In this report we have built on the inter-dependencies of the recommendations (see attached Appendix) and our assessment as at the end of December 2017 to identify some key points and recurring themes. These are set in the context of our work at NHS Tayside but may also be useful for other organisations looking to learn from this process. The latter also maps to recommendation 14 of the AAG Staging Report, which encouraged Scottish Government to embrace learning opportunities arising from the experience of NHS Tayside.
Short-term Financial Position vs Sustainable Long Term Services
This second report identifies that progress has been made in reducing the level of deficit now being forecast for the current financial year; but also highlights that continuing effort is required to sustain or improve the final outturn for 2017/18 and that equivalent or greater efforts will be required in 2018/19. The return of NHS Tayside to sustainable financial balance, which is not reliant on short term measures or non-recurring efficiencies, will only be achieved through transformational change which addresses the structural issues identified in the AAG Staging Report. Major service transformation will need to be driven by the Integrated Clinical Strategy ( ICS), but the Board also needs to be assured that opportunities for improvements and efficiencies identified by benchmarking are being examined and implemented locally wherever possible as part of business as usual operations.
There are tensions inherent in balancing the need to focus on the short term position against the strategic thinking, engagement and commitment required to deliver longer term sustainable services. It is essential that the Board ensures that its leaders have the capability and capacity to manage this.
Data and information to inform short and longer term decision making
It will not be possible to properly model, or to effectively implement, new arrangements which will enable NHS Tayside to provide quality services within its means, without also having in place comprehensive financial and workforce reporting and planning arrangements, and being able to manage prescribing costs. We are encouraged by the work that has been done to deliver new reporting arrangements, enabling a better understanding of the current position, alongside new arrangements for business planning. We believe that this work has set the foundations that will support the Board to understand the impact of new approaches that must be considered under the ICS, and to deliver the benefits of implementing these.
We have also noted the importance of having appropriate rigour around the timetables for the production of reports, particularly where these are provided to support decision making by Non-Executive Members. It is essential that information is provided in a way that allows sufficient time for it to be read, understood and thereby effectively challenged. Linked to this, NHS Tayside needs to ensure that Non-Executive Members and staff side representatives get appropriate support and training to understand the papers and proposals that are presented to them.
Capacity and Capability
There is still much work to be done to mature all the new systems and processes that have been put in place and it will be essential for NHS Tayside to have the capacity and capability to ensure that the benefits anticipated from the new arrangements are fully delivered. We have supported NHS Tayside in its efforts to secure senior support in the area of strategic planning which was recognised as being a deficit in the AAG report. We welcome the appointment of an interim Strategic Planning Director who will be critical in ensuring that the strands of financial and workforce planning are aligned in support of delivery of the Integrated Clinical Strategy. NHS Tayside will need to consider how this requirement can be fulfilled in the longer term; and to ensure that it takes a self-critical approach to continually assessing whether it has the correct skill mix to successfully address new challenges.
Team Working and Learning from elsewhere
We have seen evidence of the willingness of the Executive Team to work together on their own development, individually and as a team. Strong team working is essential to delivering high performing systems and during our engagement with the Executive Team we have seen evidence of improved team working. This progress needs to be maintained. We have also observed the impact which has resulted from a fresh approach, such as the closer involvement of Alan Gray, who was appointed as Regional Finance Lead for the North of Scotland. As the arrangements for working collaboratively across regions develop there will be further opportunities for NHS Tayside to benefit from enhanced capability and capacity across the region, and to consider what this means for existing structures within the Board. We would encourage NHS Tayside to be outward focussed, to look to learn from other systems, to be self-critical about their own ways of working, and to bring new insight and experience into the team where possible.
An Outcomes Focus
Throughout the period of our engagement with NHS Tayside, we have been aware of the significant level of activity and effort which has been dedicated to implementing the range of activities associated with the AAG recommendations. We recognise that, in such a time pressured situation, it can be difficult to find the space to take an overview. However, it is critical that NHS Tayside puts in place a process to ensure it maintains a consistent focus on the wider picture and an understanding of how, and what each of these tasks and activities contributes to delivery of the intended outcomes.
An Open and Transparent approach
Since our first involvement with NHS Tayside in July 2017 the Board has moved to a position where less business is taken in closed session and there is a more open and proactive approach to sharing information about issues and potential solutions. This has contributed to the signs of improved partnership working which we refer to in our report. Maintaining an open and transparent approach will be extremely important as NHS Tayside seeks to approve and implement the transformational change which will secure sustainable quality services.
Culture and Leadership
It will be important for the Board, the Chief Executive and the Executive Team of NHS Tayside to continue to focus on the full implementation of the recommendations in the AAG report, and particularly on ensuring that the measures that have been put in place do deliver the intended outcomes. Leadership is not the preserve of the senior team of any organisation and the Board also needs to be mindful that demonstrating appropriate leadership behaviours, and developing leadership across its staff needs to be part of on-going every day business, which is embedded as part of the organisation's culture.