« Previous | Contents | Next »
Listen
Annex 4 Case Study 4 NHS Ayrshire and Arran Health Board
Context
NHS Ayrshire & Arran is one of 15 health authorities in Scotland, and has over 6,700 direct clinical staff and 3,400 non clinical support staff. The area is home to 7.2% (367,590) of the Scottish population. The age and gender breakdown is similar to that for Scotland as a whole, with a higher proportion of elderly people in some areas 1.
On 1 April 2005, Community Health Partnerships ( CHPs) came into operation and replaced the Local Health Care Co-operatives ( LHCCs) for East, North and South Ayrshire. CHPs bring together a wide range of stakeholders including primary and secondary care, local authorities and the public to focus the development and delivery of health services and health improvement on the needs of communities. The CHPs have the formal status of sub committees of the NHS Board.
Delayed Discharge was identified as an area of poor performance for all NHS areas through their 2005 annual reviews by the Minister for Health & Community Care. Tackling delayed discharges is a high priority for the SEHD and the 15 delayed discharge partnerships across Scotland; these partnerships are made up of representatives from NHS boards and councils, based on NHS Board areas 2.
The extent of delayed discharges over 6 weeks remains a particular challenge for NHS Ayrshire & Arran. Delayed discharge is one of the HEAT (Health Improvement, Efficiency and Governance, Access and Treatment) targets for Health Boards required by the Scottish Executive Health Department. A number of initiatives are in place to prevent admission to hospital and facilitate speedy discharge in order to reduce the number of delayed discharges, and ultimately improve the quality of care and ensure the most appropriate care for the individual long term. The total number of delayed discharges was to be reduced by 20% each year to 2008. During 2004-05, the target to reduce the number of people waiting to be discharged from hospital by 20% was achieved. However, revised targets for delayed discharge were issued by the SEHD in February 2006 for 2006-07 and 2007-08.
A related development is the Older Peoples Strategy, agreed in December 2004 after consultation with the public, patients, staff and partner organisations. This aims to reduce the number of continuing care beds across Ayrshire and Arran and upgrade or replace remaining accommodation. This is intended to free up resources to develop more community-based care while improving hospital accommodation for older people who do need to stay in hospital for specialised care.
The performance management model currently being used across the NHS Ayrshire & Arran corporate performance reporting system is based on the Balanced Scorecard methodology. Although a full balanced scorecard based on strategic objectives and HEAT indicators is being developed it is the intention to begin work on particular areas, developing scorecards at this lower level. Work has begun in developing a balanced scorecard on Pharmacy Services that will, with other scorecards at this next level up, provide a composite high level corporate balanced scorecard. The Balanced Scorecard methodology is also being considered as a model for performance management within the area of delayed discharges. This would also feed into the high level corporate balanced scorecard.
The CitiStat process
The focus of the Pilot
After discussions between the Scottish Executive Health Department and NHS Ayrshire and Arran it was decided to Pilot the CitiStat approach by focusing on delayed discharges, across the three Community Health Partnership areas and acute sector. Figure A4.1 shows the original indicators and reason codes for the CitiStat process, chosen by NHS Ayrshire & Arran, based on data reported to SEHD. This information was collated for each CHP area and there was also an additional table detailing trends over several months. These indicators were based on the available data at the commencement of the Pilot.
Figure A4.1: CitiStat Indicators - Delayed Discharge
The structure of the Panel
Figure A4.2 shows that the initial formal structure of the Panel in the Ayrshire and Arran Pilot was unique in the CitiStat process as it involved the Chief Executive and Chief Operating Executive from the NHS as well as the Chief Executives from the three local authorities. The CitiStat project team was drawn solely from NHS Ayrshire & Arran and had no local authority representatives, although an Analysis group was set up and included representatives from partner organisations.
Figure A4.2 The Formal Structure of the CitiStat Panel - Ayrshire and Arran
Evaluation methods
There were two formal evaluation sessions held after the November and January CitiStat sessions. Both Panel and Podium members and observers attended these evaluation sessions. The evaluator also attended both CitiStat sessions as an observer. A number of participants from Ayrshire and Arran also attended the CitiStat Exchange Inquiry Workshop in January 2006. The proposed third CitiStat Panel session in March 2006 was cancelled, although an internal meeting on delayed discharge was held by NHS Ayrshire & Arran in lieu of the session and a short evaluative discussion was held with key staff after that meeting. In addition, the CitiStat Project Team from NHS Ayrshire and Arran and PIU, Scottish Executive identified areas for improvement and review between the Panel sessions.
