Highland Nhs Board

Assynt House Beechwood Park Inverness, IV2 3BW Telephone: 01463 717123 Fax: 01463 235189 Date of Issue: Textphone users can contact us via Friday 2 August 2013 Typetalk: Tel 0800 959598 www.nhshighland.scot.nhs.uk

HIGHLAND NHS BOARD

MEETING OF BOARD

Tuesday 13 August 2013 at 8.30 am Board Room, Assynt House, Beechwood Park, Inverness

AGENDA

1 Apologies

1.1 Declarations of Interest – Members are asked to consider whether they have an interest to declare in relation to any item on the agenda for this meeting. Any Member making a declaration of interest should indicate whether it is a financial or non-financial interest and include some information on the nature of the interest. Advice may be sought from the Board Secretary’s Office prior to the meeting taking place.

1.2 New Appointments to Highland NHS Board

THE HIGHLAND QUALITY APPROACH

1.3 Highland Quality Improvement System – Tier 1 Report Out to the Board – Radiotherapy for Patients with Breast Cancer Presentation by Anne Gent, Director of Human Resources, Linda Kirkland, Director of Quality Improvement, Elaine Mead, Chief Executive and Nigel Small, Director of Operations, South & Mid Operational Unit

This month’s update will include a presentation on Radiotherapy for Patients with Breast Cancer by Elaine Mead, Chief Executive and Nigel Small, Director of Operations, South & Mid.

The Board is asked to Note the Tier 1 Report to the Board on the Highland Quality Improvement System.

2 Minutes of Board Meetings: (a) 4 June 2013 (attached) (b) 27 June 2013 – Board in Committee (attached) (c) 27 June 2013 – Special Meeting of the Board (attached) (d) Board Rolling Action Plan (attached) (PP 1 – 24) The Board is asked to approve the Minutes. 2.1 Membership of Committees Report by Garry Coutts, Chair, NHS Highland (attached) (PP 25 – 28) The Board is asked to:  Review the current membership in view of recent vacancies and appointments.  Agree that the revised membership should be until 30/06/14 with a further report to the Board in June 2014.

3 PART 1 – REPORTS BY GOVERNANCE COMMITTEES

3.1 Argyll & Bute CHP Committee – Draft Minute of Meeting held on 19 June 2013 (attached) (PP 29 – 40) 3.2 Highland Health & Social Care Governance Committee Assurance Report of 4 July 2013 (attached) (PP 41 – 60) 3.3 Audit Committee – Draft Minutes of Meetings held on 28 May and 27 June 2013 (attached) (PP 61 – 80) 3.4 Staff Governance Committee – Draft Minute of Meeting of 21 May 2013 (attached) (PP 81 – 90) 3.5 Improvement Committee Assurance Report of 1 July 2013 and Balanced Scorecard (attached) (PP 91 – 106) 3.6 Area Clinical Forum – Draft Minute of Meeting held on 30 May 2013 (attached) (PP 107 – 116) 3.7 Asset Management Group – Draft Minutes of Meetings of 21 May and 18 June 2013 (attached) (PP 117 – 124) 3.8 Health & Safety Committee – Draft Minute of Meeting of 16 May 2013 (attached) (PP 125 – 134) 3.9 Pharmacy Practices Committee – National Appeal Panel – Decision in respect of 30 Laurel Avenue, Dalneigh, Inverness, IV3 5RP (attached) (PP 135 – 140) The Board is asked to: (a)  Note the Minutes. (b)  Note the Assurance Reports and agreed actions from the Highland Health & Social Care Governance Committee and the Improvement Committee.

Council/Highland NHS Board Joint Committees

3.10 Argyll & Bute Health and Social Care Strategic Partnership – Draft Minute of Meeting of 15 May 2013 (attached) (PP 141 – 146)

3.11 Highland Council Partnership – Adult & Children’s Services Committee – Minute of Meeting of 22 May 2013 (attached) (PP 147 – 170) The Board is asked to:  Note the Minutes.

2 4 PART 2 – THE HIGHLAND QUALITY APPROACH

4.1 Progress on Evaluation of Service Integration Report by Rachel Hill, Clinical Governance Manager, Frances Matthewson, Service Planning Analyst and Cameron Stark, Consultant in Public Health Medicine on behalf of Jan Baird, Director of Adult Care (attached)

NHS Highland as Lead Agency for adults has been progressing development of a five year strategic plan over the last twelve months, mindful of the need for synergy with other planning processes such as Community Planning and the Local Delivery planning process of NHS Scotland. Fundamental to all of this must be the ability to evidence improvements linked to the contribution integration has made. This report builds on the evidence base developed over the planning for integration stage and the evaluation work which has progressed using existing data and sourcing frontline public and staff opinion. (PP 171 – 176) The Board is asked to:

 Note information to date on the progress of services since integration.  Agree to support further work, and reporting to the Board.

4.2 Highland Quality Approach – Making it Happen – Progress to Date Report by Linda Kirkland, Director of Quality Improvement (attached)

In April and June 2013, the Board received formal Board papers on the next steps for the Highland Quality Approach and agreed a number of recommendations. This paper is an update on progress since June and details of next steps to be taken. (PP 177 – 210) The Board is asked to:

 Note the update of work in progress.

4.3 NHS Highland Workforce Development Plan 2013/14 Report by Pamela Cremin, Workforce Planning and Development Manager and Judith McKelvie, Head of Learning and Development on behalf of Anne Gent, Director of Human Resources (attached)

The Workforce Development Plan incorporates the Learning and Development Plan for NHS Highland to deliver an integrated Workforce Development Plan for 2013/14. (PP 211 – 268) The Board is asked to:

 Agree the NHS Highland Workforce Development Plan 2013/14.  Note the progress against the Workforce Plan Rolling Action Plan for 2012/13.  Note that the NHS Highland Learning & Development Plan 2013/14 has been incorporated into the Workforce Plan to deliver an integrated Workforce Development Plan for 2013/14.  Note the Workforce Plan Rolling Action Plan for 2013/14, to ensure workforce devolvement and alignment to meet the Board’s Quality Objectives and Strategic Framework.

3 5 PART 3 – CORPORATE GOVERNANCE / ASSURANCE

5.1 North of Scotland Planning Group Annual Report 2012/13 Report by Jim Cannon, Regional Director Planning, North of Scotland Planning Group (attached)

 Note the Annual Report for 2012/13.  Approve the Workplan for 2013/14.

5.2 NHSScotland Resilience – Preparing for Emergencies – Draft Guidance for NHSScotland Report by John Burnside, Business Continuity Manager on behalf of Elaine Mead, Chief Executive (attached)

“Preparing for Emergencies” is a revision of the existing national guidance for health services in Scotland, “NHSScotland – Responding to Major Emergencies” (2005) and will replace it from August 2013. The guidance promotes actions around raising the awareness of the role and responsibilities of the NHS in preparing for, responding to and supporting recovery from major incidents and emergency situations. (PP 309 – 312) The Board is asked to:

 Note the publication of the revised draft guidance.  Note the strategic nature of the guidance.  Note the final guidance will be published Mid August 2013.  Agree to its publication on the NHS Highland Intranet and Internet.

5.3 NHS Highland Financial Position as at 30 June 2013 Report by Nick Kenton, Director of Finance (attached) (PP 313 – 322) The Board is asked to:

 Note the forecast out-turn of break-even overall.  Note the requirement of a £9.8m improvement to achieve this.

5.4 Forres, Woodside and Tain (FWT) Bundle Project – Full Business Case Addendum Report by Nick Kenton, Director of Finance (attached)

The aim of the paper is to present to the Board the Full Business Case (FBC) Addendum for the FWT (Forres, Woodside and Tain) Bundle Project. This Addendum outlines briefly the changes since the FBC was presented to the Boards of NHS Grampian and NHS Highland on 5 February 2013, in particular it details the financial changes recorded at Financial Close and their variance from the figures in the Full Business Case. (PP 323 – 332) The Board is asked to:  Agree the Full Business Case Addendum for the FWT Bundle Project.

4 5.5 Infection Control Report Report by Liz McClurg, Infection Control Manager and Dr Jonty Mills, Consultant Microbiologist on behalf of Heidi May, Board Nurse Director & Executive Lead for Infection Control (attached) (PP 333 – 358) The Board is asked to:

 Note the performance position for the Board.  Note the progress to keep infection under control.

5.6 NHS Highland 2012/13 Keep Well Annual Report Report by Angus MacKiggan, Keep Well Coordinator & Public Health Business Manager on behalf of Margaret Somerville, Director of Public Health and Health Policy (attached)

NHS Boards are required to submit 2012/13 annual reports to the Scottish Government by 31 August 2013. However, there is an expectation by the Scottish Government that these reports are presented to local Boards prior to being formally submitted nationally. (PP 359 – 378) The Board is asked to:

 Note and discuss the content of the report prior to it being submitted to the Scottish Government by 31 August 2013.

5.7 Chief Executive’s and Directors’ Report Emerging Issues and Updates Report by Elaine Mead, Chief Executive (attached)

This month’s report incorporates updates on:  Argyll & Bute Mental Health Unit Development  NHS Highland Annual Review – 19 July 2013  Regional Planning – North of Scotland and West of Scotland Planning Group  Response to Audit Scotland recommendations on Improving Community Planning in Scotland  Update on Carers’ Strategy (PP 379 – 384) The Board is asked to:

 Note the Emerging Issues and Updates Report.

6 FOR INFORMATION

6.1 Date of next meeting

The next meeting of the Board will be held on 1 October 2013 in the Board Room, Assynt House, Inverness.

6.2 Any Other Competent Business

7 Close of Meeting

1 Highland NHS Board 13 August 2013 Item 2(a) Assynt House Beechwood Park Inverness IV2 3BW Tel: 01463 717123 Fax: 01463 235189 HIGHLAND NHS BOARD Textphone users can contact us via Typetalk: Tel 0800 959598 www.nhshighland.scot.nhs.uk/

DRAFT MINUTE of MEETING of the BOARD 4 June 2013 – 8 30 am Board Room, Assynt House, Beechwood Park, Inverness

Present Mr Garry Coutts, Chair Dr David Alston Mr Robin Creelman Mrs Myra Duncan Mr Mike Evans Dr Michael Foxley Mr Ian Gibson Dr Iain Kennedy Mr Alasdair Lawton Cllr John McAlpine Mr Okain McLennan Mr Ray Stewart Ms Sarah Wedgwood Ms Elaine Mead, Chief Executive Dr Ian Bashford, Board Medical Director Mrs Anne Gent, Director of Human Resources Mr Nick Kenton, Director of Finance Ms Heidi May, Board Nurse Director Dr Margaret Somerville, Director of Public Health & Health Policy

Also present Dr Adam Brown, Consultant Microbiologist, Raigmore Hospital (Item 48) Mrs Jan Baird, Director of Adult Care Ms Arlene Clark, Charge Nurse, Raigmore Hospital (Item 35) Ms Anne Cooks, Nursing Auxiliary, Raigmore Hospital (Item 35) Dr Paul Davidson, Clinical Lead, North & West (Item 36) Mr Tom Davison, Communications Manager Mr Jim Docherty, Consultant Surgeon, Raigmore Hospital (Item 35) Mr Carl Hope, Manager, Raigmore Hospital (Item ) Ms Donna Janssens, Service Manager, Raigmore Hospital (Item 35) Mrs Linda Kirkland, Director of Quality Improvement Mr Chris Lyons, Director of Operations, Raigmore Hospital (Item ) Mrs Gill McVicar, Director of Operations, North & West (Item 35 & 53) Mr Kenny Oliver, Board Secretary Mrs Lorraine Power, Board Services Assistant Mr Gordon Sansaver, Manager of Operations, Virginia Mason Institute, Seattle Ms Donna Smith, Service Performance & Partnership Manager, Raigmore Hospital (Item 54) Ms Janet Spence, Programme Manager (Modernisation and Quality Assurance) (Item 46) Ms Maimie Thompson, Head of Public Relations & Engagement

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Apologies – Apologies were received from Mrs Gillian McCreath, Mr Colin Punler, Ms Margaret Brown, Ms Deborah Jones and Mr Brian Robertson.

34 Declarations of Interest

Board members declared the following interests:

 Garry Coutts – Scottish Social Services Council (SSSC), ex officio of SSSC on the Care Inspectorate, University of the Highlands and Islands.  David Alston – UHI Board  Myra Duncan – Joint Improvement Team Action Group.  Mike Evans – Non-Executive Director, ILM Highland.  Michael Foxley – Further Education Regional Board, UHI  Iain Kennedy – member of the British Medical Association (BMA), Riverside Medical Practice  Ray Stewart – Employee Director and member of Unite.

The Board a Noted the Declarations of Interest.

THE HIGHLAND QUALITY APPROACH

35 Highland Quality Improvement System – Tier 1 Report Out to the Board – Endoscopy Redesign – Raigmore Hospital Presentation by Anne Gent, Director of Human Resources, Linda Kirkland, Director of Quality Improvement, Jim Docherty, Consultant Surgeon, Donna Janssens, Service Manager, Arlene Clark, Charge Nurse and Anne Cooks, Nursing Auxiliary

Anne Gent, Director of Human Resources advised that this Tier 1 Report out to the Board would focus on the Endoscopy Unit Redesign at Raigmore Hospital.

The team presenting to the Board were introduced and comprised:

 Mr Jim Docherty, Consultant Surgeon, Raigmore Hospital  Ms Donna Janssens, Service Manager, Raigmore Hospital  Ms Arlene Clark, Charge Nurse, Raigmore Hospital (Item )  Ms Anne Cooks, Nursing Auxiliary, Raigmore Hospital

Mr Docherty and Ms Janssens outlined the scope of the redesign, and a number of presenting issues and advised that staff were keen to improve the service. It had been agreed to focus on three workstreams:

 Improving Capacity – booking and scheduling and patient flow  Improving Flow of Patient Records and Information  Improving Space Utilisation the ‘5S’ (Sort, Simplify, Sweep, Standardise, Self-discipline)

Much work had been done in relation to ideas generation, value stream mapping and setting targets. Pre-work included booking and scheduling, looking at the demand and case mix and modelling the “list-shape”. The list modelling continued considering demand for different procedures, clinician availability and procedure room availability. In relation to the flow of patient records, this had been reduced from 8 days to 3 days.

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Achievements from the project included:  Capacity and demand model in development  Separate list for inpatients trialled  Flow of patients through the unit improved  Procedure room turnaround reduced  New reception area created  Space utilisation improved  Supplies reduced  To improve patient and staff experience.

The Board welcomed the Report Out and the Chair thanked the team for the presentation advising that the Board would wish to follow progress with the project.

The Board a Noted the Tier 1 Report to the Board on the Endoscopy Unit Redesign at Raigmore Hospital.

36 Highland Quality Approach – Making It Happen – Progress Report Report by Anne Gent, Director of Human Resources

At it’s meeting in April the Board endorsed the ‘Highland Quality Approach – Making it Happen’ document. The Progress Report provided an update to the Board on actions taken to date and identified the next steps to be taken in developing the Highland Quality Approach Implementation Plan. Mrs Gent, Director of Human Resources referred to the final visual representation of the Strategic Framework at Appendix 1 of the document and asked Ms Thompson to update on the plans for its wider circulation. It was noted that work was now underway to support wider circulation and understanding of the Strategic Framework. This would include having large poster versions visible in main NHS buildings and hospitals. The staff handbook, website and intranet were being updated to describe the thinking behind the Strategic Framework Triangle. Regular articles would be carried in Briefing Notes and Highlights and a miniature version of the Strategic Triangle was also being prepared to be used in 1:1 discussions with staff. Mrs Gent confirmed that following internal advertisement that Linda Kirkland, previously Head of Business Transformation, had been appointed to the re-profiled Director of Quality Improvement post.

The update then focussed on the Lean Leader Training Programme being delivered by Tees, Esk and Wear Valleys (TEWVs) Mental Health NHS Foundation Trust. Some of the participants in the programme had agreed to talk to the Board for 3 minutes each about their experience of the programme:

Ian Bashford, Board Medical Director – Dr Bashford praised Lean and now aimed to get this topic into every conversation with staff. He spoke enthusiastically about the training, highlighting that NHS Highland was at the beginning of a long journey, the GEMBA and the power of direct observation and the need for a common sense approach. He also emphasised the need to have simple standards in place and for absolute rigour in processes and that he was still learning every day.

Nick Kenton, Director of Finance – Mr Kenton confirmed that the training by Tees, Esk and Wear Valleys was of a very high standard. He referred to the concept of “just in time” in relation to deliveries, supplies, infrastructure etc. and also emphasised the need for rigour in our approach using the phrase “inch wide, mile deep”. All participants in the training had observed waste. Mr Kenton highlighted the need for a never-ending cycle of continuous improvement and the need to respect and empower staff to implement.

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Paul Davidson, Clinical Director, North & West – Dr Davidson highlighted that Lean was also about Quality in relation to individuals, staff and patients and NHS Highland needed to trust and co- operate with these individuals. It was also about the development of others and being permissive in encouraging people to self-develop. Regarding culture, there was a need to allow people to come forward with ideas and mentorship was also important. Dr Davidson hoped to be able to improve quality and accountability and felt that by following a Lean path that this could be achieved.

Elaine Mead, Chief Executive – Ms Mead referred to the next stage in the training, undertaking Rapid Process Improvement Workshops (RPIWs), which would lead to accreditation, and referred to the work she was leading in the Radiotherapy Department. She advised that learning becomes a way you share with staff and that you need to see things with your own eyes. Follow through on workstreams was very important, hence the planned 30, 60 and 90 day report outs during the process. Ms Mead highlighted the difference between Lean and Improvement Science; Lean relating to taking out waste, releasing capacity and using the additional capacity compared to Improvement Science, which related to small cycles of change. Both were valid and a blend of both could be used. Ms Mead also emphasised the need to see things through the eyes of the patient.

Mrs Gent advised that the Executive team were identifying priorities for RPIWs for 2013. In addition early conversations had commenced with Virginia Mason Institute regarding the possible development of a Physicians Compact. Appendices 3 and 4 of the report gave examples of the Virginia Mason Physicians Compact and the TEWVs Staff Compact.

There followed a detailed discussion on the various strands of work relating to the Highland Quality Approach. Dr Kennedy offered help in relation to the Physicians Compact, and suggested that this should be for all staff, including those in Adult Social Care. The Chief Executive confirmed this would be discussed further outwith the meeting. Dr Kennedy asked about projects in a GP or social care setting as he thought most of the HQA work related to hospitals. The Chair referred to the previous update to the Board on RNI Discharge Planning in conjunction with York Day Centre and MacKenzie Centre, which had also worked with GPs. The Chief Executive also referred to the work around patient flow and discharge planning and confirmed that there was significant input from social care and GPs, which could be evidenced. Dr Alston highlighted the need for some of NHS Highland’s partners, including local authorities, to have a sufficient understanding of the HQA. The Chair referred to a meeting arranged for 2 July with Highland Council and advised that it might be possible to extend this to a wider group. A question was raised regarding the timeline for the development of an implementation plan in relation to HQA. Mrs Gent advised that and implementation plan would be developed, considering the Local and Operational Delivery Plans, and would be reported to the Board in due course.

The Chair noted the extent of the work around HQA and Lean, advising that not all work would be reported to the Board, but that there did need to be a system in place to give the Board assurance.

The Board a Agreed the final visual representation of the Strategic Framework and plans for its wider use and circulation (Appendix I in the report). b Noted:

 The current position in relation to the recruitment to the Post of Director of Quality Improvement.  The content and format for the Lean Leader Training Programme – being delivered by Tees, Esk and Wear Valley’s Mental Health NHS Foundation Trust for participants in Cohorts 1 and 2.

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 The process for identifying priority areas for Rapid Process Improvement Workshops for 2013.  The next steps to be taken in relation to leadership arrangements and the development of a Physicians/Staff Compact.

37 Minute of Meeting of 9 April 2013

The minute of meeting held on 9 April 2013 was approved.

The Board

a Approved the Minute of Meeting held on 9 April 2013.

38 Matters Arising

Review of Governance and Membership of Committees – reference was made to the item on the Board Rolling Action Plan regarding Governance Committees and governance arrangements. The Chair advised that there was work in progress and he would write to Board members following discussion and report back to the Board either in August or October.

The Board

a Noted that there was work in progress in relation to the Review of Governance and Membership of Committees and that a report would be submitted to the Board in due course.

REPORTS BY GOVERNANCE COMMITTEES

39 Argyll & Bute CHP Committee – Draft Minute of Meeting held on 24 April 2013

Mr Robin Creelman, Chair of Argyll & Bute CHP updated on the April meeting of the Committee. This included the Francis Report, the financial position in Argyll & Bute and the review and redesign of Hospital, Community and Care Services in Kintyre. Mr Creelman extended his thanks to all staff in Argyll & Bute regarding the financial position. In relation to the review in Kintyre he advised that there was a reluctance to accept the concept of care at home in some areas. The Chair highlighted the need to engage, consult and explain to people regarding any review of services. Emphasis was also put on the phrase “just in time” as opposed to having beds available for people “just in case”. Dr Kennedy referred to Locality Clinical Leadership, which formed part of the Director of Operations report and asked why more clinicians were not coming forward for these roles. Dr Bashford, Board Medical Director confirmed that medical clinical leadership was being discussed nationally and this was a national issue as well as a local one.

It was noted that there was a minor typo in the decision box on page 17 of the minute and the words “transfer recourses” should be amended to read “transfer resources”.

40 Highland Health & Social Care Governance Committee – Assurance Report of 2 May 2013

The Assurance Report from the meeting of the Health & Social Care Committee meeting held on 2 May 2013 updated on the topics discussed at the meeting. Mrs Myra Duncan confirmed that the Operational Unit Delivery Plans had been submitted to the meeting and work was ongoing to develop the Health and Social Care Adult performance management and reporting framework.

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There had also been updates on respite care arrangements, Care Inspectorate Inspection reports and actions taken in response to national reports on Adults Support and Protection. Reference was made to the Treatment Time Guarantee and the use of the mobile theatre unit. The Chief Executive confirmed that this would probably continue to be used for another few months. Dr Foxley referred to the Care Inspectorate Report on Care at Home and whether the problems identified were being addressed. The Chief Executive confirmed that the report had been disappointing, however the concerns had not been about front line care but more relating to administration and organisation.

She confirmed that a programme of work had been put in place in relation to the care of clients and undertaking care assessments and risk assessments. Some additional resource would be used to release care officers to review clients and oversee care at home workers. The original plan had been to devolve these services to operational units from 1 April 2013, however it had been agreed to delay this for a few months to allow the various actions to be put in place.

41 Clinical Governance Committee – Draft Minute of Meeting held on 14 May 2013

Ms Sarah Wedgwood, Chair of the Clinical Governance Committee updated on the May meeting of the Committee, including Cancer Care in Highland, Weekend Admissions and Admissions on Public Holidays, the Business Intelligence and Data Warehousing Project and the Resuscitation Committee Annual Report. Mr McLennan referred to the item on the Resuscitation Committee and a conversation he had had recently with some elderly patients and asked if steps could be taken to ensure that close relatives were also involved / aware of the process. The Chair confirmed that this was a important issue for NHS Highland and suggested that there should time at a future Board Development Session to discuss this and a range of related issues.

42 Improvement Committee – Assurance Report of 29 April 2013 and Balanced Scorecard

The Chief Executive updated on the last meeting of the Improvement Committee including the Scorecard for Adult Social Care, Children and Adolescent Mental Health Services (CAMHs) and Access Targets. Ms Mead highlighted an issue relating to Insulin Pump Therapy. It was noted that NHS Highland was assured regarding progress for adults with type 1 Diabetes and the concern related to paediatric services. The Chief Executive confirmed that she had met with senior clinicians the previous day and plans were in place to bring forward our trajectory to meet the 25% target as soon as possible. There was some discussion around Access breaches and the Treatment Time Guarantee and it was noted that the financial implications of increased activity were significant.

43 Area Clinical Forum – Draft Minute of Meeting held on 4 April 2013

Dr Iain Kennedy, Chair of the Area Clinical Forum updated on the meeting, which had been chaired by Dr Robert Peel in Dr Kennedy’s absence. Dr Kennedy advised that there had been no solution to the issue of noise from televisions in wards. It was noted that the Francis Report on the Mid Staffordshire NHS Foundation Trust Public Enquiry was now a standing item on the ACF agenda.

44 Asset Management Group – Draft Minutes of Meetings held on 19 March and 2 May 2013

Mr Alasdair Lawton updated on the March and May meetings of the Group. It was noted that Health & Safety representation on the group was discussed and it was agreed that the Head of Health & Safety be invited to attend the group for three months to assess if this was beneficial. A new public member had also recently been appointed.

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The Board a Noted the Minutes. b Noted the Assurance Reports and agreed actions from the Highland Health & Social Care Governance Committee and the Improvement Committee. c Recommended that some time should be scheduled at a future Board Development Session to discuss the Resuscitation Policy and related issues.

45 Governance Committee Annual Reports Report by Kenny Oliver, Board Secretary on behalf of Elaine Mead, Chief Executive

As part of the Annual Accounts process a number of Annual Reports relating to NHS Highland Committees are produced and considered by the Audit Committee. The reports circulated were:

 Appendix 1 – Audit Committee  Appendix 2 – Staff Governance Committee  Appendix 3 – Remuneration Sub-Committee  Appendix 4 – Clinical Governance Committee  Appendix 5 – Improvement Committee  Appendix 6 – Endowment Funds Committee  Appendix 7 – Argyll & Bute CHP Committee  Appendix 8 – Highland Health & Social Care Committee  Appendix 9 – Spiritual Care Committee  Appendix 10 – Control of Infection Committee  Appendix 11 – Health & Safety Committee  Appendix 12 – Pharmacy Practices Committee

The Board a Noted the Governance Committee Annual Reports.

The Board adjourned at 10.30 am and resumed at 10.45 am.

46 NHS Highland Adult Social Care Practice Forum – Terms of Reference Report by Janet Spence, Programme Manager on behalf of Elaine Mead, Chief Executive

At the March meeting of the Highland Health and Social Care Committee, proposals for the establishment of a Highland Adult Social Care Practice Forum were discussed. This included consideration of a draft Constitution and Terms of Reference, which have now been consulted on. Janet Spence advised that it was hoped the Forum would be operational by September 2013. She indicated that staff in social work and social care had experience of engaging service users and carers and there was a proposal for two focus groups for service users and carers to feed views directly into the Forum. It was noted that the Chair of the Forum would be a member of the Highland Health & Social Care Committee. There followed detailed discussion on the proposed Terms of Reference and the following was agreed:  To remove the representative from the Scottish Association of Social Work from the membership as it was not appropriate at this stage.  Not to proceed with the Service User and Carer Focus Groups at present. It was suggested that it might be appropriate to have lay representatives on the Forum, similar to the ACF.

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 Remove paragraph 8.1 which stated that “the Chair of NHS Highland Board will approve the appointment of a Chair of the Forum.”  Include a paragraph regarding the reporting mechanism to the Highland NHS Board.  There was some discussion about the fact that the Forum related to Northern Highland only at this stage and would not incorporate Argyll & Bute. It was agreed that the Forum should be set up for Northern Highland only initially which could be reviewed at a later date.

The Board a Approved the Constitution and Terms of Reference for the NHS Highland Social Care Practice Forum, subject to the amendments discussed above. b Noted the Plan for the establishment of the Forum. c Agreed that there should be a review within 12 months of the Forum coming into operation.

Council/Highland NHS Board Joint Committees

47 Highland Council – Adult & Children’s Services Committee – Minute of Meeting of 20 March 2013

Margaret Somerville, Director of Public Health & Health Policy updated on the meeting, highlighting the Performance Report on Children’s Services and the School Leavers Destinations Return 2011/12 which she felt would be of interest to Board members. Dr Foxley advised he had been disappointed at the last meeting of the Lochaber District Partnership as there had been no information on children’s services.

The Board a Noted the minute.

CORPORATE GOVERNANCE / ASSURANCE

48 Infection Control Report Infection Control Annual Work Plan 2012/13 – End of Year Report Infection Control Annual Work Plan 2013/14 Reports by Liz McClurg, Infection Control Manager and Dr Emma Watson, Infection Control Doctor half of Heidi May, Board Nurse Director & Executive Lead for Infection Control

Ms Heidi May, Board Nurse Director welcomed Adam Brown, Consultant Microbiologist, Raigmore Hospital, to the meeting and introduced the reports presented to the Board. The Executive Summary of the main Infection Control Report, which summarised the key information in the report, is detailed below:

NHS Highland infection prevention & control targets and performance data

Group Target NHS NHS Highland Scotland Clostridium Age 65 and 39.0 20.9 Green difficile over (100,000 For period OBDs) April 2012 – March 2013. (Not yet validated by HPS)

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Staphylococcus Age 15 and 26.0 22.1 Green aureus over (100,000) For period bacteraemia AOBDs April 2012 –March 2013. (Not yet validated by HPS) Hand Hygiene 95% 95% 98% Green

Cleaning 90% 95.7% 96% Green

Estates 90% 97.3% 97% Green

Antimicrobial Hospital- 95% AMAU – 96% Green prescribing based Empiric prescribing Ward 4A – Green 96.5%

Surgical Compliant Data not yet antibiotic available prophylaxis Primary Care Compliant Yes Green empirical prescribing

Source: - Health Protection Scotland/ISD/Local data.

Ms May gave an update on infection control, advising that NHS Highland was on track to meet the HEAT targets for Staphylococcus aureus bacteraemia (SAB) and Clostridium difficile. There were no outbreaks reported in March/April 2013, however at the time of writing the report, four areas were closed due to norovirus, Ward 3C Raigmore and 3 community hospitals, Nairn Town & County, Invergordon Community and Lawson Memorial Golspie. All these areas had now re- opened and Ms May thanked the staff involved for their work in this area. Dr Brown advised that it was very difficult to reduce norovirus to zero, which made it difficult to prevent in a hospital environment. There needed to be more education or the public and signs at the entrances to hospitals. It was noted that an experienced and qualified nurse had been appointed to the Infection Control Nurse vacancy and would take up post in September 2013. A fourth Consultant Microbiologist had also recently been appointed.

Ms May referred to the Hydrogen Peroxide vapour treatment (fogging) and confirmed that the impact of this was still being monitored and would be reported back to the Board in due course. The Chair referred to the trends relating to Clostridium difficile from January 2010 – January 2013, which had continued on a downward trend and congratulated the Board Nurse Director and all staff for this achievement.

Infection Control Annual Work Plan 2012/13 – End of Year Report

Ms May introduced the 2012/13 End of Year Report and highlighted the significant progress embedding infection control procedures and confirming that NHS Highland had low infection rates which was good for our patients. It was noted that there were a number of amber ratings and NHS Highland had been short on infection control resource in the last year. Ms May updated on the amber ratings and confirmed to the Chair that these would be rolled forward into the 2013/14 Work Plan.

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Infection Control Annual Work Plan 2013/14

Dr Brown introduced the 2013/14 Annual Work Plan and confirmed that this had been amended so that every objective was measurable and quantifiable. He highlighted some of the main objectives, which included:

 Continuing to reduce the number of SAB cases to achieve the HEAT target of 24 cases per 100,000 acute hospital occupied bed days or lower by March 2015.  To reduce the number of Clostridium difficile cases to achieve the HEAT target of 25 cases per 100,000 occupied bed days in patient’s age 15 years and over by March 2015.  Infection Prevention and Control is everyone’s business – embed the importance of infection Prevention and Control into everyday practice.  HAI Education – through the HAI Education Group ensure patient / service users safety is achieved in relation to Infection Prevention and Control by standardising HAI education and training, targeted at different staff groups.  Surgical Site Infections – to reduce / maintain rates and comply with all HPS mandatory surveillance.  Water Safety – through the Water Safety Group ensure NHS Highland has robust and consistent arrangements in place for the safety of the water systems in NHS Highland and comply with legal duties and relevant guidance.

The Chair thanked Dr Brown for the comprehensive update. Myra Duncan asked if the Work Plan related to all care settings. Dr Brown advised that where appropriate care homes would be included, however some feasibility work still required to be done in this respect. The Chief Executive referred to the Water Safety Group and asked if the Estates Department was on this group. Dr Brown confirmed that Eric Green represented Estates on the Group.

The Board a Noted the performance position for the Board and the progress to keep infection under control. b Noted the Infection Control Work Plan 2012/2013 – End of Year Report. c Noted and Approved the Infection Control Work Plan 2013/2014.

THE HIGHLAND QUALITY APPROACH

49 Highland Quality Approach to Adult Care – A Five Year Improvement Plan for the Highland Partnership Report by Jan Baird, Director of Adult Care on behalf of Elaine Mead, Chief Executive

The plan pulled together the significant strands of work required to improve outcomes for adults across the Highland Council area and which are reflected at local level in the Operational Unit Delivery plans. Jan Baird, Director of Adult Care spoke to the plan which set out in a more detailed way what outputs would be expected on a year-on-year basis and how these must evidence improvements in outcomes. The plan set the Highland context which is driven by National and local policy and reiterates the outcome and performance frameworks established in the Partnership Agreement. Contained within the plan were a number of illustrations as to how inputs, outputs and outcomes could be linked and some examples of stories captured over the first year. The plan acknowledged the many strands, which need to come together to make the desired improvements such as:  Strategic Commissioning  Co-production  Shifting the balance of care

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 Integrated service delivery  Community Development  Self care  Anticipatory care planning  Outcome-focussed approach  Self Directed Support

Dr Foxley emphasised the benefits of co-location for teams, which he felt should be implemented as soon as possible. The Chair highlighted a number of bullet points in Appendix 7b, which indicated a timeline of April 2014. He suggested that it would be useful to have a separate document, which gave a timeline for the various actions, which could act as a useful checklist. Mrs Baird assured the Board that this was embedded in the Operational Unit Delivery Plans. Mr McLennan noted that the Integrated Personal Plan was due to be in place and operational across Highland and asked when this would be completed. Mrs Baird confirmed that this would be operational within the next few months and would replace single shared assessment.

The Board a Noted the Five Year plan reflecting commitments made during integration and in the Partnership Agreement.

50 Engagement and Communications: Update and Next Steps 2013/14 Report by Maimie Thompson, Head of Public Relations & Engagement on behalf of Elaine Mead

Reports presented to the Board in February 2012 and June 2012 set out the context and some of the actions required to develop and implement a more strategic approach to communications and engagement. This report updated on progress to date and next steps. Maimie Thompson spoke to the report which updated on future issues of NHS Highland News, Media releases and monitoring, Social Media including Patient Opinion and Webcasting, Internal publications, NHS Highland website, in-house filming and campaigns and other workstreams.

There was some discussion around Public Partnership Fora (PPFs) and District Partnerships and work in relation to the timing of meetings and the flow of information. Ms Thompson confirmed that she had regular dialogue with the Directors of Operations also. During discussion it was noted that there general agreement that engagement and communication had been improving for some time. Some concern was expressed regarding patient and public involvement and engagement. Ms Thompson confirmed that there had been a great deal of engagement over the last year and advised that she had been to various places throughout NHS Highland.

Following discussion the Chair advised that the Board had some differing views. It was generally accepted that there was much appreciation for the Communications and Engagement work, which was more proactive. He acknowledge the volume of engagement taking place but highlighted that this was possibly not being captured as part of an overall approach. There was a need to gather activity and report in a way that reassured the Board regarding engagement and he suggested that some further thought should be given to this outwith the meeting. In relation to public involvement in service improvement, there was no redesign without user involvement and engagement.

The Board a Noted  Updates on developments to strengthen communications and engagement.  Feedback from Opinion Survey carried in NHS Highland News.  Feedback from Participation Standards.

31 12 b Agreed  To increase the frequency of producing NHS Highland News in 2013/14.  in principle to involve service users in all improvement work.  To commission a reputational audit to assess impact of changes being progressed by NHS Highland. c Remitted to the Head of Public Relations and Engagement to consider how to better capture the activity as part of an overall approach.

CORPORATE GOVERNANCE / ASSURANCE

51 NHS Highland Local Delivery Plan 2013/14 Report by Kenny Oliver, Board Secretary on behalf of Elaine Mead, Chief Executive

The Local Delivery Plan was presented for noting to the Board Meeting on 9 April. A number of amendments had been made since then, these include:

 NHS Highland’s contribution to Single Outcome Agreements now included  A revision to the savings plan for 2013/14 showing an overall improvement in the amount of unidentified savings and an improvement in the associated risk ratings  A revised trajectory for MRSA/MSSA

The Local Delivery Plan 2013/14 had been prepared in accordance with national guidance and timescales. The initial draft was submitted to the Scottish Government Health Department (SGHD) on 15 February 2013. All comments received from within NHS Highland and additional information requested in feedback from the SGHD leads had been reflected in the final version, which was submitted by the required deadline of 15 March 2013, subject to ratification from NHS Highland Board. Some further amendments have been made as described above and the Local Delivery Plan is now presented to the Board for final ratification.

The Board a Ratified the Local Delivery Plan 2013/14 for NHS Highland.

52 Provisional 2012/13 Financial Out-turn Report by Nick Kenton, Director of Finance

The report was based on provisional year-end information and, at the time of writing, final adjustments continued to be made. The details within the attached tables were, therefore, likely to change however, there was no significant change expected at this stage.

Mr Nick Kenton, Director of Finance updated on the financial position to 31 March 2013. The report confirmed a small underspend of £68,000 at the year-end, in line with predictions throughout the year. Mr Kenton congratulated all staff and managers in achieving financial break even for 2012/13. The individual Unit out-turns are summarised below.

Dr Foxley welcomed the break-even position. He referred to Table 2 of the report and in particular the overspend attributed to the Surgical and Anaesthetic Division of Raigmore Hospital and the internal audit report on Financial Management at Raigmore Hospital which had been considered recently by the Audit Committee. He suggested that the financial pressures needed to be more forensically examined and felt that there were specific issues in relation to culture, and conflicting savings and pressures. Dr Foxley suggested that the Board and Senior Management Team needed to address these issues as a matter of urgency and work should be undertaken to identify savings and pressures.

32 13

The Chair asked that the Board not lose sight of the fact that NHS Highland had achieved break- even and confirmed that the issues at Raigmore had been identified for some time. A support team had been established as well as a Programme Board, which now had a robust plan of work. While the issues raised were correct, the Chair emphasised that work was now in progress. The Chief Executive advised that it was right for the Board to be concerned, however the work referred to had been in progress for some time. There was a need also to have a whole system approach and recognise the impact of other operational units on Raigmore. Initiatives were being put in place with the aim of balancing the whole system. The Chief Operating Officer and Director of Finance were working closely with Raigmore management to address the issues.

Breakdown of Year End Positions (provisional) Operational Unit N&W S&M Raigmore Tertiary Others HSCP A&B Corp. Quality Central Total Heading £m £m £m £m £m £m £m £m £m £m £m

Savings Operational Savings not yet achieved/identified (1.3) (0.1) (1.4) (0.3) (1.7) Highland Wide Quality Initiatives 0.0 (4.5) (4.5) In year non-recurrent benefits applied 0.0 6.7 6.7 Pressures Adult Social Care 0.0 0.0 In-year cost pressures (1.5) (0.2) (0.6) (1.0) (0.6) (3.9) (0.4) (4.3) Offsetting underspends/benefits 1.5 0.4 0.7 2.6 0.9 0.3 3.8 Actual Out-turn 0.0 0.2 (1.9) (1.0) 0.0 (2.7) 0.2 0.3 (4.5) 6.7 0.0

Previous Month - month 11 (1.2) (1.3) (2.3) (1.1) 1.9 (4.0) 0.2 0.3 (4.5) 8.0 0.0

Change 1.2 1.5 0.4 0.1 (1.9) 1.3 0.0 0.0 0.0 (1.3) 0.0

Health Change 0.8 0.4 0.1 1.3 ASC Change 0.4 1.5 (1.9) 0.0

The Board

a Noted the delivery of revenue and capital financial break-even for 2012/13.

b Noted that this was subject to no significant late adjustments and audit review.

c Noted the issues regarding Raigmore Hospital’s financial position and the steps being taken to address them.

53 Disposal of Surplus Land and Buildings – Belhaven Ward, Fort William Report by Tracy Ligema, Area Manager, West on behalf of Nick Kenton, Director of Finance

The Belhaven Ward, Fort William became vacant from 31 March 2013 when the Physiotherapy and Occupational Therapy Services occupying it on a temporary basis relocated. No other Health Service use had been identified for it and it had been declared surplus to requirements by the North & West Operational Unit. Dr Foxley suggested that it would have been helpful if the report had been considered at a Lochaber District Partnership meeting prior to consideration by the Board. He agreed that the building should be disposed of and requested that the capital receipt be ring-fenced for Belford Hospital. Mrs McVicar advised that the issue had been discussed at the last meeting of the District Partnership and that it would be good practice for relevant Board reports to be considered at District Partnership level. She suggested that this could be reviewed when the review of District Partnerships was undertaken later in the year. The Chair agreed that this would be appropriate for issues of local interest. In relation to the sale of the property it was noted that this would require to follow the NHS Property Transactions Handbook. It was suggested that if there was any local group interest in the property that this could be referred back to the Board if necessary.

33 14

The Board a Declared the Belhaven Ward, Fort William surplus to requirements and agreed to its disposal. b Noted the comments regarding local issues being submitted to District Partnership meetings when appropriate.

The Board adjourned at 12.45 pm and resumed at 12.50 pm.

54 NHS Highland Revised Local Access Policy Report by Margaret Brown, Head of Service Planning and Donna Smith, Divisional General Manager, Patient Services on behalf of Elaine Mead, Chief Executive

As a result of the introduction of The Patients Rights Act (2011) the existing Local Access Policy for NHS Highland needed to be revised. The Patients Rights Act (2011) stipulates in Sections 8 – 13 that from 1 October 2012 all eligible patients requiring inpatient or daycase treatment are to start treatment within 12 weeks of the patient and clinician jointly agreeing that the treatment is to take place.

Donna Smith, Divisional General Manager, Patient Services presented the report to the Board. The national regulations and directions require every NHS Board to have an agreed Local Access Policy, which has been legally checked for compliance with the Act, before being published on their website. In particular, each NHS Board’s Local Access Policy must contain clear policy on the following:-  The definition of a reasonable offer, including locations where treatment may be reasonably undertaken; and that a patient may be seen or treated by any competent clinician who is part of the consultant-led service in the relevant speciality. This has been addressed in Sections 6.1.6 and 6.2.4  The impact on a patient’s waiting time if they register their arrival for an appointment but then do not wait to be seen. This has been addressed in Section 7.4.3

Ms Smith advised that the main change to the policy related to locations, which could be considered a reasonable offer. In the revised policy this was defined as “an offer at any appropriate health facility within the boundary of NHS Highland. For Argyll & Bute residents the location would also be deemed reasonable within the boundaries of NHS Greater Glasgow and Clyde. In exceptional circumstances locations in NHS Greater Glasgow and Clyde, NHS Grampian, NHS Lothian; the Golden Jubilee National Hospital; and the independent sector will also be deemed as reasonable for any NHS Highland resident”.

It was noted Raigmore Patients Council had provided feedback on the policy, which had also been considered by the Area Clinical Forum on 30 May. The ACF had generally accepted that the policy was reasonable. There followed a detailed discussion by the Board on the revised policy.

