The Scottish Government

LOCAL DELIVERY PLAN 2009/10

PRIORITIES FOR NHS SCOTLAND

GUIDANCE

A printable PDF version of this document is also available.

Contents

• Introduction

• LDP - Process and Timescales

• HEAT 2009/10 Targets

• LDP - Format and Content

• Supporting the Scottish Government's Outcomes Approach and Alignment with the National Performance Framework

• NHS Board Contributions to Single Outcome Agreements

• LDP Risk Narrative

• LDP Delivery Trajectories

• Financial Planning

• Workforce Planning

• NHS Island Boards Service Level Agreements

• HEAT Change Control Process

• HEAT Standards

• Development areas for potential inclusion in HEAT 2010/11

• NHS Area Board Planning

• Freedom of Information

• Special Health Boards

• Mid-Year Stock-Take and Annual Review 2008/09

Introduction

This Guidance sets out Ministers' key operational targets and performance measures for NHS Scotland, and describes their contribution towards meeting the Scottish Government's purpose and outcomes.

The Guidance reiterates the purpose of Local Delivery Plans ( LDPs), their format and content, timescales for completing them, and further relevant information to help NHS Boards complete plans for 2009/10.

LDP - Process and Timescales

The proposed timetable for the next 12 months is:

HEAT 2009/10 Targets

Throughout the year, people from across NHS Scotland have worked with their stakeholders to develop the HEAT core set for 2009/10. The Cabinet Secretary for Health and Wellbeing has now agreed the proposals put to her. The targets for 2009/10 focus NHS Scotland on working with its partners to deliver services that will support the Scottish Government's longer term outcomes.

There are 7 targets on Health improvement which concentrate on the contribution made by NHS Scotland to improve healthy life expectancy and tackle the inequalities in Scottish society. There is a new target on inequalities targeted cardiovascular health checks which signals the move to mainstreaming of inequalities targeted anticipatory care. For all Health Improvement targets, NHS Boards will need to consider local inequalities in planning and delivering their services.

There are 7 targets on Efficiency and Governance which will support the Efficiency and Productivity programme. NHS Boards will need to continue to remain in financial balance; and deliver 2% cash efficiencies to reinvest in their services. We want to see the NHS Scotland as a leader in reducing carbon emissions - there is a new HEAT target on reducing energy consumption with new more ambitious targets under development. NHS Boards will need to ensure that they have in place the information systems required to deliver all the H E A T targets.

There are 5 Access to Services targets. We have seen a step change in the waiting times for acute services over recent years and we will deliver an 18 week RTT from December 2011. This year the focus will be on new 12 week stage of treatment targets (covering all referrals to consultants) and making the organisational cultural change required to manage 18 week healthcare from referral, through diagnosis, to treatment. Cancer treatment needs to be equitable irrespective of the route in to hospital services and this is why we have introduced a new 31 day cancer treatment target. It is increasingly apparent that access to other health services also need to be world class, this is why we have introduced new targets to offer faster access to treatment for drug misuse; and faster access to child and adolescent mental health services. We recognise that in the first instance the focus needs to be on implementing referral pathways and information systems for these services. For the first time we will be using information from patient surveys to monitor access to GP services.

Under Treatment there are 10 targets. The public must have confidence in their NHS and know that they are going to get the best possible care whenever they need to go into hospital, this is why we have introduced a new target on reducing C.diff infections. There is also a performance measure introduced for the existing target on level of older people with complex care needs receiving care at home.

HEAT 2009/10 Targets

HEAT target numbering is sequential from 2008/09 onwards.

LDP - Format and Content

LDPs set out the delivery agreement for 2009/10 to 2011/12 between DG Health and each NHS Board, based on the 29 targets and their 34 key performance measures.

• Health Improvement for the people of Scotland - improving life expectancy and healthy life expectancy;

• Efficiency and Governance Improvements - continually improve the efficiency and effectiveness of the NHS;

• Access to Services - recognising patients' need for quicker and easier use of NHS services; and

• Treatment Appropriate to Individuals - ensure patients receive high quality services that meet their needs.

The 29 targets will be performance managed using 34 key performance measures (some of the targets are expressed in a way that requires 2 or more measures to adequately reflect performance).

The HEAT targets will be kept under review with the help of the Boards, and we intend to update targets and measures by Autumn 2009, subject to approval by the Cabinet Secretary for Health and Wellbeing.