One of the first evaluation tasks was to generate local success factors for CitiStat. These were developed at the first session using postcards, to illuminate the vision of success and challenges of the process. Discussion at evaluation sessions was recorded and re-presented at the second session through a visual display board for comment and validation. This was integrated into a fuller storyboard used in the cross-Pilot CitiStat Exchange Inquiry Workshop.
As this case study has only experienced two CitiStat sessions while the others have involved more than four, this evaluation is based on a shortened period, though remains valid and of interest particularly in relation to the use of CitiStat in a partnership setting.
Success factors and challenges
The success factors and challenges were generated from an analysis of the transcript in which participants introduced their vision of success for CitiStat and the challenges to the group. These are listed in Table A4.1 and discussed more fully below.
Table A4.1: Success Factors - NHS Ayrshire and Arran
Make CitiStat work on a partnership basis
This was a very strong theme of the discussions which demonstrated a key challenge to CitiStat in Ayrshire and Arran, which was felt to be timely and distinct.
"This is a particularly interesting time in relation to delayed discharge and partnership working and how CitiStat actually fits into that. We've had quite a good reputation of working well together and as partnerships and we've done well with delayed discharge - now we've come to almost a bit of a watershed and there's some real challenges to the partnership….perhaps it is now time to look at what can we do differently?"
"Raising this agenda to such a senior level within our organisations gives it a new focus".
"It's not a game - it's real and anything we do in here will be like the butterfly effect - it won't just affect what we do here, it will impact on other things that we do and we really have to have some cognisance about other impacts that might come out of here".
The discussion illustrated the difficulties of genuine partnership working and some of the evident challenges, questioning the way that the CitiStat Pilot had commenced. Although the Panel membership was formally agreed to be the Chief Executives of the three local authorities, in practice, none of them had been able to be present at the first meeting and their role had been taken on by their Directors of Social Work, with the Heads of Service or other senior officers sitting on the Podium.
"How participative was the process at the very earliest stages of planning? How well did the process engage with key partners to ensure that key participants could be present? ….those things all inform I think how well any kind of process, particularly one as complex as this, is likely to work."
"It underlines the importance of having a shared agenda - actually agreeing together what it is that are the things we need to be pursuing"
"we say 'oh yes, we've agreed and we're all signed up', but actually it still works the same….it looks like we're joined up, but actually it's not different than what it was."
"We need to get comfortable to know that in some cases one partner might take more of the burden than others -that's a confidence we don't have".
The substantial achievement that success in making CitiStat work on a partnership would represent was acknowledged.
"…if you can succeed in bringing these people together, nationally we ( SEHD) will see that as a great success".
Indeed, one participant felt that the first meeting had made considerable progress in this direction.
"I think that you've succeeded in adapting what was probably an unworkable model in our context in A & A and you've reframed it and I think you've got a very good way of actually taking this forward on a partnership basis - the challenge today wasn't so much about delayed discharges - it was how on earth can you make something like CitiStat work on a partnership basis?"
Adapt the CitiStat process to suit our style of working
Much of this early 'reframing' was in relation to the formality and structures of CitiStat which were felt to be alien to the culture within the partnership and not to support the development of positive relationships.
"….that kind of very disciplined formality, indeed hostility - even we joked about the weakest link - but that's the impression we all had - that is not the kind of culture of any of our agencies, even though we're very different in approach and style of leadership".
"…sometimes it feels artificial. We've got a problem and we want to take advantage of this Pilot to help us get through it more expediently if possible. [It should] gradually move more to a style that we enjoy in coming together to solve very difficult problems. The investment in that relationship building is a much better longer term investment".
"I think what we're keen to test out in this Pilot - different from other areas - is how you use [data] in a constructive, positive way that is about generating ideas, solutions, without that kind of knuckle-rapping style?"
This heralded that the Ayrshire and Arran case study wanted to develop CitiStat in a distinct way that works with their organisational culture and style of partnership working.
Ensure that the process achieves change
The scale and urgency of the task in relation to delayed discharges was a clear challenge.
"[it will provide] a longer term view of where we want to get to - the mountain is quite significant - whatever project we pick for the Pilot we will really be scaling a mountain - but I see us getting to the top and actually succeeding having gone through the process - so it's about how we can use the process to our benefit? The converse is - zilch - nothing changes".
"I'm desperate! [to get some solutions through CitiStat]…. to be able to move patients out of hospital environments and also allow us to meet our targets to allow other folks in that are awaiting planned care".