It was suggested that the Golden Jubilee National Hospital should be included as a reasonable offer in unexceptional circumstances. Ms Smith advised that at present the Golden Jubilee was only included in exceptional circumstances at present but she would welcome a Board discussion on this issue. The aspiration for NHS Highland was still to continue as much local access to services as possible for Highland residents. The Chair advised that treatment within a patient’s own area would be the norm. In view of the Treatment Time Guarantee (TTG), there could be instances when NHS Highland might be vulnerable if less capacity was available than required. The Chief Executive asked the Board to consider the Golden Jubilee National Hospital to be considered a reasonable offer for NHS Highland residents. When a question was raised in relation to considering other hospitals e.g. in Grampian, as reasonable it was noted that the Golden Jubilee was specifically designed for people to travel to, with accommodation available for family.

34 15

It was noted that if Golden Jubilee were considered reasonable that NHS Highland would need to enter into more detailed discussions with the hospital regarding specific arrangements.

Following discussion the Board approved the revised Local Access Policy subject to the amendment of section 6.1.6 to include the Golden Jubilee National Hospital as a reasonable offer for NHS Highland residents. The Chair highlighted that this was a good news story for NHS Highland as patients no longer had extensive waits for treatment, with most people being seen very quickly. The TTG was very challenging for NHS Highland as a small Board with a limited number of consultants and the potential use of a national hospital could help when required. Mr Coutts suggested that the policy should be reviewed and it was noted that this would normally happen within a year. He also confirmed that the patient had a right to choose the location of treatment and that this should also be monitored in relation to the clock either stopping or being reset depending on patient choice. The Chief Executive reiterated that Highland patients want to be treated in Highland and this would continue, with the Golden Jubilee only being used when required or specifically chosen.

The Board a Reviewed the revised Local Access Policy. b Agreed to amend section 6.1.6 of the policy to include the Golden Jubilee National Hospital as a reasonable offer for NHS Highland residents. c Approved it to be checked for legal compliance with Patient Rights Act (2011). d Agreed to its publication on the NHS Highland website.

55 Chief Executive’s and Directors’ Report – Emerging Issues and Updates Report by Elaine Mead, Chief Executive

This month’s report incorporated updates on:

 Changes to UK Immunisation Programmes  Update on the Inequalities Action Plan  Initial Agreement – Critical Care Consolidation and Theatres Refurbishment – Raigmore  Post Diagnosis Support for people with Dementia  Regional Planning – North of Scotland and West of Scotland Planning Groups

Mr Kenton referred to the Initial Agreement for the Critical Care Consolidation and Theatres Refurbishment at Raigmore Hospital. It was noted that this had already been reviewed by the Asset Management Group and would require to be considered by the Board prior to submission to the Scottish Government Capital Investment Group in July. Accordingly the August Board meeting would be too late to consider this item and it was noted that it would be considered fully at a Board meeting towards the end of June, following the meetings of the Audit Committee and Board to consider the NHS Highland Annual Accounts. Dr Foxley welcomed the feedback on the “Closing the Gap” Conference on 30 April when Harry Burns, Chief Medical Officer had been a key speaker.

The Board a Noted the emerging issues and updates report. b Noted the Initial Agreement for the Critical Care Consolidation and Theatres Refurbishment at Raigmore Hospital would be considered by the Board at a meeting towards the end of June.

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56 Any Other Competent Business

There was none.

57 Date of Next Meeting

The next meeting of the Board will be held on Tuesday 13 August 2013 at 8.30 am in the Board Room, Assynt House, Beechwood Park, Inverness.

The meeting concluded at 1.25 pm.

36 17 Highland NHS Board 13 August 2013 Item 2(b) Assynt House Beechwood Park Inverness IV2 3BW HIGHLAND NHS BOARD Tel: 01463 717123 Fax: 01463 235189 Textphone users can contact us via Typetalk: Tel 0800 959598 www.nhshighland.scot.nhs.uk

MINUTE of MEETING of the BOARD IN COMMITTEE 27 June 2013 – 1.30 pm Board Room, Assynt House, Inverness

Present Mr Garry Coutts, Chair Mr Mike Evans, NHS Board Non-Executive Mrs Anne Gent, Director of Human Resources Mr Ian Gibson, NHS Board Non-Executive Mr Nick Kenton, Director of Finance Ms Heidi May, Board Nurse Director Mrs Gillian McCreath, NHS Board Non-Executive Mr Okain Mclennan, NHS Board Non-Executive Ms Elaine Mead, Chief Executive Mr Ray Stewart, NHS Board Non-Executive Ms Sarah Wedgwood, NHS Board Non-Executive

In Attendance Mr Iain Addison, Head of Area Accounting Ms Deborah Jones, Chief Operating Officer Mr Brian Mitchell, Board Committee Administrator

Apologies – Apologies were received from Mr Robin Creelman, Mrs Myra Duncan, Dr Michael Foxley, Dr Iain Kennedy, Mr Alastair Lawton, and Mr Colin Punler.

58 Annual Accounts 2012/2013

A number of members of the Board in Committee had been present at the earlier meeting of the Audit Committee, which had discussed the Annual Accounts. The External Auditor had intimated an unqualified opinion, subject to inclusion of amendments to associated commentary, as tabled at the Audit Committee meeting.

At the Audit Committee meeting the Committee had recommended approval of the draft Annual Accounts, subject to inclusion of the tabled commentary changes, and the Chairman of the Audit Committee confirmed this to the Board. The Annual Accounts for 2012/2013 would be submitted timeously to the Scottish Government Health Department and an update would be provided at a future Board Meeting. The Chair took the opportunity to thank all staff involved in producing a clear set of annual Accounts for 2012/2013.

The Board: a Approved the Annual Accounts for NHS Highland for 2012/2013, subject to inclusion of amended commentary in Pages 8 and 97, and receipt of an unqualified opinion from the External Auditor. b Agreed that these be submitted to the Scottish Government.

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59 Date of Next Meeting

The next meeting of the Board in Committee will be held on a date to be agreed.

The meeting concluded at 1.35 pm

38 19 Highland NHS Board 13 August 2013 Item 2(c) Assynt House Beechwood Park Inverness IV2 3BW Tel: 01463 717123 Fax: 01463 235189 HIGHLAND NHS BOARD Textphone users can contact us via Typetalk: Tel 0800 959598 www.nhshighland.scot.nhs.uk/

MINUTE of MEETING of the BOARD Board Room, Assynt House, 27 June 2013 – 1.35 pm Beechwood Park, Inverness

Present Mr Garry Coutts, Chair Mr Mike Evans Mr Ian Gibson Mrs Gillian McCreath Mr Okain McLennan Mr Ray Stewart Ms Sarah Wedgwood Ms Elaine Mead, Chief Executive Dr Ian Bashford, Board Medical Director Mrs Anne Gent, Director of Human Resources Mr Nick Kenton, Director of Finance Ms Heidi May, Board Nurse Director Also present Mrs Doreen Bell, Associate Director Surgery/ Clinical Advisor Mr Eric Green, Head of Estates Ms Erin Greig, Communications Manager Ms Deborah Jones, Chief Operating Officer Mr Brian Mitchell, Board Committee Administrator Mr Kenny Oliver, Board Secretary Ms Maimie Thompson, Head of Public Relations & Engagement

Apologies – Apologies were received from Mr Robin Creelman, Mrs Myra Duncan, Dr Michael Foxley, Dr Iain Kennedy, Mr Alasdair Lawton and Mr Colin Punler.

60 Declarations of Interest

Board members declared the following interests:  Garry Coutts – Scottish Social Services Council (SSSC), ex officio of SSSC on the Care Inspectorate, University of the Highlands and Islands.  Ray Stewart – Member of Unite and Staffside Chair.

The Board a Noted the Declarations of Interest.

CORPORATE GOVERNANCE / ASSURANCE

61 Critical Care Consolidation and Theatres Refurbishment – Raigmore Hospital – Initial Agreement Report by Eric Green, Head of Estates on behalf of Deborah Jones, Chief Operating Officer

The Board were advised the operating theatres at Raigmore Hospital were 25 years old and had not been refurbished since new, resulting in a fabric that was worn and increasingly difficult to maintain. 39 20

In addition, many Guidance and Regulations had changed over the intervening 25 Years and as a result the existing facility was no longer consistent with best practice. It was noted that Critical Care facilities within Raigmore had grown over the 25 year period and extended over three separate locations within the tower block. None of these facilities met current guidance. The fire upgrade work at Raigmore offered a unique opportunity to locate these services on one floor and help derive quality and operational benefit from so doing. This in turn would facilitate other moves to further improve patient care within the tower block and improve operation of the hospital.

There had been circulated an Initial Agreement for upgrading the Raigmore Theatres and combining Critical Care services at Raigmore. Members were advised this had been both discussed and endorsed by the Asset Management Group and Senior Management Team. Mr Green advised that the essential upgrade requirements, to meet current Standards, gave an opportunity for the NHS Board to address a number of associated issues at Raigmore Hospital. The proposals had been discussed with both Building Control and the Fire Service who had both indicated they were content.

During discussion, there was reference to the issue of patient safety and Dr I Bashford reminded those present that Raigmore Hospital had evidenced the second best reduction in Hospital Standardised Mortality Rate in Scotland whilst operating with an associated very low rate of High Dependency Unit (HDU) and Intensive Treatment Unit (ITU) mortality. Raigmore Hospital itself had received a Level 4 Rating in relation to the Scottish Patient Safety Programme (SPSP), one of the first facilities in Scotland to achieve this Level. The opportunity to realign services, as provided by these proposals, highlighted the commitment of NHS Highland in seeking to improve services where possible, within existing resource. Dr Bashford stated that in relation to Critical Care/Step Down care in particular, Guidance indicated the desire to seek to consolidate relevant clinical expertise, staffing resource and equipment so as to provide appropriate treatment options and flexibility of care for relevant patients. Again the opportunity to improve patient safety in this area was of real benefit.

Mr I Gibson sought clarification on whether the current proposal would offer the opportunity to increase Theatre capacity and was advised the final phase of improvement work at Raigmore would include plans to achieve that aim whilst also increasing overall hospital capacity and flexibility.

In summary, the Chair welcomed the proposal to provide upgraded Theatre facilities in Raigmore Hospital against the background of an already high level of associated patient safety.

The Board a Approved the Initial Agreement for upgrading the Raigmore Theatres and combining Critical Care Services at Raigmore. b Agreed that the Initial Agreement be submitted to the Scottish Government Capital Investment Group for their approval.

62 Any Other Competent Business

There was none.

63 Date of Next Meeting

The next meeting of the Board will be held on Tuesday 13 August 2013 at 8.30 am in the Board Room, Assynt House, Beechwood Park, Inverness.

The meeting concluded at 1.45 pm.

40 FOLLOW UP FROM BOARD ACTION PLANS – JUNE 2011 ONWARDS 21 Highland NHS Board Those items shaded grey are due to be removed from the Action Plan as they have been completed, or will be considered at 13 August 2013 the next Board. Item 2(d)

Meeting Item Action / Progress Outcome

Board 07/06/11 Audit Committee Hospital and Community Health payments to GPs in Argyll and Future Board – letter received from SG Bute – to seek clarification on this issue and report back to the 21/10/11 – being progressed Board in due course. Being reviewed by national Primary Care Leads with a view to providing additional guidance. Board 07/02/12 Highland Health & Social Care To review the governance arrangements once the structure had Board October 2013 Partnership – Proposed been operational for one year. Governance Arrangements Board 05/06/12 CHP Committees To issue a structure diagram of the revised tiers of management Work in progress – being finalised. to Board members once available. Process to appoint additional District Managers to North & West and South & Mid Operational Units ongoing. e-mail sent to Board members 31/07/13 with structure diagrams. Governance Committees – Review To review the mechanisms for governance committees to report Work in Progress of Assurance to Board to the Board.

Board 14/08/12 Supporting Highland’s Carer’s Revised Carers’ Strategy to be presented to the December Board 04/12/12 – Deferred 2012-2015 meeting of the Board. Board 09/04/13 – Deferred Board 04/06/13 – Deferred Board 13/08/13 – CEs Report – Draft Strategy to be submitted to 01/10/13 Board NHS Highland Maternity Services Approved the Maternity Services Strategy and Strategy Maternity Services Strategy updated to Strategy Workplan, subject to this being refreshed during the next year reflect the actions required by the Board. as discussed. In additions the Operational Units have Implementation Plans which are monitored through the Maternity Services Strategy Co-ordinating Group.

Highland Council – Adult & Consideration to be given to the style of assurance report Chair / Chief Executive Children’s Services Committee required from Highland Council as the Lead Agency for Work in progress / ongoing discussions Children’s Services. with Highland Council. Board 05/02/13 – To take forward work in progress in relation to assurance in respect of Children’s Services. 22 Meeting Item Action / Progress Outcome

Board 14/08/12 NHS Highland Standing Orders Standing Orders deferred to December Board Meeting. Board 04/12/12 – Deferred Scheme of Delegation to 05/02/13 Board Work in progress re Standing Orders. Highland Quality Approach To plan another team visit to Torbay to explore further how the Some District Managers and those Presentations integrated teams work in practice. This visit to include Non- expressing an interest in taking forward Executives. the Health and Social Care coordinator role across the test sites have visited Torbay and spent valuable time going out with teams across the area. This has added more detail as to how the posts function and the wider working of the teams which it is acknowledged varies even across the Torbay area. This visit was funded by RRHEAL in support of experiential learning and is now informing the test sites – Invergordon, Nairn, South Skye and Sutherland where the coordinator role and single point of access will be tested and evaluated. Communication continues with Torbay to ensure learning and sharing is ongoing. Matters Arising Evaluation of Integration – Additional funding to be provided Report to Board 13/08/13 by Scottish Government in relation to evaluating Integration. Report to be submitted to future Board.

Board 05/02/13 Risk Management Strategy – To take forward outstanding Risk Management Workshops held for action in relation to strategic risk management regarding key Board and Senior Management Team in priorities for the Board in relation to the governance of risks. June 2013.

Audit Committee – 11 December To highlight issue raised regarding Consultant Contract Review Completed by Director of Human 2012 Management Action Plan in relation to use of locums at CGH to Resources the relevant officer leading this area of work.

To consider links with other agencies (e.g. Highland Council) We are in contact with Highland Council’s prior to rolling out awareness / training in relation to Counter internal audit team regarding this issue. Fraud. This will be considered in the wider context of our action plan in response to CEL(2013)11 on Financial Crime.

2 23 Meeting Item Action / Progress Outcome

Organ Donation Committee Terms of Reference for Organ Donation Committee to be Clinical Gov. Committee – 02/10/13 reviewed and considered by Clinical Governance Committee.

Board 05/02/13 Early Years Collaboration To consider future Board Development Session on Early Years May Strategy Session – 07/05/13 Collaboration.

Board 09/04/13 Matters Arising Pyramid / Pyramis System – Progress report on the Improvement Committee – 01/07/13 – development of the Data Warehouse system to be submitted to Deferred the Improvement Committee Improvement Committee – 02/09/13

Highland Health & Social Care Agreed that Rural Resilience would be considered as a topic Item added to Forward Plan for Board Governance Committee for a future Board Development Session, Development Sessions.

Audit Committee Recommendation by the Audit Committee that there be a Item added to Forward Plan for Board Board Development Session on integrated organisational long- Development Sessions. term planning. Asset Management Group Capital Plan to be highlighted and discussed by the Area Area Clinical Forum – 30/05/13 Clinical Forum to ensure a better understanding of the position. Area Finance Report The Chair highlighted the need for the Board to have A short life working group has been set up assurance by August in relation to reporting and monitoring to look at the content and format of the mechanisms for the HH&SCC. financial reporting to the HH&SCC.

Board 04/06/13 Highland Quality Approach – To take forward the proposals within the report, as agreed and Board 13/08/13 Making It Happen – Progress produce an Implementation Plan for future consideration by the Report Board.

Review of Governance and Work in progress. Chair to write to Board members following Board 13/08/13 – Review of Committee Membership of Committees discussion and report back to the Board either in August or Membership October. Argyll & Bute CHP Committee To amend the decision box in item 12 of the minute of the A&B Completed CHP Committee on 24 April to read “Endorsed the conclusion reached to close the continuing care beds and transfer resources to the community” rather than “transfer recourses to the community”

3 24 Meeting Item Action / Progress Outcome

Board 04/06/13 Clinical Governance Committee Resuscitation Policy – time to be scheduled at a future Board Item added to Forward Plan for Board Development Session to discuss the Resuscitation Policy and Development Sessions. related issues.

NHS Highland Adult Social Care Agreed that there should be a review within 12 months of the Future Board – October 2014 Practice Forum – Terms of Forum coming into operation. Reference

Initial Agreement – Critical Care Initial Agreement to be submitted to an additional meeting of Board 27/06/13 Consolidation and Theatres the Board towards the end of June. Refurbishment – Raigmore

4 25 Highland NHS Board 13 August 2013 Item 2.1

MEMBERSHIP OF COMMITTEES

Report by Garry Coutts, Chair, NHS Highland

The Board is asked to:

 Review the current membership in view of recent vacancies and appointments.  Note that the current appointments for the positions of Vice Chair, Chair of the Highland Health & Social Care Committee, Chair of Argyll & Bute CHP Committee and the Chairs of the main Governance Committees are until 30/06/14.  Agree that the revised membership should be until 30/06/14 with a further report to the Board in June 2014.

1 Background and Summary

There have been a number of recent changes in Board membership, with three member’s terms of appointment coming to an end, and two new Board members being appointed:

 Bill Brackenridge – end of appointment date 31/05/13  Ian Gibson – end of appointment date 30/06/13  Colin Punler – relocated outwith NHS Highland and resigned from 30/06/13  Rhona MacDonald – new Board member appointed for a 4 year term from 01/07/13  Elaine Wilkinson-Crane – new Board member appointed for a 4 year term from 01/07/13.

In view of the recent changes it has been necessary to review the current membership of the various committees populated by Non-Executive Board members. It is proposed that the revised membership should be effective until 30/06/2014 as this is when the current appointments for the position of Vice-Chair and the Chairs of other Governance Committees are due for review.

Community Health Partnerships Committee Current Membership Proposed Membership Highland Health & Social Myra Duncan – Chair Myra Duncan – Chair Care Committee Vacancy Rhona MacDonald Gillian McCreath Gillian McCreath

Argyll & Bute Community Robin Creelman – Chair Robin Creelman – Chair Health Partnership Vacancy Elaine Wilkinson-Crane Local Authority Member Local Authority Member

Governance Committees Committee Current Membership Proposed Membership Audit Committee Mike Evans – Chair No Change Michael Foxley Gillian McCreath Okain McLennan Ray Stewart 26

Governance Committees (cont.) Committee Current Membership Proposed Membership Clinical Governance Sarah Wedgwood – Chair Sarah Wedgwood – Chair Committee Michael Foxley Michael Foxley Iain Kennedy Iain Kennedy Alasdair Lawton Alasdair Lawton Vacancy Rhona MacDonald

Staff Governance Vacancy – (Chair) Alasdair Lawton – Chair Committee Robin Creelman Robin Creelman Myra Duncan Myra Duncan Ray Stewart Ray Stewart Vacancy Elaine Wilkinson-Crane

Endowment Funds Ray Stewart – Chair Ray Stewart – Chair Committee Mike Evans Mike Evans Vacancy Rhona MacDonald Vacancy Gillian McCreath Vacancy Elaine Wilkinson-Crane

Remuneration Sub- Garry Coutts – Chair Garry Coutts – Chair Committee Sarah Wedgwood – Vice-Chair Sarah Wedgwood – Vice-Chair Robin Creelman Robin Creelman Myra Duncan Myra Duncan Vacancy Alasdair Lawton Ray Stewart Ray Stewart

Highland Council Committees Committee Current Membership Proposed Membership Adult and Children’s Vacancy Myra Duncan Committee Gillian McCreath Gillian McCreath Margaret Somerville Margaret Somerville

Joint NHS Highland and Argyll & Bute Council Committee Committee Current Membership Proposed Membership Argyll & Bute Health and Robin Creelman – Chair No Change Care Strategic Partnership Local Authority Member – John McAlpine

Non-Executive Representation on other NHS Highland Committees Committee Current Membership Proposed Membership Area Control of Infection Okain McLennan – Chair No Change Committee Gillian McCreath

Health & Safety Committee Alasdair Lawton No Change

Pharmacy Practices Okain McLennan No Change Committee Risk Management Steering Sarah Wedgwood No Change Group Spiritual Care Committee Sarah Wedgwood No Change

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Asset Management Group Alasdair Lawton – Chair Alasdair Lawton – Chair Vacancy Elaine Wilkinson-Crane

Non-Executive Representation on other Committees/Groups Committee Current Membership Proposed Membership National Appeal Panel for Okain McLennan No Change Entry to Pharmaceutical Lists

Integrating Care in the Vacancy Discussions ongoing with Highlands Programme Highland Council Board

2 Contribution to Board Objectives

Robust corporate governance arrangements are essential to the delivery of all of NHS Highland’s Corporate Objectives. This specifically contributes to “Better Value” where all services should be efficient and cost effective and working systems and practices are redesigned to be fit for purpose.

3 Governance Implications

As per paragraph 2 – the provision of robust governance arrangements is key to NHS Highland delivering on its key objectives and having strong governance committees is the vehicle for NHS Highland to deliver robust governance.

4 Risk Assessment

The impact of not having good governance arrangements in place would be very high. However the above committee membership will ensure that we have good governance in place which would lower the risk to medium and we can monitor its effectiveness through regular audit and review.

5 Planning for Fairness

This process does not require an impact assessment.

6 Engagement and Communication

The draft membership list has been shared with Board members. Once agreed at the Board the detail will be shared across the organisation as appropriate.

Garry Coutts Chair, NHS Highland

2 August 2013

3 28 29 Highland NHS Board 13 August 2013 Item 3.1

Argyll & Bute Community Health MINUTE OF MEETING OF THE Partnership ARGYLL & BUTE CHP COMMITTEE Aros Lochgilphead Argyll PA31 8LB www.nhshighland.scot.nhs.uk/

Mid Argyll Community Hospital & Integrated Care 19 June 2013 Centre, Lochgilphead

Present Mr Robin Creelman, Chairman, Argyll & Bute CHP Mr Derek Leslie, Director of Operations, Argyll & Bute CHP Dr Michael Hall, Clinical Director, Argyll & Bute CHP Ms Pat Tyrrell, Lead Nurse, Argyll & Bute CHP Ms Elaine Garman, Public Health Representative, Argyll & Bute CHP Ms Mary Wilson, AHP Representative, Argyll & Bute CHP Ms Elizabeth Reilly, Area Dental Committee Representative Mr Duncan Martin, Chairman, Public Partnership Forum Mr Michael Roberts, Vice Chair, Public Partnership Forum

Present by VC Councillor Elaine Robertson, Argyll & Bute Council Representative

In Attendance Mr George Morrison, Head of Finance, Argyll & Bute CHP Mr David Logue, Head of HR, Argyll & Bute CHP Mrs Sheena Clark, PA to Director of Operations - Minute Secretary

Apologies Mr Stephen Whiston, Head of Planning Contracting & Performance, Argyll & Bute CHP Mr David Ritchie, Communications Manager, Argyll & Bute CHP Ms Dawn Gillies, Staffside Representative Ms Liz McMillan, Staffside Representative Cleland Sneddon, Executive Director, Community Services, Argyll & Bute Council Jim Robb, Head of Service, Adult Care, Argyll & Bute Council Councillor George Freeman, Argyll & Bute Council Representative Ms Glenn Heritage, CVO Representative

1. CHAIRMAN’S WELCOME

The Chairman opened the meeting by welcoming everyone to Mid Argyll Community Hospital & Integrated Care Centre, Lochgilphead.

2. APOLOGIES

Apologies for absence were noted as above.

3. CONFLICTS OF INTEREST

No conflicts of interest were declared. 30

4. MINUTE FROM PREVIOUS MEETING

4.1a Minute of Meeting held on 19 June 2013

The Committee Approved the content of the Minute of the meeting on 24 April 2013.

4.1b Minute of Public Session of 24 April 2014

The Committee Approved the content of the Minute of the Public Session on 24 April 2013.

5. MATTERS ARISING FROM PREVIOUS MEETING HELD ON 24 April 2013

Page 3 – Major Incident – Mid Argyll, Kintyre & Islay – Councillor Robertson enquired if a ‘common’ list of vulnerable people will be rolled out to each CHP locality. Mr Leslie confirmed this to be the case and that the list will be updated as required by the relevant agencies. Ms Garman stated that a key point will be to agree the criteria of a vulnerable person as the situation for those named can change day to day. Lessons learned from the incident and debriefing notes are due to be discussed at an Emergency Planning Meeting and the outcome shared across localities.

6. NHS Highland Organisational Issues

6.1 Highland NHS Board – 4 June 2013

Mr Creelman reported that Dr Bashford, Board Clinical Director praised the detail of the information provided in the CHP’s Clinical Governance and Risk Management Report to the Committee.

The Committee Noted the above comment.

6.2 Director of Operations Report

Mr Leslie provided a summary of key points in the circulated report.

Helensburgh & Lomond Out of Hours Nursing Service – the status quo currently remains in the provision of this service. A meeting is scheduled at end July with NHS Greater Glasgow & Clyde to discuss the proposed redesign of the out of hours nursing service for patients in the Helensburgh & Lomond area as a result of an intimation from the West Dunbartonshire CHCP of an intention to effect changes to the SLA.

Primary Medical Services Information Sharing - the availability of a significant quantity of information to monitor and understand performance in primary care is being collected by the Primary Care management section of the CHP. Senior managers have been asked to reflect on the extent and value of this information so that any necessary refinements to the arrangements for information and intelligence collection can be agreed. The range of information and the outputs will feature at a future development session the CHP Committee.

Bereavement Strategy - an action plan has been developed to assist in the delivery of bereavement care guidelines and the development of support which will comply with the “Shaping Bereavement Care – A Framework for Action CEL9 (2011). The CHP Lead AHP has been identified as the link person to take forward the action plan.

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Early Years Collaborative – this is a significant strategic initiative by the Scottish Government in collaboration with the Council. The need for funding (amounting to £42k) has been added to the cost pressures to be managed by the CHP in order to part fund a Project Manager and Data Manager post for the next 2 years to support the early years collaborative.

Patient Management System (PMS) Update - work in relation to implementing the new PMS is progressing to plan and has been formally in operation for two months plus.

The specific challenges associated with Argyll & Bute will be addressed as the implementation progresses. It was noted that improved clinical awareness and participation into the implementation of the system will be pursued.

Delivery of Sustainable Remote & Rural Health & Social Care – the CHP contributed to a NHS Highland proposal submitted to the Scottish Government to test models for the delivery of sustainable remote and rural health and social care services which would have application across Scotland. Mid Argyll & Kintyre were identified as two strands to be linked into the work to be undertaken.

NHS Highland currently awaits feedback from SGHD on the draft proposal, with the final proposal to be submitted and a decision expected thereafter, with the resourcing availability for the project work still to be confirmed

Campbeltown Community Hospital Continuing Care Beds - members of the CHP management team and locality staff attended a meeting in Campbeltown hosted by the Campbeltown Community Council on Monday 13 May 2013. The two agenda items were the closure of continuing care beds in Campbeltown Community hospital and the substitute prescribing service. The meeting was attended by approx 190 people.

Local staff presented information about local service developments and the bed modelling process which has been in progress for two years. In relation to closure of continuing care beds, the main concerns raised were; contingency planning for emergencies, adequate beds available for those who need them locally to avoid transfers out of the area, difficulties recruiting and retaining local staff to take on skilled carers roles, how resource release and the free space in the hospital would be utilised. Reassurance was provided that contingency plans are in place to cope with the peaks and troughs in demand for in-patient beds and that a group with public representatives has been established to identify how resource release should be used to meet local gaps in community service provision.

The free space in the hospital will also be reviewed by the redesign group; to identify what local service development might be supported by the use of this additional space. Mr Leslie reaffirmed that the closed beds had not been in use.

Substitute Prescribing - the community of Campbeltown voiced many concerns related to the provision of a substitute prescribing service locally. The Kintyre Substance Misuse Working Group (KSMWG) met on 13 June 2013 to review the current position.

Building the Bridge Together - an event to consider how we can work better together to enable older people to live long, healthy and fulfilling lives in Argyll & Bute was recently held in the Corran Halls, Oban. The event was very well attended by a full range of key stakeholders with an interest and influence in reshaping care for older people who were challenged to develop a shared understanding of the ambition to reshape care for older people and contributing to defining values and behaviour to achieve this. A report on the outcome of the event will be published in due course.

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Argyll & Bute Hospital 150 Years Anniversary - more than 100 staff past and present gathered on 29 May to celebrate the unveiling of a special plaque by Thomas Byrne, Director of Mental Health Charity, Acumen to celebrate the 150th anniversary of the Argyll & Bute Hospital.

Volunteering Awards - the annual Volunteer Awards took place in Council Chambers, Kilmory on 31 May. The event is organised annually by Argyll Voluntary Action to celebrate volunteering across Argyll and Bute and is attended by organisations, Councillors, volunteers, carers and was also attended this year by Jackie Baillie, MSP. For the second year NHS Highland has sponsored a “Health Volunteer Award” for individuals who volunteer in a health environment. This year we had two prize winners.

The Committee Noted the content of Director of Operations Report.

7. Clinical Governance

7.1 Clinical Governance & Risk Management Report

Ms Tyrrell spoke to the circulated report and highlighted and summarised a number of items.

Risk Management

Incidents – the graphs illustrated the number of incidents reported through Datix over the past 13 months. As the information for April 2013–June 2013 was unavailable at the time of reporting, the report to the Committee in June will feature the top five incidents, with categories, details and actions undertaken.

Ms Tyrrell advised that the audit scores represent compliance of evidence based practice.

Mr Creelman enquired about the availability information to measure adherence to ‘surgical pause’ by surgical staff. Ms Tyrrell confirmed that this practice does take place and she will provide evidence details in future reports.

Pressure Ulcer Prevention – there has been a sustained reduction in the number of incidents due to the work of staff in applying the clinical quality indicators, with no Grade 3 or 4 hospital acquired pressure ulcers reported in Argyll & Bute since the last report. A significant amount of work continues in community settings to raise awareness of patients, carers and staff in all sectors to ensure that appropriate risk management is undertaken at all times. The recruitment of an Advance Nurse – Tissue Viability should be completed by September 2013 which will provide additional capacity to undertake this work.

Falls Prevention - as with Pressure Ulcer prevention considerable amount of work is underway to reduce the incidence of falls in both hospital and community settings. Application of evidence based interventions, in the assessment and management of risk in those likely to sustain falls, is being tested in Lorn and Islands Hospital in Oban. Some wards are showing a reduction in falls, partly due to the change in patients groups, i.e. vulnerable patients.

Serious Untoward Incidents (SUI) - Since the last report there has been one SUI related to patient suicide. The formal SER meeting took place on 10 June 2013. The report and action plan is under development and will be discussed at the next Clinical Governance and Risk Management meeting.

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Health Improvement Scotland Adverse Event Review - HIS will be reviewing NHS Highland in relation to the Management of Adverse Events on 7 August 2013. In preparation for the review visit NHS Highland has been asked to submit details of all adverse events during the 18 month period November 2011- April 2013.

A total of 28 Argyll & Bute CHP incidents have been submitted. The level of review for each of these incidents was as follows:

Full Significant Event Review (SER): 17 Local Case Review 8 Significant Event Analysis (Primary Care process) 2 SER not conducted as incident addressed via HR process 1

It is understood that 4 of the total number of incidents submitted by NHSH will be selected for further scrutiny. Further details about arrangements for the review visit are awaited.

Complaints

Of the 11 complaints received in March/April 2013 the themes can be broadly categorised as follows, with some complaints containing more than one theme:

Care / Treatment 6 Attitude 4 Communication 3 Access 3 Confidentiality 1

Pat undertook to review the detail of the information presented to the Committee around complaints reporting and provide additional detail at the next meeting.

External Review

Joint Inspection of Children’s Services in Argyll and Bute - the pilot inspection in Argyll and Bute was completed in April 2013 and verbal feedback from the Joint Inspection Team was delivered to Senior Officers on 3 May 3. The findings of the inspection were very similar to our own self evaluation findings and identified a number of strengths as well as areas requiring increased focus. The timescale for delivery of the final report has been lengthened and it is now expected that this will be received in July. The Integrated Children’s Services Plan for Argyll and Bute is under development and will contain all of the actions required to address areas identified within the inspection findings.

CPA Surveillance Inspection of LIH, Oban Laboratories – a follow up inspection took place in April and the laboratories retained their accreditation.

Quality

Older People in Acute Care

Local inspection visits were conducted at all hospitals/wards within the CHP during May 2013. The purpose of these visits is to share learning across all sites and to ensure that there is a focus on the key priorities for improvements. A range of tools were used during the visits including national tools from HEI/HIS.

Inspection included:  environmental audits  observational audits of interactions with patients;  care planning audit;

5 34

 inspection of invasive devices (peripheral vascular catheters and urinary catheters)  interviews with staff patients and carers  mealtime observations

The inspection teams included a range of staff from the CHP (external to the site being visited). Some teams also included a non-executive and patient/public partnership representative.

Ms Tyrell will update the Committee in August, detailing the outcome of the visits and of the action plan which will be developed to support improvements and shared learning.

Person Centred Care

To support our approach to delivering person centre care, the CHP was privileged to learn first hand about the Esther Network, a Swedish healthcare system which is widely recognised as a world leader in patient-centred care, committed to assessing their services “through patients’ eyes”.

Two sessions were delivered by the Director of the Esther Network and a colleague on 10 June 2013 in Oban and Inveraray. During these sessions ways to adopt the Esther approach in Argyll and Bute were explored and with the support of the Joint Improvement Team the CHP is continuing this look at this method across the partnership as part of the Reshaping Care for Older People programme.

Scottish Patient Safety Programme (SPSP)

Acute Services – progress has been sustained across the range of indicators.

Mental Health – is in the very early stages of implementing SPSP and a team has been identified to take the programme forward and a progress measurement will be put in place.

Health & Safety

Revised Health & Safety Work Programme

The NHS Highland work programme for Health & Safety 2013-2015 is being revised and updated. The CHP operational plan will contain all the work streams within the corporate plan, together with areas of work to meet local concerns. The plan will be tabled at the CHP Operational Health & Safety Group in August 2013.

Fire Safety

Actions plans are being developed following the recent fire risk assessments carried out by the CHP Risk Advisor-Fire Safety.

Councillor Robertson enquired about the timescale of completion of the Fire Service audits. Mr Leslie advised that there were no specific timescales due to the requirement to complete compartmentisation work and he undertook to provide a summary of the outcome of the audits at the date of the next Committee meeting.

The Committee Noted the content of the Clinical Governance & Risk Management Report.

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7.2 Infection Control Report

Ms Tyrrell referred to the circulated report.

Staphlococcus Aureus Bacteraemia (SAB) (including MRSA)

There have been two cases of SAB in Lorn & Islands Hospital since the last report, one due to a contaminated blood sample taken from blood cultures and the other is been subjected to a root cause analysis to identify the cause. There is a robust process in place to look at and factor in all learning from identified cases and actions taken.

Responding to an enquiry from Mr Creelman around the long term use of antibiotics at home, Ms Tyrrell advised that the CHP is currently reviewing this practice and work is currently ongoing with Community Nurse in relation to their management of patient at home.

Mr Creelman asked if MRSA screening is undertaken in the CHP. Ms Tyrrell confirmed that although compliance is only required in hospital settings, screening has been rolled out CHP wide.

Ms Tyrrell emphasised that any evidence of non-compliance by staff of the front line audit process needs to be highlighted to ensure effective control of the guidelines.

Clostridium Difficile (CDI) Target

There have been two reported cases of CDI in Argyll & Bute since the last report, one in the hospital and one in the community. Further surveillance is underway to identify the root cause of each case.

Hand Hygiene

Monthly audits continue to be undertaken by all clinical areas, the results displayed and any non-compliance addressed. The CHP continues to demonstrate compliance with standards and quality assurance is consistently monitored to ensure there is no complacency within any areas.

Cleaning & Healthcare Environment

The CHP monthly cleaning and estates audits as per the National Cleaning Services Specification demonstrated 96% compliance for domestic monitoring and 97% for estates monitoring in March/April 2013.

Results for all Argyll and Bute Hospitals recorded that all areas achieved above 90% target for April/May 2013 and above 95% for estates issues. However three sites were below the 95% compliance for cleaning standards for May, Rothesay Victoria Hospital, Helensburgh and Islay and work to address the identified deficits has been progressed.

Outbreaks/Incidents

There have been no outbreaks or incidents in Argyll and Bute since the last report.

The Committee Noted the content of the Infection Control Report.

7 36

7.3 Health Improvement

Ms Garman provided an update from submission of first Health Promoting Health Service (HPHS) annual report sent to Health Scotland and Scottish Government. NHS Highland has requested informal feedback with regards to the content and detail but this has not yet been forthcoming. It is clear after discussions with other Boards that reports will vary greatly from Board to Board as there was no real guidance with regard to this.

Formal feedback will be sent directly to Elaine Mead, Chief Executive probably by end of July, although the date is yet to be confirmed. Discussions are still ongoing at the National HPHS network meetings with regards to some of the measures e.g. one of the smoking ones is not measureable. The CHP has been assured that the template is still a working document and changes may come on the back of the formal feedback.

NHS Health Scotland has worked over past year with Health Practitioners across NHS Health Boards to develop resources that showcase Health Promoting Health Service (HPHS) work undertaken by NHS Boards across Scotland.

The resources include, five new HPHS Case Studies illustrating tangible health improvement activities in number of different settings and two new professional profiles highlighting the elements of health improvement in staff’s roles within clinical settings. We will consider how best to disseminate these to make the most impact on developing front line practitioners’ practice. All the resources are underpinned by the HPHS concept that 'every healthcare contact is a health improvement opportunity'.

Details on some of these Case Studies and Professional Profiles and where they can be found online and the links are detailed below. http://www.healthscotland.com/documents/21434.aspx http://www.healthscotland.com/documents/21437.aspx

Councillor Robertson asked if Health Improvement work is undertaken in partnership with social enterprises, with an SLA in place relating to, for example, Health & Wellbeing.

Ms Garman advised that small grants funds are available for social enterprises through the Health and Wellbeing Partnership and indicated that should larger grants/projects be required that could be considered in the context of the funding available.

Councillor Robertson clarified that her enquiry was not just project specific and related to all Health Improvement projects.

The Committee Noted the content of the Health Improvement Report. 8. Financial Governance

8. Financial Governance

8.1 Finance Report

Mr Morrison advised that at end May 2013 the CHP recorded an overspend of £137,000. He summarised the main anticipated financial challenges for the CHP to operate within the budget as:

. Containment of the NHS Greater Glasgow & Clyde Service Level Agreement . Delivery of the £2.4m saving plan . Containment of ongoing locum costs

8 37

. Increased commissioned service costs . The establishment of the salaried dental service as a cash limited service.

Mr Creelman requested further details of the ongoing locum costs. Mr Morrison advised that with regard to Cowal, plans are being developed to address the necessity for medical locum cover in casualty, out of hours and inpatient services. Within Oban there is currently a time lag in the filling of medical locum positions. Investigation is also underway to look at the unexpected variance in the provision of surgical locums, which relates to annual leave cover.

With regard to salaried dental services, Mr Morrison advised that NHS Boards have been requested to review their funding request for salaried dental services and the detail of the Scottish Government allocation is awaited. An update will be provided at the next meeting.

Mr Morrison referred to the financial challenges to the CHP to deliver the cost improvement programme 2013/14, which reflects a target of a 2% saving, with the exception of the prescribing budget which is higher due to significant savings on generic drugs and displaced staff which is a specific target relating to a small number of unfunded posts.

Mr Leslie advised that budget holders have been requested to bring forward specific initiatives of their savings plans for discussion at the next CHP Core Management Team meeting.

The Committee Noted the content of the report and the financial challenge facing the Argyll & Bute CHP in 2013/14.

9. Staff Governance

9.1 PDP/R and eKSF Implementation

Mr Logue reported the final CHP figures at end of year 2012/13 for agenda for change staff having an eKSF review carried out and recorded on line as 65.42% of staff (all) and 88.61% of staff (excluding Bank).

Monitoring progress is underway for 2013/14 and the CHP currently has 2% of all staff (2.68% excluding Bank staff) with reviews and personal development plans signed off in eKSF. Mr Logue emphasised that there needs to be a focus on:

 addressing issues of missing data for a number of staff.  ongoing work in each area to ensure that all bank staff have an identified manager, outline and review.  planning the dates for PDPs well in advance to spread reviews throughout the year  ensuring and improving quality of reviews and evidence through guidance notes and advisory sessions for managers with the Workforce Development Facilitator.

The benefits of the eKSF process being part of the day to day working process to support and inform staff is recognised by Managers. Mr Logue acknowledged the need for re- engagement with CHP focus group to provide support and assurance around the eKSF process and this will be taken forward. Ms Tyrrell suggested the development of feedback questions for team leaders to take forward with staff.

It was agreed that, when available, the results of the current staff survey will be submitted to the Committee for discussion.

9 38

The Committee:

 Noted the end of 2012/13 position.  Noted the start of year position.  Noted the progress made in embedding this in practice and the use to support and inform staff development in line with CHP and NHS Highland objectives  Note the plans to ensure reviews and PDPs are started early in the year and spread throughout the year  Note the need to ensure that all bank staff have a review.

9.2 Minute of Partnership Forum Meeting of 4 April 2013

Mr Logue highlighted the presentation given to the Partnership Forum by Ms Tyrrell on NHS Mid Staffordshire Report and the circulated Minute reflects the subsequent discussion. The Partnership also discussed the option appraisal around radiography services and it was acknowledged that this is a challenging piece of work.

The Committee Noted the verbal update and the content of the circulated Minute.

10. Partnership Working

10.1 Public Partnership Forum (PPF)

As the notes of the meeting on 21 May 2013 were unavailable, Mr Creelman requested a verbal update.

Mr Martin reported that after discussion, and taking into consideration comments from members, it has been agreed to change the core function of the Argyll & Bute PPF with the locality PPF Leads meeting quarterly where issues from each locality PPF would be discussed. Locality PPF groups will continue to meet regularly.

The Committee Noted the verbal update.

10.2 Minute of CPP Management Committee Meeting of 6 March 2013

Mr Leslie referred to the circulate Minute which was to inform the Committee of the business of the Community Planning Partnership. He advised that the draft Single Outcome Agreement will be submitted in due course to the Committee for discussion and agreement.

The Committee Noted the content of the circulated Minute.

11. Performance Management

11.1 Delayed Discharge Report

The circulated monthly census recorded zero delayed discharges >4 weeks within the CHP as at 15 May 2013.

The Committee Noted the details of the circulated report.

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12. Mental Health Modernisation Update

Mr Leslie highlighted details of the circulated report which gave an update on the implementation of the modernisation of mental health services in Argyll & Bute.

Capital Project Stage 1 Approvals – the revised stage 1 report was submitted by Hubco to NHS Highland during May, and has been passed to our advisors for review and comment. The Outline Business Case (OBC) is being updated with information from the stage 1 report. At present no dates have been set for presenting the OBC as discussion are ongoing with regard to “bundling” this project with another NHS Highland or NHS Grampian Project. More detail on this is available later in this report.