The LDPs for 2009/10 will support their purpose of recording agreement on Boards' planned progress towards meeting key national targets, and the additional local commitments made to support the relevant Single Outcome Agreements. They will cover a period of 3 years, with the opportunity to review and adjust future years' plans each year. The LDP templates for 2009/10, to be completed by all Boards, are attached:

Annex 1 Supporting the Scottish Government's Outcomes-based approach

Annex 2 LDP Risk Narrative

Annex 3 LDP Delivery Trajectories

Annex 4 LDP Financial Plans

Annex 5 Summary of main workforce issues facing Boards

Annex 6 Additional Local Commitments to support Single Outcome Agreements

As for 2008-09, the LDPs include Delivery Trajectories and Risk Narrative for each target and these are supported by workforce narrative and financial plans.

The 2009/10 LDP Methods and Sources describes the performance measures used to monitor performance.

Supporting the Scottish Government's Outcomes Approach and Alignment with the National Performance Framework

In order to comply with the Public Bodies guidance on developing an outcomes-based approach, in his letter to Chief Executives on 30 September 2008, Kevin Woods explained that the 2009/10 LDP guidance would include suggested text (to be amended as appropriate to reflect local circumstances) for inclusion in NHS Board 2009/10 LDPs. This suggested text (Annex 1) sets out the way in which the process of developing and agreeing the HEAT targets for NHS Scotland reflects the outcomes-based approach required of public bodies in Scotland, how it complements and supports Health Board discussions with their Community Planning Partnerships (CPPs), and ultimately how it underpins their contribution to the achievement of the Government's Purpose and National Outcomes. It also provides a suggested mapping between the 2009/10 HEAT targets, the relevant National Outcomes and the Purpose Targets to further support these discussions.

NHS Board Contributions to Single Outcome Agreements

To reflect the discussions Boards will be having with their CPPs, for the first time in the 2009/10 LDP, Boards are invited to set out a brief narrative describing any additional priorities they commit to, over and above those described by the HEAT targets, which underpin their contribution to the shared Local Outcomes agreed through the Single Outcome Agreement process. This narrative should summarise the relevant local outcome(s); the workforce and financial resource associated with the commitments; and the measures that you will be using to performance manage the commitments. Annex 6 should be used to set out this narrative. We plan to discuss progress against these commitments at the mid-year stock-takes and Annual reviews. It is recognised that the SOA process continues to evolve, so this approach will be reviewed during 2009/10.

LDP Risk Narrative

Boards should, as in previous years, use the LDP Risk Narrative (Annex 2) to provide contextual information on key risks to delivery of each target and how risks are being managed regarding.

• Delivery: briefly highlight local issues and risks that may impact on the achievement of targets and/or the planned performance trajectories towards targets and how these risks will be managed.
• Workforce: brief narrative on the workforce implications of each of the HEAT targets where appropriate and relevant. This should include an assessment of staff availability to deliver the target, the need for any training and development to ensure staff have the competency levels required, and consideration of affordability cross referenced to the Financial Plan.
• Finance: Where applicable boards should identify and explain any specific issues e.g. cost pressures or financial dependencies specifically related to achieving the target. There is no need to repeat generic financial risks that apply to all targets.
• Improvement: Where applicable, boards should outline any risks to sustainable improvement, particularly in respect of their national improvement programmes and implementation of lean methodology, required to deliver and sustain targets and how these are being managed.

The template has been revised this year so that the description of the key risk should be provided in the first column and detail on how the risk is being managed should be provided in the second column. Cross-refer to local plans where necessary.

LDP Delivery Trajectories

Setting out planned performance against key measures in the LDP Delivery Trajectories (Annex 3) will enable Boards and DG Health to track actual operational performance against Boards' plans. This therefore provides an objective, factual basis to discuss with Boards any operational performance issues that may arise during the plan period and to offer support to achieve improvement if that is needed. Please ensure that the correct pro-formas are completed in line with the guidance and if in doubt, ask for assistance. Please submit the pro-formas in Excel, and not as a Word document; submit the pro-formas as a stand-alone file and not embedded within the LDP Risk Narrative; and ensure that planned levels/trajectories use the correct units/measure (rates etc) at the requested time frequency. If the pro-formas are not completed as requested, we may have to return them to be corrected.

LDPs should provide 34 trajectories showing planned levels of performance against each of the key performance measures over the 3 years 2008-09 to 2010-11. The Scottish Government will also be monitoring progress against delivery milestones, for those targets that do not have performance measures (for example, drug misuse treatment and CAMHS).

The Health Delivery Directorate will continue to support Boards in benchmarking their performance, and will work on spreading good practice associated with good and improving performance.