"It's really serious ……every year we've dealt with this by throwing money at it… this is the year it's come to an end… unless we find more upstream solutions to this we will simply be here over and over again".
Ensure that data informs management decisions
There were a number of questions and challenges about the usefulness and nature of the data available and whether they can be used for management decisions.
"The important thing is the data and how management respond to those data and how they use it is important because if those data are irrelevant why are we collecting them if they're not informing our management actions?"
"…maybe we need to stop collecting some things?"
The value of qualitative data which allows for deeper investigation of the causes of delayed discharge was also acknowledged.
"We do need to balance statistical data with more qualitative information- I don't think in health care you can do one successfully without the other. We might ask what else might we collect that we want to look at that is actually useful compared to what we currently have? It was quite a stark lesson today".
"The data we were using today was very much in terms of the symptoms, but what the Podium people need are data that give them an indication of causes. Although today there were some examples, it would be useful to see what else is required for our key colleagues to say 'actually these are the reasons'".
Hit our targets, but don't miss the point
Some saw success as being the ability to hit the targets, although others felt that this attitude was too simplistic and would miss the complexity of the issues as well as not being realistic in the time available.
"Success will be quite easy to define and easy to see in terms of service improvement- if you are able to achieve that target then you know you've been successful".
"There's a danger that we're focusing very narrowly on the 'magic number' …[that comment] suggests very strongly that if we hit the magic number this will have been a success and if we don't then all of this will have been in vain. I'm really uncomfortable with thinking of it like that…. the reason we have the level of delayed discharges across A & A is multi-faceted and it's for a whole plethora of reasons and we cannot undo or address all of the reasons - we cannot put them all right between now and a magic date, in January or the 31 st March!"
The need to develop shared ownership of the targets, but also to recognise the limitations of targets to reflect the complexity of the issues was an important theme.
"….it is a very narrow target and it's consistently felt like one for which we [local authorities] were held accountable".
"[We need to] make sure the process doesn't become so purely operational - a quick fix - tick the box! - that we do have enough time for discussion both within and outwith the meeting to look at some of the medium and long term strategic areas of working".
Make this different to previous efforts to tackle delayed discharge
There was a very strong desire that CitiStat should be an opportunity to tackle an enduring issue in a different way. Testing out what's different and distinctive about the CitiStat process is an important aspect of the Pilot.
"We've been here before many times - delayed discharge has been around for 15 years….it's not a new issue - are we going to go through this process and come out at the end any different? Or are we going to be in the same position as other experiments have been? So can we make this one different? I think that will be the challenge".
"We need to think of a different solution to the problem ….we may leave the room thinking of solving the problem the way we've always solved it. We may have to think about how do we solve it differently? That's the challenge".
"Is there something that is different, distinctive, structured and of value once you take away the room and the Podium and the big flashing screen?"
Ensure the costs of the exercise are worthwhile.
There were concerns about the number of people involved in CitiStat and the costs of the exercise.
"I'm really concerned about the cost of this exercise - it's very expensive if you added the salaries up in this room. It would pay for a number of people to be discharged."
"[One of the challenges is that…..] this is full of bodies - and I think we need to lose some of the bodies if we're to continue on this journey for it to become more meaningful."
"I was struck by a number of people saying 'talking shop' - 'not achieving anything' - that's to acknowledge the point that this is a labour-intensive, expensive process….if we don't get anything out at the end of it - it'll be dispiriting to say the least."
Findings
The content of the CitiStat Panel discussions
There have been two CitiStat Panel sessions. Despite formal agreement to participate in the Pilot as shown in Figure A4.2, in practice none of the local authority Chief Executives attended and the third session was cancelled as all three could not attend. In the first two sessions, the roles of the local authority Chief Executives were taken on by their respective Directors of Social Work, although no-one from East Ayrshire Council was able to attend either meeting to be on the Panel or the Podium due to conflicting diary commitments.
The first meeting was held in a large formal room within a non- NHS and non-local authority venue, whilst the second meeting took place in a less formal room in a non- NHS venue. In both meetings the Panel sat facing the Podium members. At the first meeting there were 16 observers; these included representatives from Ayrshire and Arran NHS, North and South Ayrshire Councils, South Ayrshire CHP, North Ayrshire CHP and the Scottish Executive. The second meeting took a decision to reduce the number of observers to two per organisation to reduce the artificiality of the process. The Panel also proposed that observers should be able to ask questions at the end of the meeting. It was also agreed to change the set up of the room for future sessions, although in the event these meetings have not proceeded.