Inpatient Services - the bed compliment remains at 28 plus 3 minimal supervision places in the refurbished Firgrove building.

Budget - The bridging allocation for the project during 2013/14 remains unchanged at £500k as set by the CHP management team. his will largely be used to cover the capital project, project management and advisor costs, which are expected to exceed £400k this year and drop off during 2014/15. A review of the expected capital project costs for 2013/14 will take place after decisions are made regarding “bundling” options.

Community Mental Health Team Base – both Kintyre and Dunoon CMHS bases are almost complete. The Kintyre team will move into their new base in Campbeltown Hospital, along their Social work colleagues and the Kintyre ABAT team, later this month. The Cowal Integrated CMHS will also be relocating from Dochas Lodge to their new base in Cowal Community Hospital later in June.

Supported Transfer of Detained Patients – a staff/management working group has been established to take forward the implementation of this service development. Proposals for an increase in hospital nursing staff was taken to the vacancy monitoring group and approved in principle, but requiring approval by the core team due to the cost implications, as this development requires an additional £100k recurring funding to implement. Staff meetings have also been organised to explain the changes to staff, in particular the alteration to their shift patterns to enable the service to operate at times when it will be most effective for patients.

“A Vision for Mental Health Service in Argyll & Bute” – Workshop held on 29th April - the “Vision” working group met recently to review the outputs from the workshop and to use them to update the vision statement. The revised vision statement will be circulated internally and to partners during June/July for comment.

Mr Leslie summarised that while progress continues to be made in establishing new community services and upgrading current hospital services; the capital project is entering a critical phase. Key decisions will soon be made with regard to bundling with another capital project which will enable the project to continue to progress. Decisions taken over the next few weeks will be vital in terms of defining the length of time to complete, and the overall cost of the new mental health unit.

The Committee Noted the current key issues and progress against the action plan.

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13. AOCB

There was no other business.

14. DATE, TIME & VENUE FOR NEXT MEETING:

Wednesday 21 August 2013, Meeting Room, Fire Station, Oban

12 41 Highland NHS Board 13 August 2013 Item 3.2

HIGHLAND HEALTH & SOCIAL CARE GOVERNANCE COMMITTEE Report by Deborah Jones, Chief Operating Officer

The Board is asked to:

 Note that the Highland Health & Social Care Governance Committee met on Thursday 4 July 2013 with attendance as noted below.  Note the Assurance Report and agreed actions resulting from the review of the specific topics detailed below.

Present: Myra Duncan, Board Non Executive Director – Chair (excl. Item 4.4) Jan Baird, Director of Adult Care Mr Quentin Cox, Area Medical Committee Representative – Consultant (to 1.10pm) David Garden, Head of Financial Planning Bren Gormley, Elected Member, Highland Council Gavin Hogg, Patient/Public Representative Deborah Jones, Chief Operating Officer Tracey Ligema, Locality General Manager Chris Lyons, Director of Operations – Raigmore Hospital (from 9.40am to 1.10pm) Fiona MacFarlane, Pharmacist Representative Margaret MacRae, Staffside Representative Gillian McCreath, Board Non Executive (Chair – Item 4.4) Ailsa McInnes, Area Optometric Committee Representative Okain McLennan, Board Non Executive Director (to 11.45am) Helen Morrison, Associate Director (NMAHP Workforce Planning and Development) Linda Munro, Elected Member, Highland Council Brian Robertson, Head of Adult Social Care JeanPierre Sieczkarek, Area Manager Dr Chris Williams, Area Medical Committee Representative – GP

In Attendance: Brian Mitchell, Board Committee Administrator Kenny Oliver, Board Secretary Dr Ken Proctor, Associate Medical Director (Primary Care) Simon Steer, Head of Strategic Commissioning (to 1.05pm) Janet Spence, Programme Manager (Adult Social Care) (for Item 3.2) Maimie Thompson, Head of Public Relations & Engagement

Apologies: Helen Bryers, Head of Midwifery David Flear, Patient/Public Representative Malcolm Jones, Area Dental Committee Representative – Dental Practice Advisor Gill McVicar, Director of Operations – North & Mid Adam Palmer, Staff Side Representative Nigel Small, Director of Operations – South & Mid Kate Stephen, Elected Member, Highland Council Bob Summers, Head of Health & Safety Katherine Sutton, Associate Director, AHPs Philip Walker, Head of Personnel Mhairi Wylie, Public/Patient Member Representative – Voluntary Sector 42

AGENDA ITEMS

 Self Directed Support  Highland Health and Social Care Finance Sub Committee Proposals

 Financial Position Report as at 31 May 2013

 Health and Social Care Financial Plan 2013/2014

 Update on Change Fund Activity, Proposals, Spend Profile and Attribution

 Adult Services Balanced Scorecard

 Highland Health and Social Care HEAT Targets Balanced Scorecard

 Integration Programme Board – Progress on Outstanding Actions

 Care Inspectorate Reports Improvement Activity and Enforcement of Embargoes

 Care at Home Services – Response to Care Inspectorate Report March 2013

 Five Years Adult Care Plan

 Operational Unit Reports

 Anticipatory Care Plans, Polypharmacy Assessments and GMS Contract (Scotland)

 Minute of Meeting of the Adult Support and protection Committee held on 19 February 2013

 National Programme for Unscheduled Care and Integration of Winter Plans

 Committee Function and Administration

 Confirmation of Development Day to be held on 26 August 2013

DATE OF NEXT MEETING

The next meeting will be held on Thursday 12 September 2013 in the Board Room, Assynt House, Inverness at 9.30pm.

2 43 HEALTH AND SOCIAL CARE COMMITTEE – ASSURANCE REPORT Meeting on Thursday 4 July 2013

1 TOPIC: Declarations of Interest Issues Assurance Actions Do members have any interest to D Garden (Item 3.2) – Director/Trustee of Health Action: declare in relation to any Item on & Happiness Charity.  G McCreath to Chair meeting for Item 4.4 – the agenda? M Duncan (Item 4.4) – Contracted employment Committee Administrator with Joint Improvement Team.

2 TOPIC: Assurance Report and Rolling Action Plan – 2 May 2013 Issues Assurance Actions Need to amend Assurance Page 16, Item 10, Items for Future Meetings – Action: Report. Amend first bullet point to read “Quarterly – Care  Assurance Report to be amended – Committee Inspectorate …” Administrator

Is current Assurance Report Reported that aim of Assurance Report is to  Agreed to discuss issues at Development Session format fit for purpose? record actions and provide assurance. – Chair/Committee Administrator Webcasting to be introduced for meetings from later in 2013.

Rolling Action Plan Agreed as accurate.  Agreed completed Actions to be removed from Plan – Committee Administrator

3.1 TOPIC: Professional Executive Committee – Verbal Update – Deborah Jones, Chief Operating Officer Issues Assurance Actions Need to ensure appropriate Meeting held with Clinical Leads and discussion Action: clinical engagement and held at SMT. Agreed to establish PEC from  Agreed Terms of Reference be circulated to all leadership arrangements. Need September 2013. Chair for initial meting has Professional Advisory Committees once finalised to define PEC membership. been identified and membership agreed that and agreed - Chief Operating Officer/Committee includes all Professional areas. Committee to be Administrator subject to review after six month period. Terms  Agreed PEC Chair to be member of HHSCC – of Reference to be finalised by end July 2013. Committee Administrator 44

3.2 TOPIC: Self Directed Support – Janet Spence, Programme Manager, Adult Social Care Issues Assurance Actions What progress is being made in Report indicated Social Care (SDS) (Scotland) Action: relation to Self Directed Support? Act 2013 to be implemented from 1 April 2014,  DVD presentation to be given to Development giving individuals four options for accessing Session – Head of Adult Social Care Social Care, applicable to both adults and  Agreed SDS form Standing Item on Finance Sub children. Service outcomes are agreed with the Committee – Head of Financial Planning service user and provides opportunity for people  Agreed SDS Development Session include aspects to control their lives. £3.85m of resource has relating to RAS monitoring, management of been committed to SDS. Resource Allocation identified risks, identification of ‘What ifs’, and staff System (RAS) being developed and tested, with awareness – Chair/Head of Adult Social Care expected rollout by 1 April 2014. A Five Year Plan for SDS in Highland being developed. Key challenges include moving resource away from building-based services, ensuring quality and sustainability of services and defining future demand levels. DVD presentation is also available. Consultation Events held in relation to draft Scottish Government Regulations and Statutory Guidance, and HHSC response to be submitted. Communications Strategy under consideration to ensure consistent message.

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4.1 TOPIC: Highland Health and Social Care Performance and Finance Sub Committee Proposals – Kenny Oliver, Board Secretary Issues Assurance Actions What progress is being made in Report indicated the Sub Committee would Actions: relation to establishment of Sub monitor finance, and performance against HEAT  Agreed establishment of Sub Committee. Committee? targets as well as the measures set out in the  Agreed to remit development of Terms of NHSH/THC Partnership Agreement. It would Reference – Chair/Chief Operating Officer. request reports on key areas of performance  Agreed draft Terms of Reference be submitted to where there is concern, discuss these and agree next meeting – Chair/Chief Operating Officer action plans. Sub Committee will provide  Agreed Short Life Working Group be established – assurance to this Committee on finance and Head of Financial Planning performance. This Committee will then provide relevant assurance to NHSH/THC. This Committee will be able direct the Sub Committee in areas of scrutiny.

The Short Life Working Group will be looking at the presentation of financial information and will feed its work into the Sub Committee.

4.2 TOPIC: HHSCC Financial Position as at 31 May 2013 – David Garden, Head of Financial Planning Issues Assurance Actions What is the financial position in Report indicated position to 31 May 2013, Action: year and where are current highlighting forecast overall breakeven position financial pressures? by 31 March 2014, subject to the improvement of £8.2m required to deliver the forecast. A break down of the current reported overspend forecast was given and it was noted that cost pressures within the South and Mid Operational Unit related, in the main, to the high cost associated with Independent Social Care Packages. Care Packages represented long term financial commitments and would have to be managed in partnership with THC.

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Whilst financial forecasting in this area of activity Action: was difficult to achieve progress was being made in this aspect. Care Packages continued to be subject to review to ensure these were tailored to patient needs. The Committee noted that the reasons for the current financial position are known, that work is underway to profile expenditure more accurately and that some savings remain to be identified. It also noted the work of Audit Committee in overseeing the action plan of the internal audit on financial management. The committee expressed its concern regarding the financial position.

What resource is received in DG advised Scottish Government do provide relation to Treatment Time financial resource, the level of which is unknown Guarantee activity? at this time.

What is impact of embargoed DJ confirmed Business Support Team requested  Noted further detail on implications of embargoes beds on ASC activity? to provide relevant data for next meeting. to next meeting – Chief Operating Officer

What activity is underway to Short Life Working Group will feed into improve performance reporting, Performance and Finance Sub Committee to presentation of data etc? consider relevant reporting aspects.

4.3 TOPIC: Highland Health and Social Care Financial Plan – David Garden, Head of Financial Planning Issues Assurance Actions What progress is being made in DG advised development of robust Financial Action: development of a HHSC Financial Plan in progress. Discussion ongoing with Head  Agreed Plan for 2013/2014 be submitted to next Plan? of Finance, Directors of Operations etc. Years 1 meeting - Head of Financial Planning and 2 reasonably defined at this point. Overall Plan should be available later in year.

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4.4 TOPIC: Change Fund Activity, Proposals, Spend Profile and Attribution – Simon Steer, Head of Strategic Commissioning Issues Assurance Actions What Change Fund activity has Report reflected on use of Change Fund, Action: been undertaken to date, and involving multi-agency/multi-sector approaches.  Agreed more detailed report on activity to date be what benefits have been Allocated resource of approx. £4m represented brought to the next meeting – Director of Adult realised? 2% of the total budget in this area and should be Care. seen in context. Initially was requirement to  Agreed draft Strategic Commissioning Plan be identify 3:1 return on investment. In past year submitted to Committee early 2014 – Director of there was decision to avoid further commitments Adult Care. on the Fund without clear strategic investment/disinvestment framework. The Fund balance has been protected. It was stated the “Change Plan” has ended. Partners are required to produce Strategic Commissioning Plan for Older People (SCPOP). Change Fund Working Group is now looking at small scale projects allocated via community networks and alignment of future use to the emerging SCPOP. It was noted overall Change Fund activity to date had resulted in meaningful changes at Operational Unit level. Achievements were outlined although attribution was complex. The Fund had allowed Units to trial changes that otherwise would not have been achievable. Future activity would relate to the Quality Approach to Safe and Effective Admission, Transfer and Discharge.

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4.5 TOPIC: Adult Services Balanced Scorecard – Kenny Oliver, Board Secretary Issues Assurance Actions What constitute valid Key DJ reminded members the Finance and Action: Performance Indicators (KPIs) for Performance Sub Group would consider actual Integrated Services in Highland? performance against targets and report to this  Agreed L Munro be briefed on Indicators 44, 56a Committee on an exception basis. The aim was and 56b outwith meeting – Head of Adult Care also to provide Operational Units with a level of  Agreed Strategic Key Performance Indicator Group performance data not available to date to enable (SKPIG) consider relevancy of listed Indicators – greater focus and attention to specific area detail. Chief Operating Officer This Committee would consider both the relevant  Agreed consideration be given to reporting on data and actions outlined for addressing issues. Respite Care activity – Chief Operating Officer KPIs do not necessarily measure quality and are in some cases historic. It was suggested reporting on Respite Care should be included. It was suggested that the presentation of the information be reviewed in terms of legibility of the colour annotation used.

4.6 TOPIC: HHSC HEAT Targets Balanced Scorecard – Kenny Oliver, Board Secretary Issues Assurance Actions What was performance against Outturn report circulated detailing performance Action: HHSC HEAT Targets in against targets. Report on performance to date  Agreed report on 2013/2014 activity to next 2012/2013? in 2013/2014 to be submitted to next meeting. meeting – Board Secretary

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5.1 TOPIC: Integration Programme Board – Progress on Outstanding Actions – Jan Baird, Director of Adult Care Issues Assurance Actions What progress is being made Latest report submitted to Integrating Care in the Action: against outstanding actions Highlands (ICH) Programme Board circulated relating to Central Support and this included list of outstanding Phase 1  Agreed report on Human Resource issues to next Services from Phase 1 of issues. The list included issues not necessarily meeting – Director of Adult Care implementation? escalated to programme level, and as such not recorded in the formal ICH Programme Issues Log. The report gave detail in relation to aspects such as a HR, Property, Finance, Transport, and the Redesign and Implementation of Adult and Children’s Services. There were no recommendations contained in the report.

What actions remain outstanding JB reported issues remain in relation to access to for IT and Communications? IT and relevant information etc. There was need for proper coordination and integration of IT systems and processes. Discussion had been held between NHSH and THC and assurance given to the Chief Executive. It had been agreed this was to be a priority area.

6.1 TOPIC: Suspension of Admissions to Care Homes – Brian Robertson, Head of Adult Social Care Issues Assurance Actions What arrangements and Report advised as to previous arrangements as Action: processes are in place for the to suspending admissions for poor performance, suspension of admission to Care where a Care Inspectorate Grading of 2 or below  Agreed draft suspension of admissions checklist Homes? was received, and outlined a proposed and actions – Head of Adult Social Care formalised approach to be consistently applied  Agreed relevant contract monitoring include within NHSH. The report included a proposed reference to implementation of actions, their suspension of admission checklist and actions. respective timelines, and associated impact on services – Head of Adult Social Care

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It was stated that to ensure an equitable  Agreed that number of admission suspensions approach across the Care Home sector it was lifted through discretionary arrangement be proposed the approach be applied to in-house reported to Committee – Head of Adult Social Care Homes. Directors of Operations would Care have discretion to lift a suspension prior to re-  Agreed Committee receive full report on all aspects inspection where the Care Inspectorate are in first instance and receive quarterly exception unable to schedule an early re-inspection, and reports thereafter – Chief Operating Officer where appropriate and subject to satisfactory assurance relating to issues raised. The Report also reflected on the impact of a more robust Inspection regime applied by the Care Inspectorate, resulting in more Gradings of 2 or below and consequently a greater level of suspensions being applied. This matter impacted on hospital discharge. The Service Improvement Lead for Care Homes was to review improvement plans developed as a requirement of the Care Inspectorate prioritising those areas where the impact on hospital discharge is most severe. The Service Improvement Lead was to liaise closely with District Teams in reaching any decision to re- instate admissions. It was noted that self- funders were responsible for administering their own respective care contracts.

What is the impact of imposing This aspect is a balance of relevant risk  Agreed to ensure elected members kept informed financial incentives to address elements, especially for existing residents. This as to issues in their constituency – Directors of quality issues timeously? also presented a reputational risk for service Operations/District Managers providers and requires appropriate management.

What are the reasons for Third BR stated there was consistent application of  Agreed issues be raised through the Strategic Sector Homes receiving Inspectorate Gradings. DJ confirmed issues Commissioning Group – Chief Operating Officer consistently higher Inspectorate would be discussed at Strategic Commissioning Gradings? Group to ensure an appropriate shared learning approach is adopted.

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6.2 TOPIC: Care at Home Service– Response to Care Inspectorate Report March 2013 – Jan Baird, Director of Adult Care Issues Assurance Actions What progress is being made in The report indicated that an Action Plan to Action: relation to actions following the address issues raised as part of a Care  Agreed Progress reports and report on follow-up Care Inspectorate report on Care Inspectorate inspection in February 2013 had Inspection be submitted to this Committee – at Home Services received in been developed. The Chief Executive leads a Director of Adult Care March 2013? working group to ensure all issues are addressed with immediate effect. The Action Plan had been agreed with the Care Inspectorate and was aligned to Highland Quality Approach activity. A follow up inspection was to be scheduled for 2013/2014.

How are issues relating to A caseload review is being undertaken and will capacity being taken forward? establish where there is a shortfall in capacity of existing Care at Home Officers. A workload analysis would also be undertaken to establish capacity level.

6.3 TOPIC: Adult Care – Five Year Improvement Plan – Jan Baird, Director of Adult Care Issues Assurance Actions What are the Plans for improving The report indicated the circulated Improvement Action: Adult Care in Highland? Plan draws together the significant strands of  Agreed progress reports be submitted to future work required to improve outcomes for adults meetings – Director of Adult Care across the Highland Council area and which are reflected at local level in the Operational Unit Delivery Plans. The Plan would replace the Community Care Plan previously developed. It was reported that outcomes agreed in previous Plans, and endorsed by Scottish Government remain unchanged.

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The Plan provides detail in relation to expected outputs on a year on year basis and how these must evidence improvements in outcomes. It also reiterates the outcome and performance frameworks established in the Partnership Agreement. The Plan included illustrations as to how inputs, outputs and outcomes can be linked and acknowledges the many strands which require to come together to achieve the desired improvements. It was important to work with communities to ensure appropriate resilience and overall this was a complex area of activity. The Plan was welcomed as a key vehicle for taking forward plans across Highland.

7.1 TOPIC: Chief Operating Officer Verbal Report – Deborah Jones, Chief Operating Officer (COO) Issues Assurance Actions Risk Management Reported that an NHS Board Development Session Action: on Risk Management had been held and that the Senior Management Team had also undertaken a Risk Workshop, both led by Scott-Moncrieff, Internal Auditors. A Short Life Working Group had been established. This Committee would require to consider Operational Unit Risk Registers, in relation to which Units will be required to highlight specific risks relating to Integration and develop associated Action Plans.

Unscheduled Care NHS Boards had been requested to develop Local  Agreed Winter Pressure Plans to be submitted to Unscheduled Care Action Plans (LUCAPs), to September 2013 meeting – Chief Operating improve capacity and flow to help sustain Officer Emergency Access Performance. Winter Plans will be integrated into the wider Action Plans. NHS Boards were expected to present a detailed Winter Plan to their Board meeting by the end of October 2013.

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The formal sign-off should confirm planned actions are effectively funded, provide appropriate and safe care, and that required standards of performance will be maintained during the period November 2013 to March 2014. The matter will be a central agenda item at the Unscheduled Care Workshop in September 2013 and a formal letter on specific planning priorities across the winter period will be issued to NHS Boards at that time.

There is to be a programme of events to raise the Commissioning Event profile and awareness of commissioning activity. The  Agreed further detail on Commissioning be first event was held the previous week and there had brought to a future meeting – Chief been strong representation from the Acute and Third Operating Officer Sector, the latter having helped chair the event. There would be further engagement activity up to September 2013, including with the Joint Improvement Team (JiT). January to April 2014 would represent the Commissioning Phase. It was reported that priority access to an Accredited National Course on Commissioning had been secured for relevant staff members.

It was stated levels of Delayed Discharge represented a Delayed Discharge key area for measurement of the success of Care Integration. Up to date data was relayed to members. It was stated reasons for delayed discharge included processes for patient assessment and resource allocation, residential care capacity, Care at Home capacity and the exercise of patient choice. It was clear long term strategic solutions were required and it was reported progress was being made and evidenced, as reported to the Committee. There was a need for increased access to Care at Home and Reablement services. Having appropriately trained staff was key. There were issues relating to interpretation of legislation for Adults with Incapacity and these were being considered at national level.

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7.2 TOPIC: Operational Unit Reports – Directors of Operations Issues Assurance Actions North and West Operational Unit Report Financial Position Forecast of a year end overspend of £667k, which includes a predicted underspend on Adult Social Care of £72k, the detail of which is being examined.

Waiting Times Belford Hospital subject to Rapid Process Improvement Workshop relating to unscheduled care demands. Endoscopy service in Caithness General Hospital to be subject of a Lean project and both Endoscopy and Ambulatory Care are key aspects of the Caithness General Hospital workstream of the Adult Services Review. The Chronic Pain Service subject to pressure at this time due to demand and absence of one Clinician. The service is being re-profiled, with work shared across the clinical team although there remains a need for more clinic and theatre sessions. Recruitment of a locum is being pursued.

Delayed Discharge There continue to be issues in meeting targets in North where a Care Home embargo in Wick is having an impact. Belford Hospital experiencing issues due to limited Care at Home capacity and nursing home beds. All discharges being expedited to ensure complex cases appropriately managed. There remains a focus on more preventative and early intervention approaches although Community Teams capacity issues remain.

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Sickness Absence Continues to be matter of concern, in relation to Care Home staff. All managers continue to ensure consistent application of Promoting Attendance Policy.

Caithness General Hospital Recruitment to vacant Consultant Physician vacancies remains challenging although one appointment has now been made. A further round of interviews has been scheduled for the near future.

South & Mid Operational Unit Forecast of a £4.4m overspend, relating entirely Financial Position to Independent Sector Care (ISC) spend within Adult Social Care (ASC). There has been high demand for ISC high tariff Learning Disability packages.

It was reported that embargoes on admissions Care Homes for Care Homes was impacting on Delayed Discharge levels. Subject to urgent discussion to find potential solution that improves access whilst maintaining standards of commissioned care.

Development of Single Hospital It was noted an Initial Agreement document was Action: Site in Badenoch and Strathspey to be brought to the Committee and then  Initial Agreement document to be submitted to a submitted to the NHS Board for consideration future meeting – Dir of Operations (South and and subsequent submission to Scottish Mid) Government Capital Investment Group (SGCIG).

Raigmore Operational Unit Interviews held on 30 April 2013 but no Action: Appointment Process for Lead appointment was made. Closing date for re-  Outcome to be reported to next meeting – Dir of Nurse advertisement was 14 June and interviews Operations (Raigmore) scheduled for 1 and 2 July 2013.

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Fire Upgrade Work and Initial Agreement document now been approved Reconfiguration of Tower Block by SMT and NHS Board. Submitted to SGCIG who were to meet on 2 July 2013.

Review of Nurse Staffing Levels Work on review is nearing completion and Action; across Medical and Surgical outcomes will be reported to next meeting.  Outcomes from Review to next meeting – Director Division. of Operations (Raigmore)

Cancer Services HEAT Targets NHSH, along with NHS Grampian now have to submit weekly Action Plan to Scottish Government outlining improvement plans. A Rapid Improvement Week had been conducted, facilitated by the Chief Executive and had identified a number of areas which have the potential to significantly reduce the pathway and waiting time and by doing so maximise the existing scarce staffing resource.

Central Records Compliance with implementation of the Public Records Scotland Act an issue along with implementation of Internal Audit Recommendations relating to management of central paper records. A number of actions being taken forward as indicated.

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TOPIC: Anticipatory Care Plans, Polypharmacy Assessments and GMS Contract (Scotland) – Dr Ken Proctor, Associate 7.3 Medical Director (Primary Care)

Issues Assurance Actions What is the current position Reported that GMS Contact in Scotland Action: relating to these matters? diverging from that in rest of UK, especially with  Agreed update be provided to next meeting - regard to QoF, whereby 55 associated points Associate Medical Director (Primary Care) were now available to GP Practices for Anticipatory Care Plan (ACP) and Polypharmacy activity. Parallel Local Enhance Service (LES) activity also maintained and this helps facilitate early discussion with patients and carers.

Primary Care would be involved in a range of activity in 2013/2014 relating to review and development of Care Pathways, with a focus on Mental Health. By considering pathway design from a community based team perspective it was anticipated there would be real benefits to be accrued from this activity.

What are the current risks relating The role of Primary Care is crucial in this area  Agreed consideration be given to a development to Social Care in the Primary and there is a need to define associated risks Session relating to Primary Care activity - Chair Care setting? and their potential impact on Social Care services.

7.4 TOPIC: Minute of Meeting of Adult Support and Protection Committee held on 19 February 2013 Issues Assurance Actions Any issues arising from Minute? No Issues reported. Action:  Noted Minute.

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8 FUTURE AGENDA ITEMS AND DEVELOPMENT SESSION TOPICS

Meeting on 12th September 2013:  CHP Assurance Close Down Reports – Directors of Operations  Contracted Services Monitoring Report – due 12th September 2013 – Brian Robertson  Update on Respite Care Arrangements in Highland – due September 2013 – Brian Robertson  Maternity and Children’s Services  Report on evaluation of redesign of Mental Health Services  Unscheduled Care

Items for 12th September – from Assurance Report  Performance and Finance Sub Committee draft Terms of Reference – Deborah Jones  Report on Financial Impact of Enforcement of Embargoes on Admissions to Care Homes – David Garden  Highland Health and Social Care Financial Plan 2013/2014 – David Garden  Report on Detail of Change Fund Activity – Jan Baird  Report on Performance to date 2013/2014 re HHSC HEAT Targets – Kenny Oliver  Integration programme Board – Update on Outstanding HR Issues – Jan Baird  Suspension of Admissions to Care Homes – Discretionary Lifting of Embargoes – Brian Robertson  Winter Pressure Plans 2013 – Deborah Jones  Update on Appointment of Lead Nurse, Raigmore Hospital (DOO’s Report) – Chris Lyons  Outcome from Review of Nurse Staffing Levels across Medical and Surgical Division (DOO’s Report) – Chris Lyons  Anticipatory Care Planning Activity – Ken Proctor?

Future Meetings:  Quarterly – Risk Registers – due 7th March 2013 – Directors of Operations in Operational Unit Reports then quarterly thereafter  Quarterly – Car Inspectorate Inspection Reports in Highland (incl comparator data pre and post integration, Action plans, timescales for action and interim support arrangements) – Brian Robertson  Standing – Adult Support and Protection Committee Minutes  Standing – Financial Position Updates – David Garden  Standing – Suspension of Admissions to Care Homes – Exception Reports – Brian Robertson  Standing – Adult Social Care Balanced Scorecard  Progress on integration of Patient/Client information systems (Chief Operating Officer’s Report)  Update on progress with reconfiguration of Raigmore Hospital Tower Block (include in Dir. of Operations Report) – Chris Lyons

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 Transitions – update on progress with Strategy – Chief Executive  Report on Implications of Welfare Reform on Charging for Social Care Services – Brian Robertson  Developing the Highland Strategic Commissioning Plan for Older People and Effect on Care Groups – Simon Steer  Childrens’ Services and Devolved Service Delivery Update – Jan Baird  Reablement Strategy – Brian Robertson  Update on Early Years Agenda and Activity  Case mix profile for relating to Emergency Department admissions – Deb Jones/Margaret Brown (include in COO report)  Progress Report and outlining of practical examples of DALLAS activity – Maggie Clark  Supporting Carers – Annual monitoring outcomes report (incl update on number of Care Support Plans) - Theresa James  Local Delivery Plans Six Monthly Update – due November 2013 – Directors of Operations  Local Delivery Plans Year End Progress Report – due March 2013  Savings Plan 2013/2014 (linked to Financial Plan 2013/2014) – David Garden  Maternity and Children’s Services  Health and Safety Update  Draft Strategic Commissioning Plan – Deborah Jones/Jan Baird  Initial Agreement for development of Single Hospital Site in Badenoch and Strathspey – Nigel Small

Development Sessions:  Self Directed Support (DVD Presentation) – RAS monitoring, mgt of identified risks, identification of ‘What Ifs’, and Staff Awareness  Health Inequalities  Reablement, Delayed Discharge and Shifting the Balance of Care  Remote and Rural Sustainability  Primary Care  Highland Health and Social Care Committee Governance Review

9 TOPIC: Highland Health and Social Care Development Day 26 August 2013 – Brian Mitchell, Board Committee Administrator Issues Assurance Actions What Subjects are to be It was suggested the first meeting should include Action: discussed at the forthcoming aspects relating to Balanced Scorecard reporting  Agreed to consider linking respective Agenda Items Development Session? and understanding as well as Governance. – Chair/Committee Administrator Members should feel free to suggest additional subjects for consideration.

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9.2 TOPIC: Committee Administration Schedule 2014 – Brian Mitchell, Board Committee Administrator Issues Assurance Actions What is the Committee Schedule Report outlining Schedule circulated. Action: for 2014?  Agreed Schedule be circulated separately to members – Committee Administrator

DATE OF NEXT MEETING

The next meeting of the Committee will take place on Thursday 12 September in the Board Room, Assynt House, Inverness at 9.30am

20 61 Highland NHS Board 13 August 2013 Item 3.3(a) Assynt House Beechwood Park Inverness IV2 3BW HIGHLAND NHS BOARD Tel: 01463 717123 Fax: 01463 235189 Textphone users can contact us via Typetalk: Tel 0800 959598 www.nhshighland.scot.nhs.uk

DRAFT MINUTE of MEETING of the NHS Board Audit Committee Tuesday 28 May 2013 – 10.00 am Board Room, Assynt House

Present: Mr Mike Evans, Chair Mrs Gillian McCreath, NHS Board Non-Executive Mr Okain McLennan, NHS Board Non-Executive

Also Present: Dr Michael Foxley, NHS Board Non-Executive Ms Deborah Jones, Chief Operating Officer Mr Nick Kenton, Director of Finance

In Attendance: Mr Iain Addison, Head of Area Accounting Mr Chris Brown, Audit Partner, Scott-Moncrieff Brenda Dunthorne, Head of Finance, Raigmore Hospital Mr John Huband, Head of Employment Services Mr Chris Lyons, Director of Operations, Raigmore Hospital Mr Brian Mitchell, Board Committee Administrator Mrs Helen Morrison, Associate Director (NMAHP Workforce Planning and Development) Ms Pearl Tate, Senior Audit Manager, Audit Scotland

1 WELCOME AND DECLARATION OF INTERESTS

1.1 Apologies

Apologies for absence were received on behalf of Robin Creelman, Myra Duncan, Ian Gibson, Dr I Kennedy, Heidi May, Ray Stewart and Sarah Wedgwood.

1.2 Declaration of Interests

Members were asked to consider whether they had an interest to declare in relation to any Item on the Agenda for this meeting. There were no declarations of interest made.

2 MINUTE AND ACTION PLAN OF THE MEETING HELD ON 12 MARCH 2013

The Committee:

 Approved the Minute of the meeting held on 14 March 2013.  Agreed the Action plan be updated for the next meeting. 62

3 MATTERS ARISING

3.1 Argyll and Bute CHP Governance and Management

Mr Kenton confirmed an update in relation to this subject was to be submitted to the meeting to be held on 10 September 2013.

The Committee so Noted.

3.2 Hospital and Community Health (HCH) Payments, Argyll and Bute CHP

Mr Kenton advised the Scottish Government was to publish a national Statement of Financial Intentions and this may address and clarify the issue in question.

The Committee so Noted.

3.3 Budget Management for Adult Social Care Services

Ms Jones advised a short life working group for budget management and presentation had been established and was to meet next in July 2013.

The Committee Noted the position.

3.4 Risk Management

Mr Kenton advised there was to be a Risk Workshop held as part of the next NHS Board Development Session and that a similar Workshop would be held for the Senior Management Team on 27 June 2013.

The Committee so Noted.

3.5 Capacity Planning

Mr Kenton advised he had met with and discussed this issue with Directors of Operations. Local Delivery Plans would make reference and were currently in development. Further detail would be provided to the meeting to be held on 10 September 2013.

The Committee Noted the position.

3.6 Patient’s Paper Records Management

There had been previous agreement that this matter be escalated for inclusion within the Corporate Risk Register. Ms Jones undertook to confirm this action had been undertaken.

The Committee so Noted.

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3.7 Assurance Relating to Local Action Plans on Waiting List Management

Ms Jones advised a short life working group had been established to ensure delivery of actions and this met on a bi-monthly basis. There had also been circulated NHS Highland response to a request from Scottish Government relating to recommendations made as part of the initial Review of Waiting List Management.

The Committee:

 Noted the establishment of a short life working group.  Noted the NHS Highland response in relation to delivery against recommendations made as part of the initial Review.

4 INTERNAL AUDIT

4.1 Internal Audit Summary Report

There had been circulated a copy of the progress report, which summarised Internal Audit work undertaken up to 27 May 2013, including seven reports. Eight Grade 4 issues, and six Red Control Objectives, had been raised across two of the Reviews, full reports in relation to which were circulated for consideration. The report indicated that Scott-Moncrieff remained on course to deliver the 2012/2013 audit plan. The report also indicated those Reviews in relation to which fieldwork was in progress or now complete. It was advised that good progress was being made in relation to the 2013/2014 programme.

The Committee then considered the following summary reports:

 Income and Expenditure

The circulated summary report concluded that although the transfer of data from the Highland Council ledger to the NHS Highland ledger in this transitional year had been heavily reliant on manual spreadsheets, assurance had been gained that reasonable arrangements were in place to ensure timely, accurate and complete transfer of the data.

 Use of Bank Staff

The circulated summary report concluded that the centralised integrated Staff Bank for Nursing and Midwifery is helping the NHS Board to manage this challenging area. Whilst issues had been identified which required further action, the NHS Board had demonstrated that it is aware of the need to monitor this area closely. There were no major weaknesses evidenced as part of the Review. The report indicated whilst there are good controls in place, improvements to the current arrangements could be made to further improve the system, specifically ensuring regular data reconciliation between key systems, regular senior management review of Policies and procedures, and regular monitoring undertaken to ensure expired/soon-to-expire statutory training and NMC registrations are identified and followed up in a timely manner.

During discussion, it was confirmed that Bank Staff were subject to Working Time Regulations and were restricted to working a total maximum of 35 hours per week. Mr Lyons emphasised the need to be able to utilise Bank Staff to give appropriate staffing flexibility. Mr Huband confirmed that the Personnel Team receive relevant payroll reports in relation to staff members with more than one contract and discussions were held with staff where appropriate in relation to excess hours worked. There was need for the Staff Governance Committee to be assured in relation to the various issues raised in the Review. 3 64

 Health and Safety in Care Homes

The circulated summary report stated no major weaknesses had been identified in Health and Safety arrangements at the facilities visited. Improvements were however required to ensure the consistent application of NHS Highland Health and Safety procedures across all Care Homes and day centres, to ensure effective reporting on incidents and improvement plans to the Health and Safety Committee. It was noted that Health and Safety arrangements within Care Homes were in transition and used a mix of NHS Highland and Highland Council Policies, procedures, guidance documents and forms. It was stated that IT infrastructure should be improved to ensure all staff have access to NHSH corporate information and systems such as DATIX and LEARNPRO. Training needs were being addressed through a training programme rolled out to all staff that had transferred from Highland Council and this had yet to be completed at the time of the Review.

During discussion, there was reference to requirements relating to Fire Safety training in Care Homes, mandatory annual inspections relating to which came into effect from 1 April 2013. There was a need to ensure this was prioritised within Care Homes under the control of NHS Highland. There was need for the Health and Safety Committee to consider relevant issues.

After discussion, the Committee:

 Noted the circulated Review Summaries.  Agreed the Staff Governance Committee also be requested to consider the Review findings in relation to the Use of Bank Staff.  Agreed issues relating to Health and Safety in Care Homes be discussed with the Head of Adult Social Care.  Agreed the Health and Safety Committee be requested to consider issues relating to Fire Safety Training within NHS Highland Care Homes.

4.2 Individual Reports for Consideration

Raigmore Hospital Financial Management

Mr C Brown spoke to the circulated report which concluded that there is general lack of ownership and accountability for the delivery of balanced budgets. As a result, key financial governance processes, including effective budget control, were not always being followed. The report indicated the need to continue recent work to address these perspectives, and stated management must take a two stage approach that optimised efficiency and challenged existing expenditure patterns whilst seeking to identify underfunding in specific budget areas. Main Review findings included an absence of formal sign-off processes for budgets prior to the start of each financial year, including in relation to high cost services such as surgery and medicine. Where budgets have not been agreed, and so were not owned by the budget holders from the financial year start, this can result in overspend with no agreed plan to bring these back on track. It was acknowledged that financial reports and assistance, provided by the Finance Team, were both timely and accurate, with current expenditure forecasts and taking into account any known cost changes. The report stated that anticipated increases in demand for services would increase existing cost pressures and recommended a strategic review to identify those services that are affordable at Raigmore and to develop service plans, including costed proposals. Management should seek establish a true understanding of where services were genuinely underfunded compared to where opportunities for efficiencies existed. With regard to staffing, relevant savings tended to be opportunistic in nature as opposed to planned. In this regard it was stated there was a likelihood that if service efficiencies are achieved to the levels required then the associated staffing levels may also require to be reduced. Utilisation of a voluntary severance scheme 4 65 had not been formally considered by the NHS Board. The report stated if savings targets are to be achieved clinicians required to become more engaged in the process of identifying and delivering savings. Effective monitoring and control of the delivery of future financial and performance objectives and targets is crucial, with closer scrutiny of performance and formally agreed recovery plans required. Mr Brown highlighted a number of the key issues included in the associated Management Action Plan and advised the Committee since the Review was conducted positive progress had been made in a number of the areas identified.

During discussion, there was concern expressed at the apparent lack of service planning within Raigmore as well as the same in relation to accurate budget setting and associated clinical buy-in. Ms Jones advised that the Raigmore Programme Board, through the Highland Quality Approach, was making progress in this area and the appointment of a new Head of Finance had helped. There were clearly cultural matters to address as part of this activity and the establishment of a quarterly Clinical Forum was intended to assist in engaging clinicians in the overall financial management process. Mr Lyons stated a proactive approach was being taken in relation to a very complex area of business and highlighted a significant level of Non-recurrent savings had been identified. Whilst there had been numerous examples of successful savings activity there was an acknowledgement that Raigmore Hospital would be required to adapt to ever changing demand patterns. The appointment of a Head of Finance and the associated Finance Team have helped to provide much more financial transparency. The multi-faceted improvement activity required to address the identified issues would require effective implementation of aspects of both HQA and Lean methodology. Ms Dunthorne confirmed that individual budget detail was being established, including historic spend profile, and additional finance forecasting and reporting elements were also in development. A weekly budget management team meeting had been introduced, involving relevant budget holders/managers.

Members welcomed the more forensic approach to budget management being introduced and emphasised the need for budget holders to be aware of the overall financial position within the Operational Unit that determines that if relevant savings are not made in one area then resource from other areas of activity will require to be utilised. A more dynamic and responsive approach was required. Mr Lyons advised positive progress was being made through provision of robust, detailed financial data and highlighted there were a number of existing examples of where significant savings had been achieved as a result. Ms Dunthorne emphasised real change was being evidenced and highlighted that financial management activity required to be supported by appropriate management skills to be successful. Budget holders needed to fully understand their respective budget management role and this raised issues relating to training and development to address any identified skills deficit in this area. It was stated this Audit Review had highlighted the need for clinicians to be involved in budget management activity through the relevant Clinical Forum.

Mr Lyons went on to state that Raigmore, as the primary Acute Care facility in Highland was impacted, including financially, by the range of decisions taken elsewhere within the organisation and highlighted that approximately 80% of costs relate to staffing. Staffing levels were already managed in terms of skilled/unskilled mix levels in an efficient, responsive manner. Ms Jones echoed the view that external pressures can impact heavily on Raigmore, including ever increasingly complex patient care needs and acknowledged the need for improved financial control systems and management. Mr C Brown stated that overall the Review had highlighted the need for robust service planning activity and also for an increased awareness, within the clinical community, as to their role in seeking to address these matters. There was reference and short discussion in relation to employment aspects, including the principle of voluntary severance and it was agreed such matters should be discussed with the NHS Board Chair outwith this meeting. He confirmed that progress in relation to the circulated Management Action Plan would be reviewed for the September 2013 meeting of the Audit Committee.

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The Committee:

 Noted the report findings.  Agreed there be appropriate Review follow-up and a progress report submitted to the meeting to be held on 10 September 2013.  Agreed matters relating to employment issues should be discussed with the NHS Board Chair.

Ms Dunthorne and Mr Lyons left the meeting at 11.40am and the Committee agreed to consider the following Item at this point in the meeting

5 COUNTER FRAUD

5.1 Annual Report 2012/2013

Mr O McLennan spoke to a Counter Fraud Annual report for activity in 2012/2013, advising as to two reactive and three proactive 3 cases investigated in year.

The Committee Noted the report content.

Mr Mclennan left the meeting at 11.45am and the Committee agreed to revert to the original Agenda at this point in the meeting.

6 INTERNAL AUDIT

6.1 Internal Audit – Individual Reports for Consideration

Consultants Contracts

Mr C Brown spoke to the circulated report which concluded that improvements have been made to the arrangements around Consultant contracts, with a greater level of engagement in the job planning process and ongoing support by Medical Staffing. It was stated more progress was required across the various process stages for relevant sign-off to ensure the system is robust. A programme of training on the Zircadian system throughout the organisation, by the Medical Staffing Team, had been undertaken and this had now resulted in 100% Consultant registration. Despite this improvement in activity the report indicated, at the time of Review, that 28% of contracts had been signed-off, 40% remained in the discussion stage, with the remainder at different stages of sign-off. One of the key recommendations that emerged as part of the Review was that NHSH should continue to explore restrictions on pay progression where Job Plans are not signed-off appropriately and also explore options for making line managers more accountable for supporting and monitoring such sign-off, with regular reporting against relevant Key Performance Indicators (KPIs) and milestones to senior management. This approach recognised the differing roles involved in Job Plan progression and eventual sign-off. On the issue of ‘satisfactory participation’ in the job planning process, it was reported that the “Medical and Dental Bargaining Group” had recently defined this and clearly communicated this to Consultants. This issue had been raised as part of a previous Review, and could potentially delay progression through relevant seniority points. At the time of Review a number of Consultants had yet to reach the ‘satisfactory participation’ stage. In terms of Risk Management this issue should be recorded on either the Corporate Risk Register or Operational Unit Risk Register until sufficient further progress is made.