This quantified and measured approach to performance planning and monitoring does not imply any reduction in the importance of the qualitative aspects of performance. Providing assurance to the Board, its Clinical Governance Committee and the public about the quality of healthcare services continues to be a vital task for each Board. Local monitoring of quality will continue to be augmented at the national level by NHS QIS's reviews of NHS Boards' performance against national clinical standards. QIS reports will continue to be monitored by DG Health.

Trajectory Change Control Process

Once an LDP has been agreed and signed off by DG Health and the Board, any mid-year alterations to trajectories need to be agreed between the Health Delivery Directorate and the Board. The trajectory change control process to alter trajectories will be operated by the performance management teams in Health Delivery Directorate. If a Board wants to propose changes to trajectories after they are agreed and signed off, they should contact John Connaghan, Director of Delivery, in the first instance.

Financial Planning

Financial planning is an integral component of LDPs. NHS Boards should include draft financial plans as part of their LDP submission, in line with the timetable presented in paragraph 3. In particular, NHS Boards are asked to complete the financial templates at Annex 4. Particular emphasis should be placed on workforce planning and NHS Boards should provide assurances that their proposed staffing requirements are affordable.

The detailed financial information included in the templates will be used to assess each Board's financial projections, including key risks/assumptions, to ensure achievement of financial targets. Monthly performance assessment of the agreed financial plan/trajectory will continue to be based on the Monthly Monitoring Returns.

Workforce Planning

Workforce planning continues to be a key factor in enabling NHS Boards to ensure that the delivery of services is focused on patient need. The workforce narrative at Annex 2 therefore helps to ensure that the workforce implications of key HEAT targets are fully taken into account in NHS Boards' LDPs. It is recognised, however, that HEAT targets and LDPs do not represent the complete range of NHS Board services which rely on the right workforce mix for successful delivery.

NHS Boards are therefore also required to publish their wider workforce plans by April 2009. As for last year, although they remain an important NHS Board function, these plans do not require to be formally submitted to the Scottish Government, since they are primarily for the use of NHS Boards as part of their overall business planning. However, as for last year, a workforce projections template will be required to be completed and submitted to the Scottish Government by April 2009 but with some enhancement as set out below.

Workforce projections were collected in April 2008 as part of a plan of action set out in Better Health, Better Care: Planning Tomorrow's Workforce Today. That document also asked Regional Workforce Directors to consider how best to capture headline information data on staff groups over the short to medium term. To ensure clearer linkages between workforce plans and projections, and to move forward that second action, NHS Boards will be required to include some additional narrative in their workforce projections in April 2009. Detailed guidance on, and a template for, workforce projections will be issued in due course but the additional narrative will seek to capture headline information which will include at least:

• information on significant changes in skill mix and the plans to take this forward;

• existing and planned new service areas with particular workforce pressures and possible solutions; and

• other significant workforce issues that the Scottish Government should be aware of that may require a national focus.

It is recognised that the full detail around these 3 headlines will not be available by the deadline for submission of LDPs on 18 February 2009. However, NHS Boards are invited to include in their LDPs at Annex 5, a brief summary of the main workforce issues, based around the 3 headlines above, which are likely to be explored further in their April projections return. This will allow those issues to be flagged up earlier in the overall planning cycle and for further movement towards greater alignment between service, financial and workforce planning as set out in Better Health, Better Care: Planning Tomorrow's Workforce Today.

NHS Island Boards Service Level Agreements

The Scottish Government is committed to retaining and ensuring the long term sustainability of Scotland's three island Boards (NHS Orkney, NHS Shetland and NHS Western Isles). The independence of these Boards allows them to develop and deliver services which meet the needs of their local population in ways that reflect the challenges of providing high quality services for island communities.

Each island Board has, over many years, played a full and active part within the regional planning process under which Boards agree to collaborate in order to develop and sustain healthcare services. It has now been agreed to provide the support funding to enable NHS Boards to extend the concept of collaborative working to non clinical as well as clinical issues. Additional funding has been allocated to each island Board to enable them to enter into arrangements with their respective partners to strengthen their capability in areas such as: Human resources; Finance / Payroll; Governance; and Planning. It will enable Boards to set out an agreement that describes joint programmes of work between:

• NHS Orkney and NHS Grampian;
• NHS Shetland and NHS Grampian; and
• NHS Western Isles and NHS Highland

The three island Boards will remain independent and the precise shape and form of these partnership arrangements will be a matter for the members of the partnership themselves. They will be developed as a partnership of equals and it is anticipated that a Non Executive Director from each partner will attend the Board meeting of the other partner in order to ensure effective ongoing liaison at the very highest level. The annual service agreement itself will form an addendum to the 2008-09 Local Delivery Plan of each partner. There may, of course, be some exceptional circumstances in which the partners agree that the identified mainline partner Board is unable to provide a particular service, and in these cases, the island Board will be able to source this requirement from an alternative partner. All Boards have committed to developing agreements with their partner Boards by 30 November 2008.