CitiStat sessions in Ayrshire & Arran have been several hours long and quite discursive, with a fair bit of discussion amongst the Panel as well as between the Panel and the Podium. They have focused on the local challenges of delayed discharge and discussed issues of resources, capacity and the operation of choice. There have also been discussions of the wider context and demographic pressures.
In relation to delayed discharge, it was agreed that no-one had a complete overview of the issue and that it was not possible to examine it in isolation from other factors, such as looking at preventing admission to hospital and to also take into account wider issues, such as housing provision. It was agreed that no single organisation had the full picture of all the activity and issues around delayed discharges. On this basis it was agreed that a whole system approach to tackling delayed discharges was needed.
These discussions did lead to agreement on a number of actions. There was an agreed need for validated data, especially on the reasons for delayed discharges to support analysis of hot spots. The second meeting agreed a new target that there should be no delays over 6 weeks, although a timescale was not established.
The second meeting agreed to refocus the CitiStat process by asking the CitiStat team to undertake a joint programme of work to review process and procedures, suggest revised processes, an implementation plan and identify appropriate improvement measures to enable performance management of service delivery. It was proposed that the CitiStat Panel would continue to review, steer and support the work programme and evaluate progress for continuous improvement using the measures identified during the process.
Although the next meeting of the Panel had been set for March 2006, in the event, the inability to guarantee attendance by all three local authority Chief Executives led to a decision to cancel the meeting. In its place, an internal NHS meeting was held to discuss delayed discharge on the basis of the data generated and the implications of revised targets for delayed discharge issued by the SEHD in February 2006. The latest data showed that delayed discharge has worsened with the problem being particularly concentrated in North Ayrshire.
In the light of these developments, NHS Ayrshire & Arran agreed to ensure that they are doing all that they can in areas that they are responsible for in relation to delayed discharge. It was proposed that the CitiStat Pilot should not be abandoned but that it should continue as an internal NHS Ayrshire and Arran meeting focusing on hot spots, as illustrated by the analysis of data. It was noted that the CitiStat process to date had made this evident and helped to escalate the process of scrutinising data. In addition, NHS Ayrshire & Arran intend to propose meetings with individual local authority partners to address specific issues which have been identified through the CitiStat process. There is some urgency evident as the data illustrates that the problem is worsening and recent policy decisions in relation to funding of local authority services may impact adversely on key areas of community care, with knock on effects on delayed discharge across the whole system
The achievement of success factors and response to the challenges presented
The second evaluation session was attended by six participants, including members of the Panel, the Podium and observers. There was also an evaluative discussion after the internal NHS meeting in March 2006. Scottish Executive support for the CitiStat Pilot process formally ended in March 2006 and the evaluation process also ended at the same time.
Outcome 1: Make CitiStat work on a Partnership basis
The goal of making CitiStat work on a Partnership basis was a clear priority. After the second meeting, there was a sense of achievement in bringing the parties together.
"….we actually had the local authorities and health service at a very high level sitting round the table for the second time and we've not done that before have we at the high strategic level?"
"I expected more challenges and difficulties because we've never had these conversations together before…."
Despite the later developments, this sense of achievement did not entirely dissipate; NHS Ayrshire & Arran participants noted that the CitiStat process had probably been the first time that the organisations had come together to talk about delayed discharge and it was felt to have been useful for them to observe and learn about each other. The agreement to reduce the target of delayed discharges of over six weeks to zero, was also an important decision.
The CitiStat process did highlight a number of weaknesses in the partnership arrangements, as well as in operational performance management which were ultimately to lead to a refocusing of the process. At the second meeting, the process raised issues of accountability between the four organisations and whether the Chief Executive of Ayrshire and Arran NHS could legitimately hold local authorities to account. The nature of the governance arrangements across the agencies would suggest that an NHS Chief Executive could not do this. However, this view was challenged.
"…..except that we are part of a partnership, we have all signed up to a partnership….and my argument has always been we just agree to them, we've not actually made them active…… we've signed up to this partnership, as you have, and that partnership should be delivering A, B and C. And so in that regard we've actually tweaked our governance arrangements and our accountability already but we haven't fully acknowledged them".
"I think we've just written them [the partnership agreements] up, put them on a shelf and moved onto the next bit of business when in fact we've got a vehicle there that really could deliver for us."