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There followed discussion, and on the point raised Mr Brown advised that development of relevant Service Plans were required to ensure appropriate population of Consultant Job Plans. Ms Jones echoed this point stating Local Delivery Plans were the first step in ensuring appropriate and meaningful discussion and engagement. She highlighted the need to support ‘emergent leaders’ in this area. Discussion with the Board Medical Director and Director of Human Resources had led to agreement that there be greater focus in this area, and highlighted the need for Directors of Operations to be much more involved.

The Committee:

 Noted the report findings.  Agreed progress be reported to future meetings.

Mr J Huband left the meeting at 12.05pm

Governance Statement Readiness

Mr C Brown spoke to the circulated report which concluded that NHS Highland has a framework of controls in place that includes the key documentation and internal controls expected in relation to the four strands of governance outlined in Scottish Government guidance. The Scottish Public Finance Manual (SPFM) Internal Control Checklist had been completed, the detailed findings in relation to which were outlined. It was stated this had identified no fundamental gaps in the NHS Board’s internal control framework although work in year had highlighted some opportunities for improving effectiveness in certain areas. The report highlighted nine Internal Audit Reviews in 2012/2013 that were of relevance to the assurance provided through the Governance Statement and should be used to inform that Statement. The report referred to a number of ‘Red’ control issues identified in year relating to Risk Management, Raigmore Financial Management and Paper Records Management. In relation to the latter Review, the Public Records (Scotland) Act 2011 had come into effect on 1 January 2013 and the Audit Committee had previously noted the need to consider the implications of non-compliance with legislation when preparing the Governance Statement. Other matters requiring to be considered as part of the preparation of the Governance Statement included aspects relating to commentary summarising the findings of the Waiting Times Audit, review of Board Effectiveness, and Best Value issues. In respect of Board Effectiveness, a self-assessment should be undertaken otherwise an appropriate Disclosure should be included within the Governance Statement.

The Committee:

 Noted the report findings.  Agreed the relevant Effectiveness self-assessment be completed.

Follow Up

Mr C Brown spoke to the circulated report summarising progress made in implementing agreed management actions arising from internal audit reviews issued up to December 2012. It was advised that 51 actions had been closed and a further 2 removed where these were deemed no longer applicable. A number of outstanding actions were partially complete and it was noted no updates had been received for 58 recommendations, seven of which were rated as higher risk. Of those actions that remained incomplete, eight were designated as High Priority. Relevant issues had been discussed with the Chief Operating Officer and Director of Finance and there had been agreement to introduce a template for more proactive internal tracking. More frequent, targeted follow-ups would be conducted in 2013/14 with formal quarterly updates provided to meetings of the Senior Management Team 7 68

(SMT) and six monthly updates submitted to this Committee. It was stated that moving forward, there would be a more formal and direct escalation process to allow issues of non- response to be raised and addressed efficiently and effectively.

During discussion, Mr Kenton advised the detail of the circulated report had been considered by the Executive Team and progress was now being made in a number of areas. Ms Jones emphasised the importance of being able to track such progress at SMT level, this being a management role that should be appropriately aligned in relevant Management Objectives.

After discussion, the Committee:

 Noted the report findings.  Noted the Agreed forward reporting arrangements to this Committee and the Senior Management Team.  Agreed the Chief Operating Officer be furnished with a Summary Template of the Review Sponsors and Responsible Officers for those outstanding recommendations.  Agreed Review Sponsors and Responsible Officers for outstanding recommendations with a Grading of 3 or 4 be invited to attend the next meeting.  Agreed Review Sponsors and Responsible Officers for outstanding recommendations with a Grading of 1 or 2 be invited to attend the December 2013 meeting.

6.2 NMAHP Mandatory Training Requirements

Mrs H Morrison spoke to the circulated report and associated Action Plan which outlined action to provide assurance to management in relation to mechanisms for ensuring that minimum training standards are being met across key processes. It was advised the Area Nursing, Midwifery and Allied Health Professions (NMAHP) Professional Leadership Committee had considered the position whereby there was no current electronic system in operation within NHS Highland that could collect, collate and report on whether or not NMAHPs have received training, in response to the identification of need, based on the training prospectus. There had been agreement that a quality assurance system to monitor nursing practice and workforce, developed in NHS Forth Valley, could provide the necessary assurance and following initial exploration, that system was considered in practice and had been agreed as the preferred option. Work was underway to develop a more detailed proposal, in association with NHS Forth Valley. It was noted that a number of actions had been taken meantime to improve compliance and monitoring, such as a re-issue of the training prospectus, a re-audit in Autumn 2012, establishment of a short life working group to review and update the prospectus, introduction of better links between AT-L and eKSF, and establishment of an Infection Control Improvement Group Education Sub Group.

After discussion, the Committee:

 Noted actions taken to improve compliance with the NMAHP Mandatory Training Prospectus.  Agreed a further update be provided to the meeting to be held on 10 December 2013.

7 ASSURANCE REPORTS

7.1 Audit Assurance Reports on External Systems

There had been circulated report by the Director of Finance in relation to received annual assurance reports from the audit process for National Services Scotland (NSS) and

8 69 considered in detail by the NSS Audit and Risk Committee. The reports, whilst meeting the requirements of the NSS Board, also provide assurance to the wider NHS in Scotland. The circulated report gave Summaries of the formal Reports, and copies of the original documents were available to members. The report indicated that in relation to Practitioner Services an unqualified audit opinion had been given, with thirteen low level control weaknesses identified compared with six identified the previous year. Action had been taken to address all of the control weaknesses identified in previous Service reports. In relation to the National Ledger (NSI – National Single Instance), an unqualified audit opinion had been received, with two control weaknesses identified. The relevant Management responses had been referenced and notice given that both issues had now been resolved. With regard to National IT, the report indicated that the Auditors had provided an unqualified opinion. Issues highlighted had included ten Priority Three Recommendations, in relation to which management responses, and actions to be undertaken, had been identified and would be followed up in the coming year.

The Committee Noted the satisfactory Service Audit Reports on Practitioner Services, National Ledger (NSI) and National IT Services.

8 ANNUAL ACCOUNTS 2012/2013

8.1 Annual Accounts Process and Accounting Policies

Mr I Addison confirmed that the current process remained on target and Draft Accounts had been produced for consideration by Auditors by the mutually agreed date of 7 May 2013.

The Committee so Noted.

9 COUNTER FRAUD

9.1 Dissemination of Counter Fraud DVD and Awareness Raising Activity

Mr Addison advised the DVD had been re-launched by Directors of Operations, who would cascade relevant training and awareness raising activity. A presentation was also to be given to the SMT on 30 May 2013.

The Committee so Noted.

9.2 General Financial and Counter Fraud Training for Transferred Staff

Mr Addison advised appropriate financial training had now been completed for all relevant transferred staff involved in financial activity. Training delivery had been based on advice as to appropriateness by relevant managers so as to ensure was received by those who required the same. All relevant staff had been advised as to appropriate Counter Fraud processes and contact/role details for the Fraud Liaison Officer.

The Committee so Noted.

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10 CORPORATE GOVERNANCE

10.1 Annual Reports

The Committee were advised that as part of the Annual Accounts process a number of Annual Reports were to be produced, including a specific declaration that the systems of control within their respective areas are considered to be operating adequately and effectively. The Annual Reports are considered by the Chief Executive and the Audit Committee to ensure they receive sufficient information to assess the process through which the Governance Statement has been prepared and that the Chief Executive is discharging responsibilities appropriately in the preparation of the Governance Statement. There had been circulated the following Annual Reports:

 Staff Governance Committee  Remuneration Sub Committee  Clinical Governance Committee  Improvement Committee  Endowments Fund Committee  Argyll and Bute CHP Governance Committee  Highland Health and Social Care Committee  Control of Infection Committee  Health and Safety Committee  Pharmacy Practices

During discussion there was reference to the assurance statement contained within the Clinical Governance Committee Annual Report. Mr C Brown advised that further consideration of the wording of this element may be worthwhile and it was agreed this be reflected upon for the 2013/2014 financial year.

The Committee otherwise:

 Noted the Annual Reports received.  Noted that an Audit Committee Annual Report would be submitted to the meeting to be held on 27 June 2013.

10.2 Standing Financial Instructions

Mr I Addison advised no further changes were required at this time to the Standing Financial Instructions (SFIs) approved at the meeting held in December 2012. SFIs are a permanent set of instructions which do not change over time and they are also subject to review as part of the audit process. Changes would continue to be made to Delegated Levels of Authority where appropriate.

The Committee so Noted.

11 FINANCIAL GOVERNANCE

11.1 Tender Waiver Register

There had been circulated Tender Waiver Register 2012/2013. Mr Addison advised this would be updated to include the Waiver in relation to the Conversion of Combustion

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Equipment for the Raigmore Hospital Biomass Unit, as approved by the NHS Board at their meeting held on 9 April 2013.

The Committee otherwise Noted the Tender Waiver Register 2012/2013.

12 AUDIT SCOTLAND

12.1 Improving Community Planning in Scotland

The Committee were advised the report was designed to make a constructive contribution to the debate about how community planning in Scotland can, and should, be improved to meet the significantly raised expectations for community planning set out in the Scottish Government and COSLA Statement of Ambition. Ms P Tate advised that Audit Scotland were encouraging NHS Boards in Scotland to discuss the implications of the report, much of which would be driven by the service integration agenda in Scotland. It was suggested this topic should be considered for a future NHS Board Development Session.

The Committee:

 Noted receipt of the report.  Agreed the matter of community planning be considered as a topic for a future NHS Board Development Session.

13 ANY OTHER COMPETENT BUSINESS

There were no matters raised under this Item.

14 DATE OF NEXT MEETING

The next scheduled meeting will be held on 27 June 2013 at 12.00 pm in the Board Room, Assynt House, Inverness.

The meeting closed at 1.05 pm.

11 72 73 Highland NHS Board 13 August 2013 Item 3.3(b) Assynt House Beechwood Park Inverness IV2 3BW HIGHLAND NHS BOARD Tel: 01463 717123 Fax: 01463 235189 Textphone users can contact us via Typetalk: Tel 0800 959598 www.nhshighland.scot.nhs.uk

MINUTE of MEETING of the NHS Board Audit Committee Wednesday 27 June 2013 – 12.00 pm Board Room, Assynt House

Present: Mr Mike Evans, NHS Board Non-Executive (In the Chair) Mrs Gillian McCreath, NHS Board Non-Executive Mr Ray Stewart, Employee Director

Also Present: Mr Garry Coutts, Chairman, NHS Board Mr Ian Gibson, NHS Board Non-Executive Ms Deborah Jones, Chief Operating Officer (from 1.00pm) Mr Nick Kenton, Director of Finance Mr Okain Mclennan, NHS Board Non-Executive Ms Sarah Wedgwood, NHS Board Non-Executive

In Attendance: Mr Iain Addison, Head of Area Accounting Mr Stephen Boyle, Audit Scotland Mr Chris Brown, Audit Partner, Scott-Moncrieff Mr David Eardley, Audit Manager, Scott-Moncrieff Mr Paul Kelly, Scott-Moncrieff (Videoconference) Ms Elaine Mead, Chief Executive (from 1.00pm) Mr Brian Mitchell, Board Committee Administrator Mr Stephen O’Hagan, Assistant Director, Audit Scotland Mr Bill Reid, Head of eHealth Ms Pearl Tate, Senior Audit Manager, Audit Scotland

1 WELCOME AND DECLARATION OF INTERESTS

1.1 Apologies

Apologies for absence were received on behalf of Robin Creelman, Myra Duncan, Dr Michael Foxley, Dr Iain Kennedy, Alastair Lawton, and Colin Punler.

1.2 Declaration of Interests

Members were asked to consider whether they had an interest to declare in relation to any Item on the Agenda for this meeting. The following interest(s) were declared:

 Ray Stewart – Member of Unite and Staffside Chair.

The Committee Noted the declaration of interest. 74

2 MINUTE AND ACTION PLAN OF MEETING HELD ON 28 MAY 2013

The Committee were advised the Minute and Action Plan relating to the meeting held on 28 May 2013 would be presented to the meeting to be held on 10 September 2013.

The Committee so Noted.

3 MATTERS ARISING

3.1 Laboratory Managed Service Contract Review – Action Plan Update

Mr N Kenton advised that Audit Scotland had appraised the Action Plan developed in relation to this subject, all actions in relation to which had been completed with the exception of sourcing relevant training activity. Such training was an issue across NHS Boards in Scotland. Mr Kenton advised that having approached National Procurement in this regard they had indicated this should be more appropriately provided by the Central Legal Office. It was noted that there were no similar contracts being proposed moving forward at this time.

The Committee Noted the position.

4 CORPORATE GOVERNANCE

4.1 Governance Committee Annual Reports 2012/2013

There had been circulated Audit Committee Annual Report 2012/2013. Mr Kenton advised the Annual Report relating to the Asset Management Group would be circulated to members outwith the meeting and formally submitted to the next meeting. The two key issues highlighted would be in relation to development of the Asset Management Strategy, and agreement/management of the Capital Plan. Both matters had previously been reported to the NHS Board.

The Committee:

 Noted the Audit Committee Annual Report 2012/2013.  Noted the position in relation to the Asset Management Group Annual Report 2012/2013.

5 ASSURANCE REPORTS

5.1 Notification from Sponsored Body Audit Committee

There had been circulated draft letter, from the NHS Highland Audit Chair to the Scottish Government Health Finance Division, relating to annual notification of any significant issues of wider interest. The letter indicated no significant issues had been identified in 2012/2013.

The Committee Noted the content of the draft letter, which was to be issued to the Scottish Government.

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6 ANNUAL ACCOUNTS 2012/2013

6.1 Outstanding Internal Audit Reviews 2012/2013

Integrating Care in the Highlands – Phase 2

Mr P Kelly spoke to the circulated report which concluded that there were a number of areas where improvement was required in respect of the eHealth workstream of the Integrating Care in the Highlands (ICH) programme. The eHealth project had not progressed as had been anticipated. Focus had been on providing interim solutions to ensure that relevant staff affected by the integration of services had access to the technology they require as part of business as usual activities. The broader eHealth plan, involving the transformation of the eHealth/ICT infrastructure to support the delivery of change, had largely been suspended. It was noted this was due to the eHealth service having yet to receive clear requirements in relation to the redesign of services required. There would be a need for development of a Project Initiation Document defining the forward scope and objectives of the eHealth workstream and detailed project planning once the specification of requirement is further defined. There would also be a need to ensure formal governance arrangements for the Central Support Services workstreams, given the extent of interdependencies, as well as a consistent approach to recording and monitoring risk. The main findings of the Review were outlined and these included maintenance of project plans, inconsistent application of risk assessment methodology, application of change control procedures, and establishment of a baseline position for the provision of eHealth services.

During discussion, Mr B Reid advised the lack of a clear programme plan to work to in relation to adult care services had been a real challenge to the eHealth service, resulting in a reactive approach. A meeting was planned with the Chief Executives of both partner organisations with a view to developing and engaging with an appropriate Plan. Mr Gibson, member of the Integrating care in Highland Programme Board, advised the overarching programme had suffered a lack of focus on this area in the absence of a Project Manager, and having now been appointed she had introduced a noticeable drive towards greater structure and discipline for improvement activity. Mr Reid confirmed this appointment, which particularly relates to Phase 2 of the ICH Project, would primarily support the integration of support services while ensuring completion of any actions outstanding from Phase 1.

IT Service Delivery

Mr C Brown spoke to the circulated report which outlined the findings of a Review of IT service delivery, measured against the International IT Management Standard ISO20000. The Review involved production of a gap analysis against the Standard and concluded that there were a number of areas where controls can be improved. It was stated these related mainly to areas of improvement and the need for processes to be enhanced or further developed, as opposed to there being a fundamental absence of such controls. The report indicated the need for eHealth service delivery to be developed further to achieve consistent end to end processes and more formal mechanisms for liaising with and reporting to customers. It was suggested that adoption of a project approach to such activity would ensure the lifecycle of processes and associated interfaces are reviewed and so deliver greatest benefit. There would be need for management to consider how such a project may be appropriately resourced.

During discussion, and in response Mr B Reid stated that there were a number of aspects of the circulated report, both in relation to findings and recommendations, that required further consideration and discussion with Internal Audit as an end of audit meeting had not yet taken place. The issues to be discussed would include the rationale of selecting an International Standard which NHS highland and other Scottish NHS Boards have not formally ascribed to as a comparator. Mr Brown advised that in the absence of internal Standards for Service 3 76

Delivery, this particular comparator was chosen as an appropriate benchmark. In response to points raised, Mr Kelly stated the Standard considered issues relating to process and service delivery, and advised the eHealth service was fully compliant in terms of planning and implementation aspects. Mr Coutts stated there were a number of control issues raised as part of this Review, irrespective of whether the Standard referred to had been applied and the key consideration would be whether the NHS Board accepted these risks or sought to address these as appropriate. Mr Gibson expressed the view that actions should be prioritised to ensure visible, measurable positive change in the quality of service delivered.

After discussion, the Committee:

 Noted the circulated Review Summaries.  Agreed a formal update on ICH Phase 2 activity be brought to the September 2013 meeting, including the required baseline position and defined timescales for completion of Management Action Plan actions.  Agreed a further detailed report on IT Service Delivery be brought to the September 2013 meeting.

Mr Reid left the meeting at 12.35pm

6.2 Internal Audit Annual Report 2012/2013

Mr C Brown spoke to the Annual Report, which outlined the roles and responsibility of management and Internal Audit, along with an outline of the internal audit planning process. It was indicated the 500 planned days of activity had been met and there were no resource limitations that impinged on meeting the full audit needs of NHS Highland, nor restrictions placed on activity. Changes to the audit plan in year were as indicated. The summary of recommendations indicated those reviews completed in year and a summary of conclusions from reviews was also appended. It was confirmed there were no Grade 5 recommendations and no control objectives assessed as ‘Black’. In the overall Internal Audit Opinion it was confirmed that NHS Highland has a framework of controls on place that provides reasonable assurance regarding the effective and efficient achievement of the organisation’s objectives and the management of key risks. Various areas for development had been identified although none of these were rated as fundamental. Key themes for development related to a coordinated approach to longer term planning and integration, risk management and Raigmore financial management. It was noted further work was required in relation to paper records management. It was also stated appropriate arrangements were in place, in the areas reviewed, to promote value for money, deliver best value and secure regularity and propriety in the administration and operation of the organisation.

During discussion, Mr Brown confirmed the range of findings was not atypical although stated that given the current period of service integration in Highland this would lend itself to a higher than usual number of risks and identifiable areas for improvement. It was confirmed all recommendations are to be followed up, and an internal process was being established whereby the Senior Management Team would receive a live tracker spreadsheet on a quarterly basis for consideration and action. A report on this activity would be submitted to the next meeting, with follow up reports submitted six monthly thereafter.

After discussion, the Committee:

 Noted the report.  Noted the overall Internal Audit Opinion.  Noted a report on outstanding actions would be submitted to the next meeting.

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6.3 External Auditor’s Report – Scotland’s Public Finances Follow Up Audit

Ms P Tate spoke to the circulated report which outlined the key questions and findings from the follow up audit, which had incorporated utilisation of the Planning and Resource Alignment Best Value (BV) Toolkit. The key findings related to the NHS Board Vision and Strategic Planning arrangements and it was noted there was a strong commitment to continuous improvement. The Board had set out a very clear vision through use of the Local Delivery Plan (LDP) and Highland Quality Approach (HQA). It was noted that Operational Service Plans, supporting the Strategic Plans, were in the process of development. Other key findings related to the NHS Board Planning Framework and Financial Plans, and Scrutiny and Delivery of Outcomes. It was stated there was a continuing reliance on Non- recurring savings to achieve financial balance and this remained an issue for NHS Highland. The report indicated that whilst the Board demonstrated a clear commitment to continuous improvement, specific areas were identified in relation to development of longer term planning and resource alignment, finalisation of Operational Unit Plans, development of more robust longer term financial plans, identification and delivery of a higher level of recurring savings, consideration of appropriate benchmarking arrangements with a view to identifying efficiencies and improvements, and a need to ensure that actions included in all Plans are SMART (Specific, Measurable, Attainable, Realistic and Timely) in nature.

During discussion, Mr Coutts advised, in relation to public engagement, NHS Highland could evidence strong activity in this area, greater detail in relation to which could be provided to Audit Scotland if required. On the overall issues raised, he stated it may be advisable for the NHS Board to consider a Development Session on benchmarking activity, and stated it would be beneficial if this involved support from both the Internal and External Audit Teams.

After discussion, the Committee:

 Noted the report findings.  Agreed consideration be given to an NHS Board Development Session on benchmarking activity, supported by both Internal and External Audit Teams.

6.4 External Auditor’s Report – Review of Internal Control Systems 2012/2013

Ms P Tate spoke to the circulated report, including Management responses, in relation to the assessment of systems of internal control put in place by management. Ms Tate advised reliance had been placed on the work of Internal Audit. It was noted there had been a number of changes to staffing within the Internal Audit team in-year although this was not expected to impact ability to deliver the audit plan for 2013/2014. Overall assessment was that the key controls within the NHS Board’s main financial systems are operating satisfactorily. Issues raised had included adequate segregation of duties within Argyll and Bute CHP in relation to certain financial processes, variation in practice and procedure between the Highland Health and Social Care and Argyll and Bute CHP areas, reconciliation in relation to Primary Care/Family Health Services, the trade receivables office at Caithness General Hospital, cash and cash equivalents, and a required update of financial procedural instructions.

The Committee Noted the NHS Highland 2012/2013 Review of Internal Control Systems findings, proposed actions, and Management Responses to address the issues raised.

Ms Jones and Ms Mead joined the meeting at this point.

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6.5 ISA 260 Report on Matters Arising from Audit of Financial Statements

Mr S O’Hagan spoke to the circulated Report by Audit Scotland on the Annual Accounts which set out the matters arising from the audit of the financial statements for 2012/2013, advised that work in this area was substantially complete, and that relevant matters raised had been discussed with the relevant staff. He advised that it was anticipated that an unqualified auditors report would be issued. Significant issues being reported to the Committee included Adult Social Care Pension costs, the Surplus Sites Agreement for New Craigs Private Finance Initiative (PFI), balances with other NHSScotland Bodies, provision for public holiday pay relating to backdated Maternity Leave, and the impact on the Capital Resource Limit (CRL) of two payments designated as fruitless. In addition, it was noted that in relation to the pension costs of the NHS scheme, the revaluation had been based on a previous actuarial valuation, with a moratorium on such valuations at this time given consultation on reform of public sector pension schemes. As such this represented a financial risk to the NHS Board. With regard to outstanding information, the report indicated that this included the formal Letter of Representation prior to the auditor’s certification of the accounts, the relevant consolidation template, and a completed certified minimum data set. The Report also included a draft of the proposed Independent Auditor’s Report, which as stated above, was anticipated to include no qualifications.

The Committee Noted the draft clear Audit Certificate and associated points raised by the External Auditor.

6.6 Draft Annual Accounts 2012/2013 including Summary of Losses and Special Payments

Mr N Kenton spoke to the circulated report incorporating the consolidated Annual Accounts for NHS Highland for the year ended 31 March 2013 including the Summary/Schedule of Losses and Special Payments. He advised this was a groundbreaking set of Accounts for NHS Highland given the introduction of a new national ledger, and a period of service change and integration. The report gave an overview of the principal activities and developments in 2011/2012. Mr Kenton advised that NHS Highland had met the relevant financial targets set for the organisation. There had been an underspend, of approximately £273,000, in terms of the Revenue Resource Limit. In terms of performance against Key Non Financial Targets there had been included a copy of the Balanced Scorecard for 2012/2013 as at 31 March 2013. There had also been included a Sustainability and Environmental Reporting Statement. The Governance Statement for 2012/2013 included relevant Disclosures in relation to Records Management, Financial management at Raigmore Hospital, and Waiting Times. The draft report of the External Auditor indicated that there were to be no qualifications to the Accounts, that the financial statements gave a true and fair view of the state of affairs of the NHS Board as at 31 March 2013 and of its net operating cost position, and that these been prepared in accordance with International Financial Reporting Standards (IFRS) and the requirements of the National Health Service (Scotland) Act 1978.

Mr I Addison then took the Committee through the detail of the circulated set of draft Accounts during which the following particular amendments and points of interest were subsequently discussed:

 Page 110, Item 17 – The narrative for this Item was to be amended to read ”On 29 May 2013, the NHS Boards in Scotland were informed of the Scottish Terms and Conditions Council’s decision that women health workers in Scotland were to receive back-dated public holiday pay that they were entitled to whilst on maternity leave. The impact to NHS Highland of back-dating this to April 2008 is estimated as £900,000 and this has been included in the accounts for 2012/2013 as a provision.” 6 79

 Pages 152-154 – it was advised these elements reflected the Adult Social Care budget element in the Annual Accounts, the additional funding provided to cover the pension valuation adjustment of the Highland Council pension scheme and the change in assets and liabilities to reflect clinical negligence claims.  Pages 165 and 166, Item 17 – it was advised that this Item reflected the change of accounting policies in relation to the pension cost provision for those Highland Council staff having transferred to NHS Highland employment.  Page 199, Note 20 - The narrative for this Item was to be amended to read ”On 29 May 2013, the NHS Boards in Scotland were informed of the Scottish Terms and Conditions Council’s decision that women health workers in Scotland were to receive back-dated public holiday pay that they were entitled to whilst on maternity leave. The impact to NHS Highland of back-dating this to April 2008 is estimated as £900,000 and this has been included in the accounts for 2012/2013 as a provision.”

During discussion, there was clarification given on a number of specific matters included within the Annual Accounts in relation to estimation of assets and liabilities of the Pension Scheme, and relevant Counter Fraud Service activity in-year.

The Committee was advised that the Accounts would become public information after being placed in front of Parliament.

After discussion, the Committee Recommended approval of the draft accounts, subject to inclusion of the amendments to the commentary included in Pages 110 and 199 outlined above.

The Committee adjourned at 1.30 pm for a meeting of the Board in Committee to approve the Annual Accounts and resumed at 1.45 pm.

Mr G Coutts left the meeting at 1.45 pm.

7 ANNUAL ACCOUNTS 2012/2013

7.1 Patients’ Private Funds

Mr Addison spoke to the circulated report relative to the Abstract of Receipts and Payments for the Patients’ Private Funds, which summarised the funds held by NHS Highland on behalf of long term patients in hospital who were incapable of looking after their own finances. It was advised that these accounts were audited separately from the main accounts previously discussed. The value of funds held at 31 March 2013 was £370,089.

During discussion, the individual case management arrangements within NHS, and Private, Care Homes was raised and it was advised that separate records were kept for Private Care Home residents under the relevant applicable Mental Health legislation. There was also reference to the contract arrangements for the audit of these Accounts and it was advised this currently operated on a roll-forward basis following appropriate tendering processes, and was subject to costs being covered by Exchequer funding arrangements.

The Committee Approved the Patients Private Funds accounts.

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8 ANY OTHER COMPETENT BUSINESS

Mr O McLennan advised a CEL document in relation to Fraud had recently been received and requested the associated the Senior Management Team report be brought to the next Committee meeting for consideration.

The Committee Agreed a report on the recent Counter Fraud CEL document be submitted to the next meeting.

. 9 DATE OF NEXT MEETING

The next scheduled meeting of the Committee will be held on 10 September 2013 at 10.00am, in the Board Room, Assynt House, Beechwood Business Park, Inverness.

The meeting closed at 2.00 pm.

8 81 Highland NHS Board 13 August 2013 Item 3.4 Assynt House Beechwood Park Inverness, IV2 3BW Telephone: 01463 717123 Fax: 01463 235189 Textphone users can contact us via Typetalk: Tel 0800 959598 www.nhshighland.scot.nhs.uk

DRAFT MINUTE of MEETING of the STAFF GOVERNANCE COMMITTEE 21 May 2013 – 10:00 Multi-Purpose Room, Centre for Health Sciences, Raigmore, Inverness

Present Mr Colin Punler, Non- Executive Director (Chair) Mrs Myra Duncan, Non-Executive Director Mr Ian Gibson, Non-Executive Director Mr Ray Stewart, Employee Director

Also Present Ms Sarah Wedgwood, Vice Chair, Highland NHS Board

In Attendance Mrs P Cremin, Workforce Planning and Development Manager Mrs Anne Gent, Director of Human Resources Ms Margaret MacRae, Staffside Representative Mr Brian Mitchell, Board Committee Administrator Mrs Lindsey Mitchell, Medical Workforce Manager

1 WELCOME AND APOLOGIES

Apologies for absence were received on behalf of Garry Coutts, Robin Creelman, John Huband, Dr Ian Kennedy, Heidi May, Elaine Mead, and Adam Palmer.

1.1 Declarations of Interest

Members were asked to consider whether they had an interest to declare in relation to any Item on the Agenda for this meeting. Mr R Stewart declared that he was a lay member of UNITE Trade Union, was an employee of NHS Highland, and was Staffside Chair of the Highland Partnership Forum.

2 MINUTE OF MEETING HELD ON 19 FEBRUARY 2013

The Minute of the meeting held on 19 February 2013 was Approved subject to the following amendment:

Page 6, Item 8, Decision Box – Amend to read “After discussion, the Committee Noted…”

3 MATTERS ARISING

3.1 Internal Audit – Consultant Contract Update

Mrs Gent advised an update on progress against the Management Action Plan was to be presented to the meeting of the Audit Committee to be held on 28 May 2013. The Medical Staffing Team had undertaken a programme of training, including one-to-one sessions with 82

Consultants, to raise awareness and increase the knowledge of how to use the new e-job planning system, Zircadian. The Chief Operating Officer was to ensure appropriate engagement from Directors of Operations and Clinical Directors. On the point raised, it was confirmed that NHS Highland continued to consider enforcing restrictions on pay progression where job plans were not appropriately signed off.

The Committee Noted the position.

3.2 National HR Services – Baseline Services

It was reported that the baseline exercise had now been completed, with relevant data having been submitted. Feedback was expected in due course.

The Committee so Noted.

4 STAFF STORY

The Committee Noted that the Staff Story, due to be received at this meeting, had been deferred to the meeting to be held on 27 August 2013.

5 REPORTS FROM OTHER COMMITTEES

5.1 Minutes of Meetings of NHS Highland Partnership Forum – 15 February, 15 March and 26 April 2013

Mr Stewart spoke to a circulated Briefing document relating to the Staff Survey 2013, which was to take place between 27 May and 5 July 2013. Staff would be asked to complete the Survey online however 3,000 paper copies had been made available for issue within NHS Highland and these would be targeted at specific staff groups and geographical areas. Individual NHS Boards were responsible for local communications and a Plan had been agreed with the Communications Team. Key to delivery of the message would be to ensure buy-in from all levels of management. It was important that Survey results be used to identify areas/issues that require more focused work under the auspices of the Highland Partnership Forum. It was noted that within the Survey amendments had been made to the “Where do you work?” section to reflect changes in NHS Highland following service integration on 1 April 2012. Mrs Gent advised that the Staff Experience Project would help to inform the relevant Survey question set, which would be relatively shorter overall than previous versions. The Chair emphasised the need to act upon Survey results as outlined.

The Committee otherwise Noted the circulated Minutes.

5.2 Draft Minute of Meeting of Health & Safety Committee – 7 February 2013

Mrs Gent advised the circulated Minute had been considered by the NHS Board. It was noted that 2012/2013 had been an extremely busy period for NHS Highland in relation to Health and Safety matters. On the point raised in relation to integrated services, and governance of related Health and Safety matters it was confirmed that there was appropriate representation on the Planning for Integration Programme Board. There were a number of examples of joint working in this area. In terms of resource and capacity, Mrs Gent advised that Ms Maria Carpenter, Health and Safety Manager had been seconded to provide additional resource for Adult Social Care related matters.

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Issues still to be resolved with Highland Council related to resource for Moving and Handling activity and overall administrative support. Mrs Gent added that these issues represented a risk for the NHS Board. Mr R Stewart advised that the Head of Health and Safety had been added to the membership of the Asset Management Group on a short term basis to ensure issues relating to property were considered and addressed. It was noted that staff transferred to NHS Highland would be subject to an enhanced Occupational Health Service and again there was an issue with regard to the level of associated resource transferred to NHS Highland for this activity. Financial resource issues were being discussed with the Director of Finance. Sickness absence levels within Adult Social Care Services were being monitored by the Highland Health and Social Care Committee (HHSCC).

After discussion, the Committee otherwise Noted the circulated draft Minute.

6 WORKFORCE 20:20 VISION UPDATE

There had been circulated documentation which had been considered by the Scottish Workforce and Staff Governance Committee (SWAG) at their meeting held on 19 April 2013. The documentation provided a general update on development of the draft ‘Many Voices, one vision’ document. The overall vision was defined as:

“By 2020 every one working for NHSScotland will focus on providing safe, effective and person-centred care to support people to live longer, healthier lives at home or in a homely setting.

We will do this by adopting new ways of working, being flexible, and working with colleagues across NHSScotland and partner organisations. We will innovate and embrace technology and live up to our core values.”

This vision would be supported through the associated NHSScotland core values of care and compassion; openness, honesty and accountability; working to the best of our ability; and continually improving. The circulated document also included the key themes that had emerged as part of the early engagement process in development of the 2020 Workforce Vision.

Mrs Gent advised the final Vision would be launched at the annual NHSScotland Event to be held on 11 and 12 June 2013 and that further supporting documents relating to key themes would emerge later. In terms of the NHS Highland Strategic Framework, there were similar themes around the embedding of values etc.

After discussion, the Committee Noted the circulated documentation.

7 IMPLEMENTATION OF ELECTRONIC EMPLOYEE SUPPORT SYSTEM (eESS)

Mrs Gent advised relevant technical aspects were progressing well and that the transfer of NHS Highland data was to be signed-off in early course. Limited access for Human Resources staff was now anticipated from 1 June 2013. It was stated that relevant links to the ePayroll system had yet to be finalised, a final date for which was awaited, and this element was key for greater staff engagement. The relevant Project Team were proceeding on the basis of access to staff self-help elements with effect from 1 September 2013 and as such relevant aspects were being discussed with Directors of Operations etc on how best to plan and roll that out.

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The Committee:

 Noted the position in relation to implementation of eESS.  Agreed Minutes of Meetings of the Programme Board be submitted to future meetings.  Agreed the relevant overall Project Timetable be shared with the Committee Chair.

8 HIGHLAND QUALITY APPROACH

8.1 NHS Highland Strategic Framework – Final Version

There had been circulated final iteration of the visual representation of the NHSH Strategic Framework. Ms Thompson stated that having finalised the Framework it was important to now consider the relevant communications strategy and process. Recent Rapid Process Improvement Workshop (RPIW) activity would be used to test relevant Framework elements.

The Committee Noted the Strategic Framework diagram.

9 WORKFORCE PLANNING

9.1 Update on Development of the NHS Highland Workforce Plan 2013/2014

Mrs P Cremin spoke to a circulated report advising that the NHSH Workforce Planning and Development Sub Group was to oversee the development of the NHSH Workforce Plan 2013/2014, ensuring an integrated approach across workforce, finance and service planning; and business transformation. Focus would be in relation to workforce development and workforce contribution to quality improvement and service redesign, with alignment to overall NHS Board capacity planning. A workforce planning section had been completed as part of the Local Delivery Plan 2013/2014 and Operational Unit Delivery Plans were in the process of development. Annual workforce projections for NHS Boards, to be completed for SGHD, were to be submitted by 30 June 2013. The Scottish Government would then publish workforce projections for all NHS Boards in August 2013. Overall it was planned that a final Workforce Development Plan would be available at end June 2013 and submitted to the NHS Board for sign-off on 13 August 2013. Issues relating to future reporting arrangements would be discussed at the forthcoming NHS Board Development Session relating to Risk.

During discussion, there was reference to issues relating to service fragility, especially in the remote and rural setting, illustrating the need for a Workforce Risk Register. It was noted there were particular national recruitment issues with regard to qualified Radiotherapy staff. The Raigmore Hospital establishment review was raised, and the Committee was advised that this was being undertaken in partnership via the use of appropriate establishment validation tools. A number of developments had already taken place and the Workforce Planning and Development Sub Group would consider the results of reviews undertaken.

After discussion, the Committee:

 Noted the approach to be taken to develop the NHSH Workforce Development Plan 2013/2014 and associated content and timescales.  Noted results from establishment reviews in Raigmore Hospital would be reported to a future meeting.

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9.2 NHS Highland Workforce Plan Rolling 2012/13 Action Plan Update

Mrs P Cremin spoke to the circulated report giving a Month 12 update on progress in relation to the NHS Highland Workforce Plan Rolling Action Plan 2012/2013, this having been developed to support the delivery of the NHSH Workforce Plan throughout 2012/2013. It was reported a number of actions were scheduled for completion within the relevant agreed timescale and a number of others would be carried forward into the Plan for 2013/2014. Mrs Cremin highlighted the following points:

Action 7 Rural General Hospital Workforce Planning – discussions taking place at both local and national level regarding vulnerability and sustainability of RGHs, this remaining a key workforce challenge for NHSH. A workshop has been arranged for 26 September 2013, for all RGHs to discuss workforce development needs.

Action 11 Implementation of Health Care Support Workers (HCSWs) – Policy now in place to ensure staff can meet mandatory induction standard and code of conduct, and Scottish Social Services Council Code of Practice. Systems also in place to record compliance and progress against standards and codes, monitored by Learning and Development Team in association with Recruitment Team and Operational Managers. Work is underway to identify those employed between 1 January 2011 and 31 January 2013 and confirm standards of induction and code of conduct have been achieved and are recorded on SWISS system.

There had been circulated, as part of the report, NHSH Workforce projections for 2012/2013. This indicated that on the issue of planned workforce reductions progress was being made toward meeting the projected reduction of 105 wte, with 65.73 wte having been achieved as at 31 March 2013. There had also been circulated detail of spend relating to Supplementary Staffing to 31 March 2013 and a comparison report for 2011/2012. There was also circulated a table showing medical locum agency spend. The Medical Workforce Manager continued to investigate the relevant issues around locum use, as previously reported, and processes were in place to recognise and address any associated risk.

During discussion, there was reference to the use of Supplementary Staffing and the associated reduction in use of Overtime. It was advised Supplementary Staffing was being used to support service change/redesign scoping activity. Mrs Macrae advised dashboard reports were being used to track agreed establishment against use of supplementary staffing and this allowed for investigation as to appropriate usage etc.

The Committee otherwise Noted progress against the Workforce Plan Rolling Action Plan 2012/2013.

9.3 Workforce Development Plan 2012/2013 – Update on Key Developments Around Medical Workforce Issues

Mrs L Mitchell spoke to a circulated report, including the NHSScotland and NHS Highland responses to the ‘UK Shape of Training Review – Call for Evidence’, advising as to the main issues relating to the medical workforce in NHS Highland. Mrs Mitchell updated the Committee as follows:

Use of Medical Locums – a revised Policy on the use of locums had been developed and circulated for consultation. A Standard Operating Procedure had also been drafted to help simplify and clarify relevant processes and responsibilities. The Director of Medical Education was to lead a Group to review and implement consistent locum induction processes. It was stated a review of current financial systems was required in order to effectively monitor and report on spend across the NHS Board.

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Medical Bank – It was reported that it would no longer be possible to deliver a national infrastructure to support establishment of a medical Bank and NHS Boards were being actively encouraged to develop their own Banks utilising existing infrastructures. Initial discussions had been held with NoSPG around establishing a Regional Medical Bank which would better support both NHS Highland and the smaller Island Boards.

Medical Workforce Risk Assessment – NHSH piloting a risk assessment tool developed by colleagues in South East Region, looking at specific risks across the trained and trainee medical workforce as well as Nursing and AHP support roles. This work was to be completed in conjunction with an age profile for all specialties to identify retiral trends. The assessment has been completed for Paediatrics and Emergency Medicine, with the remaining acute specialties due for completion within six months. Mrs Cremin confirmed the tool would be applied in relation to Healthcare Scientists

Reshaping the Medical Workforce (CEL 28) – the process for 2013 was now complete and the associated reduction in national training numbers agreed at 24. Two posts would be lost from the North Region as a whole, with one post in Old Age Psychiatry and one from Obstetrics and Gynaecology.

Recruitment to Training Posts for August 2013 – Annual recruitment process now complete and final offers to be issued that week. National clearing day for final vacancies will be in June 2013 and the North Deanery to hold a recruitment day on 18 June 2013. In relation to risk, there were a reported 19 vacancies in GP Specialist Training within the North Region, 11 of which were allocated to Highland programmes with a number based in Rural General Hospitals.

Physician Assistant – agreed programme of clinical placements for student Physician Assistants from Aberdeen University and St Georges University, London. An opportunity existed to develop an internship year programme for 2014 that would coincide with the graduation of the second cohort from the Aberdeen University programme. This would support the induction of the Assistant role to NHS Highland and consideration would need to be given as to where these posts would fit within existing and future services.

During discussion, Ms Wedgwood stated that Medical Workforce issues raised matters relating to both Financial and Clinical Governance. Mrs Mitchell advised that Locum Agency staff were all subject to quality assurance processes and in terms of financial governance issues relating to Waiting List Initiatives and extra clinic provision were considered. Matters relating to workforce were discussed at a regional level and development of a North of Scotland Medical Bank was being discussed as indicated. Mrs M Duncan referred to issues relating to quality training experience within the remote and rural areas, and Mrs Mitchell advised the key was to ensure trainees received adequate support.

After discussion, the Committee Noted the main issues relating to the medical workforce in NHS Highland.

9.4 Socially Responsible Recruitment – Framework and Action Plan

Mrs Cremin spoke to a circulated report advising that following an NHS Board Development session to explore the many components of socially responsible recruitment there had been agreement to develop a relevant framework. This was to illustrate the overall approach and engagement with partner agencies to ensure that the workforce reflects the population of Highland, and that opportunities for education and employment for all groups in society is equitable and accessible. The aim of socially responsible recruitment is to get young people, graduates, multi-disadvantaged groups and long term unemployed to work within the organisation which will deliver positive health and social benefits. It was noted that NHS organisations, as public sector employers, have a duty to increase employment opportunities

6 87 for multi-disadvantaged groups as well as meet the requirements of equality legislation including the Equality Act 2010. NHSH was already working with a range of partners including Jobcentre Plus to promote the range of opportunities that NHS organisations can offer including apprenticeships, internships, work experience and volunteering. The circulated report also included detail of both current and future NHS Highland approaches in socially responsible recruitment, relating to such aspects as volunteering, internships, supported employment, health and social care careers for school pupils, youth employment, improving recruitment from the most health deprived areas, and issues relating to Looked after Children (Family Firm and Corporate Parenting).

During discussion, Ms Wedgwood made reference to the need to be able to map relevant activity in this area, assess effectiveness, monitor success and conduct suitable review. She added there was evidence that the existing Volunteering Policy may actually act as a barrier in some cases and the reasons for this required to be scoped and considered. Mr I Gibson stated that this area of activity was not restricted to providing employment opportunities, such as for looked after children, but also encompassed elements relating to provision of appropriate support arrangements for this and similar groups. It was hoped the stories of looked after children, and the two initial placements established, may help to inspire future activity across the scope of socially responsible recruitment. Mr Stewart emphasised there was a real opportunity for NHS Highland, as the largest Highland employer, to have a real impact in this area although stated, in his opinion, any agreed internships offered should be remunerated. Mr Punler stated there was need for this matter to be subject to the Planning for Fairness process as there was a need to ensure activity was delivering a positive impact on employment opportunity provision. There was overall general agreement that NHSH had an opportunity to make a positive impact in this area, subject to Planning for Fairness assessment of the various activity strands, and appropriate governance arrangements.

