky. • Stimulating day – excellent papers included as pre-event information. • Stimulating – excellent networking and lots of horizon scanning and looking over the horizon as well.

I felt energised and part of a vibrant, robust and forward looking family. • The location of the event merits consideration. Aberdeen may be a more convenient venue for the

majority.

Documents

North of Scotland Planning Group Annual Event