There was a strong sense that the key task for CitiStat was to establish accountable, responsible relationships first, before using the process as a performance management tool. This might mean that it could take longer to tackle the issue of delayed discharges and that targets may not be met, but that there would be benefits in the long term.
"Together we say 'hang on a minute Minister. We don't blame each other, we are really fighting this corner together and that's a long term benefit".
In this sense, Ayrshire and Arran CitiStat had begun to make progress towards their vision of success, effectively prioritising the development of a joint and genuinely shared agenda. The process had managed to get the NHS and some of the local authorities together at a high level; this was seen as an energising and significant achievement.
The vulnerability of the mechanisms for accountability were illustrated by the issue of revised targets for delayed discharge by the SEHD in February 2006; these hold the NHS to account for delayed discharge rather than joint accountability with local authorities. This highlighted that whilst the four organisations do have mechanisms for joint planning, they do not have mechanisms for joint accountability; " SEHD are talking to the wrong people". This illustrated that to make CitiStat work on a partnership basis would require clarification of the joint accountability of the various organisations for reaching the target and shared prioritisation of the tasks required to do so across the partnership.
Outcome 2: Adapt the CitiStat process to suit our style of working
Important changes were made to the CitiStat process. A decision was taken to reduce the number of observers to make the process feel less artificial. The meetings were also significantly longer than the formal 'hour' and were based on dialogue between all the participants, including some involvement from observers.
"One of the things we're doing is kind of moulding CitiStat to our way of working which is not necessarily a bad thing, although if the desire for CitiStat was that it was going to deliver those kind of meetings where you said 'why haven't you done this, do it by next week' then we've failed."
Thinking had also developed about the appropriate focus of the Pilot. There was a sense that no single organisation had a full overview of what was happening across the area; "nobody in any system understands it all." This suggested that rather than focusing on the 'hot spot' of delayed discharges that the Pilot should take a 'whole system' view looking across a range of issues that could contribute to delivering the outcome of better care for the elderly. This perspective would look at a range of indicators that do not measure delayed discharges, but the provision of a service by a number of different providers and agencies. The process had exposed a significant weakness in the knowledge base, since the data available for the process did not allow investigation of causes or measure outcomes. These developments informed the decision to take a step back in the process and refocus the process through the Discharge and Capacity Planning Group.
Other outcomes
The developments in the CitiStat Pilot in Ayrshire & Arran mean that there is limited evidence in relation to the other success factors listed in Table A4.1. Participants from NHS Ayrshire & Arran believe that CitiStat has contributed towards improving the quality of data and that better data have allowed clearer identification of 'hot spots'. However, the CitiStat Pilot is credited with prompting a number of other developments. These include an internal NHS Ayrshire & Arran review of data systems and processes in delayed discharges to achieve improvements in data quality and availability; measures to strengthen the evaluation of the work of the Discharge and Capacity Group and proposals for meetings with partners to discuss progressing towards new targets. The development of local key indicators and a balanced scorecard to reflect these are also being considered as a way forward to look at performance indicators that link to performance improvements in this area. Partnership arrangements have also been highlighted as an area for review.
Whether these developments ensure that the CitiStat process achieves change, is different from previous efforts to tackle delayed discharge and is one for which the costs of the exercise are worthwhile remains to be seen.
Conclusions and implications
The Ayrshire and Arran case study demonstrates a number of useful strategic lessons about how to use CitiStat on a partnership basis. It highlighted weakness in existing partnership arrangements and the lack of any joint performance management of partnership agreements. It highlighted a lack of recognition amongst key professionals of the scope of existing governance and accountability arrangements embodied in partnership agreements and thereby opened up the possibility to making those partnerships work more effectively. It also illustrated that effective partnership working requires clear direction from the Scottish Executive in order to ensure that all partners recognise their role in relation to delayed discharge and give priority to tackling it.
CitiStat has enabled some important joint decisions to be made in relation to delayed discharges within Ayrshire and Arran and allowed the negotiation of and clarity about the nature of the issues, shifting the focus to a broader, whole system perspective to enable a collective overview to begin to be developed. This approach was ultimately undermined by the weaknesses in the accountability arrangements for measuring joint performance within the partnership; however, improvements in the quality of data available may now allow for the development of a realistic and feasible targeted approach.
Ayrshire & Arran made a number of small, but significant changes to the way that CitiStat sessions operated to better suit their style of working. Their experience shows the flexibility of the CitiStat model and the extent to which it can be re-invented rather than strictly replicated, to suit the local context and working cultures.
« Previous | Contents | Next »