HEAT Change Control Process

The HEAT change control process (for HEAT Targets and Measures) will as before consist of an annual review and be co-ordinated by the Health Delivery Directorate. Any proposals for change will go to Ministers for approval. Any changes agreed by Ministers would be incorporated into the LDP Guidance for 2009-10.

HEAT Standards

7 HEAT 2008/09 targets will become HEAT 2009/10 standards. Performance against these standards will be monitored. The Annual Review would pick up any NHS Boards failing to sustain performance across all sites, and the target would be added to those NHS Boards' HEAT targets for 2009/10.

• E1 Lab requests with a valid CHI (Universal use of CHI target).

• E2 NHS Boards to achieve a sickness absence rate of 4% from 31 March 2009.
• A3 To respond to 75% of Category A calls within 8 minutes from April 2009 onwards across mainland Scotland.
• A4 As a milestone in achieving 18 weeks referral to treatment, no patient will wait longer than 15 weeks from GP referral to a first outpatient appointment from 31 March 2009.
• A5 As a milestone in achieving 18 weeks referral to treatment, no patient will wait longer than 15 weeks for inpatient or day case treatment from 31 March 2009.
• A6 As a milestone in achieving 18 weeks referral to treatment, no patient will wait longer than 6 weeks for one of the 8 key diagnostic tests from 31 March 2009.
• A7…,and from end 2007 no patient will wait more than 4 hours from arrival to admission, discharge or transfer for accident and emergency treatment.

Development areas for potential inclusion in HEAT 2010/11

The Health Improvement Performance Management group has been reviewing the child oral health target with the intention for a new target in HEAT 2010/11. This will focus on an effective NHS contribution (fluoride varnishing of children's teeth) towards reducing inequalities in child dental health (National Indicator 11). This target would be delivered through Childsmile - and it is therefore necessary that Childsmile is fully rolled out across Scotland before it can be introduced. Childsmile is due to be fully integrated by 2011. A HEAT target that represents the immediate result of the NHS contribution to Childsmile will help mainstream practise as identified in SIGN 83. There is a need to ensure that the numbers accessing preventive care is increased

The Efficiency and Productivity Programme established in April 2008, and described in Better Health Better Care, will review the 2009/10 HEAT targets, and make recommendations relating to proposed revised or new targets for 2010/11 which are agreed to support NHS Scotland in achieving required cash efficiency savings. In particular, we would expect to see a new targets on theatre utilization and variation in outpatient referrals to be considered for inclusion in HEAT 2009/10.

The Community Care Outcomes working group is developing HEAT performance measures and (where possible) targets for six themes - user satisfaction, faster access, support for carers, quality of assessment, risk of admission, and balance of care. The HEAT standard on delayed discharges supports 'faster access'. The existing HEAT target to increase the level of older people with complex care needs receiving care at home supports the 'balance of care'; although we are keen to develop a better performance measure which would take better account of people's relative needs irrespective of the way these needs are met. To this end plans to introduce the Single Shared Assessment - Indicator of Relative Need (IoRN) in HEAT 2010/11 will be taken forward with NHS Health Boards and local authorities. Work is also underway to develop performance measures for the other themes, and for some at least (e.g. risk of admission) we would expect to receive proposals to include in next year's HEAT.

Following the completion and publication of the Collective Assessment of Special Health Boards work may be required to consider the development of HEAT targets that reflect the delivery of patient / public facing services by such Boards. This will be confirmed by end November 2008.

Development work is also underway across a number of areas in primary and community healthcare including:

• Diabetes Care by non-specialists in a community healthcare setting;
• Palliative Care - improved co-ordination of patient care in accordance with their needs and wishes;
• the Community Pharmacy Chronic Medication Service;
• reducing the variability of OOH contacts with NHS24 and referrals to PCEC/OOH Centres through improved access to in-hours care;
• routine assessment of bone health in people who have a history of fragility and low impact fracture, in the age group 60 to 75 years" (secondary prevention of fractures and reducing future fractures and any related hospital attendances/admissions) as suggested by the Scottish hip Fracture Audit Report of 2007, SIGN Guideline 71 and NICE Health Technology Appraisal guidance and guidelines; and
• Self care / self management in light of the new self management strategy for Scotland.

For these targets, work is required to develop the evidence base and to seek further views from NHS Boards over the coming year.