The Committee:

 Noted the approach being taken to develop a Framework to support socially responsible recruitment within NHS Highland.  Noted current approaches already mainstreamed and future plans needing progression.  Noted the relevant timescales, Lead Officer and Targets for interventions.  Noted plans to widen socially responsible recruitment to areas that consistently appear among the most health deprived and the least health improved measures.  Agreed the need to scope the impact of the current NHSH Volunteering Policy.  Agreed the need for establishment of relevant baseline data and defined inequities.  Agreed the need for Planning for Fairness assessment.  Agreed an update on planning for 2014/15 be submitted to the February 2014 meeting.  Agreed an Annual Report on activity be developed.

Mrs L Mitchell left the meeting at 11.50am

10 STAFF GOVERNANCE

10.1 Workforce Report – Sickness Absence

Mrs Gent spoke to the circulated report to end March 2013 and advised there would be a return to full reporting on workforce matters following introduction of the eESS system. She advised whilst the transfer of Adult Social Care staff had impacted on overall sickness absence levels there had also been a rise in the corresponding national rate over the same period. The number of staff transfers would have an impact on Occupational Health Service delivery and resource was being targeted at those currently on long term absence. Application of the Promoting Attendance Policy was expected to help reduce sickness absence within the Adult Care Service staff cohort.

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During discussion, there was agreement that a proactive approach to helping avoid sickness absence would have greatest immediate impact, as opposed to managing such absence. It was important to consider sickness absence levels in the context of the national position and it was agreed future reports provide that comparison detail.

After discussion, the Committee Noted the circulated report.

10.2 Implementation of Knowledge and Skills Framework

Mrs Gent spoke to the circulated report outlining progress against trajectory for 2012/2013, this showing 75.2% of staff having had reviews completed and signed off on eKSF at 1 May 2013. This figure was lower when taking Adult Social Care staff in isolation and it was noted that an associated activity recording issue had impacted on reported numbers. Actions had been identified to support and embed the development review process during 2013/2014 for this staff group. Overall, the figure for Reviews at all Stages (excluding Bank Staff) indicated that Reviewers continued to undertake reviews and are actively engaged in the positive management of the review process. It was reported a joint KSF/eESS project had commenced on 1 April 2013 to scope the requirements for delivering the KSF review process through eESS and it was anticipated KSF representatives from NHS Boards would be invited to contribute to work flow groups to take the project forward. In terms of planned activity for 2013/2014 the role and function of the KSF Team had been reviewed and would be embedded into the work of the Learning and Development Team. Work would continue with staff and managers to provided 1:1 and team support and it was noted that WebEx was increasingly being used to allow delivery of relevant training activity. KSF Guidance documents would be reviewed and updated in line with Reviewer/Reviewee requirements and with the introduction of an upgrade to the eKSF system itself. The KSF Team continued to work with closely with the Clinical Lead Nurse Bank and Staff Bank Operational Group (SBOG) to provide necessary ongoing support, and one of the key challenges related to the identification and assignation of reviewers for workers that do not undertake shifts within the same work area on a regular basis. Relevant management representatives had been invited to work with SBOG to seek an appropriate solution. In relation to Adult Social Care Services, work was underway to develop a review process that was consistent with the principles and format of the KSF development review process.

After short discussion, the Committee Noted progress against trajectories for 2012/2013.

10.3 Staff Governance Self Assessment Audit Tool (SAAT) Updates

Mr R Stewart advised no Action Plan had been developed for 2012/2013 however activity was ongoing, with this fully embedded into routine daily business. There was a desire to introduce formal recording mechanisms for relevant Staff Governance activity. Results from the Staff Survey 2013 would be used to set appropriate action and associated targets in year.

The Committee so Noted.

10.4 Staff Governance Committee Annual Report 2012/2013

There had been circulated Staff Governance Committee Annual Report 2012/2013.

The Committee Approved the Annual Report for submission to the Audit Committee.

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11 NATIONAL POLICY AND LOCAL IMPLEMENTATION

11.1 Whistleblowing and NHS Scotland National Confidential Alert Line Update

Mr R Stewart advised rollout of the revised NHSH Whistleblowing Policy would be undertaken following proposed discussion with Governance Committee Chairs as to their potential role as Internal Confidential Contracts. Once these arrangements had been agreed and confirmed a Joint Statement would be released by the Chief Executive and Employee Director highlighting the relevant local Policy and arrangements, as well as the introduction of the National Confidential Alert Line. Mrs Gent advised she was to act as the NHSH contact for the National Alert Line and emphasised the need for appropriate internal escalation routes for highlighted issues. Overall the key concern was to ensure a number of appropriate available options for enabling staff to raise concerns.

The Committee Noted the position.

12 FOR INFORMATION

There were no matters discussed under this item.

13 AOCB

The Committee took the opportunity to thank Mr Punler, who was fulfilling the role of Staff Governance Committee Chair for the last time at this meeting, for his leadership and direction during his tenure as Committee Chair. The Committee wished Mr Punler well in his future endeavours.

14 DATE OF NEXT MEETING

The next meeting was scheduled for 27 August 2013 at 10.00am in the Board Room, Assynt House, Inverness.

The meeting closed at 12.30 pm.

9 90 91 Highland NHS Board 13 August 2013 Item 3.5 IMPROVEMENT COMMITTEE Report by Elaine Mead, Chief Executive

The Board is asked to:

 Note that the Improvement Committee met on Monday 1 July 2013 with attendance as noted below.  Note the Assurance Report and agreed actions resulting from the review of the specific topics detailed below and the Balanced Scorecard (attached).

Panel: Mr Garry Coutts, Chair Dr Ian Bashford, Medical Director Cllr Alasdair Christie, The Highland Council Dr Iain Kennedy, Non-Executive Director Ms Sarah Wedgwood, Non-Executive Director

In Attendance: Mr Bill Alexander, Director of Health and Social Care Ms Margaret Brown, Head of Service Planning Mr Kenny Oliver, Board Performance Manager Miss Irene Robertson, Board Committee Administrator

Apologies – Mrs Linda Kirkland, Mrs Gill McVicar, Ms Elaine Mead, and Dr Margaret Somerville.

Respondents: Mr Robin Creelman, Chair, Argyll & Bute CHP (videoconference) Mrs Myra Duncan, Chair, Highland Health & Social Care Governance Committee Ms Brenda Dunthorne, Head of Finance, Raigmore Hospital (item 2b) Dr Paul Findlay, Consultant Stroke Physician (item 3.1b) Ms Christian Goskirk, Quality Improvement Lead (item 3.1b) Dr Roderick Harvey, Associate Medical Director, Raigmore Hospital Ms Deborah Jones, Chief Operating Officer Mr Nick Kenton, Director of Finance (item 2b) Mr Derek Leslie, Director of Operations, Argyll & Bute CHP (Videoconference) Mr Chris Lyons, Director of Operations, Raigmore Hospital Mr Brian Robertson, Head of Adult Social Care Mr Tom Slavin, Head of Finance, North & West Highland Operational Unit deputising for Mrs Gill McVicar Mr Nigel Small, Director of Operations, South & Mid Highland Operational Unit Ms Donna Smith, Service Performance and Partnership Manager (item 2c) Mrs Katherine Sutton, Associate Director AHPs (item 1a(i))

TOPICS DISCUSSED

1. Integration – Quality and Improvement

a. Scorecard for Adult Social Care (i) Reducing the number of falls related A&E admissions (ii) Long Term Housing Support 92

b. Scorecard for Children’s Services 2. Review of Board Assurance Report Actions

a. Telecare/Enhanced Telecare Services b. Financial Position - Highland and Operational Units c. SMR Return Rate d. Insulin Pump Therapy

3. Balanced Scorecard  Assurance of delivery of HEAT Targets and Standards for 2013 - 14

3.1 Heat Targets

a. Child and Adolescent Mental Health Services b. Stroke Services

3.2 Standards

a. Cancer Services – 62/31 day Targets b. Access Targets:  12 Weeks Outpatients  12 weeks TTG c. Access Targets – 8 Key Diagnostic Tests d. DNA Rates

DATE OF NEXT MEETING

The next meeting will be held on Monday 2 September 2013 in the Board Room, Assynt House, Inverness at 1.30pm.

2 93 IMPROVEMENT COMMITTEE – ASSURANCE REPORT Meeting on 01 July 2013

The Committee’s role and remit is to scrutinise NHS Highland’s performance and ensure remedial action is taken, as required. NOTE: To ensure the quality of reporting to the Committee those papers being submitted are required to contain more associated commentary and follow the prescribed template as agreed.

1 INTEGRATION – QUALITY AND IMPROVEMENT Issues/Risks Assurance Actions Scorecard for Adult Social Care: Work is in progress to further define and clarify A report to be prepared for the next meeting of There is an overlap between the Improvement the respective roles and responsibilities of the the Improvement Committee updating on the Committee and the Health & Social Care committees and groups. The HSCC will establishment of the improvement groups and Committee (HSCC). The roles of the various provide the main scrutiny of the Adult Social providing assurance that these groups have the groups and committees are still evolving. Care Scorecard while the Improvement appropriate skill mix and capacity to fulfil their There is a need to ensure that indicators Committee will look at areas of poor remits, with an indication of timescales for showing red are referred to the appropriate performance/targets not being met. The reporting in relation to improvements made. improvement groups for consideration and Strategic Key Performance Indicators Group Action: B Robertson / D Jones action as required. will review measures and whether they are appropriate.

An issue was raised regarding a potential role To consider proposed role for the Area Clinical for the Area Clinical Forum in relation to Forum in reviewing measures and indicators. reviewing the measures and indicators and their Action: I Kennedy / D Jones appropriateness.

Indicator 36 Anticipatory Care Plans: Indicator 36: The figures relating to the number of plans in It was clarified that because of the way in which place were queried. the data is received that an average figure is recorded in the Scorecard.

Indicator 13 Reducing the number of falls There is some evidence of reductions in the A detailed report to be prepared for the related A&E admissions: number of occupied bed days as a result of November meeting of the Improvement Impact of falls on older people’s quality of life falls, due to a combination of factors. Committee describing progress with the delivery and ability to live independently. A range of actions is being progressed within of the action plans developed by the Operational Implications of falls for health and social care each of the Operational Units. Units. The report to give details of how the service delivery. It was agreed to progress the recommendation funding invested in falls prevention and in In addition to falls at home and prevention of to develop a falls reduction project charter, physical activity initiatives for older people is hospital admissions there are also falls in driver diagram and associated measurement being used; it should also include some case 3 94 IMPROVEMENT COMMITTEE – ASSURANCE REPORT Meeting on 01 July 2013 hospitals. Data relating to each of the majority plan to provide assurance of measurable histories to illustrate outcomes of interventions of these elements is limited and a more robust improvements in relation to reduction of bed and benefits realised. measurement framework is needed. occupancy and A&E attendance as a result of Action: K Sutton / Directors of Operations There is a need to reconfigure community falls. systems and develop a pathway to ensure a The figures relating to costs of occupied beds rapid response enabling people to be cared for days in North Highland and in Argyll & Bute to be at home rather than being admitted to hospital, verified. as at present, as a result of a fall. Action: M Brown / D Leslie Data relating to patients presenting at their GP surgery/GPs being called out to a patient’s home after a fall would also be useful.

Indicator 21 Long Term Housing Support: Work is ongoing to further develop and refine The Strategic Key Performance Indicator Group This indicator needs to be further defined. It indicators. and the relevant improvement group to review shows the number of people supported through the appropriateness of this indicator and consider the use of the long term housing support budget whether the budget should be ring fenced/how and this in itself is not an indicator of a potential resources can be maximised to achieve outcome in terms of the number of hours each beneficial outcomes. client has received from the service and how Action: B Robertson / D Jones they may have benefitted from it. The budget is ring fenced, and the current service is funded mostly through block budgets, which poses some challenges in devolving budgetary control to the Districts.

Children’s Services Scorecard: The position continues to be monitored by the Consideration to be given to the committee / There is an issue around data collection. Adult & Children’s Services Committee. Work improvement group structure and the need for a A small number of breaches of the 26 week is ongoing to improve data availability and streamlined process. target occurred during 2012-13. robustness. Action: Chair /J Baird

Indicator 53b Complaints Monitoring: The issue raised in relation to Complaints to be A concern was raised regarding the complaints clarified. process and response times. Action: B Robertson / B Alexander

4 95 IMPROVEMENT COMMITTEE – ASSURANCE REPORT Meeting on 01 July 2013

2 REVIEW OF BOARD ASSURANCE REPORT ACTIONS Issues/Risks Assurance Actions Telecare/Enhanced Telecare Services: Work is ongoing however little progress has Progress report to be submitted to the next Consequent on the restructuring of Care at been made to date. meeting of the Improvement Committee. Home there is a need to review the hosting Action: B Robertson / G McVicar /N Small arrangements for Telecare/ Enhanced Telecare Services and how they will be managed within the Operational Units.

Financial Update – position at 31 May 2013 Operational Units to continue to develop and (month 2): implement plans to achieve the necessary savings. Highland position: Highland: Action: Directors of Operations Current reported overspend forecast at £8.2m. Overall we are in a slightly better position this Need to remove reliance on non-recurring year than at the same time last year. savings. Delays in identifying recurrent savings could result in further reliance on non-recurrent resource, in-year.

Issue around presentation of financial Training events and workshops have been held information, recognising the different accounting to promote a common understanding of the processes in NHS Highland and The Highland financial aspects and processes. Council.

South & Mid Operational Unit: South & Mid Operational Unit: Pressures in the independent spend particularly Work is ongoing to manage the overspend on care homes, learning disabilities etc. relating to the adult social care budget. Analysis by the finance teams has highlighted there has been reliance on non-recurring money to deliver services in the Unit. This year the Unit needs to fund additional care packages in the adult care sector some of which are very complex and expensive.

5 96 IMPROVEMENT COMMITTEE – ASSURANCE REPORT Meeting on 01 July 2013

North & West Operational Unit: North & West Operational Unit: Cost pressures - OOH, rural general hospital Proposals are being worked up to minimise locums, running 4 vacant general practices. costs being incurred. Potential additional cost pressure if Care at Work is ongoing around the cash releasing Home and Reablement, currently sitting within savings target. central budgets, are moved back into the Operational Units.

Argyll & Bute CHP: Argyll & Bute CHP: Continuing costs of locums to fill hospital and Work is ongoing to fill the vacancies and to try GP vacancies. Engagement with NHS Greater and find more sustainable solutions to remote Glasgow and Clyde to find a longer term and rural challenges. settlement. Significant investment in dental salaried service.

Raigmore: Raigmore: Raigmore: Significant overspend in relation to the 2012-13 Measures being taken to tighten financial An update on the work of the Programme Board non-recurrent carry forward; increased controls; raise overall financial awareness; and to be submitted to the next meeting of the expenditure to meet Time to Treatment promote a better understanding of budget Improvement Committee. Guarantee, and other in-year cost pressures management and the financial implications of A report on the work being undertaken by the including filling vacant consultant posts, their activity among service managers and Clinical Forum to be prepared for submission to increased drug expenditure, increased locum clinicians. the Health and Social Care Committee. costs, capacity issues particularly in Oncology, Six main projects are underway, overseen by Action: D Jones/C Lyons Haematology and Radiology. the Raigmore Programme Board, some of Impact of delayed discharges – a significant cost which have the potential to make savings or pressure. offset expenditure. A clinical forum has been set up to consider issues such as access to, and criteria for treatment.

SMR Return Rate: Highland: Highland: A report will be required for the Improvement A system needs to be put in place that will Most of the larger health boards code from Committee only if the proposed system is not ensure the sustainability of clinical coding discharge letters. NHS Highland has recently implemented. activity across the area. Qualified coders are entered into negotiations with NHS Greater Action: D Smith few in number and recruitment is challenging. Glasgow & Clyde to develop an agreement

6 97 IMPROVEMENT COMMITTEE – ASSURANCE REPORT Meeting on 01 July 2013

whereby we will send our discharge letters (the The issue raised regarding confidentiality and Final Discharge Letter) to them for coding and sharing of information across boards to be return. This will increase our capacity and referred to the Caldicott Guardian. achieve some consistency without Action: D Smith / M Somerville compromising quality to any significant extent. The proposed system will be run initially as a pilot test.

North & West Operational Unit: North & West Operational Unit: Overall return rate is 90% against the target of Action plans are being implemented to ensure 95%. Several factors (sickness absence, robust systems are in place. Additional training maternity leave) are impacting on the position. It and increased coding capacity will provide is challenging in small teams to ensure sufficient better absence cover to prevent backlogs in the people are trained and remain proficient in future. coding.

Raigmore Hospital: Raigmore Hospital: Currently below target at 81%. A meeting is taking place on 3 July 2013 to Coding staff capacity. discuss options for addressing the issues, including the possibility of outsourcing coding.

Insulin Pump Therapy Update: A detailed plan has been developed to achieve Update in due course to the Committee. To increase the availability of Insulin Pump the targets and this has been submitted to the Action: M Somerville therapy to patients of all ages with Type 1 Scottish Government. We are on track to meet Diabetes. the adult trajectory. A meeting will be taking place with representatives of the Scottish Government on 11 July 2013 to discuss the trajectory for the children’s service.

3 BALANCED SCORECARD The Balanced Scorecards for 2012 – 13 and 2013 – 14 were circulated and noted. There was tabled draft paper detailing the HEAT targets and the Standards for 2013 – 2014 with Lead Executives identified for the delivery of these Targets and the Standards.

7 98 IMPROVEMENT COMMITTEE – ASSURANCE REPORT Meeting on 01 July 2013

It was agreed that the paper would be discussed by the Executive Team and a further draft brought back to the next meeting of the Improvement Committee. Action: K Oliver

Drugs and Alcohol Treatment Waiting Times, which was noted for a future agenda, were showing red in the Scorecard. Nigel Small advised there had been an improving position over the last two years with an increasing percentage of patients being seen within three weeks. There were currently three vacant posts which was impacting on the position.

3.1 BALANCED SCORECARD 2012 – 13 - HEAT TARGETS Issues/Risks Assurance Actions CAMHS – Specialist Services, Raigmore: The 26 week target is currently being met and The position to continue to be monitored. A There are short and long term recruitment in some cases the 18 week target is also being report to be submitted to the January 2014 challenges within the service. achieved; however there may be an issue with meeting of the Improvement Committee in the Several vacancies exist due to maternity leave, under-referral to the service because of the event that the trajectory is not on track. retirement, and staff relocating to other areas. waiting list. Recruitment plans are ongoing; the Action: C Lyons It is expected that the 26 week target will be psychology staffing position has improved. breached in the short term. There will be an additional challenge of seeing all 16 and 17 year olds by 2015.

Stroke Services: Over the last few months the position has Reports on performance against the target to be Deteriorating position at Raigmore in respect of improved across the board in relation to all the submitted on a routine basis to the Health & performance against the target for admission to Standards except for brain scan and aspirin. A Social Care Committee and the Argyll & Bute the Stroke Unit after the diagnosis has been range of actions is being implemented to CHP Committee. A follow up report to be established in the Acute Medical Admissions improve the position in each of the stroke units. prepared for the Improvement Committee Unit. Delays in patient flow to and from the Work is underway in relation to reporting and meeting in January 2014. Stroke Unit resulting from delayed additional training for nursing and AHP staff is Action: I Bashford / C Goskirk / P Findlay discharge/transfer from the Unit to an being delivered. appropriate rehabilitation setting. With regard to access to stroke units work is The HIS standards for brain scan and aspirin ongoing with the Associate Director of AHPs have changed. The standard for with the aim of ensuring stroke patients who neurophysiology is quite challenging having are clinically fit are discharged as quickly as changed from 7 to 4 days. possible into the community for reablement.

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A proposal was put forward to identify beds in the community specifically for the care and management of stroke patients.

3.2 BALANCED SCORECARD 2012 – 2013 – STANDARDS

Issues/Risks Assurance Actions Cancer Services - Raigmore: An action plan with timescales has been To monitor progress against the action plan and Breaches in both 62 and 31 day targets, the developed to address the key factors that are identify any risks at an early date. main reasons for which are delays to surgery contributing to the breaches. The position is Action: C Lyons (urology and breast in particular), lack of reported to Scottish Government on a weekly radiotherapy capacity and pathway issues, and basis. lack of oncology capacity which is a major issue Figures for June 2013, as yet unvalidated, across Scotland. indicate 96.5% for 62 days and 95.5% for 31 days. A number of patients are also waiting for adjuvant radiotherapy.

Access Targets - 12 weeks Outpatients / Focused work has made a considerable impact Position to continue to be monitored. Treatment Time Guarantee (TTG) / Referral to on the position and the process and systems Action: C Lyons Treatment Time (RTT) now in place are robust, however sustaining the position is dependent on having full staffing Raigmore: capacity. Outpatient Pathway linkages are Breaches occurring in a number of specialities, being improved in preparation for the in particular in ENT and Ophthalmology. implementation of the new Patient Issue around reporting. Management System. Impact of meeting TTG requirement on the The work done by Margaret Brown and her achievement of other targets. team to resolve some of these issues was acknowledged.

Access Targets – 8 Key Diagnostic Tests: Update to be prepared for next meeting Raigmore: identifying impact of actions taken. Delays in reporting (MRI, CT and plain film) due Action: C Lyons to capacity issues. As a result there are a

9 100 IMPROVEMENT COMMITTEE – ASSURANCE REPORT Meeting on 01 July 2013 number of patients breaching the overall 6 week An action plan is in place to address the target for diagnostic radiological tests and capacity issues and reduce the backlog. investigations to be performed and reported, Where appropriate unreported cases will be which may impact on the cancer pathway. outsourced; it is also intended to increase the consultant establishment to cover the whole range of reporting duties. In addition a mobile MRI unit is to be brought in to increase capacity and reduce waiting times. Introducing extended working days/weekend working for in- house staff is also being explored.

Endoscopy: A Rapid Process Improvement Workshop was Breaches occurring due to pressures on the carried out in April which identified a number of service in terms of increasing demand and areas for improvement. Work is ongoing to complexity of procedures being performed, and address these issues. staffing capacity issues.

DNA Rates: Raigmore Hospital: Raigmore Hospital: Raigmore: With regard to New Outpatient Appointments In general the target is being met in those Focused work to be done to improve the position there is significant variation within the specialties where Patient Focussed Booking in OMFS. specialties; in particular the DNA rate in Oral (PFB) has been introduced. Work is ongoing to Action: C Lyons Maxillo-Facial Surgery (OMFS) is high. roll out PFB to other specialties. It was noted the DNA rate for return appointments is slightly higher than that for new appointments.

North & West Operational Unit: North & West Operational Unit: North & West: In the North area the DNA rate in Obstetrics Overall the Unit is currently complying with the The position in Obstetrics and Gynaecology to be appears particularly high compared with other standard. Actions are being taken to maintain clarified. specialties; the figure relating to Gynaecology is and improve performance. Action: G McVicar also high.

South & Mid Operational Unit: South & Mid Operational Unit: South & Mid Operational Unit: Standard not being met. The DNA rates for new There has been a slight improvement in the Agreed to obtain figures relating to other Boards’ and return patients in General Adult Psychiatry overall position; in particular the figures relating performance for comparison purposes. are high and remain challenging. to old age psychiatry are low. Actions are Action: N Small

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being taken to support the ongoing reduction in the DNA rate.

Argyll & Bute CHP: Argyll & Bute CHP: Argyll & Bute: Variable position, the DNA rates remaining high A range of actions is being implemented to A more detailed report to be prepared for the in some sites. improve performance. Chair and Chief Executive. The introduction of an automated telephone Action: D Leslie reminder system is being explored.

4 FUTURE AGENDA ITEMS

Meeting on 2 September 2013:  Update on establishment of Improvement Groups  Telecare/Enhanced Telecare Services  Review of Raigmore Programme Board  CAMHS  Children’s Fluoride Varnishing  Data Warehouse Project

Future Meetings:  Progress report on delivery of Falls Prevention Action Plans (November meeting)  Stroke Update (January 2014 meeting)  Insulin Pump therapy Update  Quality Outcomes Framework  Detect Cancer Early Programme  Dashboard for data scrutiny around waiting  Adult Social Care Indicators: Respite Care; Complaints; and Accessing Mental Health Services  Drugs and Alcohol Treatment Waiting Times  Unscheduled Care  Keep Well

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5 SCHEDULE OF IMPROVEMENT COMMITTEE MEETINGS 2013

The Improvement Committee will meet on the following dates in 2013:-

 2 September  4 November

6 DATE OF NEXT MEETING

The next meeting of the Improvement Committee will take place on Monday 2 September 2013 in the Board Room, Assynt House, Inverness at 13:30.

12 NHS Highland - "At A Glance" HEAT Targets 103 Summary of the Operational Units performance as per the Balanced Scorecard reported to the Improvement Committee on1st July 2013 Targets with a delivery date by the end of March 2013 e d e t on t ut t e i s t s t B i e a a por D E e W os e nd y r P & a or & r l h e d l h h r v t gm i i l gy ont oa a or r e out

B Target M R N S A D

FinancialPerformance Mar-13 Mar-13 CashEfficencies Mar-13 Mar-13

Drug&AlcoholTreatment:ReferraltoTreatment Dec-12 N/A N/A N/A N/A Mar-13 FasterAccesstoSpecialistCAMHS Mar-13 Mar-13

90%ofpatientsdiagnosedwithstrokeadmittedtoastrokeunit Mar-13Currently reported at Board Level Only Mar-13 DelayedDischarges-28days Apr-13 Mar-13 MRSA/MSSA Bacterium: 30% reduction Mar-13Currently reported at Board Level only Mar-13 C.DiffInfections:30%reduction Mar-13Currently reported at Board Level only Mar-13 ReductioninEmergencybeddaysforpatientsaged75+ Dec-12 N/A Mar-13 Targets with a delivery date beyond March 2013 e d e t on t ut t e i s t s t B i e a a por D E e W os e nd y r P & a or & r l h e d l h h r v t gm i i l gy ont oa a or r e out

B Target M R N S A D EarlyAccesstoAntenatalServices Mar-13Data sources being developed Mar-15 No Trajectory DetectCancerEarlyData sources being developed Apr-15 ChildHealthyWeightInterventions Mar-13 N/A N/A N/A Mar-14 SmokingCessation-2mostdepriveddatazones Mar-13 N/ACurrently reported at Board Level Only Mar-14 SmokingCessation-generalsmokingpopulation Mar-13 N/A N/A N/A Mar-14 ChildFluorideVarnishApplications Jun-12 N/ACurrently reported at Board Level Only Mar-14

ReduceCarbonemmissions Mar-13Currently reported at Board Level Only Mar-15 ReduceEnergyConsumption Dec-12Currently reported at Board Level Only Mar-15

No Trajectory FasterAccesstoPsychologicalTherapiesTrajectory in development Dec-14

RateofattendancesatA&E Jan-13 N/A Mar-14 NHS Highland - "At A Glance" Standards e d e t on t ut t i s s t B i e a por E e W os e nd r P & a or & l h d l h h r t gm i gy ont oa a or r out

B Target M R N S A Alcohol\BriefInterventions Mar-13 N/A InequalitiesTargetedCardiovascularHealthchecks Mar-13 N/A N/A Breastfeedingat6-8week-Target36% Sep-12 N/A N/A N/A MMRuptakerates-target95%at5yearsold Dec-12 N/A

SicknessAbsence-4%target Mar-13 N/S SMR returnrate- 90%of SMR1returns receivedwithin6weeks Mar-13 Complaints-80%ofcomplaintscompletedwithin4weeks Mar-12 Complaints-No.over40workingdays-Target0 Mar-13 Complaints-No.ofcomplaintsreceivedTargetlessthan33 Mar-13 Complaints-No.categorisedasHighRisk-Targetlessthan7 Mar-13 Daycaserates-Target78.9% Mar-13 N/A Outpatients-DNArate-Target6.9% Mar-13 ReducePreOperativestay-Target0.65days Feb-13 N/A NewtoReturnOutpatientattendanceRatio-Target2.02 Mar-13 eKSF&PDP's-Target80% Mar-13

Suspicion of cancer referrals (62days) (Due for Delivery Dec 2010) Mar-13 Reported at Board Level only Dec-11 AllCancerTreatment(31days)(DueforDeliveryDec2010) Mar-13 Reported at Board Level only Dec-11 18weeksReferraltoTreatment(DueforDeliveryDec2010) Mar-13 Currently reported at Board Level only Dec-11 NewOutpatientWaitingtimes-12weeks(allreferralsources) Mar-13 N/A N/S Inpatient/DayCasesWaitingtimes-9weeks Mar-13 N/A N/S CataractWaitingTimes-assessment-9weeks Mar-13 N/A Hipsurgery-98%ofpatientstreatedwithin24safeoperatinghrs Mar-13 N/A N/A N/A Angiography-4weekwaitingtime Mar-13 N/A N/A N/A Daignostictestswaitingtimes-4weeksfor8keytests Mar-13 N/A A&E Waiting times - 4 hours Mar-13 N/S Annual AdvanceBooking-GP's N/S

CervicalScreening-80%uptakeof 20-60yroldwomenscreened Mar-13 N/A ReduceOccupiedBeddaysforlongtermconditions Dec-12 N/A Dementia (Unvalidated -validatedpositionavailableannually) Mar-13 N/A N/S

N/S : National Standard NHS Highland - "At A Glance" HEAT Targets 104 Summary of the Operational Units performance as per the Balanced Scorecard reported to the Improvement Committee on1st July 2013 Targets with a delivery date by the end of March 2014 e d e t on t ut t e i s t s t B i e a a por D E e W os e nd y r P & a or & r l h e d l h h r v t gm i i l gy ont oa a or r e out

B Target M R N S A D ChildHealthyWeightInterventions Mar-13 N/A N/A N/A Mar-14 SmokingCessation-2mostdepriveddatazones Mar-13 N/ACurrently reported at Board Level Only Mar-14 SmokingCessation-generalsmokingpopulation Mar-13 N/A N/A N/A Mar-14 ChildFluorideVarnishApplications Jun-12 N/ACurrently reported at Board Level Only Mar-14

FinancialPerformance Mar-13 Mar-14 CashEfficencies Mar-13 Mar-14

RateofattendancesatA&E Jan-13 N/A Mar-14 Targets with a delivery date beyond March 2014 e d e t on t ut t e i s t s t B i e a a por D E e W os e nd y r P & a or & r l h e d l h h r v t gm i i l gy ont oa a or r e out

B Target M R N S A D EarlyAccesstoAntenatalServices Mar-13Currently reported at Board Level Only Mar-15 DetectCancerEarlyCurrently reported at Board Level Only Apr-15

ReduceCarbonemmissions Mar-13Currently reported at Board Level Only Mar-15 ReduceEnergyConsumption Dec-12Currently reported at Board Level Only Mar-15

FasterAccesstoSpecialistCAMHS-18weeks Mar-13 Dec-14 No Trajectory ReduceIVFWaitingTimesData sources being developed Mar-15 4HourA&EWait Sep-14 FasterAccesstoPsychologicalTherapies Dec-14

ReductioninEmergencybeddaysforpatientsaged75+ Dec-12 N/A Mar-15 DelayedDischarges-14days Apr-13 Mar-15 No Trajectory AccesstoDementiaSupportData sources being developed Mar-16 MRSA/MSSA Bacterium Mar-13Currently reported at Board Level only Mar-15 C.DiffInfections Mar-13Currently reported at Board Level only Mar-15 NHS Highland - "At A Glance" Standards e d e t on t ut t i s s t B i e a por E e W os e nd r P & a or & l h d l h h r t gm i gy ont oa a or r out

SicknessAbsence-4%target Mar-13 N/S SMR returnrate- 90%of SMR1returns receivedwithin6weeks Mar-13 Complaints-80%ofcomplaintscompletedwithin4weeks Mar-12 Complaints-No.over40workingdays-Target0 Mar-13 Complaints-No.ofcomplaintsreceivedTargetlessthan33 Mar-13 Complaints-No.categorisedasHighRisk-Targetlessthan7 Mar-13 SameDaySurgeryRate Mar-13 N/A Outpatients-DNArate-Target6.9% Mar-13 ReducePreOperativestay Feb-13 N/A eKSF&PDP's-Target80% Mar-13

Suspicion of cancer referrals (62days) (Due for Delivery Dec 2010) Mar-13 Reported at Board Level only AllCancerTreatment(31days)(DueforDeliveryDec2010) Mar-13 Reported at Board Level only 18weeksReferraltoTreatment(DueforDeliveryDec2010) Mar-13 Currently reported at Board Level only NewOutpatientWaitingtimes-12weeks-Completed Mar-13 N/A N/S New Outpatient Waiting times - 12 weeks - Ongoing New Outpatient Social Unavailability New Outpatient Medical Unavailability 12 week Treatment Time Guarantee (TTG) Admission Waiting List - Social Unavailability Admission Waiting List - Medical Unavailability Hipsurgery-98%ofpatientstreatedwithin24safeoperatinghrs Mar-13 N/A N/A N/A 8KeyDaignostictests-CompletedWaits Mar-13 N/A 8 Key Daignostic tests - Ongoing Waits Return Waiting List - Completed Waits Return Waiting List - Ongoing Waits Insulin Pumps - Under 18's Insulin Pumps - Over 18's Drug&AlcoholTreatment:ReferraltoTreatment105 Dec-12 N/A N/A N/A N/A ReduceOccupiedBeddaysforlongtermconditions Dec-12 N/A ReduceAverageLengthofStayforContinuousEpisodeofcare Mar-13 N/A End of Life Care Measure Dementia (Unvalidated -validatedpositionavailableannually) Mar-13 N/A N/S 90%of patients diagnosedwithstrokeadmittedtoastrokeunit Mar-13 Currently reported at Board Level Only

N/S : National Standard 106 107 Highland NHS Board 13 August 2013 Item 3.6 Assynt House Beechwood Park Inverness IV2 3BW Tel: 01463 717123 Fax: 01463 235189 Textphone users can contact us via Typetalk: Tel 0800 959598 www.nhshighland.scot.nhs.uk/

DRAFT MINUTE of MEETING of the AREA CLINICAL FORUM 30 May 2013 – 1.30 pm Board Room, Assynt House, Inverness

Present Dr Iain Kennedy, Chair Rev Dr Derek Brown, Area Nursing, Midwifery & AHP Committee Mrs Mary Burnside, Area Nursing, Midwifery & AHP Committee Mr Ryan Cooper, Area Healthcare Science Forum Mr Quentin Cox, Area Medical Committee Mr Colin Crawford, Area Dental Committee (by video conference) Mr Paul Davidson, Clinical Lead Mr Doug Hutchison, Vice Chair Mr Duncan Martin, Patient Representative Ms Mary Morton, Head of Community Pharmaceutical Services Dr Rob Peel, Raigmore Hospital Dr Boyd Peters, South & Mid Highland Operational Unit Mr Duncan Railton, Area Dental Committee Mrs Margaret Steventon, Area Optometric Committee Mr Ray Stewart, Employee Director Mrs Pat Wells, Patient Representative

In Attendance Dr Ian Bashford, Board Medical Director Mrs Margaret Brown, Head of Service Planning Mr Nick Kenton, Director of Finance Mr Chris Lyons, Director of Operations, Raigmore Hospital Mrs Margaret Somerville, Director of Public Health Mrs Donna Smith, Divisional General Manager for Patient Services and SLA Performance Planning Manager Mrs Christine Thomson, Board Committee Administrator

1 WELCOME AND APOLOGIES

Dr Kennedy welcomed those present to the meeting.

Apologies were received from Deborah Jones, Heidi May, Elaine Mead, Margaret Moss, Anne Pollock, Sheelagh Rodgers and Ian Rudd.

1.1 DECLARATIONS OF INTEREST

Iain Kennedy declared an interest as member of the BMA and Executive Partner at Riverside Medical Practice.

At this stage it was agreed to alter the order of consideration of items on the agenda. 108

2 DRAFT CAPITAL PLAN 2013/2014

Mr Kenton spoke to his circulated report on the Capital Plan stressing that it was important to engage the clinical community in the whole asset management process. He advised that the key governance group was the Asset Management Group (AMG) and that previously clinical representation had been the Chair of the ACF together with 2 Clinical Directors. However the Group had been revamped last year and had now become a formal governance committee of the Board, chaired by a non-executive member and with both staff-side and public involvement. Mr Kenton stressed that high quality asset management strategies would have a better chance of attracting government money and that the group required to consider matters such as leasing and innovative methods of funding developments. Mr Kenton advised that the AMG had two clinicians invited (although they often did not attend) and that the lead officers for medical equipment, radiology and IT were expected to engage with the clinicians before the meeting as appropriate. He added that in reviewing the terms of reference he had realised that the Chair of the ACF should also have been given a standing invitation – this omission was an administrative error resulting from a late change in the terms of reference not being reflected in the final version. He stressed the importance of clinical input to the group but recognised the pressure on clinical colleagues’ time and stated that he was in no way criticising current AMG members who had been unable to attend regularly. The demands on clinical time were noted and Dr Kennedy advised that he personally would not have time to attend the Asset Management Group but that it may be the case that the Vice Chair or another member of the Forum could attend.

The Forum:

 Agreed that further discussion take place on how best to represent clinical views at the AMG.  Agreed that Mr Kenton speak further to the Forum at the next meeting to be held on 8 August 2013 if this should be required.

3 CLINICAL INPUT INTO THE SUPPORT SERVICES DIRECTORATE

Donna Smith and Chris Lyons advised that there had been no Clinical Lead within the Patient Services Division and that it had now been agreed to proceed to make this appointment.

4 HIGHLAND RETURN OUTPATIENTS WAITING LIST

Speaking to her circulated report Margaret Brown requested that the Forum note the current information available for patients who have been added to the Return Outpatients Waiting List. She advised that the present policy stated that any patient leaving a clinic who requires a return appointment within 6 weeks should be booked before leaving the clinic and was not required to be added to the Return outpatient Waiting List but that any patient requiring a return appointment in more than 6 weeks should be added to the return outpatient waiting list and that the list should therefore contain all patients who have a planned review date in more than 6 weeks whether they were booked or not. Ms Brown indicated however that there were inconsistencies in the system which had meant that some patients were not recorded on the Return outpatient waiting list who should have been. The quality of data was highlighted as an issue due to the restrictions of the iSoft system and pressures on administrative time. It was noted that the PAS system could not alter the planned review date for patients to reflect periods when the patient has been unavailable, refused dates to attend or remained on the list after failing to attend or consistently cancelling an appointment. In addition some patients remained on the list who should have been removed.

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The recommendation to undertake a staged review of the data held on the list with clinical input for each specialty to prioritise the area of greatest potential risk was noted. It was noted that a new system would be implemented in October/November 2013 but that there were also issues with the new PMS product and Mrs Smith advised that attempts were being made to develop a report which would identify the number of times a patient had failed to turn up and that this remained a challenge to extract this information from the system.

The main area of concern was the number of patients who were booked after the planned review date, or remained unbooked beyond their planned review date.

The latest position in both Northern Highland and Argyll & Bute CHP both in terms of Operational Unit and specialty was noted. Dr Peel raised concerns about the delay in this information being made available to the Forum, but Ms Brown advised that the data presented had been available for some time and that a weekly analysis was produced of the return outpatient waiting list which provided further analysis of the “slippage” patients, and these reports were available through the intranet to the service to monitor performance.

Mr Lyons confirmed that there was risk of possible harm to the patient if they had to wait too long but that this risk could not be resolved by money alone and that clinicians would require to be receptive to different approaches to review of patients. It was also noted that clinical variation may be contributing to some of the pressures within the service, as well as non- attendance at clinic.

Colin Crawford expressed concern that the phone number identification when receiving a call from the hospital identified as “withheld” and advised that many people would not answer this call which would lead to a corresponding delay in the time it took to arrange an appointment. Donna Smith confirmed that this problem was being tackled and that the number which was identified was an 0800 number and that the television screens in the hospital advised patients of the number to expect. It was agreed that it may be helpful to produce a simple leaflet which could be issued by GPs when they see their patients.

Margaret Brown confirmed that there were no national targets for return appointments as the focus had been on new appointments.

It was further noted that discussion would be taking place with the communications team with a view to compiling a package advising patients of their rights and responsibilities against all of the waiting times targets.

For assurance purposes, Dr Bashford suggested that the Forum write to the Chief Operating Officer requesting that if there was an issue of clinical concern raised that this should be responded to immediately. Mr Lyons confirmed that a risk register exists at Raigmore and that the whole service was looked at.

The Forum:

 Noted the current information available for patients who have been added to the Return Outpatient Waiting List.  Noted the need for Board policy to be followed for the recording of Return Outpatients awaiting review.  Noted the variance in approach between Northern Highland and Argyll & Bute CHP  Noted the data quality issues affecting the content of the Return Outpatients Waiting List and the recommended review of the data on the list.  Agreed that for assurance purposes if there was an issue of clinical concern raised then this should be responded to immediately.

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5 NHS HIGHLAND REVISED LOCAL ACCESS POLICY

Speaking to her circulated report, Margaret Brown updated members on the draft Local Access Policy which had been revised to reflect the Patient Rights (Scotland) Act 2011 which indicated that from October 2012 all eligible patients requiring planned inpatient or day case treatment must start treatment within 12 weeks of the patient and clinician jointly agreeing that the treatment is to take place. She advised that there were some exclusions to this Treatment Time Guarantee Guidance and stressed the relationship with other targets being 18 weeks Referral To Treatment, 12 weeks new outpatient appointment and 6 weeks for the 8 key diagnostics. She stressed that the only legal target was the Treatment Time Guarantee.

Measurement was noted to be key to the process which stated that a reasonable offer consisted of 4 elements these being: 2 dates; a notice period of a minimum of 7 days but 14 days was good practice; the Board setting out in the Local Access Policy the service locations where treatment may be reasonably undertaken; and any competent clinician being used who is part of the consultant-led service. It was noted that wherever possible treatment should be provided locally and that currently any patient offered a procedure outwith NHS Highland would not be penalised if they refused. However the Board would be discussing the possible extension of this to include the Golden Jubilee National Hospital as a reasonable offer of location. In addition it was stressed that patients needed to understand what would happen should they refuse a reasonable offer. As regards measurement of notice period it was noted that national guidance was a minimum of 7 days but NHS Highland would continue to measure against 14 days locally.

Chris Lyons gave the Forum his assurance that meetings take place every week to assure that no patient is disadvantaged by the way in which the rules are interpreted. He stressed that patients should all be seen in turn by clinical priority.

The Forum Noted the update on the Local Access Policy.

Margaret Brown left the meeting at 3.10pm.