NHS Board Planning

As noted above, NHS Boards should continue with planning arrangements at local and regional level, engaging with local and regional partners across the full range of health policy, planning, service re-design and delivery issues. Boards should ensure that these activities and their LDPs are consistent with the direction set in Better Health, Better Care. Boards are free to use the formats and timings that suit them and their partners, within existing agreements and guidance on local, community and regional planning. Boards should ensure that they continue to fulfil their statutory obligations on co-operation and public involvement. Boards should also ensure that local and regional planning supports their performance agreement with DG Health set out in the LDP, and that focus and alignment is maintained across the full range of local service planning and delivery to ensure achievement of planned progress towards meeting the key targets in the LDP.

The LDP process is consistent with the current work being undertaken by NHS Boards in developing, supporting and setting objectives for CHPs. Clearly the efforts and performance of CHPs will be vital in meeting some of the key targets and Boards need to ensure that CHPs play their full part in helping to meet the key targets as planned.

The LDP process continues to sit within the broader planning framework for NHS Boards. The future development of this framework is currently subject to review by NHS Directors of Planning and at present therefore existing guidance on elements of the planning process (for example the arrangements described for Pay Modernisation Plans ( HDL 2005/28) and Regional Planning ( HDL 2004/46)) remain in place. The achievement of targets set out in LDPs is also underpinned by service delivery and improvement work across the Service including that co-ordinated by the Improvement and Support and Access Teams in the Health Delivery Directorate and policy leads within Health Directorates. This detailed underpinning work will continue to play a vital role in supporting Boards to meet the targets set out in the LDP.

Freedom of Information

LDPs will be releasable under the Freedom of Information Act and Boards will want to make arrangements locally to place them (once agreed) in the public domain alongside other local plans.

Special Health Boards

Special Health Boards are expected to comply with the Public Bodies guidance on developing an outcomes-based approach. Special Health Board LDPs will include a section describing how their objectives support the national outcomes.

The Collective Assessment of the role of Scotland's Special Health Boards is due to report in November 2009. Amongst other things, this will examine the role of performance management in relation to Special Health Boards and make recommendations about the future development of such approaches. This may include the development of one or more new / revised HEAT targets covering patient / public services provided by such Boards (see paragraph 34)

For 2009/10 SHBs are required to complete LDP Risk Narrative and LDP Delivery Trajectories (Annexes 2 and 3) for the following targets:

• E5 NHS Boards to operate within their agreed revenue resource limit; operate within their capital resource limit; meet their cash requirement.
• E6 NHS Boards to meet their cash efficiency target.
• E8 NHS Scotland to reduce emissions over the period to 2011
• E10 NHS Boards to ensure at least 80 per cent of staff covered by Agenda for Change to have their annual Knowledge Skills Framework development reviews completed and recorded on e-KSF by March 2011.
• T2 QIS clinical governance and risk management standards improving

SHBs are also required to complete their Financial Templates (Annex 4)

SHBs will also identify in their LDPs their contribution towards achievement of the 29 HEAT targets, where that is appropriate (not all SHBs make a contribution to all targets). The approach to detailing and assessing this contribution is also subject to consideration within the Collective Assessment of Special Health Boards and it is intended to confirm any changes to the guidance in this respect by mid December 2008.

Health Directorate lead sponsors will provide guidance and advice on LDP content and will advise on any implications stemming from the Collective Assessment of the Special Health Boards. It is anticipated that for 2009/10 these are likely to focus in particular on demonstrating the support provided to territorial Boards in achieving key HEAT targets across Scotland measured through SMART targets and performance measures.

SHBs should submit their LDPs by 18 February 2009, together with their associated financial plans.

Any change to SHBs' LDP after sign-off in March 2008 must be agreed with the Health Directorates, following the same processes set out in earlier.

Mid-Year Stock-Take and Annual Review 2008/09

The Annual Review will continue to focus on performance against HEAT targets. Guidance will be issued shortly on the use of performance information and wider outcome measures in NHS Boards' self assessments to help provide the public with an understanding of how NHS Boards are contributing to the Scottish Government's national outcomes and purpose.

NHS Board Chief Executive and senior management team mid-year stock-takes with the Scottish Government Health Directors will provide the opportunity to take stock of 2008/09 performance, and also to look ahead to 2009/10.

The Chief Executive of NHS Scotland will be publishing an Annual Report in November 2008 which will report progress against the HEAT targetsfor 2007/08.

The Directorate of Delivery is considering options for a public facing website to report progress against HEAT targets. The future development of the HEAT Performance Management IT system ( http://bi.nss.scot.nhs.uk/heat) is also under consideration.