6 CENTRALISED RECEPTION PROJECT

Donna Smith updated the Committee on how the Highland wide centralised reception project fitted in with the national programme. She advised that no new outpatient facilities would be built in Scotland in the foreseeable future. Mrs Smith advised that the transforming of outpatients project involved 6 major workstreams, these being patient booking methodology, moving and handling of health records, OPD clinic utilisation, creation of centralised reception, introduction of skills for health in OPD and creation of a lead OPD nurse. As regards the centralised reception it was noted that the new centralised reception had gone live on 1 April 2013. After some initial teething problems a survey had identified an increase in patient satisfaction with the new centralised reception which ensured improvements in patient confidentiality, increased the capture of patient registration details, improved the quality of workload for receptionists and provided reception cover to all clinics not just those that were consultants led. In addition there was an increase in satisfaction with the waiting area. The issue of missing health records was noted as a continuing problem and it was agreed that there was a need to alter the culture within the organisation by ensuring effective tracking of the notes and ensuring that notes were not kept for unnecessarily long periods of time. It was considered that this was an ideal area in which to adopt a lean approach and it was agreed that the situation with the notes required to be tackled by clinical and administrative staff working together. The issue of patients carrying their own Health Records was also an issue and it was noted that two models were currently being trialled to identify the most appropriate.

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The Forum Noted the update on the centralised reception project.

Dr Bashford left the meeting at 3.20pm.

7 INTERNAL AUDIT REVIEW OF PATIENT’S PAPER RECORDS MANAGEMENT REPORT – PUBLIC RECORDS (SCOTLAND) ACT 2011

There had been circulated copy of letter from Mike Evans, Chair of the NHS Highland Audit Committee stressing that compliance with the Public Records (Scotland) Act 2011 regarding the use, management and custody of patients’ paper records was required and that failure to do so by January 2014 would be breaking the law. It was noted that the problem did not relate only to Raigmore Hospital but rather was endemic in all hospital locations. Donna Smith advised that work was taking place to improve matters such as the used of locked cupboards for storage of files at ward level and use of locked trolleys for transport. Margaret Somerville expressed concern that she as Caldicott Guardian had not been notified of this before and stressed that these matters had to be dealt with soon in order that the Audit Committee could be given assurance that every effort was being taken to ensure that clinical staff were aware of the issues and were engaged with the actions being developed to ensure such compliance.

The Forum Noted the requirement for compliance with the Public Records (Scotland) Act 2011 regarding the use, management and custody of patients’ paper records.

Donna Smith left the meeting at 3.25pm.

8 MINUTE OF MEETING HELD ON 4 APRIL 2013

Dr Kennedy thanked Dr Peel for chairing the previous meeting and the minute of the meeting held on 4 April 2013 was proposed by Quentin Cox and seconded by Derek Brown and thereafter accepted as a true record.

9 MATTERS ARISING

9.1 Noise from Televisions in wards

Rev Brown advised that further to the discussion at the last meeting further investigations had taken place with Chris Lyons with the outcome that there was unfortunately no technical solution to the running noise from televisions.

9.2 Update on Ordercomms

The Chair advised that an update on Ordercomms would be provided by Anne Pollock at the next meeting of the Forum to be held on 8 August 2013.

9.3 Francis Report on Mid Staffordshire NHS Foundation Trust Public Inquiry

Dr Paul Davidson advised that the Mid Staffordshire information was now being presented to clinical forums in the localities in North West.

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10 HIGHLAND QUALITY APPROACH (ELIMINATE HARM, ELIMINATE WASTE AND MANAGE VARIATION

10.1 Health Care Science HQA

Ryan Cooper spoke to the Highland Quality Approach as it affects the Healthcare Science (HCS). He advised that as a group HCS were proud of the HQA approach NHS Highland had adopted. He advised that many items had arisen from the HCS Leads meeting and the ACF Development Day and that NHS Lancashire had been used as a guinea pig to show skills HCS staff have.

Ryan Cooper advised that Clinical Pathology Accreditation (CPA) was now owned by the UK Accreditation Service (UKAS) although the brand name CPA still remained for global recognition. He advised that labs have for some time, used a 4 year cycle involving 8 groups of standards these being: organisation and quality management system; personnel; premises and environment; equipment; information systems and materials; pre examination process; examination process; post examination process; and evaluation and quality assurance.

He advised that there was an embedded culture which still needed continually managed. He stated that accreditation had given labs a focus and reduced complacency as peer review happened regularly and should reduce waste variation if managed effectively, this exemplifying the LEAN culture. It was noted that a full audit trail of the specimen journey was now available and results could be compared to those of other Boards and in addition had led to the extension of HCS staff roles to include advanced dissection and preliminary reporting.

Mr Cooper stressed that through the accreditation the Healthcare Scientist had become a group of staff with skills and knowledge of continual cross departmental audit and review who had experienced LEAN working through continual improvement. He stressed that the staff had the skills and were available to share and use these with other staff. He stressed the need for a “gap” analysis across all departments with a generic set of standards and stressed that the expertise which already exists in HCS could be used elsewhere within the organisation to develop the Virginia Mason concept.

Margaret Somerville agreed that the organisation should use quality improvement techniques from within in tandem with the Virginia Mason ideas.

In summary it was stressed that many of the skills NHS Highland were seeking in the LEAN process were already available in HCS and it was noted that there was a need to combine these with the Virginia Mason concepts. An early meeting with Linda Kirkland, Director of Quality Improvement and including other top management would be requested to progress this further.

The Forum:

 Noted the presentation.  Agreed that a meeting be sought with the Director of Quality Improvement with a view to combining internal quality skills with the concepts learned at Virginia Mason.

10.2 Spiritual Care – Future Direction in Highland

Dr Brown explained that there was a need to look at the future direction of spiritual care in NHS Highland as the Spiritual Care Strategy had reached its review date and the Spiritual Care Policy required review. He stressed that NHS Highland was aiming towards a

6 113 reduction in the amount of time people spend in hospital and an increase in the amount of care being delivered in the community setting. In addition he stressed the need for spiritual care to embrace the NHS Highland/ Highland Council integration.

Dr Brown reported that the situation had been discussed as a team and a number of roadshows had been held, the outcome of which was to consider repositioning spiritual care as a service that is provided by all staff.

The themes which had been highlighted at the Spiritual Care Annual Conference were noted as being: communication, community care, workforce development, education and quality. He advised that various actions had been identified at the conference under each of these categories which had been used as the basis of consultation at the Roadshows. The consultation had identified various strengths and risks.

The main aim was to try to ensure that spiritual care was delivered by frontline staff wherever they were rather than be seen as an extra service provided by a few members of staff.

It was considered that chaplaincy resources should be utilised to support delivery via frontline staff, that there should be minimal hands on delivery via chaplaincy staff, that there should be clarity regarding what is required to be delivered by qualified chaplains, that there should be revision of volunteering arrangements, that there should be robust connections with spiritual care communities, that there should be a review of confidentiality arrangements, that there should be a review of the Spiritual Care Committee Constitution, that there would be a review of leadership, management and communication arrangements for chaplaincy services across Highland and that there should be a review of on-call arrangements for chaplaincy services. In addition it was stressed that the resource was not limited to patients only and is available to support staff professionally and personally.

The Forum:

 Noted the situation regarding the Spiritual Care Committee.  Agreed that the delivery of Spiritual Care should take place along the lines of the suggested revised arrangements.

11 ACF DEVELOPMENT SESSION – Feedback from Facilitator

Dr Kennedy referred to the circulated initial feedback from the facilitator and confirmed that he would be meeting with the facilitator to summarise the findings further and create an action plan which would be considered at a future meeting of the Forum.

12 NATIONAL AREA CLINICAL FORUM CHAIRS GROUP

The Chair advised that he had attended a recent meeting of the National Area Clinical Forum Chairs Group at which the theme had been empowerment and innovation amongst clinicians. The subject of support to ACF chairs had been considered and he had subsequently raised this issue with the Chief Executive and Chairman of NHS Highland.

He reported that the next meeting would take place at the Scottish Parliament on 5 June 2013 when the group would be meeting Bill Scott, Chief Pharmaceutical Officer (CPO) for Scotland. It was commendable that Highland ACF (via our Area Pharmaceutical Committee) was the only ACF that had prepared questions for the CPO.

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13 SCOTTISH GOVERNMENT COMMUNITY HOSPITALS STRATEGY REFRESH

Speaking to his circulated report Boyd Peters advised that the Scottish Government Community Hospital Strategy was a year old and that a refresh of the strategy had taken place. The Board Executive Lead in this work was Nigel Small. It was noted that the Community Hospital Improvement Network website was now launched and that the intention was to cascade this down through various groups. Nine main action points for Health Boards were noted and it was agreed that Boyd Peters should report back to the Forum on progress at a future point and meantime that any comments be channelled through Nigel Small or Boyd Peters.

The Forum:

 Noted that any comments should be channelled through Nigel Small or Boyd Peters.  Agreed that Boyd Peters report progress to a future meeting of the Forum.

14 NHS HIGHLAND BOARD MEETING – 4 JUNE 2013

14.1 NHS Adult Social Care Practice Forum – Terms of Reference

There had been circulated report by Janet Spence, Programme Director identifying the Terms of Reference of the NHS Adult Social Care Practice Forum.

14.2 The Highland Quality Approach – Making it happen – Progress Report

There had been circulated a report by Anne Gent, Director of Human Resources, indicating progress with the Highland Quality Approach.

14.3 Highland Quality approach to Adult Care – a Five Year Improvement Plan for the Highland Partnership

There had been circulated a report by Jan Baird, Head of Adult Care, outlining the 5 year improvement plan for the Highland Partnership.

14.4 Local Delivery Plan 2013/14

There had been circulated report by Kenny Oliver, Board Secretary, requesting the Board to ratify the 2013/14 Local Delivery Plan.

14.5 (a) Infection Control Report (b) Infection Control Annual Work Plan 2012/13 – End of Year Report (c) Infection Control Annual Work Plan 2013/14

There had been circulated reports by Liz McClurg, Infection Control Manager and Dr Emma Watson, Infection Control Doctor

14.6 Chief Executive’s and Directors’ Report

The circulated report was noted

The Forum Noted the circulated reports.

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15 REPORTS / MINUTES FROM PROFESSIONAL ADVISORY COMMITTEES

15.1 Area Nursing, Midwifery and AHP Advisory Committee

Rev Derek Brown reported that the meeting due to take place on 28 May had not taken place due to the fact that access to the room booked had not been available timeously and that the Committee had been inquorate. There was no feedback to report to the Forum.

Rev Brown left the meeting at 4.55pm

15.2 Area Dental Committee

There had been circulated minute of the meeting of 27 February 2013. In addition a further meeting had taken place on 29 May 2013.

Duncan Railton advised members that the position of restorative dentists, one for Grampian and one for the Highlands were currently out to advert with a closing date of June.

He further advised that a great deal of work was being undertaken at present due to the requirement for all dental practices to have a local decontamination unit.

15.3 Area Medical Committee

There had been circulated minute of meeting held on 2 April 2013. A further meeting had taken place on 28 May April 2013 but there was nothing further to report at the present time.

15.4 Area Optometric Committee

There had been circulated the minute of meeting held on 25 March 2013. The next meeting will take place on 9 September 2013. There was nothing further to report at the present time.

15.5 Area Pharmaceutical Committee

There had been circulated the minute of meeting held on 25 March 2013. A further meeting had taken place on 27 May when Mary Morton had been appointed as Chair following the resignation of Andrew Paterson. Following a presentation by the Royal Pharmaceutical Society on the guidance “Improving Patient Outcomes – The better use of multi-compartment compliance aids” a short life working group had been set up looking at developing the monitored dosage policy. Mrs Morton advised that a movement away from monitored dosage systems in future was expected as it was now considered that pre packed blister packs were safer to use. Boyd Peters suggested that this could lead to friction between those prescribing and those providing care.

Mrs Morton further advised that the constitution had been updated to reflect the new name of the regulatory body – General Pharmaceutical Council.

Due to time constraints, discussion of the Francis Report had been postponed to the next meeting of the Committee when it would be considered as a major item.

15.6 Psychology Advisory Committee

It was noted that there had been no further meeting since the last meeting of the ACF.

15.7 Area Healthcare Science Forum

There had been circulated minute of meeting held on 21 March 2013.

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Ryan Cooper advised that a presentation by the Patient Management System (PMS) Group had since taken place. He advised that NHS Highland was the first board to receive certain parts of the PMS and that this would have implications for the wards, in particular bed management.

Mr Cooper advised that he was raising interest in the NES Healthcare Science Refreshing Leadership course which was to be held over 4 days (1 day per month) and was investigating whether it may be possible to attend this over a shorter more compressed timescale.

As regards the Francis report, he advised that Mary Morton had taken a note of all questions Elaine Mead had requested be answered and that these would be shared with Ryan Cooper and other groups

Iain Kennedy stressed that the Forum should provide a final document providing feedback from the Francis report to the Board.

The Forum noted the updates from the Professional Advisory Committees.

16 FOR INFORMATION

16.1 Attendance Record

Members were advised the Attendance Record would be updated and circulated after the meeting.

The Forum Noted the attendance record.

16.2 Dates of Future Meetings 8 August 2013 26 September 2013 28 November 2013

17 ANY OTHER COMPETENT BUSINESS

There was no other competent business.

18 ITEMS FOR FUTURE ACF MEETINGS

Future Agenda items were noted as follows:

Highland Quality Approach – Point of Care update for August meeting Endoscopy Service feedback Francis Report on Mid Staffordshire NHS Foundation Trust Public Inquiry Whistle Blowing and new National Confidential Alert Line Patient Management System

19 DATE OF NEXT MEETING

The next meeting will be held on Thursday 8 August 2013 at 1.30pm in the Board Room, Assynt House Inverness.

The meeting closed at 5.30pm 10 117 Highland NHS Board 13 August 2013 Item 3.7(a)

Assynt House Beechwood Park Inverness IV2 3BW Tel: 01463 717123 Fax: 01463 235189 HIGHLAND NHS BOARD Textphone users can contact us via Typetalk: Tel 0800 959598 www.nhshighland.scot.nhs.uk

MINUTE of MEETING of the NHS Board Asset Management Group Tuesday 21 May 2013 Ante Room, Assynt House, Inverness 2.00 pm

Present: Alasdair Lawton, Non Executive Director and Chair Nick Kenton, Director of Finance Malcolm Iredale, Head of Procurement Eric Green, Head of Estates Bruce Merchant, Public Representative Ian Scott, Clinical Director, South & Mid Carol Marlin, Monitoring Accountant Chris Lyons, Director of Operations, Raigmore John Crossley, Section Head, Medical Physics Alex Javed, Service Manager – Labs and Radiology

In Attendance: George Morrison, Director of Finance A&B (by VC) Donna Mackay, Project Director (item 4) Bob Summers, Head of Health and Safety Lynda Main, Personal Assistant (minutes)

1 WELCOME/INTRODUCTIONS

Alasdair Lawton welcomed everyone to the meeting, particularly Bruce Merchant who was attending his second meeting as public representative and everyone around the table introduced themselves.

Apologies for absence were received on behalf of John Bogle, Ray Stewart, Mike Hall, Bill Reid, Linda Kirkland and Derek Leslie.

2 MINUTE OF THE MEETING HELD ON 2 May 2013

The minutes were approved.

3 MATTERS ARISING

GP Premises – Eric Green confirmed that this is still being worked on; he will keep the Group updated. 118

Clinical Representation – Nick Kenton had spoken with Ian Scott who confirmed he would attend the meetings when available. Nick Kenton would take the issue of clinical representation to the Area Clinical Forum.

Theatres Refurbishment – The Initial Agreement had been approved at the previous AMG. The next stages are for it to go to the Board and Capital Investment Group as per the meeting schedule.

Endoscopy – This issue is still ongoing.

Actions:

 Nick Kenton to report back on issue of membership after the Area Clinical Forum meeting.

4 A&B MENTAL HEALTH PROJECT

This project was originally being taken forward under Frameworks but is now being taken forward via Hub. A stage 1 submission was made in November 2012, but this had to be rejected as it was non-compliant. The Scottish Government have subsequently confirmed that the project is too small to be considered as a standalone project. The project is estimated to cost around £9m and as such was close to the original perceived threshold of £10m. However, the money market has since moved and it is now the case that only projects exceeding around £15m can offer value for money from the hub route. This project therefore needs to be ‘bundled’ with another. There are several projects which this could be bundled with – Badenoch and Strathspey, Argyll and Bute Education and NHSG Inverurie Medical Centre and Maternity. The A&B Education project is 18 months behind so that has been ruled out. The most likely choice would be NHS Grampian Inverurie Medical Centre and Maternity Unit as the two projects are closest in terms of programme. The design for the A&B project has already been signed off and discussions are taking place to see how the projects could be aligned.

Donna Mackay will keep the Group updated.

Actions:

 The AMG was asked to note the progress.

5 ASSET MANAGEMENT STRATEGY

Input has now been received from eHealth and Transport, Eric Green would pass to Nick Kenton tomorrow and then it would come back to the June Asset Management meeting before going to the NHS Highland Board in August. This would also be discussed with Mike Baxter when he visits in June.

6 STORES AT RAIGMORE

Funding is required to resolve transport issues at the stores department at the back of the hospital. There are many pedestrians in the area and vehicles constantly reversing, traffic calming measures have been put in place but this remains a high health and safety risk.

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Around £7-£9k is required to re-design the area. Carol Marlin confirmed this would be capital. It has been put through the risk management scoring system but unfortunately, did not score very highly. The score does not reflect the actual risk. John Crossley added that the scoring system needs to be refined. Service heads would meet to discuss how best to do this and report back to the Group in July.

The Group approved the spend for the re-design of the area at the back of stores.

Actions:

 Service heads meet to discuss the risk management scoring system and report back to July meeting.

7 PROPOSED 20:20 VISION FOR CAPITAL AND FACILITIES

Eric Green attended an event in Glasgow on the vision for Capital and Facilities, the Government need a better vision on capital needs going forward to 2020 and beyond. This should be linked in with the capital strategy and they want to see a clear integrated strategy between capital spend and workforce planning. They are looking for a completed plan by May 2014. However at the event there was discussion relating to population numbers per facility, it was pointed out that this wouldn’t work in Highland due to the geographic spread. Travel time would also need to be taken into consideration. Nick Kenton would make Elaine Mead aware of this and also make the point when Mike Baxter visits in June.

8 REDESIGN OF SERVICES IN BADENOCH AND STRATHSPEY AND SKYE, LOCHALSH AND WESTER ROSS

Work is being carried out in order to progress the Initial Agreement for the above projects and Roger Tanner from Strategem has been appointed as Project Manager and Aileen Walker from Atkins as Healthcare Planner. Initial workshop sessions are being organised for relevant user groups. The Initial Agreement will go to the Capital Investment Group in December 2013 and will come back to the Group before then for approval.

Actions:

 The Group noted the position.

9 WESTER ROSS COMMUNITY NURSING AND SOCIAL CARE STAFF

It is proposed to locate Wester Ross and Social Care staff as close to Gairloch Health Centre as possible in order to promote integrated care. There is the possibility of renting an office at the rear of the Health Centre, this would mean that NHS Highland could declare Poolewe Nurse’s House as surplus and a modest revenue saving will result. The Group approved this.

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10 REPLACEMENT OF PATIENT MONITORS

The replacement of several patient monitors were included in the capital plan, John Crossley asked for approval to replace these as they fail, which is anticipated at 4 monitors a year. This will all be covered within the existing budget. The Group approved this.

11 DATE OF NEXT MEETING

The next meeting will be held on 18 June at 2pm in the Ante Room, Assynt House, Inverness.

The meeting concluded at 3.00pm

4 121 Highland NHS Board 13 August 2013 Item 3.7(b) Assynt House Beechwood Park Inverness IV2 3BW Tel: 01463 717123 Fax: 01463 235189 HIGHLAND NHS BOARD Textphone users can contact us via Typetalk: Tel 0800 959598 www.nhshighland.scot.nhs.uk

MINUTE of MEETING of the NHS Board Asset Management Group Tuesday 18 June 2013 Ante Room, Assynt House, Inverness 2.00 pm

Present: Alasdair Lawton, Non Executive Director and Chair Nick Kenton, Director of Finance Bruce Merchant, Public Representative Ian Scott, Clinical Director, South & Mid Carol Marlin, Monitoring Accountant Ray Stewart, Staffside Rep Chris Lyons, Director of Operations, Raigmore John Crossley, Section Head, Medical Physics Alex Javed, Service Manager – Labs and Radiology Mike Hall, Clinical Director, A&B (by VC)

In Attendance: George Morrison, Director of Finance A&B (by VC) Lynda Main, Personal Assistant (minutes)

1 WELCOME/INTRODUCTIONS

Alasdair Lawton welcomed everyone to the meeting and everyone around the table introduced themselves.

Apologies for absence were received on behalf of John Bogle, Eric Green, Malcolm Iredale, Bob Summers, Linda Kirkland, Derek Leslie and Bill Reid.

2 MINUTE OF THE MEETING HELD ON 21 May 2013

The minutes were approved.

3 MATTERS ARISING

Matters arising have been included in the agenda.

4 MONITORING REPORTS

There are currently no issues at the end of month two. Carol Marlin asked everyone to pay particular attention to the last page which shows expenditure by scheme. She asked that everyone check their particular projects and the budget and that the managers of larger schemes provide her with a spend profile. Alasdair Lawton suggested that this should be an agenda item for the next meeting. 122

Actions:

 Spend profile to be added to the July meeting agenda.

5 GROUP MEMBERSHIP

Nick Kenton attended the Area Clinical Forum to update them on the Capital Plan and to discuss clinical representation on the AMG. He noted that the chair of the ACF should have been a member of the Group, however when the Terms of Reference were being finalised this was missed off the final version. Iain Kennedy (ACF Chair) indicated that he would struggle to attend meetings but could send a deputy, however the Group had previously stated that they did not want deputies where possible – but had subsequently accepted deputies on the strict understanding they came with sufficient knowledge and mandate to contribute to discussions and decision making. Nick Kenton left the issue of Clinical Representation with the ACF and will return to a future meeting. Iain Kennedy will be invited along to future AMG meetings.

Actions:

 ACF Chair to be invited along to future meetings.

6 ASSET MANAGEMENT STRATEGY

The Group commended Eric Green for the work he has put into this document and acknowledged the challenges he faced gathering the information required.

The Group went through the documents page by page and comments are below:

 Page 4 – talks about the integration of adult social care causing a fundamental change in estate, the Group concluded that the word fundamental should be changed to significant.  Page 7 – talks about shared services, however clarification was required on what happens next (first paragraph).  Page 12, 13 and 14 – a key is required for the diagrams on this page, there is nothing to identify what A, B, C and D are.  Page 14 – it was noted that the Government will focus on the under-used figures on the table.  Page 22 - considered a key part of the document and it was noted again that it is not appropriate (in NHS Highland’s context) to talk about hospitals in terms of population. Mike Hall added that the table needed to be more specific.  Page 26 and 27 – George Morrison queried who was consulted on for the Argyll and Bute information; he would look at document and feedback to Eric Green.  Page 27 – states that Raigmore accounts for 50% of the Highland estate – clarification was required on this – is it value?  Page 28 – it needs to be highlighted that A&B use Glasgow.  Pate 29 – typing error – second last paragraph – 10-5 years should read 10-15 years.  Page 30 – The last two projects (Inveraray Primary Care Centre and Rothesay Master Plan) are not included in the Capital Plan.  Page 31 – PFI contracts – the Group would seek clarity from Alastair Wilson on proposals for the end of PFI leases and also the status of all PFI assets at the end of 2 123

the lease term. Clarify with Eric Green if on target to hit 10% of backlog maintenance.  Page 37 and 38 – an explanation of the figures on the table is required  Page 41 – it was queried who sets the KPI’s and the Group weren’t sure if the table was helpful. It was suggested that the information should go back to Bill Reid to expand the detail in this section.  Page 42 – Alex Javed noted that all the information he passed to Eric Green on Radiology is missing from this section. John Crossley added that the medical equipment appendices are all missing from the end of the document also.  Page 42 and 43 – George Morrison added that that service contract doesn’t include Argyll and Bute. Also that Argyll was spelt incorrectly at various points in the document.  Page 53 – Planning – it was agreed the document should say our transport strategy is in progress, not that we don’t have one. It is also stated that the AMG ratifies vehicle acquisitions and this is not the case. Feedback on their procedure would be sought from Transport prior to the August meeting.  Page 57 – It was queried if there was too much information included on catering.

Actions:

 Nick Kenton would pass comments to Eric Green.  George Morrison to liaise with Eric Green on information included for Argyll and Bute.  Get feedback from transport on procedure for vehicle acquisitions for the August meeting.

7 BELFORD TROLLEY

A food trolley at Belford Hospital is no longer working; there is currently no budget for this, so a bid was being made for £9k from the contingency. It has been put through the scoring system. The Group approved this.

8 MEDICAL EQUIPMENT

John Crossley informed the Group that a catastrophic fail had occurred with a therapeutic gastro scope, the cost of a replacement is £35k. This is on the medical equipment list and will be managed within the current budget. An operation microscope is also in need of repair, however if this cannot be repaired the cost of a new one would be £120k. Nick Kenton will flag up this issue with Mike Baxter when he visits next week.

Actions:

 Nick Kenton to speak with Mike Baxter regarding medical equipment.

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9 RESEARCH AND DEVELOPMENT – ADDITIONAL OFFICE AND STORAGE SPACE AT CFHS

A bid for additional office and storage space was received via Helen Emery on behalf of Frances Hines, Research and Development Manager. The Group agreed that they couldn’t support this until they knew all other options had been looked at. NHS Highland is presently trying to reduce its footprint. It was suggested it should be taken to the Space Utilisation Group and also the Group would required more detail and to see that all options had been explored.

Actions:

 Feedback to Helen Emery/Frances Hines.

10 DATE OF NEXT MEETING

The next meeting will be held on 23 July at 2pm in the Boardroom, John Dewar Building, Inverness.

The meeting concluded at 3.20pm

4 125 Highland NHS Board 13 August 2013 Item 3.8 Assynt House Beechwood Park Inverness IV2 3BW Tel: 01463 717123 Fax: 01463 235189 Textphone users can contact us via Typetalk: Tel 0800 959598 www.nhshighland.scot.nhs.uk DRAFT MINUTE of MEETING of the HEALTH and SAFETY COMMITTEE 16 May 2013 – 10.30 am Board Room, Assynt House

Present Mr Alasdair Lawton, Joint Chair Ms Elspeth Caithness, Joint Chair and RCN Health & Safety Rep Mr Allan Gowie, Ms Fiona Miller, North Highland CHP (by videoconference) Mr Stephen Don – Unite Mrs Anne Gent, Director of Human Resources Mr Iain King, CSP Mrs Liz McClurg, Infection Control Manager Mrs Janette McQuiston, UNISON Mr Owen Rawlins, UNITE

In attendance Mrs Rosie Brunton, Health and Safety Manager, Raigmore Ms Fiona Campbell, Clinical Governance Manager, Argyll & Bute CHP (videoconference) Mrs Pauline Craw Mrs Anne Frame, Dental Operational Manager Mr Eric Green, Head of Estates Mr Bob Summers, Head of Health & Safety Ms Maria Carpenter, Health & Safety Officer Mrs Cathy Steer, Head of Health Improvement Mrs Christine Thomson, Board Committee Administrator

1 WELCOME AND APOLOGIES

Alasdair Lawton welcomed everyone to the meeting.

Apologies for absence were received from Fraser Brunton, Pauline Craw, Dawn Gillies, Amanda Glen, Nick Kenton, Chris Lyons, Gill McVicar, Fiona Miller, Mirian Morrison, Ken Oates, Owen Rawlins, Linda Rawlinson, Colin Shields, Nigel Small, Audrey Urquhart.

1.1 Declarations of Interest

There were no declarations of interest.

2 MINUTE AND ACTION PLAN OF MEETING HELD ON 7 FEBRUARY 2013

Some minor amendments to the minute were suggested by Mrs McClurg which were agreed and the minute of the meeting of 7 February 2013 was approved as an accurate record. The Action Plan was noted. 126

3 MATTERS ARISING

3.1 Provision and Maintenance of Community Equipment

Bob Summers reported that the workshop on 20 February 2013 had proved to be very successful and that a small group had now been established to consider community equipment and stores issues. Eric Green advised that Argyll & Bute was well advanced in this area and that it may be possible to share their knowledge or hold further workshops.

Elspeth Caithness queried whether there was a process for ensuring the transfer of lessons learned. Anne Gent confirmed that “share and spread” was part of the Quality Improvement Methodology. It was noted that the issues to be tackled had been identified in a mind map but that no time scale had yet been agreed.

On a query from Rosie Brunton it was confirmed that the Argyll & Bute Group have an equipment tagging system which it is possible to access.

It was further noted that Argyll & Bute do not cover all items such as physio equipment.

3.2 COSHH Procedure and Guidance Note

Bob Summers reported that the COSHH procedure and Guidance note had been completed, published, and communicated widely in various formats across the organisation.

He explained that over the past 2½ years NHS Highland had, through the work of the Workplace Hazards Sub Group, made a number of major improvements to its arrangements for managing hazardous substances in respect of the Board duties under COSHH, but he suggested that we still had more to do. This involved a 2 phase plan.

Phase 1 of this plan was to improve the systems and methods of control in those departments that undertake tasks / activities using medium-higher risk substances. A series of COSHH validation exercises were undertaken over 2011-2012 in conjunction with local managers and Health and Safety staff, in Estates, Pharmacy, Labs, Hotel Services and Catering. This work was also supported by:

 Manager Awareness Training  Bespoke COSHH Assessor Training  Better integration of SYPOL into NHSH COSHH Management Arrangements  The development of a new COSHH procedure (PN08)  The development of a supporting COSHH PN08 - Guidance Note 1, a step by step guide to complete And the development of new procedures on Health Surveillance (PN06 NHSH Health Surveillance Procedure)

Phase 1, is now nearing completion, and as a result local implementation now needs to be checked to ensure the departments above have safe operating and compliant systems. To this end a series of COSHH Audits will be carried out between Aug and Sep 13.

Operational Health and Safety Managers will make contact with local departmental managers in July and arrange dates and times to conduct the audits. The audit rationale and question set will be distributed well in advance of the audit date in order to prepare departments. Each department will receive an audit report with recommendations for action. All audits will be collated centrally and findings reported to the November 2013 Health and Safety Committee.

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The results of those audits will help determine the extent of that implementation, identify any remedial interventions required, and help established the next steps for the WHaG action plan for 2013-2015. Phase 2 (which begins later in 2013) is to focus on providing simpler systems for those departments using lower risk substances such as the general ward areas.

In the interim, managers / COSHH Assessors are encouraged to familiarise themselves with the COSHH Procedure, Guidance Note and Health Surveillance Documentation. Additional advice and guidance can be sought from local health and safety staff.

The Committee Supported the ongoing work and forthcoming audits

4 STAFF STORY

Elspeth Caithness advised that there was no specific staff story to report on this occasion.

5 REPORTS BY OPERATIONAL UNITS

5.1 Verbal updates/ minutes of last operational meetings

The Committee received the undernoted minutes/reports from the Operational Units’ Health and Safety Groups:-

(a) Argyll & Bute CHP – Next meeting 30 May 2013 (b) North and West Operational Unit – minute of 6 March 2013 (c) Caithness Health & Safety Group draft minute of 26 February 2013 (d) Raigmore Hospital – minute of 24 January 2013 (e) South and Mid Operational Unit draft minute of 13 March 2013

The minutes of the various meetings and additional comments were noted as follows:

Argyll & Bute Operational Unit

Fiona Campbell reported that the last meeting had been cancelled due to the number of apologies received. It was noted that the next meeting would take place on 30 May 2013 where the focus would be on moving and handling and an update on progress with integration with Argyll & Bute Council.

North & West Operational Unit

Noted

Caithness Health & Safety Group

Noted

Raigmore Hospital

Rosie Brunton reported that a bid had been submitted for funding for traffic management improvement works in particular for areas at the rear of the hospital and pedestrian access. It was anticipated that the result of this bid would be available within six weeks. In addition approval had been given for funding for all banksman training throughout the site

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She further advised that a Raigmore Hotel Services Health & Safety Forum would take place in June and confirmed that this would involve Raigmore staff only, at this point of time.

It was noted that the staffside rep on the Health & Safety Group would be J McQuiston.

The notes of 2 meetings of the Medical Gases Committee, dated 6 March 2013 and 8 May 2103 were also circulated together with the skeleton policy. Three short life working groups had been identified in respect of:

1. Transport of medical gas cylinders across Highland including Argyll & Bute and Care homes

2. Handling and storage of medical gas cylinders

3. Training on medical gases

An action plan with timescales had been developed and Peter Mutton, Head of Specialist Pharmaceutical Services, had been invited to attend the next meeting of the Health & Safety Committee to be held on 15 August 2013.

South and Mid Operational Unit

As regards stress at work, it was noted that the approaches which had been used to date had not always achieved the desired impact. There was therefore a need for a review of the approach to preventing and improving the mental well being of staff. This would require further discussion with Directors of Operations and Lead Managers and may be more appropriately taken forward as part of the Staff Experience Project.

The Committee:

 Noted the updates/minutes.  Agreed that the current approach has not been successful and that a new strategy/approach is required linked to the Staff Experience Project

5.2 Reports by Health & Safety Representatives

Elspeth Caithness circulated a draft Health & Safety Rep role descriptor and guidance advising that this would be shared at operational units. It was noted that comments on the draft were required as soon as possible with the final draft being available for April 2014.

It was generally agreed that there was a need to promote the use of reps across the operational units. Elspeth Caithness confirmed that a considerable amount of development for Health & Safety Reps had been completed by Highland Council which could possibly be adapted for use by NHS Highland.

The Committee:

 Noted the updates.

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6 ADVISER’S REPORTS

6.1 Clinical Governance and Risk Management

Bob Summers spoke to the circulated report advising that there had been 8 incidents reported under RIDDOR in the last quarter, 4 of which were related to dermatitis. Concern was expressed that an increasing number of staff appeared to be to attending their GP in respect of skin related incidences rather than following the management referral route to Occupational Health. Pauline Craw agreed to feedback to the next meeting on reports she had received regarding staff being sent a leaflet advising them to attend their GP.

Bob Summers advised that the report was an overview and that there was a need to interpret the figures better. Anne Gent confirmed that the information should be used to identify priorities as we move forward. Rosie Brunton requested that the number of incidents relating to staffing levels be included in the dashboard.

6.2 Facilities

Speaking to his circulated report, Eric Green advised that good progress had taken place with the fire training and that the Scottish Fire and Rescue Service had visited many NHS Highland buildings with most of the work identified by them as being required now being underway. He reported that all Community Hospitals should reach acceptable standard by the end of the summer. He advised that positive discussions had taken place regarding the staffing levels for evacuating buildings at night. In addition a successful fire evacuation exercise had taken place in Ward 7a of Raigmore hospital.

As regards water systems, he confirmed the water policy had been circulated and that the water treatment plant for Raigmore was being commissioned on 21 May 2013.

Mr Green further reported that window restrictors would require to be fitted in the tower block at Raigmore hospital.

It was noted that the control of contractors Policy would be available to be rolled out shortly and that trial areas for the contractors were Lybster GP practice, Lochshell Dental practice and the County Hospital, Invergordon.

Liz McClurg expressed concern over the water flushing and Eric Green stressed that high risk areas needed to flush on a daily basis. It was noted that the rationale for the flushing had not always been made clear to staff and that there had consequently been lack of ownership. Mrs McClurg requested that information explaining why it was necessary to flush and for the senior charge nurse to e-mail confirmation would be helpful. She advised that the process in the ward area was adequate as there was interaction between the domestic and nursing staff but queried whether there was an alternative method of advising Estates when this work had been carried out. It was agreed that Eric Green attempt to find a solution to this issue with the Charge Nurses and report this back to the next meeting of the Committee to be held on 15 August 2013.

6.3 Infection Control Report

Liz McClurg spoke to her circulated report advising that the HAI Education Group had met 4 times to date and that work on identifying the induction programmes appropriate to all staff groups was almost complete. In addition a spreadsheet identifying specific HAI training needs, appropriate to staff discipline and grade was being developed and the system of recording what training had been undertaken was under review.

It was noted that some education had taken place with care home staff but that care at home education had not yet commenced.

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As regards face fit testing for FFP3 masks agreement had been reached to approach the preferred company to train the trainers and it was noted that the Operational Units had agreed to bear the cost. It was hoped to find a project lead for this work but in the meantime Liz McClurg would fulfil this role. It was further noted that extensive work on fit testing had taken place in Argyll & Bute and that it would be helpful to link in to this.

6.4 Occupational Health

6.4.1 Final Draft NHS Highland Service Level Agreement for the Provision of Occupational Health Services for 2013/2014

The Committee agreed the circulated Final Draft NHS Highland Service Level Agreement for the Provision of Occupational Health Services for 2013/2014.

6.4.2 Occupational Health Annual Report

The circulated Occupational Health annual Report was noted with a request that the pie chart on presenting issues be amended to include a specific section on skin and dermatitis issues.

6.5 Radiation Protection

In the absence of Fraser Brunton, it was noted that progress against the action plan had been slower than hoped but that progress was being made.

The Committee Noted the reports, the issues identified and the actions being taken.

7 TOPIC SPECIFIC ITEMS

7.1 Highland Quality Approach – Mistake Proofing

Mrs Anne Gent spoke to her presentation on the Highland Quality Approach to mistake proofing. She reminded the Committee of the key concepts of Lean working and waste, emphasizing that the aim was to enhance value through the elimination of waste. The aim was to develop systems which eliminated the possibility of waste together with the use of devices, systems and standards of work which prevent defects. The advantages of mistake proofing were noted as improving quality and increasing productivity, eliminating rework, increasing safety, reducing cost, improving schedule performance, creating self satisfaction and eliminating the need for quality control. It was noted that a mistake was something done incorrectly due to misunderstanding, unreliable process or human error, whereas a defect was an uncorrected mistake and that the aim was to eliminate mistakes and defects and reduce the culture of expecting mistakes. Mrs Gent suggested that inspection methods and methods of mistake proofing were required to ensure that quality was built into the systems. She requested that Health & Safety staff think about the concept of mistake proofing in addition to inspection which should be built into standard work. It was noted that healthcare was a process with safety considerations at every step and that the goal should be zero safety defects in healthcare. The need to recognise and address mistake prone situations was noted together with the fact that mistakes should be corrected as soon as possible and as close as possible to the point of origin. In particular she stressed that anyone should be able to “stop the line” for safety concerns.

In discussion the need for a culture change with staff challenging themselves to question why and how tasks were completed was noted together with the concept of ownership at every level. Pauline Craw advised that in Caithness the strapline “See it, own it, fix it” had been used for some time in order to prevent mistakes at an early stage.

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The Committee:

 Noted the Quality Approach to mistake proofing in the Health & Safety setting.

7.2 Health & Safety Committee Work Programme for 2013/2015 – Standardisation of Agendas for Operational Units

Bob Summers spoke to his circulated report identifying what had been achieved over the past 18 months. He highlighted that he was in the process of reviewing and updating the priorities for the new work programme for 2013-15 and that the first draft of the 2013-15 programme would be available in mid June. He stressed that Health and Safety was a management function, which was based on self-regulation, and thus had to be “owned” by NHS Highlands’ Board and its Operational Units, specifically the Directors of Operations.

He emphasised that the Operational section of the Work Programme should not be owned by Health and Safety Managers. Whilst they had a key role, in facilitating and supporting management, it could create a conflict of interest, and reduce the role managers had in managing their own risks. Good and effective planning was key to successful implementation, and operationally this should be done in consultation with management, staff and staffside safety representation . Mr Summers highlighted that emphasis had to be placed on prioritising what was and what was not important. A continual drive for full legal compliance was energy consuming, costly and resource intensive. In the current economic climate it was necessary to ensure that our plans and actions for compliance were risk based and central to this approach and, a key theme running through the work programme, was risk assessment. This would lead to a more efficient approach but would require strong senior manager leadership and support to implement well.

The Committee:

 Supported the approach recommended by Mr Summers  Supported the integration of the Work Programme into Operational Delivery Plans  Agreed that the revised Health & Safety programme be circulated to members on conclusion of the meeting

7.3 Annual Report

It was noted that the Annual Report was being finalised and would be circulated in due course prior to consideration by the Audit Committee.

7.4 Lone Working Pilot

Bob Summers spoke to his circulated update on the Lone Working Pilot. He reminded members that a pilot with one provider had taken place in 2012 which had identified that communications needed to be improved. A further trial due to start on 17 May 2013 would be undertaken with a second provider. This trial was taking place in the Community Team in Dingwall, Estates in Inverness and in Wick and would run until the end of June when it would be evaluated and, if it was considered that this was the best way forward, a business case presented in November. It was stressed that staff engagement with the pilots was essential as this was the opportunity to keep themselves safer.

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The Committee:

 Agreed that feedback from the pilot be presented to the August meeting of the Committee.

7.5 HSE Activity

Bob Summers reported as follows:

Invernevis House – The investigation had now concluded and the investigating inspector had submitted a report for consideration by her Principal Inspector. The outcome was awaited. Ian King expressed concern that the infection control measures were not always being adhered to and that he had advised the local manager accordingly. He suggested that reinforcement and support was required and Mrs McClurg undertook to investigate and report back to the August meeting of the Committee. It was noted that NHS Highland had satisfied the Moving and Handling and Infection Control aspects of this investigation.

New Craigs – HSE had concluded their investigations to the incident that took place in March 2012, and the outcome was awaited. Ross Memorial Hospital – HSE were currently investigating a RIDDOR reportable incident. An SER was undertaken swiftly and a robust action plan was being implemented.

Dermatitis – NHS Highland received its first HSE Fee for Intervention notification at the end of April 2013 for failing to manage dermatitis effectively under Regulation 11 of COSHH. The matter had now been rectified.

The Committee:

 Noted the report on HSE activity.

7.6 The Health & Safety (Sharp Instruments in Healthcare) Regulations 2013

Bob Summers reported that the HSE released supporting guidance to the new Health and Safety (Sharp Instrument) Regulations 2013 in March 2013. This was supported more recently by the CMO CNO Letter Dated 02 May 2013, (SGHD/CMO/(2013)5). The HSE Guidance was simple to follow and it, along with the CNO/CMO letter, directed and remitted Boards to:

 Have effective arrangements in place for the safe use and disposal of medical sharps  Provide the necessary information and training to staff  Investigate and take action in response to work related sharp injuries

He stated that the priorities for reducing sharp injuries should be based on risk, which meant that healthcare sites, departments, wards etc should in the first instance concentrate on the following:

 Those injuries that pose the greatest bloodborne virus transmission (e.g. the prevention of injuries with exposure prone procedures)  The frequency of injury with a particular device and  Those specific tasks that contribute to high frequency injuries (e.g. sharps manipulation, assembly, handling and/or disposal).

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He stated that none of the statutory requirements were new, albeit the fact that they were now explicit in law. The Sharps Group was working through a number of recommendations and actions at present and these would be formulated in a rollout plan.

Mr Summers further explained that guidance would be distributed to the Operational Units shortly. Departmental Managers were encouraged to review the HSE Guidance in light of their existing practice and ensure that risk assessments and local procedures were valid, that all sharp related injuries were reported and proportionality investigated, and that staff were up-to-date with their sharps related training.

The Committee:

 Noted the report.

8 INTEGRATING CARE IN THE HIGHLANDS

Bob Summers updated the Committee on the situation regarding integrating care in the Highlands from a Health and Safety perspective. He reported that a comprehensive plan had been developed, and implementation had begun in some areas. However out of the many issues to resolve and work through, a key risk, which could impact on patient/client safety, would be the failure to resource the Moving and Handling team appropriately. This matter was in hand however Mr Summers stressed that the time delay in resolving this issue should rectified as soon as possible. It was agreed that Anne Gent should provide an update on this to the next meeting of the Committee to be held on 15 August 2013.

The Committee:

 Noted that an update would be provided at the next meeting of the Committee to be held on 15 August 2013.

9 ANY OTHER COMPETENT BUSINESS

10 DATES OF FUTURE MEETINGS

The dates of future meetings of the Committee in 2013 were noted as:

15 August 2013 14 November 2013

11 DATE AND VENUE OF NEXT MEETING

The next meeting of the Health and Safety Committee will be held on Thursday 15 August 2013 at 10.30am in the Board Room Assynt House.

The meeting closed at 1.00pm

9 134 135 136 137 138 139 140 141 Highland NHS Board 13 August 2013 Item 3.10

Argyll & Bute Health and Social Care Strategic Partnership

Minute of Meeting held on Wednesday, 15 May 2013 Mid Argyll Community Hospital & Integrated Care Centre, Lochgilphead @ 10.00 am

Present

Jim Robb (Chair) Head of Adult Care (A & B Council) Derek Leslie Director of Operations (Argyll and Bute CHP) Jan Baird Director of Adult Care (NHS Highland) Cleland Sneddon Executive Director - Community Services (A&B Council) Councillor Dougie Philand Argyll and Bute Council Councillor Elaine Robertson Argyll and Bute Council Louise Long Head of Children & Families (A & B Council) PatTrehan JointPerformance&PlanningOfficer(A&BCouncil) Lorna McCallum (minutes) Admin Officer – Learning Disability (A & B Council)

Apologies

Robin Creelman Chair – Argyll & Bute CHP Sally Loudon Chief Executive – Argyll & Bute Council Dr Michael Hall Clinical Director (Argyll & Bute CHP) Pat Tyrrell Lead Nurse (Argyll & Bute CHP)

Item: Action 1. Introductions

Jim Robb welcomed everyone to the meeting and agreed to act as Chair for the meeting in the absence of Robin Creelman.

It was noted that the meeting was not quorate as a minimum of 8 members (as defined within the Standing Orders) were required to be in attendance. Therefore, it was agreed that any decisions would be deferred to the next meeting.

2. Minute of Previous Meeting & Matters Arising

Subject to noting that Jan Baird was present, the minute of the For noting meeting held on 15 February was agreed as an accurate record.

Matters Arising

Review of Partnership Agreement & Standing Orders – For noting Governance arrangements will be reviewed as part of the integration agenda. It was noted that the engagement of children’s services with the Strategic Partnership has greatly improved and as such, the Integrated Children’s Services Plan will now be noted as a L. McCallum standing item on the agenda. 142

Item: Action

Proposed Implementation of Self Directed Support (SDS) – For noting Jim Robb advised he has met with Susan Spicer & Allen Stevenson to discuss SDS and a paper will be presented to Council’s DMT then Strategic Partnership Committee. It is proposed that SDS will be implemented in Argyll & Bute during the latter part of 2013/14 for all new referrals prior to formal implementation in April 2014. A communication strategy will be developed for Elected Members, staff, Carers and Service Users with briefings planned between August – October. The implementation plan will include guidance on policies and exemptions. Individuals funding will be calculated via the Resource Allocation System (RAS) which will be tied into their assessed need and outcome focussed care plan. Derek Leslie reported Highland Partnership has produced a paper on SDS and D. Leslie that he would circulate this to the group.

Carers Strategy – Pat Trehan advised Tricia Morrison previously D. Leslie updated the Carers Strategy with assistance from Pat. Derek Leslie agreed to discuss with Pat Tyrrell and Anne Austin and if work has been completed, the updated Carers Strategy will be brought back to the next meeting for consideration.

Joint Children’s Inspection - Louise Long reported the results of For noting the Joint Children’s Services Inspection were as follows – 1 very good; 4 good and 3 adequate. The Inspectors acknowledged the partnerships capacity for change and that we are on the right improvement journey. Louise advised that there was an issue with two of the grades awarded which the Partnership will have the opportunity to challenge once detailed feedback has been received on all quality indicators at the end of May. The Partnership will then have two weeks to respond and challenge any of the findings if necessary and produce an action plan. The finalised report will be published mid June and report presented to the Council meeting after the July recess.

As this was an initial joint inspection by the Care Inspectorate, a multi-agency learning report will be agreed by the Partnership and presented to the Inspectorate to assist with future inspections. Once this report is agreed by CAPCOG, the findings will be shared with Local Authorities and Partnerships.

It was agreed that once the final report is published, all those involved in the process will be acknowledged and thanked for their efforts.

3 (a) Update on Redesign of Older Peoples Services

Outcome of Market Test for Older People – Jim Robb advised For noting the outcome of the market test to provide extra care housing and specialist dementia placements to deliver the preferred model of care at home, will be presented to the Project Board/Special Committee.

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Item: Action Outcomes will be presented on a locality basis and also detail what we provision is currently available and future possibilities for each Council care home. However, no specific recommendations will be made regarding any potential closures.

The Project Board previously recommended the planned closure of Struan Lodge due to the high unit cost and surplus capacity in Dunoon. This was agreed at the Council budget meeting on 14 February. However, at the meeting of the full Council on 24 April, a motion was passed which deferred the decision back to the Project Board, with a further review of options undertaken. Meetings have been held with staff, the Unit Manager and local community group to identify any efficiencies. Detailed proposals are being sought and will be collated by Anne Austin who will then report these back to the Project Board/Special Committee.

Councillor Robertson enquired if consideration would be given to creating additional Quality Assurance posts for monitoring services within Care Homes. Jim Robb responded that at present, each Care Home as a link community nurse with health and Social Care input plus the Commissioning Team are actively involved with the care homes on a weekly basis. Councillor Robertson suggested that perhaps QA could be monitored from out with the local area to ensure objectivity.

Jim Robb also advised that increased engagement with Community Care Forums will be developed and a report will be presented to the Project Board detailing proposals on how this will be achieved. The long term strategy will be to enhance community engagement and community capacity to look for local solutions in partnership with the independent and voluntary sectors.

Learning Disability Service Review Update – Consultation For noting meetings with all LD Day Service staff have now concluded and the Formal 90 day consultation period will conclude on 14 June. Feedback from this process will be reported back to the Project Board.

3 (b) Update on Mental Health Redesign

Update report prepared by John Dreghorn was circulated and For noting content noted.

Derek Leslie provided an overview of the above report in particular highlighting that Hub Stage 1 approval is due on 17 May; investment in Community Mental Health Teams is complete; the CMHS Team base is currently being refurbished and this is due for completion by end of May; investment is being made in additional nursing staff to support the transfer of detained patients and; approximately 70 – 75 people attended the MH Services in Argyll and Bute “The Vision” event on 29 April in Inveraray and positive feedback was received.

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Item: Action 3 (c) Reshaping Care for Older People

Joint Commissioning Plans are due to be updated. No formal For noting feedback has been received since February; however, feedback from the JIT representative has been positive.

A joint Performance Outcomes Framework is now been reported on via Pyramid. Pat Trehan is currently reducing into four workstreams from the current twelve.

It was agreed that the Commissioning Plan would become a standing agenda item for both this meeting and the Joint Management Meeting. The Action Plan will also be amended to include more specific details such as identifying a Lead Officer and timescales for each outcome. Narrative will also be added detailing how outcomes will be achieved or issues addressed.

IRF Detailed Expenditure – partnership working will be redefined with the independent sector. Voluntary organisations and carers groups will be reminded that they must be prepared to redesign their service as required and not solely for us to commission services from them.

3 (d) Partnership Working – Integrated Services

Cleland Sneddon provided an update on the current position as For noting follows:

Meetings between the two Chief Executives and the Leader of the Council and Chair of NHS Highland are ongoing.

Draft Terms of Reference for the Project and job description for the Joint Accountable Officer have been prepared.

The Council is establishing an in-house Project Team to progress the integration agenda from the Council’s perspective.

COSLA has provided a response to the Scottish Government paper suggesting a further three models of governance without consultation with Local Authorities. Work is ongoing on workstreams and monitoring of output and once these are agreed the partnership will clarify how these will be delivered locally.

Implementation has been delayed until April 2015. It was noted that the lack of clarification on governance arrangements is resulting in staff frustrations regarding operational issues and impacting on the implementation of Reshaping Care for Older People. It was noted that the Partnership had concerns regarding any further delays, however, the Partnership would continue to build upon the good work already undertaken and any further delays may have a negative impact on this.

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Item: Action Derek Leslie advised that Stephen Whiston will be the lead officer for Argyll & Bute CHP re integration.

4. Re-design of NHS Services – Campbeltown Hospital

Report on community feedback from the public consultation event, For noting held on 14 March, and report to Argyll & Bute CHP Committee were circulated for information.

Derek Leslie advised that a programme of engagement has been in place since 2010. A public meeting was arranged to discuss the proposed reduction to the continuing care bed complement within Campbeltown Hospital, which would move the balance of care from a hospital setting into the community. Any resource release from the closure of these beds would be reinvested in community services.

An implementation group is being established to progress the withdrawal these beds.

5. Joint Performance Update

Report prepared Pat Trehan was circulated for information. For noting

The overall balance of care is improving although, there remains inconsistency across localities.

Integrated Equipment Store data will be included in April’s report. It was noted that good progress is being made an update report will be brought to a future meeting.

6. Data Sharing

Scottish Government have agreed that local partnerships can For noting progress locally data sharing agreements, therefore an agreement has been made that Argyll and Bute Council, Highland Council and NHS Highland take forward introducing a system to share information. At present, both Local Authorities use CareFirst with NHS Highland using a separate system. Joint assessment work held on CareFirst is duplicated onto MIDIS but a system will be developed which will allow this information to transfer directly from CareFirst to MIDIS. A Project Manager will be appointed to progress this.

7. Date of Next Meeting

The next meeting will be held on Wednesday, 4 September 2013 @ All 10.00 am in the Mid Argyll Community Hospital & Integrated Care Centre, Lochgilphead.

5 146 147 Highland NHS Board 13 August 2013 Item 3.11 The Highland Council

Minutes of Meeting of the Adult and Children’s Services Committee held in the Council Chamber, Council Headquarters, Glenurquhart Road, Inverness on Wednesday 22 May 2013 at 10.05 am.

Present:

Highland Council:

Dr D Alston Mr G MacKenzie Mrs I Campbell Mr T MacLennan Mr A Christie (Chair) Ms L Munro Mrs M Davidson Mrs M Paterson Ms J Douglas Mr M Rattray Mr B Fernie Mrs F Robertson Mr B Gormley Ms G Ross Mr K Gowans Mr G Ross Mr M Green Ms J Slater Mr E Hunter Ms K Stephen Mrs L MacDonald (Vice Chair) Ms A Taylor Mrs D Mackay

NHS Highland: Religious Representatives:

Mrs M Duncan Ms M McCulloch Dr M Somerville Rev C Mayo Mr G Smith

Non-Members also present:

Mr A Baxter Mr D Millar Mr B Clark Mr A Rhind Mr J Gray Mr R Saxon Mr R Laird Mrs G Sinclair Mr A MacLeod

In attendance:

Mr H Fraser, Director of Education, Culture and Sport Mr B Alexander, Director of Health and Social Care Mr D Yule, Director of Finance Mr R MacKenzie, Head of Support Services, Education, Culture and Sport Service Mr C MacSween, Head of Education, Education, Culture and Sport Service Ms S MacLeod, Head of Health, Health and Social Care Service Ms F Palin, Head of Social Care, Health and Social Care Service Ms K McAvoy, Area Manager West, Health and Social Care Service Ms A Gordon, Resource Manager Fostering & Adoption, Health and Social Care Service Ms S Russel, Principal Officer – Nursing, Health and Social Care Service Ms A Tissington, Nurse Consultant Health Protection, NHS Highland Ms R Binks, Quality Improvement Manager, Education, Culture and Sport Service Ms N Murray, Catering and Cleaning Manager, Education, Culture and Sport Service Mr D McCartney, Quality Improvement Officer - Inverness Area, Education, Culture and Sport Service Mrs Y Cairns, ICT in Schools Development Officer, Education, Culture and Sport Service Mr E Foster, Finance Manager (Education, Culture and Sport and Health and Social Care) 148

Mr C Munro, Highland Children’s Forum (Third Sector) Ms A Darlington, Action for Children (Third Sector) Ms V Gale, Care and Learning Alliance (Third Sector) Miss J Maclennan, Principal Administrator, Chief Executive’s Office Mrs R Daly, Committee Administrator, Chief Executive’s Office

Also in attendance:

Ms S Macleod, Highland Youth Parliament (Youth Voice) Ms B Nicolson, Highland Youth Parliament (Youth Voice) Mr F Allmond, Highland Youth Parliament (Youth Voice) Chief Superintendent J Innes, Police Scotland Mrs T Sinclair, Head Teacher, Tarradale Primary School Mrs M Mackenzie, Head Teacher, St Clements School Mrs J Bentley, Head Teacher, Marybank Primary, Strathgarve Primary Mrs A Graham, Acting Head Teacher, Cannich Bridge Primary Mr I Abbot, Youth Development Officer (Participation), High Life Highland Ms A Anthoney, Senior Youth Development Officer (Participation), High Life Highland

An asterisk in the margin denotes a recommendation to the Council. All decisions with no marking in the margin are delegated to the Committee.

Mr A Christie in the Chair

Preliminaries

Prior to the commencement of formal business the Chairman, on behalf of the Committee, welcomed Mrs M Duncan, NHS Highland and Ms A Taylor, Youth Convener to their first meeting of the Adult and Children’s Services Committee.

Business

1. Apologies for Absence Leisgeulan

Apologies for absence were intimated on behalf of Mrs B McAllister and Mr D Hendry, Highland Council and Mrs G McCreath, NHS Highland.

2. Declarations of Interest Foillseachaidhean Com-pàirt

The Committee NOTED the following declarations of interest:-

Item 5 - Ms J Douglas, Mr K Gowans, Mr T MacLennan (Non-financial) Item 9 - Ms J Douglas, Mr K Gowans (Non-financial) Item 12 - Ms J Douglas, Mr K Gowans (Non-financial) Item 14 - Ms J Douglas, Mr K Gowans (Non-financial) Item 21 - Ms J Douglas, Mr K Gowans (Non-financial) Item 22v – Mr G Ross (Non-financial) Item 25 - Mr B Gormley, Mr K Gowans, Ms J Douglas, (Non-Financial)

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Ms G Ross declared a non-financial interest in those items which might raise discussion on Thurso High School, as her husband was a teacher at the School, and advised that if there was any specific discussion in relation to Thurso High School she would leave the room.

Dr D Alston declared a non-financial interest in those items relating to integrated health and social care services as a Board Member of NHS Highland but, in terms of the dispensation granted by the Standards Commission, remained to participate in discussion.

3. Developing Youth Participation Com-pàirteachasÒigridhann an DealbhadhSeirbheis

There had been circulated Report No ACS/41/13 dated 11 March 2013 by the Director of Education, Culture and Sport which provided an update on Youth Participation in Highland. The report accompanied a presentation by Ms Ainya Taylor, Youth Convener, Mr S Macleod, Ms B Nicolson and Mr F Allmond of Highland Youth Parliament (Youth Voice) and Chief Superintendent Julian Innes, Police Scotland, outlining their experience and the benefits of youth participation.

Youth participation involved young people in policy development, service planning and service delivery. It was of benefit to the Council and public organisations because it allowed them to improve services based on the views of young people and encouraged organisations to design services which properly met the needs of young people. Youth participation supported the current focus on preventative expenditure by taking account of service users’ views at an early stage of service design. It encouraged young people to take an interest in politics and in how local and national decisions were managed.

The Police Service had taken steps to test whether responses to their community consultation surveys were also in line with the views of young people in Highland. This had been carried out through interactive engagement with young people at the Badaguish Outdoor Centre and which concluded that the views of young people generally tallied with other responses but highlighted that there were some priorities specific to young people: drugs, alcohol abuse and road safety. In addition, improved engagement between the Police Service and young people had emerged as a key theme. Police Scotland and the Scottish Fire and Rescue Service would also attend the Youth Voice Conference in June.

Increased engagement with young people had led to a direct impact on policing activity in the Highlands, particularly in relation to road safety in the vicinity of schools and test purchases for the sale of alcohol to underage individuals. Feedback to young people explaining how they had influenced policing in their areas would also be prioritised.

Members welcomed the presentation, the enthusiasm and commitment of the Youth Parliament and during discussion, the following comments were made:-

 it was very encouraging that the Police Service had taken action on the views expressed by Highland Youth Voice and that this would be fed back to the young people involved. It was clear that the most successful method of engaging with young people was to meet, listen and respond; 3 150

 the issue of transport was a significant barrier to youth engagement in the Highlands and further consideration of this would be beneficial;  it was important to appreciate that all topics considered by Ward Forums could be pertinent to young people and would benefit from their input and views;  the Highland Youth Parliament had previously been criticised for not having been representative of young people and it was encouraging now to see increased engagement with it. Information was requested on what steps were being taken to expand the Highland Youth Parliament and to increase awareness of it;  information was requested on how barriers were being broken down between the Police service and young people who might be drawn to illegal or antisocial activity;  Youth Voice involvement in the Council’s budget consultation had been particularly valuable and the Council’s Community Safety, Public Engagement and Equalities Committee looked forward to hearing feedback from young people on matters relating to democratic representation and elections and to scrutinise the Highland-wide Police Plan;  it was important to capture the views of young people and to draw their attention to social and health inequalities;  the benefits of consulting with young people on all aspects of Council work should be stressed and staff should be trained and provided with necessary resources to consult with young people as a matter of course; and  it was acknowledged that the young people who might benefit most from engagement through Highland Youth Voice were hard to reach and so it was important to ensure that consultation with these young people was taking place. In this regard, it was intended that the Director of Education, Culture and Sport would report to a future meeting of the Committee how the coverage of Youth Voice could be increased to include hard to reach young people.

Responding to these and other comments it was confirmed that good practice in youth engagement and participation was embedded in the way the Council and Committee operated. Young people were regularly consulted and invited to present their views and, in this way, created their impact on Council policies. It was disappointing, but not surprising, to hear that, in the past, youth participation had been less inclusive and representative. It was felt that much progress had been made in recent years with youth participation now seen as a central consideration with widely recognised benefits. Engagement with all age ranges had made a significant impact on how policy was developed and this was complemented by Pupil Councils and through the Curriculum for Excellence, which educated children in the democratic processes.

The Committee:-

i. NOTED the presentation on youth participation by young people and Police Scotland; ii. AGREED that the Director of Health and Social Care work with the youth participation structures to ensure that young people were involved in the planning, delivery and evaluation of For Highland’s Children 4; and iii. AGREED to request a report to a future meeting regarding transport for young people.

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4. Membership of Sub-Committees BallrachdFho-chomataidhean

The Committee AGREED the following:-

 Adult Services Development and Scrutiny Sub-Committee – Ms K Stephen to replace Ms L Munro  Criminal Justice Sub-Committee – Ms L Munro to replace Ms K Stephen  Culture and Leisure Contracts Scrutiny Sub-Committee – Mr M Green to replace Mr W Mackay  Education Transport Entitlement Review Sub-Committee – Mr M Green to replace Mr W Mackay

5. Revenue Budget 2013/14 – Monitoring BuidseatTeachd-a-steach 2013/14 – Sgrùdadh

Declarations of Interest:

Ms J Douglas and Mr K Gowans declared non-financial interest in this item on the grounds of being Directors of High Life Highland but, having applied the test outlined in Paragraphs 5.2 and 5.3 of the Councillors’ Code of Conduct, concluded that their interests did not preclude their involvement in the discussion.

Mr T MacLennan declared a non-financial interest in this item on the grounds of being the Chair of Lochaber Care and Repair but, having applied the test outlined in Paragraphs 5.2 and 5.3 of the Councillors’ Code of Conduct, concluded that his interest did not preclude his involvement in the discussion.

i. Education, Culture and Sport Foghlam, CultaragusSpòrs

There had been circulated Report No ACS/42/13 dated 13 May 2013 by the Director of Education, Culture and Sport setting out the 2013/14 Education, Culture and Sport revenue budget and which confirmed that detailed monitoring of the 2013/14 Budget would not commence until the end of May. The initial management focus would be to address the budget pressures that emerged during the previous financial year. The near final outturn position for 2012/13 would be available in early June and would identify any underlying budget pressures that had to be addressed in the current financial year.

The savings target for 2013/14 amounted to £2.624m and it was assumed that appropriate management action would ensure that this savings target would be achieved.

Responding to questions, it was confirmed that all groups that had taken part in the budget consultation had received individual feedback on the outcomes and details were contained also on the Council’s website. It was also confirmed that some budget pressures such as those relating to food costs had been known for some time. An action plan was being prepared which would identify the full range of pressures and would consider how the Council would address them.

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Thereafter, the Committee NOTED the current financial position.

ii. Health and Social Care SlàinteagusCùramSòisealta

There had been circulated ACS/43/13 dated 13 May 2013 by the Director of Health and Social Care setting out the revenue monitoring statement for the Health and Social Care Service budget for the first month of the new financial year for which, at this early stage, it was not possible to identify any significant budget variance.

During discussion, the following comments were made:-

 reference was made to the 5% annual population increase in elderly people and that voluntary organisations were expected to provide their vital services in terms of preventative care on stand-still budgets; and  concerns were expressed that the Adult Services budget was no longer available for Members’ scrutiny.

In response it was confirmed that the Adult Services budget was reported to the NHS Board, NHS Highland Health and Social Care Committee and the NHS Improvement Committee. Reports could also be fed into the Adult Services Development and Scrutiny Sub-Committee on this budget.

It was explained that all authorities were addressing the financial challenge of social care across Scotland. In Highland an additional £1m had been invested in services for older people as part of shifting the balance of care. Work was ongoing with NHS Highland to establish preventative services and reports would be submitted to future meetings. All of this activity was material to the discussions underway with the Adult Services Development and Scrutiny Sub-Committee. It was also explained theta consultation exercise was progressing with a view to a report being submitted to the August meeting of the Committee evaluating the whole preventative spend agenda against expected outcomes.

Thereafter, the Committee AGREED:-

i. the first budget monitoring report of the 2013/14 financial year; and ii. preventative spend funding of £0.05m in 2013/14 and 2014/15 for Children First.

6. Capital Expenditure 2013/14 – Monitoring CaiteachasCalpa 2013/14 - Sgrùdadh

i. Education, Culture and Sport Foghlam, CultaragusSpòrs

There had been circulated Report No ACS/44/13 dated 14 May 2013 by the Director of Education, Culture and Sport which advised the near final outturn expenditure position for the 2012/13 Education, Culture and Sport Capital programme along with information on the 2013/14 programme. The report also sought approval for a range of new projects and informed Members of progress 6 153 on several prioritised feasibility studies as well as the Sustainable School Estate Review. Finally, there were proposals to address various communication issues and several specific matters for which actions were recommended for approval. During discussion, Members made a range of comments, including:-

 information was requested on timescales for the completion of the swimming pool changing facilities at Culloden Academy;  regarding the proposed replacement of school playing fields with multi-use games areas, there was a request for further reassurance that the Council was making appropriate choices. Further, reassurance was sought on whether the Council was increasing its own expertise to make these decisions or whether there was a need to access external specialist expertise;  there had been support expressed for the upgrade of Thurso swimming pool. In addition, the proposal for a feasibility study for Thurso High School running track was particularly welcomed and so too was the work proposed for Mount Pleasant and Pentland Primary Schools;  assurance was sought that the Committee would soon be in a position to consider the all-weather pitch at Lochaber High School;  it had been understood that a report would be presented to the Committee addressing public access to school sports pitches and it was hoped that the Council would not need to consider charging groups or individuals to use them; and  it was suggested that dialogue should be held with Elected Members to devise an appropriate communication strategy for Electoral Wards.

Responding to these and other comments, it was confirmed:-

 in terms of extensive and flexible community use, all-weather pitches and multi-use games areas for community use were the most appropriate strategic way forward. Maintenance of grass pitches now extended beyond cutting grass and involved maintenance work on an annual basis which had a cost implication. It was expected that there would be a contract in due course for the care and maintenance of pitches alongside maintenance of multi-use games areas;  it was intended that a briefing note would be presented to the August meeting of the Committee regarding use of school sports pitches;  levels of costs were being considered for Lochaber High School all- weather pitch in comparison with the original proposal and the intention was to bring a proposal to the August meeting of the Committee; and  it was confirmed that Service Directors had been asked to provide Outline Business Cases for the ten year capital programme and this had included the Dornoch Sport Facility and would be brought before the Council in June.

Thereafter, the Committee:- i. NOTED the near final outturn expenditure position for the 2012/13 Capital programme as detailed in Section 2 and Appendix 1 of the report; ii. NOTED the status of the Capital programme from 2013/14 to 2015/16 as detailed in Section 3 of the report; 7 154

iii. APPROVED the recommended actions in relation to the Thurso schools; iv. APPROVED the proposed new projects as detailed in Section 4 of the report; v. NOTED the status of the prioritised feasibility studies as detailed in Section 5 and Appendix 2 of the report; vi. NOTED the status of the Sustainable School Estate Review as detailed in Section 6 of the report; vii. NOTED the proposed measures to improve communication with Ward Members as detailed in Section 7 of the report; viii. AGREED that the Head of Support Services meet with Members prior to finally determining a communication system for Electoral Wards; ix. APPROVED the recommendation to purchase a replacement coach for the Sutherland School Transport fleet as detailed in paragraph 8.1 of the report; and x. AGREED that Mrs G Sinclair be provided with information as to the timescale for the completion of the changing rooms at Culloden Academy.

ii. Health and Social Care SlàinteagusCùramSòisealta

There had been circulated Report No ACS/45/13 dated 14 May 2013 by the Director of Health and Social Care which provided an update on progress to date with the Health and Social Care Capital Programme, a monitoring report on expenditure as at 30 April 2013 and an update on work being undertaken on fire safety and other health and safety capital works.

During discussion, Members commented on a need to pay closer attention to investigating the roof conditions of properties being renovated under the Capital Programme. This comment was raised particularly in relation to the current project at Invernevis House and other projects which had not identified the need for roof repairs until close to the end of the project.

Following discussion, the Committee:-

i. APPROVED the report and budgetary position; ii. AGREED that an update on progress at Urray House be provided to Mrs M Paterson; iii. AGREED that information be provided to Mr T MacLennan on the full costs of replacing the roof at Invernevis House; and iv. AGREED that information be provided to Mrs M Davidson on the number of beds currently out of use in formerly Council run Care Homes.

7. Adult and Children’s Services Budgets BuidseatanSheirbheiseanInbheachagus Chloinne

There had been circulated Report No ACS/46/13 dated 2 May 2013 by the Director of Finance which provided a reconciliation of the budget for Adult Services that transferred to NHS Highland and provided an update on other financial issues relating to Integrating Care in the Highlands.

During a summary of the report, it was explained that the Council had agreed a final budget quantum for Adult Care Services in March 2013 when Members had also 8 155 requested a budget reconciliation and an outline of the changes that had been made during 2012/13.The report summarised the main adjustments to the core budget which reassured Members that this had been a robust and challenging process which had taken significant time to complete. A brief explanation was offered as towhee the budget figure and year end estimate for the commissioned Adult Care Services differed from the quantum figure and it was confirmed that a briefing paper for Members would be issued clarifying this situation more fully.

During discussion, Members raised a range of issues, including:-

 Members recognised the importance of fully understanding and scrutinising the budget figures;  NHS had almost a £2m overspend at the end of the financial year which was fully rectified by the time of the final reconciliation due to the receipt of £1m from the Highland Council and £1m transitional funding from the Scottish Government. It was unclear at what point Councillors might be advised during the current financial year if the situation reached crisis point again in the Adult Social Care budget and it was emphasised that scrutiny of this would be particularly important in the first few years following integration. Integration of services had involved two different cultures of financial management – the NHS budget was used to receiving Scottish Government budget feeds throughout the financial year whereas the Council received a budget which it was expected to manage. As Members were no longer able to scrutinise the Adult Social Care budget, this presented a potential financial risk. The Adult Services Development and Scrutiny Sub-Committee received only exceptions reports which did not cover financial considerations;  there appeared to be a change to the definition of shifting the balance of care. It had originally been understood that this meant moving money from acute services into the community but this had not actually taken place. Clarity on this was a priority as the current situation was no longer acceptable; and  since national guidance and regulation to deliver policy outcomes was still awaited, a suggestion was made as to whether this should be highlighted to Highland MSPs to assist in formulating the guidance.

Responding to these comments, it was stressed that it was the Council’s responsibility to define outcomes for integration and consider whether the right quantum of financial support was handed over to NHS to deliver these services. The business of managing and scrutinising the budget for Adult Services was now the responsibility of NHS Highland and not the Council. The NHS Highland Health and Social Care Committee had mechanisms for monitoring expenditure against budget –through the Improvement Committee and another through regular financial reporting to the Committee itself.

Regarding shifting the balance of care, both organisations remained committed to this, but it was important to recognise that this was a complex issue that required ongoing and full consideration. This had to include a shift from acute and institutional services to the community services, but there was on-going discussion regarding the details of this.

Reassurance was given that Council officials were working closely with their NHS counterparts to agree a budget protocol which would require a regular exchange of financial information. Any financial risk to the Council would of course be raised with 9 156

Members and action taken to protect the Council. Discussions had been held to ensure that robust monitoring procedures were in place and included in the budget protocol would be clarification on how NHS Highland would engage with the Council’s budget process from this financial year onwards.

After discussion, the Committee:-

i. NOTED the reconciliation of all budget movements and that a number of issues remained to be resolved at both a local and national level; and ii. AGREED to provide a written briefing to Members explaining how the total budget quantum, in 2012/13, of £86.902m compared with the £88.505m referred to in the 2013/14 Revenue Report.

8. Performance Report – Children’s Services AithisgDèanadais – Seirbheisean Chloinne

There had been circulated Report No ACS/47/13 dated 13 May 2013 by the Director of Health and Social Care which provided an update on the performance framework for Children’s Services at the end of 2012/13.

During discussion, Members commented on a number of areas in the performance framework as follows:-

 Indicator 3 – while accepting that it was a national target, the aim of ensuring access to a Primary Mental Health worker within a 26 week timeframe was still too long. It was felt that information should also be provided about whether these children were accessing other services;  Indicators 4 and 5 – it was unclear how self-evaluation could address variances encountered in the level of information from the large number of agencies inputting to Children’s Plans and what on-going training had been established to address this;  Indicator 7 – the percentage of babies exclusively breastfed at 6-8 weeks was disappointing;  Indicator 29 – while supporting the proposed reduction in placement moves for Looked After Children, it was recognised that this was a complex issue and perhaps should not be assessed solely on the number of moves. Some moves might prove necessary and a more qualitative assessment might be more helpful;  Indicator 34 – the reduction in the number of offences by young people were remarkable;  Indicator 36 – with regard to supporting Looked After Children through the Family Firm scheme, it was understood that the Barnardos Children’s charity was currently undertaking a piece of work on this theme in relation to children with high level support and further information was requested on what shape this might take; and  Indicator 41 – it was pleasing to see a reduction in the number of Looked After Children in Out of Authority Placements.

In response, it was clarified in relation to Indicators 4 and 5 – Child’s Plans – these had been ragged green and amber respectively. Audit analysis to date had focussed on how effective the Plans were in defining needs and identifying appropriate services

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and had now permitted the Council to roll out Version 2. This had already been accomplished within schools and was now being introduced to Health staff and would be written into the new Social Work Management Information system. A further audit of Version 2 would take place together with refresher training following the summer period.

Regarding Looked After Children and placement moves, there were particular challenges caused by Highland geography and a more sophisticated measure had been sought. Measures were now being considered to assess the number of moves over time periods. Regarding the Family Firm, regular reports had been submitted and input had been received from Barnardos and the Director was keen to update the Committee.

A detailed report on the Primary Health Indicators outlining the challenges on how well or not Highland Council and NHS Highland whereat meeting timelines would be presented to the August meeting of the Committee. While the 26 week target was the current national timeframe, this would reduce to 18 weeks by the end of 2014. This was the focus of significant work between the Council and NHS Highland.

The figures cited for breastfeeding were based on June 2012 figures, it being explained that the time lag was a feature of the method by which data was collected. This area of work was subject to an intensive focus through the Early Years Collaborative and, while it might appear a disappointing figure, Highland nonetheless performed well compared with the rest of Scotland.

Following discussion, the Committee:-

i. NOTED the performance information contained in the report; and ii. AGREED that the report to be submitted to the next Adult and Children’s Services Committee detailing the Primary Mental Health Service also address the challenges involved in meeting the timescales at which young people gained access to a Primary Mental Health Worker.

9. For Highland’s Children 4 AirsonClannnaGàidhealtachd 4

Declarations of Interest:

Ms J Douglas and Mr K Gowans declared non-financial interests in this item on the grounds of being Directors of High Life Highland but, having applied the test outlined in Paragraphs 5.2 and 5.3 of the Councillors’ Code of Conduct, concluded that their interests did not preclude their involvement in the discussion.

There had been circulated joint Report No ACS/48/13 dated 13 May 2013 by the Directors of Education, Culture and Sport and Health and Social Care which provided an update on progress made in developing the Integrated Children’s Service Plan.

The Committee NOTED that there would be detailed discussion on the Children’s Services Plan at the for Highland’s Children’s 4 Community Care Seminar on 6 June 2013.

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10. New Primary School North of the River Wick Bun-sgoilInbhirÙige a Tuath

There had been circulated Report No ACS/49/13 dated 13 May 2013 by the Director of Education, Culture and Sport which provided details of the contractual process to be followed as a result of the new primary school north of the River Wick being built on a design and build basis by Hub North Scotland Limited and sought approval for the proposed capital affordability cap figure.

During discussion, Members welcomed the progress that had been made and commended officers for the way in which they had engaged on this project. Local meetings had raised the key issue of the name of the new school – Wick North Primary School already existed and the new school, which although north of the River Wick, needed to have its own name. It was felt that this would be important to engender ownership for pupils, parents and teachers. It was also suggested that there might have been Gaelic implications which should have been recorded in the report and that this be considered for future reports.

Responding to these comments, it was confirmed that a report would be submitted to the next meeting of the Stakeholders Group at the end of June which would include proposals for transitions, staffing, safer routes to school and consideration of the names of the new school. It was suggested that a local naming competition might be held to find a suitable solution.

The Committee:-

i. APPROVED the New Project Request document as detailed in Appendix 2 of the report; and ii. AGREED that the approval of the related Stage 1 submission from Hub North Scotland Limited be approved under delegated powers by the Depute Chief Executive/Director of Housing and Property Services, the Director of Education, Culture and Sport and the Director of Finance on the basis that the affordability cap figure approved within the New Project Request document was not exceeded.

11. Curriculum for Excellence – The Highland Literacy Strategy CurraicealamairsonSàr-mhathais – Ro-innleachdLitearrachdnaGàidhealtachd

In terms of Standing Order 18, the Committee AGREED that this item be taken at this point in the proceedings.

Declarations of Interest:

There had been circulated Report No ACS/51/13 dated 13 May 2013 by the Director of Education, Culture and Sport which explained that, to equip Highland’s young people for life in the 21st century, provision must enable all to acquire the talking, 12 159

listening, reading and writing skills needed to be successful learners, confident individuals, effective contributors and responsible citizens. In so doing, provision must take account of a wider ‘21st century’ definition of literacy. It must be available from pre-birth to adulthood. It must identify and support all learners – but particularly those at risk. It must embrace information technology in all its forms.

The Literacy Strategy had been structured to align with the Numeracy and Health and Wellbeing strategies. It was supported by a comprehensive package of resources, many developed in Highland. In partnership with parents, practitioners would use these resources to meet individual learner needs and develop excellence in their own schools, within associated school groups and across their communities.

During discussion, Members welcomed the strategy, the appointment of the Literacy Development Officer and the training that was associated with this programme. Curriculum for Excellence now drew attention to the need for literacy as a core area throughout the curriculum. It had been helpful to hear from employers that literacy skills had been a weakness and this would direct effort to assist in this area. Further, links in the strategy to transitions were particularly important. It was queried whether the Council was confident it could move forward in improving listening skills.

The Literacy Strategy would also play a particularly helpful role in reducing health inequalities and it was important to identify those pupils who struggled with literacy. In this connection, it was queried whether literacy attainment was included in the Child’s Plan and whether it could be monitored in that way. Further, it was also queried whether there were geographical areas causing greater concern and whether resources were directed appropriately.

Responding to these and other comments, it was confirmed that monitoring and analysis of literacy and core skills started in early years and continued throughout mainstream education. Class teachers were asked to monitor and track the areas of literacy with which pupils might be experiencing problems and interventions were in place in direct correlation with this information. Achievement was also monitored on a geographical basis and resources allocated according to need.

The Committee NOTED the Highland Literacy Strategy.

12. Facilities Management Project – Progress Report and Proposed Implementation Plan PròiseactRianachdGhoireasan – AithisgAdhartaisagus Plana Buileachaidh a Thathar a’ Moladh

There had been circulated Report No ACS/50/13 dated 10 May 2013 by the Director of Education, Culture and Sport which provided feedback on the introduction of the Facilities Management (FM) operating model in Badenoch and Strathspey from July 2012 and an update on implementation in the Black Isle/Dingwall area from October 2012. The report also provided details of the proposed FM rollout plan to all Areas over the next 2 year period.

Mrs T Sinclair, Head Teacher, Tarradale Primary School and Mrs J Bentley, Head Teacher, Marybank and Strathgarve Primaries provided a brief outline of their experiences to date of the FM Project. It was emphasised overall that the positive outcomes of the FM Project would grow over time and that the current negative 13 160 experiences would not be insurmountable. There were many positive aspects to the Project, namely:-

 the new approach introduced flexibility to direct FM staff within the ASG and maximise the benefit of the wide range of staff skills;  the new system could facilitate a team approach to certain larger tasks; and  the system aimed to balance out janitorial time in schools. Many schools now had a frequent janitorial presence where previously this had not been the case.

There were still some areas which required further consideration particularly in relation to improvements in communication between Team Leaders/Janitors and Head Teachers, namely:-

 communication was key to ensure that a janitor was present to monitor work being undertaken as it was not appropriate to depend on a Head Teacher to do this. This sometimes took Head Teachers out of meetings or could even put demands on them during teaching time;  some relatively simple tasks still required contractors to be brought in which was time consuming and expensive;  budgetary constraints prevented some tasks from being undertaken; and  it could be argued that facilities management had reduced a sense of ownership and loyalty individual schools and janitors could no longer get to know pupils in smaller schools.

It was recognised that the janitor had been central to the life of schools but previously in Highland only 44 of the 180 primary schools had benefited from janitorial support. The modernisation programme meant that janitorial services were now balanced more evenly over all schools. The programme was about adopting a common sense sharing of skills and time in a formal setting and it was clear that there was a need to pay attention to communication and information exchange.

During discussion, Members welcomed the report and the information presented by the Head Teachers and made a range of comments as follows:-

 it was hoped that parents, Parent Councils and teachers could play a larger role in developing the FM project and receive the necessary feedback;  the report had not indicated a strong commitment to fix the problem of communications and it was hoped that a report could be presented focussing specifically on this aspect of the project;  it was not clear what collaborative working would mean for secondary schools, especially those with primary schools close by – it was requested that a list be provided of the schools that would be considered;  in terms of the arrangements to deal with emergency situations such as the cleaning up of bodily fluids, assurances were sought that there would be a practical, appropriate and immediate response;  it was encouraging that health and safety issues with janitors should now be addressed through the new system;  where Primary Schools had previously had a fulltime janitor, this was clearly a loss in service and it was important to consider how to manage the change as perceptions and realities in such schools could be vastly different;

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 the consultation exercise for Kinmylies Primary School had not involved the Parent Council who still had concerns and it was hoped that they could benefit from a separate briefing; and  it was clear that the janitorial role was immeasurable and invaluable and could not easily be compared with the new role of facilities management and it was therefore queried whether savings had been created with facilities management.

Responding to these comments, it was explained that, with the Secondary sector, the Project aimed to move away from exclusive working arrangements across the Associated School Group and was part of a wider exercise exploring where practical skills could be best used. It would be appropriate to establish key performance indicators to manage performance and record communications and response times as part of the roll out of the process. There was a need to ensure that there was a way of measuring how this was progressing.

It was confirmed that schools had procedures in place to deal with emergency situations, particularly in relation to the cleaning up of bodily fluids. It was also confirmed that there were no savings benefits from the FM Project as it was being operated on a cost neutral basis.

Following discussion, the Committee:-

i. NOTED the evaluation of phase 2 and the related actions; ii. NOTED that the evaluation of phase 3 would be reported to the Adult and Children’s Services Committee in November 2013; iii. AGREED the implementation programme outlined in Appendix 6 to the report; iv. AGREED that consultation would begin on the proposal to transfer line management of all existing primary school janitorial staff to Catering, Cleaning and FM in advance of the FM rollout programme being completed and that a further update be reported to the Adult and Children’s Services Committee in November 2013; v. AGREED that consultation be undertaken with Head Teachers of secondary schools that had primary schools, either on the same campus or immediately adjacent, in order to establish how the FM model would be implemented and that a further update be reported to a future meeting of the Committee; vi. AGREED that a report be submitted to the Adult and Children’s Services Committee on 25 September 2013 addressing the communication issues which had been highlighted; vii. AGREED to provide Ms J Douglas with a list of schools that were to be involved in the next phase; and viii. AGREED that a briefing be made available on the Facilities Management Project for Kinmylies Parent Council.

13. Monitoring, Tracking and Reporting of Pupil Progress and Achievement Sgrùdadh, LeantainnagusAithris a thaobhAdhartas is CoileanadhSgoilearan

There had been circulated Report No ACS/52/13 dated 13 May 2013 by the Director of Education, Culture and Sport which provided information on emerging approaches in Highland to monitor and track pupil progress and achievement and how the E1 Managing Information System could be used to facilitate this.

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Mrs Y Cairns, ICT in Schools Development Officer, made a brief demonstration of the E1 Managing Information System. The system recorded and could monitor both academic and wider achievement, pupil attendance, provide a snapshot of recent achievements and detail where specialist supports were in place.

During discussion Members welcomed the development of the system in schools and the potential uses of the information collected which should lead to more effective evaluation. It was particularly significant that the system permitted the input of evidence which could be useful for HMI Inspectors in identifying positive outcomes. It was welcomed that the system would have a positive input to Individual Education Plans and Child Plans and was particularly impressive in that it could provide information on specific and individual support required. In this connection, however, assurance was sought on the reliance of using GLOW.

The system would be a huge support to those children not in full time education, however, it could only be as good as the information put into it. It was vital to the Additional Support Allocation Model that the system was properly informed and used. It was suggested that this system might be particularly helpful for supply teachers in charge of pupils with additional support needs and could provide assistance prior to entering the classroom.

Responding to queries it was clarified that permissions for access to the system were on a needs basis with different layers of confidentiality and access as appropriate. Access to the system was discussed at a strategic level and not determined on an ad hoc basis.

The Committee NOTED the progress made to date in tracking and monitoring pupil progress and achievements and AGREED to support the further development of the E1 Managing Information System.

14. School Lets - Proposed Pilot Project GabhaltasanSgoile – PròiseactPìolait a Thathar a’ Moladh

Declarations of Interest:

Ms J Douglas declared a non-financial interest in this item on the grounds of being a Girl Guide Leader but, having applied the test outlined in Paragraphs 5.2 and 5.3 of the Councillors’ Code of Conduct, concluded that her interest did not preclude her involvement in the discussion.

There had been circulated Report No ACS/53/13 dated 13 May 2013 by the Director of Education, Culture and Sport which proposed changes to the current operating model for school lets and that a centralised management and administrative system be introduced on a pilot basis from August 2013.

During discussion, Members made a range of comments as follows:- 16 163

 the school facilities belonged to the community and it was suspected that there would be greater savings to be found if more trusted people could have access to keys to the schools – this would obviate the need to incur costs for janitorial overtime;  the proposed centralised management and administrative system represented significant investment and it was suspected that savings would be sought as an outcome – it was not clear what system might be in place prior to any future proposals being put in place;  while the report appeared simply to seek improved information gathering, it did not offer justification for this or scope out reasons. This led to fears that changes might already be designed but were not indicated at this stage;  it was felt that this would streamline the process and the report aimed to give improved public access;  there was a request for further clarity with how the Council would engage with young people, what kind of organisations would be contacted and what geographical spread would the information gathering process cover;  community groups should be consulted from the outset and with a view not to impact on the quality of any programmes they might already have planned;  insurance charges and responsibilities meant that keys could not be made available to any member of the community and this was part of the reason for the proposed pilot project;  the cost of utilities and administration costs were rising and this impacted on making buildings accessible, safe and sustainable; and  the pilot should not be about saving money in terms of the levels of subsidy the Council wished to provide but should recognise the benefits of allowing community groups to use schools and take a holistic approach with outcomes for communities being of the predominant motivation.

Responding to these comments it was clarified that the report did not intend to explore details, rather it sought a mechanism for improved management information gathering to inform the next stage proposals for the school lets system which would be implemented in August 2014. During the course of the academic year, information gathering would commence and with input from Local Members and local communities so that there would be well thought out and workable proposals for August 2014. It was also explained that liaison would be undertaken with the Youth Convener, Community Groups, Community Councils and users groups. The consultation would be on a Highland-wide basis and explore both urban and rural areas.

The Committee AGREED proposals to change the current operating model for school lets as follows:- i. from August 2013, provide improved management and financial information to better inform future policy discussion and decision-making by implementing an improved management information system; and ii. from August 2014, informed by improved management information and following extensive local consultation:-

 Streamline business processes  Implement a consistent operating model  Improve cost management and potentially improve income generation 17 164

 Provide an opportunity to pro-actively manage lets  Reduce/remove an administrative burden from schools

15. Professional Update for Teachers FiosProifeiseanta as Ùr do Thidsearan

There had been circulated Report No ACS/54/13 dated 10 May 2013 by the Director of Education, Culture and Sport which provided information on a new scheme of re- accreditation for teachers registered with the General Teaching Council for Scotland. The report also sought approval to be involved with the General Teaching Council for Scotland in the second phase of a pilot scheme of re-accreditation for teachers entitled “Professional Update”.

During discussion, Members welcomed the report and recognised how challenging this would be to implement through schools. Head Teachers and senior staff should receive all the support they needed to implement it.

It was confirmed that no decision had as yet been taken as to which ASG would be involved in the pilot.

The Committee:-

i. NOTED the national developments affecting the statutory registration of teachers in Scotland resulting from the Public Services Reform (General Teaching Council for Scotland) Order 2011; ii. NOTED the implications for Highland Council; and iii. AGREED to the involvement of Highland Council in Phase 2 of the General Teaching Council for Scotland Pilot for the Professional Update for Teachers.

16. Intensive Fostering Service Seirbheis Dian-dhaltachd

There had been circulated Report No ACS/55/13 dated 14 May 2013 by the Director of Health and Social Care which described the main elements of the proposed Intensive Foster Care resource and made recommendations about the criteria for carer applicants, including support and fee payments.

During discussion, Members welcomed the report and raised a number of issues, including the following:-

 there were presently between 40 and 50 children in Out of Authority placements which made life more difficult for those children and families. Assurance was sought that the Intensive Foster Care initiative and the many other initiatives currently aimed at this sector would make a difference;  regular statements of children in Out of Authority placements had been previously been requested and it was suggested that this should be provided from the next meeting onwards – this would clarify which initiatives were making the desired impacts;  a request was made as to how many children were currently in private sector children’s residential units in Highland;

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 the flexibility of the proposed initiative was particularly welcome, if it demonstrated that more care could be provided in the Highlands and that there was scope for expansion. Assurances were also sought that this would be a cost effective option;  reassurance was sought that there would be enough support for parents and for birth children and to ensure that this was constantly monitored; and  the Committee had previously taken a decision to hold a reception for foster carers as a sign of the value the Council put on them and it was stressed that this should take place as a matter of priority.

Responding to these comments, it was explained that there would always be a small percentage of children who required a specialist placement and for whom specialist care could not expect to be met within Highland. The specialist fostering initiative for children in specialist placements sought to ensure that more children could continue to receive support in the Highlands. Two staff had been deployed to oversee the detail of this and support from other agencies would be fundamental.

Following discussion, the Committee:-

i. AGREED the details of the Intensive Fostering Service, as set out in the report; and ii. AGREED TO RECOMMEND the associated changes in staffing establishment to the Finance, Housing and Resources Committee.

The Committee adjourned for lunch at 1.00 pm and resumed at 1.30 pm.

17. Trainee Scheme: Public Health Nursing SgeamaFoghlamaich: NursadhSlàintePhoblaich

There had been circulated Report No ACS/56/13 dated 12 May 2013 by the Director of Health and Social Care which set out proposals for a trainee scheme for Public Health Nurses.

Having welcomed the proposals which, it was hoped, would help to address recruitment difficulties, the Committee:-

i. AGREED the proposals for a Public Health Nursing Training Scheme; and ii. AGREED TO RECOMMEND the changes in establishment set out in the report to the Finance, Housing and Resources Committee.

18. Criminal Justice Services for Women Offenders Com-pàirteachasÒigridhann an DealbhadhSeirbheis

There had been circulated Report No ACS/57/13 dated 3 May 2013 by the Director of Health and Social Care which provided an overview of the development of services for women offenders provided by Criminal Justice Services, including the redesign of services in line with the recommendations of the Commission on Women Offenders (2012) and following the establishment of the Community Integration Unit (CIU) in HMP Inverness in mid-2010. The report also provided information on the function of an additional social work post recently agreed by the Council, as well as other recent initiatives.

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During discussion, Members expressed disappointment regarding the temporary closure of the CIU in Inverness due to a lack of women meeting the strict criteria. The Unit provided valuable support to women offenders and the 5% reconviction rate was commended. It was suggested that the Governor of HMP Inverness be invited to attend a future meeting of the Criminal Justice Sub-Committee to discuss the criteria and the possibility of the Unit being allowed to re-open.

The establishment of a Social Worker post to work exclusively with women offenders was welcomed. However, it was important to ensure that there was adequate cover in place to create a consistent and sustainable service.

Thereafter, the Committee:-

i. NOTED the development of services for women offenders; ii. AGREED that the Governor of HMP Inverness be invited to a future meeting of the Criminal Justice Sub-Committee to discuss the criteria for the Community Integration Unit and the possibility of it being allowed to re-open; and iii. AGREED to ensure that there was adequate cover in place for the social worker post to create a consistent and sustainable presence.

19. Mental Health Officer Service SeirbheiseanOifigearSlàinteInntinn

There had been circulated Report No ACS/58/13 dated 7 May 2013 by the Director of Health and Social Care which provided an update on the performance and impact of the Mental Health Officer Service within Highland Council which was established in April 2012.

In response to concerns raised, it was confirmed that there were some gaps in service provision as a result of staff moving to the Council’s Mental Health Officer Service and plans were in place to recruit social workers to vacancies in the mental health teams. It was suggested that that information on gaps in provision, including timescales for recruitment, be provided to Members.

Thereafter, the Committee:-

i. NOTED the issues raised in the report; and ii. AGREED that information be provided to Mrs M Davidson regarding gaps in provision and the timescales involved for these being filled.

20. Developments in School-based Immunisation Programme Leasachaidheanann am PrògramBanachdaich nan Sgoiltean

There had been circulated Report No ACS/59/13 dated 12 May 2013 by the Director of Health and Social Care which set out requirements for new developments in school based immunisation and provided information on measles immunisation.

During discussion, the Vice Chair referred to recent press coverage and clarified that she had no reservations regarding the flu vaccination. Her comments had related solely to the Human Papillomavirus (HPV) vaccination and the importance of parents being fully informed of potential side effects.

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In response to a question, it was confirmed that there was a risk of a measles outbreak as a result of the low uptake in vaccinations following the unfounded MMR scare in the late nineties. Measles was could be a serious disease which could be fatal or lead to long term complications. It was important to promote this message and ensure those at risk were inoculated. Younger children were protected, with immunisation rates having risen to approximately 95-96% in under five year olds. However, immunisation rates were not sufficiently high in ten to seventeen year olds and some adults. Information on local uptake rates and how to get the MMR vaccine was available from the Health Protection team.

The importance of educating parents, particularly in relation to the flu vaccine and the difference between true flu and other illnesses, was acknowledged and it was expected that national materials would be provided. Flu was a serious illness which could have a detrimental impact if contracted at a critical time in a child’s education. Whilst the flu vaccine was not quite as effective as some other childhood vaccines, it did provide substantial protection and models indicated that introducing it in primary schools in Highland would lead to in the region of 2000 fewer consultations with GPs, 66 fewer hospital admissions and 12 less deaths. It was clarified that the pilot did not relate to the vaccine itself but to the systems for delivering vaccinations in schools and the logistical issues to be addressed.

Thereafter, having emphasised the importance of Members encouraging MMR vaccine uptake in local communities, the Committee:-

i. NOTED the issues raised in the report; and ii. AGREED the appointment of a temporary post of Schools Immunisation Project Lead.

21. Community Learning and Development Consultation Co-chomhairleIonnsachadhagusLeasachadh Coimhearsnachd

Declarations of Interest:

There had been circulated Report No ACS/60/13 dated 13 May 2013 by the Director of Education, Culture and Sport which provided information on the Scottish Government’s consultation on new legislation to place a responsibility on Local Authority Education Services to coordinate the delivery of Community Learning and Development Services from 1 September 2013.

The Committee:-

i. NOTED the direction of the draft legislation; and ii. AGREED to homologate the response attached as Appendix 1 to the report.

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22. Minutes Geàrr-chunntas

Declarations of Interest:

Mr G Ross declared a non-financial interest in item 22v on the grounds of being of a family member being in receipt of home care but, having applied the test outlined in Paragraphs 5.2 and 5.3 of the Councillors’ Code of Conduct, concluded that his interests did not preclude his involvement in the discussion.

There had been circulated various Minutes of Meetings for noting or approval as appropriate.

During discussion, clarification was provided on a number of specific points. In particular, it was explained that:-

 the Action Plan in relation to the Care at Home service had been received by the Council on 21 May 2013 and would be circulated, as previously agreed, to Members of the Adult Services Development and Scrutiny Sub-Committee;  a report on the Change Fund, including the bids submitted and the outcomes expected, would be presented to a future meeting of the Adult Services Development and Scrutiny Sub-Committee;  in relation to the difficulties in recruiting home care workers, this was an issue which required to be taken up by NHS Highland and monitored by the Adult Services Development and Scrutiny Sub-Committee. New thinking was required on how to promote vacancies in particular geographic areas and encourage people to apply; and  with regard to the flow of information from NHS Highland to Elected Members, a newsletter was circulated to Members following each NHS Board Meeting. If Members had any comments on the detail, these would be relayed to the NHS Press Office which was very receptive to feedback.

Thereafter, the Committee NOTED, and APPROVED where necessary, the following Minutes of Meetings:-

i. Highland Alcohol and Drugs Partnership Strategy Group of 12 February 2013; ii. Adult Services Development and Scrutiny Sub-Committee of 21 February 2013; iii. Child Protection Committee of 12 March 2013; iv. Culture and Leisure Contracts Scrutiny Sub-Committee of 2 May 2013; and v. Adult Services Development and Scrutiny Sub-Committee of 2 May 2013.

The Committee also AGREED that:-

i. the Action Plan in respect of the Care at Home service be provided, as previously agreed, to Members of the Adult Services Development and Scrutiny Sub- Committee; and ii. a report be submitted to a future Adult Services Development and Scrutiny Sub- Committee on the Change Fund.

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23. Exclusion of Public Às-dùnadha’Phobaill

The Committee RESOLVED that, under Section 50A(4) of the Local Government (Scotland) Act 1973, the public be excluded from the meeting during discussion of the following items on the grounds that they involved the likely disclosure of exempt information as defined in Paragraphs 6, 7 and 9 of Part 1 of Schedule 7A of the Act.

24. Health and Social Care Complaints Review Committee Report AithisgComataidhAth-sgrùdaidhGhearaineanSlàinteagusCùraimShòisealta

There had been circulated to Members only joint Report No ACS/61/13 dated 13 May 2013 by the Assistant Chief Executive and the Director of Health and Social Care which set out the findings and recommendations following a Complaints Review Committee on 13 February 2013. The report also provided an overview of the complaints process and highlighted the requirement for decisions of the Complaints Review Committee to be reported to the Adult and Children’s Services Committee.

The Committee AGREED the recommendations in the report.

25. Linnhe Leisure Update Fios as Ùr mu SpòrsanLinneDhuibh

Declarations of Interest:

Mr B Gormley declared a non-financial interest in this item on the grounds of being a Director of Linnhe Leisure but, having applied the test outlined in Paragraphs 5.2 and 5.3 of the Councillors’ Code of Conduct, concluded that his interest did not preclude his involvement in the discussion.

There had been circulated to Members only Report No ACS/62/13 dated 20 May 2013 by the Director of Education, Culture and Sport setting out the current situation in relation to Linnhe Leisure Limited.

Following discussion, during which Members emphasised the importance of corporate governance for Boards, the Committee AGREED:-

i. the recommendations as detailed in the report; and ii. that the assistance provided by High Life Highland and the Highland Council include support for the Board and not just the management of the Centre. The meeting concluded at 2.20 pm.

23 170 171 Highland NHS Board 13 August 2013 Item 4.1

PROGRESS ON EVALUATION OF SERVICE INTEGRATION

Report by Rachel Hill, Clinical Governance Manager, Frances Matthewson, Service Planning Analyst and Cameron Stark, Consultant in Public Health Medicine on behalf of Jan Baird, Director of Adult Care

The Board is asked to:

 Note information to date on the progress of services since integration.  Agree to support further work, and reporting to the Board.

1 Background and Summary

The plan which has been widely shared with Operational Units and the Executive team will replace the Community Care Plan previously developed by the Highland Council in partnership with NHS Highland and has been presented to a previous Health Board meeting.

The outcomes agreed in previous plans and endorsed nationally by Scottish Government remain unchanged and as articulated in the Partnership Agreement, but the purpose of the five year plan is to focus on what outputs year on year will be required to ensure delivery of the outcomes.

These outputs are reflected in local delivery plans linked to the development of significant redesign of existing resource and illustrate the interdependencies between the development of integrated teams, the building of community resilience, the promotion of self care and health improvement and the shift from institutional emergency care to more planned and anticipated care, delivered as close to home as possible.

Fundamental to all of this must be the ability to evidence improvements linked to the contribution integration has made. This report builds on the evidence base developed over the planning for integration stage and the evaluation work which has progressed using existing data and sourcing frontline public and staff opinion.

2 Service Changes since Integration

Service integration is a major task, and there was a significant risk that the effort devoted to integration could have lead to a deterioration in service delivery. A monitoring mechanism was therefore established to permit active monitoring of routine service delivery, linked to existing data collection. Table 1 shows information on some key measures. 172

Table 1: General Hospital Comparisons over time, HSCP Area

Measure HSCP Area Notes Accident and Emergency April 2011 – 5,911 Monthly figures conceal seasonal Department new attendances April 2012 – 5,593 variation, with higher attendances (Number) April 2013 – 5,581 each summer, but no evidence of an increase around the time of integration Emergency Admissions to Year ending: General Hospitals April 2011 – 6,303 (Annual rate / 1,000) April 2012 – 6,233 April 2013 – 6,249 Emergency Occupied Bed Year ending: This average conceals an increase Days April 2011 – 19,261 in the North area in 2012/13, (People aged 75 years and April 2012 – 18,646 possibly related to reduced care over, rate / 1,000) April 2013 – 19,261 home access. Emergency occupied bed Year ending: days for people with long- April 2011 – 95 term conditions April 2012 – 83 (Rate / 1,000) February 2013 – 80

Hospital Standardised Mortality Ratios (HSMR) is a nationally calculated measure of the quality of in-patient care. They compare the statistically predicted number of deaths for a hospital service, based on the age, gender, illness type and previous admissions of each patient, with the actual number of deaths. If there are more deaths in a hospital than would be nationally predicted, then the ratio is greater than one, if there are fewer deaths than predicted, then the ratio is below one.

The last available period is October – December 2012. The overall Scottish HSMR was 0.93, compared to 0.83 at the Belford Hospital, 0.90 at Caithness General Hospital, and 0.71 at Raigmore Hospital, indicating that all three hospitals were below the Scottish average. Hospitals have different case mixes and making direct comparisons to one another using HSMRs is not advised by the Scottish Patient Safety Programme. For example, some hospitals in rural areas have a greater proportion of palliative care admissions because of less hospice care and of greater distances making community provision challenging. A better use of the measure is thought to be comparison within a hospital over time, as case mix within a hospital tends to be relatively consistent. Compared to the baseline period in 2007, the Belford Hospital has shown a 12.6% average reduction in HSMR, Caithness General Hospital a 16.5% reduction, and Raigmore Hospital a 20.5% reduction.

Overall, hospital data shows no unexpected increase in Accident and Emergency Department attendances or acute hospital admissions in the Highland Council area, and a continuing decrease in emergency admission rates of people with long term conditions. Hospital Standardised Mortality Ratios are lower than the Scottish average in hospitals in the area, and have shown significant improvements over time.

Community Services

Community care services can be supplied directly by NHS Highland; provided under a block contract with other providers, or commissioned for an individual with complex needs under a specific contract relating to their care needs. In some cases, an individual may have a package of care which includes more than one provider. Some people have Self-Directed Care packages where they receive a budget and purchase their care directly, but this is less common at present, although expected to increase over time. There is no record of privately purchased care, for example care purchased by an individual or a family direct from a private care provider.

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In the HSCP area there were

 2,021 adults receiving publically funded home care services from any provider in April 2011; 1,981 in April 2012 and 1,947 in April 2013.  The average monthly number of new home care packages in the financial year 2011/12 was 66, and in 2012/13 was 78.  The average number of scheduled hours in a new package was 5.8 in 2011/12 and 5.5 in 2012/13.

The volume of care provided has shown no significant change in 2012 / 13, and the number of people receiving a service has also remained consistent.

Wide ranging and creative ways will need to be employed to capture community service user feedback in a formal way. Some service user feedback was gained as part of the information meetings with community groups in Spring 2012, and reported to the Board previously.

From this, a service user questionnaire was developed and refined and is being piloted with the Health and Social Care Adult Care Review Team. Review officers are presenting the questionnaire with an explanation at the end of each review. This method will take time to develop, but it should provide an additional route to obtain information from people for whom postal questionnaires are not appropriate.

Large surveys do have a place, however. All users of the Care at Home Service were sent a postal questionnaire in June 2013 (with the option to complete online if preferred). The survey gained a good response of around 50% (678 responses). Respondents report high satisfaction with service provision overall, and with specific aspects of the service, e.g.

 “I have a good relationship with my Care at Home workers” (98% agreement)  “My Care at Home Workers are always polite and courteous” (98% agreement)  “My care and support package helps me to maintain my independence” (95% agreement)

Service users also identified aspects of the service which they felt required improvement, including consistency of care input, timing and flexibility of visits and communication with the Care at Home office.

In addition, there has been work to develop a shorter questionnaire that can be used by services monthly to monitor service user satisfaction. The questionnaire developed for hospital services was not suitable for this, as the hospital questionnaire asks for opinions of a care episode. Some community care is continuous, and so the questions on a care episode can be less relevant.

A revised questionnaire has been developed and is being piloted with the Health and Social Care Adult Care Review Team. Review officers are presenting the questionnaire with an explanation at the end of each review. This method will take time to develop, but it should provide an additional route to obtain information from people for whom postal questionnaires are not appropriate.

Further work is planned to develop more ways to capture more in depth information from both service users and carers. The Highland Senior Citizens’ Network (HSCN) is running a project to obtain detailed information from people who have been recently discharged from hospital in the HSCP area. Work in 2013/14 is intended to repeat the large survey; extend the use of the directly provided questionnaire, and to undertake some detailed qualitative interviews with carers, to supplement the work with service users being undertaken by the HSCN.

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NHS Staff

Staff feedback

The importance of capturing staff experiences about integration was identified as a key part of the evaluation process. In September 2012, all staff in the Health and Social Care Partnerships were invited to complete a survey about their experience of integration so far. The survey aimed to gain feedback on what was working well, what could be better and staff perceptions of the effects of integration on service delivery and day to day work at that early stage.

This was a baseline survey of staff views in the first few months of integration. 673 responses were received, 56% from former Highland Council staff and 44% from existing NHS Highland staff. Many respondents qualified their responses by noting that “it is too soon to comment”, either because the integration process is not complete or because they have not yet seen any changes in their working environment.

Staff who responded to the survey identified areas of service improvement and enhanced team working including effective, accessible management; improved communication; being consulted and listened to, and co-location of team members

Staff also identified a number of concerns, including the importance of communication, both at the time of formal integration, and during the development of integrated teams. It was clear that not all staff experiences had been positive, and that some staff had not felt informed and involved. A key theme was the need to keep staff engaged and informed, including suggestions for regular team meetings, engagement / information events and newsletters.

The report was presented at the Senior Management Team on 31 January 2013, where it was agreed that the survey should be repeated in September 2013 and then annually for the duration of the 5 year redesign, to enable comparison of staff views over time. Later interviews with 20 people who agreed to provide further feedback produced no new themes, but emphasised the wish for clear information provided directly to staff, and confirmed that some staff felt that overall organisational integration had not yet always led to integrated working.

Plans are in place to co-locate and integrate workforce as outlined in the Operational Unit Delivery Plans. There is also a specific workforce plan being developed for Care@Home in response to recruitment and retention challenges. The Board has developed its Workforce Development Plan for 2013/14 illustrating workforce demand for health and social care services and new role of 4.0 WTE health and social care co-ordinators to be a first point of contact for referrers and to access appropriate services quickly for people.

The Board also has a Local Unscheduled Care Action Plan in place, which will support ongoing reduction in emergency admissions.

Conclusion

There has been no evidence of adverse effects of integration on hospital services. Volumes of community care delivery have been maintained, and user satisfaction with home care services was high in a recent postal survey. There is an expectation that care packages will become more intensive in order to support a return to independent living, and future work will look at the detail of care package delivery.

In order to identify the impact of integration alongside the wider change programme for Adult Care, a focus on evaluation and feedback is required. This will build on data collected in relation to Community Care performance and reported through the Balanced Scorecard but

4 175 will also involve qualitative evidence gathered over the life of the plan to identify incremental change. Case examples of change are being collected, both to identify developments, and to allow learning. This will be supplemented by interviews with staff, patients and carers, to capture information that may not be revealed in large scale surveys. Wherever possible, lessons from Highland experience that may be of wider value in Scotland will be identified and disseminated.

3 Contribution to Board Objectives

This work is integral to meeting the Health Board’s objectives of improving quality and efficiency and will provide snapshot and longer term information to evidence the benefits of integration and the wider change agenda over the life of the five year plan.

4 Governance Implications

Any impact identified through this work will be flagged through the Governance route but there is an understanding that all activity is progressed within existing resource, follows the Staff Governance Standards, engages the public and patients in an acceptable manner and does not adversely impact on clinical care.

5 Risk Assessment

Any risks identified as a result of this work will be directed to the appropriate management team.

6 Planning for Fairness

Any actions arising from this work will be impact assessed in accordance with Board policy.

7 Engagement and Communication

This report illustrates progress in engaging public and staff in the evaluation process and follows the agreed standards for patient and public involvement.

Cameron Stark Consultant in Public Health Medicine Department of Public Health

2 August 2013

5 176 177 Highland NHS Board 13 August 2013 Item 4.2

THE HIGHLAND QUALITY APPROACH – MAKING IT HAPPEN – PROGRESS TO DATE

Report by Linda Kirkland, Director of Quality Improvement

The Board is asked to:

 Note the update of work in progress.

1. Executive Summary

In April and June 2013, the Board received formal Board papers on the next steps for the Highland Quality Approach and;

 Agreed the final visual representation of the Strategic Framework and its use and circulation.  Endorsed the requirement to make a step change on our improvement journey to fully embed the Highland Quality Approach.  Agreed the priority areas for Rapid Process Improvement Workshops and other quality improvement in 2013/14.  Approved In April and noted in June the recruitment to the post of Director of Quality Improvement.  Note the plan to utilise existing resource of £968K available in 2013/14 n a more focused way and to approve the funding of £278K of additional resource for 2013/14.  Heard about the content and format for Lean Leader Training.  Noted the next steps to be taken in relation to the development of a Physicians/Staff Compact.

This paper is an update on progress since June and details of next steps to be taken.

2. The Highland Quality Approach – Making it Happen

The 3 areas encompassed within the Highland Quality approach of Leadership and Culture (who), Focus and Delivery (what) and Improvement Methodology (how) have all been progressed since April and a programme for implementation is underway.

2.1 Leadership and Culture (Who)

The NHS Highland Quality Hub is beginning to emerge and a number of staff are now actively engaged in supporting on a variety of quality improvement initiatives and projects.

The establishment of the Hub and the Quality Improvement Work plan is detailed in the attached Implementation Plan (Quality and Efficiency Funding Allocations 2013/2014). Recruitment to the post of Senior Quality Improvement Lead (SPSP) is complete and Maryanne Gillies is confirmed in post. The Senior Quality Improvement Lead (Lean) is being advertised at present.

The Quality Hub is jointly led by the Director of Quality Improvement, Linda Kirkland, Consultant in Public Health, Dr Cameron Stark and Board Medical Director, Dr Ian Bashford. 178

2.1.1 Values and Value Based Behaviour

One of the strategies within the strategic framework (see below) is “Care” (we create a caring experience) and this is also one of the values. Care and compassion has been the subject of recent reports such as Francis on the Mid Staffordshire Foundation Trust. NHS Highland like all other boards faces the challenge of how we ensure we deliver the strategy and live our values and behave in a caring and compassionate manner

The methodology developed for customer care of creating team values, observing behaviours, reflecting back to the team on how their behaviours align with their values has been very powerful in those team who have taken this forward. However much needs to be done in the share and spread of this across NHS Highland. It is becoming clear that this is one part of the “culture change bundle” but it cannot be seen in isolation. The Older People and Acute Care (OPAC) work is taking forward a number of initiatives including addressing Care and Compassion as values and strategies as laid down in the Strategic Framework. This together with the Person Centred collaborative, the Staff Governance Standard, the Staff Experience work stream and the “Give Respect, Get Respect” all need to be aligned with this work and this will be a key work stream for the coming year

2.1.2 NHS Highland Quality Improvement Fellows

The learning we have gained from other organisations such as Virginia Mason has shown that Clinical leadership in its widest sense is crucial to the success of quality improvement. It is very important that staff are engaged in quality improvement work and that we nurture staff who can

2 179 lead quality improvement work, and influence views. We propose to have four NHS Highland Quality Improvement Fellowships. These posts will be for two days a week for between one and two years depending on individual preference and circumstance. In the first instance we plan to appoint clinical staff to these posts because most quality improvement work is currently focused on clinical services, but extending the posts to cover non-clinical staff in due course may be appropriate.

The Fellowships will be advertised and subject to competitive appointment procedures. The posts will include:

 Training as a certified Lean Leader  An appropriate training budget to allow book purchases and relevant site visits  The opportunity to contribute to, and then lead improvement projects within NHS Highland  Playing a key role in the development of a physician compact (see below).  Publishing their work where appropriate, and to present work at relevant conferences and meetings.

All posts will be secondments, and both the applicant and their manager will be expected to commit to leading work on quality within their own service once their Fellowship is complete.

2.1.3 Physician Compact

Doctors play a key role in the delivery of health care. Work on high performing health care organisations in the United States has found that one of the common features of organisations that delivery high quality services are the existence of physician compacts. These are agreements state what doctors can expect of the organisation in which they work, and what expectations the organisation has of them.

The documents are social contracts that make values explicit, rather than a legally enforceable contract. They are, however, helpful to doctors in deciding if the values are those of an organisation in which they would be willing to work, and to the wider organisation in making expectations and support requirements for doctors clear.

Discussion with staff side representatives indicates that frameworks including the Staff Governance Standard and the Staff Experience work has the potential to deliver this for other staff. General Practitioners are subject to different contractual arrangements, but may be interested in the content of a compact with hospital doctors.

At the present time hospital doctors are engaged in hospital management in many ways, including the department and Clinical Directorate structure. This reflects a view of leadership as being concentrated in particular posts. Department heads and Clinical Directors have an important role, but recent work suggests that clinical leadership is a more diffuse function, and that staff at many levels can provide leadership in their role. Doctors are in a powerful position to do this, and so wider engagement of doctors in quality improvement work is particularly important.

Advice from other areas which have created Physician Compacts is that the process of developing the compact provides much of the value. It must be inclusive, measured and methodical. Methods in other services have included large group meetings; working groups, focus groups, and engagement and other dissemination methods that feed developing work back to the larger body of doctors.

We will seek the advice of the Associate Medical Directors on the best methods of initial engagement with their medical colleagues. The methods agreed will then depend on the feedback from the wider group of employed doctors. Experience in other areas indicated that the process of agreeing a compact can take some considerable time. It is important, however, that all doctors feel that they have had a chance to be involved and for their views to be heard.

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2.2 Focus and Delivery (What)

Appendix 1 & 2 is a draft plan which has been submitted to Scottish Government Quality and Efficiency support team as a bid for our funding for 2013/14, Appendix 1 represents a high level work plan for the coming year and embraces the Quality Improvement work being undertaken using all of the methodologies (Lean/SPSP/Productive series). Appendix 2 is the timetable of Rapid Process Improvement Work streams planned for this year. The plan is work in process and is evolving, the attached being a snapshot in time, however the plan will be updated and can be found on the intranet here http://intranet.nhsh.scot.nhs.uk/HQA/Focus/Pages/Default.aspx (quality and efficiency strategy)

2.3 Methodology (How)

NHS Highland uses the model for improvement as the framework to guide improvement work. (See below) It is important that we do not lose the integrity of any of the quality improvement methodology; however it is also important that we have a common language and reporting mechanism. This is a key part of the evolving and emerging Highland Quality Improvement System.

What are we trying to accomplish?

How will we know that a change is improvement?

What changes can we make that will result in improvement?

Act Plan

DoStudy

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Scottish Patient Safety Programme (SPSP) has been operational within NHS Highland for a number of years. The programme has been overseen by local Operational SPSP Meetings and Board wide Leadership Group which meets monthly. The Leadership Group chaired by the Board Medical Director reviews performance and guides continuous improvement. Latterly the group has evolved to embrace the additional aspects of SPSP (maternity, paediatric, neonatal, mental health and primary care) and to the guidance of the share and spread of the improvement model.

The governance of Productive Series and the Lean work is not as well developed. The Productive Series reports through the Nursing, Midwifery and AHP Directorate and the Lean work through a series of Report Outs in the Operational Units and Corporate Services.

It is timely with the creation of the Quality Improvement Directorate to review this and learn from the success of the SPSP Leadership Group. It is therefore proposed to establish the Highland Quality Approach Leadership Group which will oversee and provide governance across all of the Quality Improvement Work.

As part of this work the HQA Charter database is being further developed to enable run charts to be produced on an ongoing basis and this will be a major method in reporting progress

3. Share and Spread

The Director General, Derek Feeley and Clinical Director, Jason Leitch for NHS Scotland visited NHS Highland in mid July. The opportunity was taken to display both to them and to each other examples of the Quality Improvement work underway in NHS Highland and in partnership with The Highland Council. In the morning there was an impressive breadth and spread of posters including Dementia Champions, Older Peoples care, Values and Value based Behaviour, Preventative spend and Scottish Patient Safety Programme. They then visited the RNI Hospital, York Day Hospital and Mackenzie Day Centre to see and hear at first hand, the different approach being taken to improve services for patients and clients.

The day was a great success and it led to discussion about how NHS Highland could be positioned to support NHS Scotland in some of the training and development in Quality Improvement and to possible collaboration with the Institute of Health Improvement in Boston. Support for the challenge to share and spread improvement has been offered both by the visitors (Jason and Derek) and by NHS Highland. All of this will be key areas for development over the coming year.

4. Continuous Learning

The Board is aware and has supported the approach taken of visiting and collaborating with a wide range of organisations who have had a successful impact of change and quality improvement to help learn from test our approach to large scale redesign. This work has also been important to highlight areas where we are further ahead in our thinking, strategy and implementation. We continue to seek learning from those at the forefront of quality. Our partnership with Virginia Mason Medical Centre in Seattle and Tees, Esk and Wear Valley NHS foundation Trust have been reported on many occasions to the Board. We are now in discussions with South Central Foundation in Alaska and are exploring the model they have developed of “Nuka” which boils down to some basic ideas. The relationships are key to healthcare, that patient care should be integrated, there should be same day access to primary care, customer-owners are partners in their own health care and there should be ample opportunity to offer advice and feedback. And to make all of this happen, there should be a culture where training and retraining is valued. Nuka and the model accords very well with the Highland Quality approach, and they deliver this in a very remote and rural area

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5. Contribution to Board Objectives

This report contributes to achieving all the specific objectives of NHS Highland through the further development and implementation of the Highland Quality Approach.

6. Governance Implications

 Staff Governance – The Lean Methodology fully engages and empowers staff in all quality improvement activities. The development of a proactive programme to ensure all staff are developed into new roles as appropriate will also be developed.

 Patient and Public Involvement – Patients and the Public have been and will continue to be actively engaged in quality improvement work.

 Clinical Governance – The provision of safe, effective, high quality services is fundamental to delivering the Highland Quality Approach.

 Financial Impact – There are no Financial implications.

7. Risk Assessment – Priorities for Quality Improvement work will link with the Corporate Risk Register.

8. Planning for Fairness – The Board Paper on the Equalities Act demonstrates how promoting Equality is very much part of the Highland Quality Approach.

9. Engagement and Communication Significant engagement and communication plans with staff regarding the Highland Quality Approach have already taken place and will continue.

Linda Kirkland Director of Quality Improvement

2 August 2013

6 183 APPENDIX 1

Quality and Efficiency Funding Allocation 2013 – 14

NHS Highland

Lead Contact;

Linda Kirkland, Director of Quality Improvement

Quality and Efficiency Plan Returns

1. Please provide the strategic narrative which links specific projects to an overall Board plan for CQI capacity and capability

The NHS Highland Quality and Efficiency Plan is embedded within the Highland Quality Approach, which provides the framework for all delivery plans.

Highland Quality Approach

Since 2010, NHS Highland has been developing and fully embedding the Highland Quality Approach (HQA) as part of the NHS Highland Strategic Framework and ensuring that we transform the way we design and deliver safe, effective and person centred services. This is an ambitious goal, but one the Board believes is critical in ensuring that quality health and social care services are sustainable into the future.

Changing demographics, advances in technology, increasing expectations of the people we serve, the challenging economic circumstances and the accelerated pace of change all serve to drive the need for transformational organisational change.

The key elements of our Strategic Framework are summarised in our Strategic Triangle. 184

The Strategic Triangle is designed to place the individual at the top, with everything else we do supporting the person. In developing our approach we have drawn from the best learning we could find. In particular, the key elements summarised in the Strategic Triangle are adopted from Virginia Mason Medical Centre. The foundation of the Strategic Triangle is the Highland Quality Approach which describes “the way we do things in Highland”

The Highland Quality Approach is based on 3 fundamentals

 Culture and Leadership (who)  Focus and Delivery (what)  Improvement Science Methodology (how)

Funding from Quest has supported and continues to support all 3 elements of the approach and in particular in building capacity and capability for quality improvement.

We have clear evidence to support us in determining what we need to do, how we need to do it and how we can make it happen. To achieve our goals and for every member of our staff to understand and live the Highland Quality Approach, we now need to refocus our existing resources and invest further in our infrastructure, to ensure we set ourselves up for

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success – success that can be sustained overtime and transform the way our organisation runs its business.

The shift in emphasis away from the general nature of the allocation towards a much greater priority and accountability for the deployment of resources to support delivery of improved patient flow is welcomed, and in addition NHS Highland will continue to build capacity and capability with the funding.

Strategic Context

A range of National Reports and Programmes of Work provide the strategic and policy context for our Quality Improvement work and support the direction of travel and the development of the Highland Quality Approach including;

1. The Scottish Government’s 20:20 Vision

The HQA aligns with the Route Map for 2020 vision and a number of the priority areas are supported by the Quest funding (highlighted below) 2020 2020 Vision/Quality Ambitions Vision Safe, effective and person-centred care which supports people to live as long as possible at home or in a homely setting

Triple aim Quality of Quality of Quality of Care Care Care Independent living Quality Healthier Effective Outcomes Services are living resource use safe

Engaged workforce

Positive experiences Priority Areas

1. Person-centred care 7. Early Years

2. Safe Care 8. Health Inequalities

3. Primary Care 9. Prevention

4. Unscheduled and Emergency Care 10. Workforce

5.2Integrated NHS Scotland Care Healthcare Quality Strategy11. 2010 Innovation

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The Strategy identifies three Quality Ambitions – Safe, Effective and Person-Centred Care, with quality improvement and people at the heart of all that we do. The Quality Strategy builds on the significant progress made in improving healthcare over the last few years in terms of:

 Reducing waiting times  Improving access in Primary Care and for Dental treatment  Healthcare and support for people with long term conditions  Better outcomes for people with Cancer, Stroke, Heart Disease and Diabetes

3. The National Person-Centred Health and Care Programme.

4. Values, Behaviours & Customer Care.

5 The Francis Report 2013.

6 Performance, Improvement and Co-production Derek Feeley, Director General Health and Social Care and Chief Executive of NHS Scotland outlined at the 2012 NHS Scotland Event, his vision for ‘Getting to the third curve’. The development of the Highland Quality Approach is NHS Highland’s considered strategy and operational plan to take us through this process.

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2. Please provide Information on the proposed split of the allocation between the key priority areas, highlighting which of your key delivery risks, such as those outlined in your LDP, this funding will support you to address. (For the mental health access targets please cross reference to the HEAT Self-Assessment Risk Returns. For the acute flow returns please cross reference to the relevant access targets and standards.

Total funding received of £382,988.

Allocated as advised

47% Acute Flow £180,004

24% Mental Health £91,917

29% Capacity & Capability £111,016

The HQA is marbled through the NHS Highland Local Delivery Plans but the funding is particularly supporting a number of quality improvement initiatives which in turn will support achievement of several access targets (highlighted in key delivery risk section).

1. Deliver faster access to mental health services by delivering 26 weeks referral to treatment for specialist Child and Adolescent Mental Health Services (CAMHS) from March 2013; reducing to 18 weeks by December 2014; and 18 weeks referral to treatment for Psychological Therapies from December 2014.

2. To deliver expected rates of dementia diagnosis and by 2015/16, all people newly diagnosed with dementia will have a minimum of a year’s worth of post diagnosis support co-ordinated by a link worker, including the building of a person-centred support plan.

3. Reduce the rate of emergency inpatient bed days for people aged 75 and over per 1,000 population, by at least 12% between 2009/10 and 2014/15.

4. No people will wait more than 28 days to be discharged from hospital into a more appropriate care setting, once treatment is complete from April 2013, followed by a 14 day maximum wait from April 2015.

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3. Proposals for the use of Quality and Efficiency Funding for 2013 / 14

Allocations area Specific Articulate the Give an outline of the Provide a clear Strategic link programmes / proposed benefits proposed approach to process for sharing projects to be and outcomes for internal communications, learning and progressed each project governance and on-going spreading support for delivery improvements

Mental Health Deliver faster A small number of 6 weeks of admin agency All records will in LDP access to mental patient records are backfill, to allow the work to future be held on the (Psychological health services still held separately be completed in protected central PAS system Heat (mental health) services) by delivering 26 in a standalone time. iSoft/Helix and weeks referral to database and transferred to Patient treatment for require to be Mental Health Operational Management System specialist Child transferred into the Group oversees actions (PMS) later in the and Adolescent iSOFT system in which reports to Mental year Mental Health North Highland and Health Steering group Services the Helix system in Waiting times access group (CAMHS) from Argyll & Bute also oversees and reports March 2013; to Board Improvement reducing to 18 committee weeks by December 2014; and 18 weeks referral to treatment for Psychological Therapies from December 2014

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Psychological Therapies HEAT Target - information.

Mental Health Deliver faster There is currently For North Highland All records will in LDP access to mental no electronic Employment of a fixed term, future be held on the (Psychological health services outcomes full time Band 4 Clinical central Patient Heat (mental health) services) by delivering 26 measurement Assistant. This post will Management System weeks referral to within the collate the currently (PMS) later in the treatment for psychological collected information then year specialist Child therapies services pull all together onto a and Adolescent in North Highland. database for use by all until Mental Health Each department an electronic system is in Services collects their own place. (CAMHS) from paper-based March 2013; outcomes For Argyll & Bute reducing to 18 measures but there Appointment of 1.0 WTE weeks by is no means of Band 4 system December 2014; collating these. administrator for 6 months and 18 weeks to supervise the referral to implementation of the treatment for system; assist clinicians In Argyll and Bute with setting up the system; Psychological we are currently Therapies from and dealing with early implementing the implementation problems. December 2014 Core.net outcome

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Psychological measure tool. To Mental Health Operational Therapies HEAT fully establish this Group oversees actions Target - Outcome system there is a which reports to Mental Measurement. need to appoint a Health Steering group system administrator for a Waiting times access group fixed term period also oversees and reports until the system is to Board Improvement fully operational committee across the CHP

Mental Health Deliver faster Admin staff in the Employment of a fixed term, Patient Focused LDP access to mental clinical psychology full time Band 5 post to Booking was (Psychological health services department in New work with the NHS Highland established in NHS Heat (mental health) services) by delivering 26 Craigs Hospital Patient Focussed Booking Highland some time weeks referral to spend a significant Team to introduce PFB into ago and this is part f treatment for amount of time the clinical psychology the roll out of this specialist Child dealing with patient department at New Craigs service to others and Adolescent appointments. As Hospital. specialties Mental Health a result they have Services less time to support Mental Health Operational (CAMHS) from clinical staff, who in Group oversees actions March 2013; turn carry out their which reports to Mental reducing to 18 own admin tasks, Health Steering group weeks by thus impacting on Waiting times access group December 2014; clinical availability. also oversees and reports and 18 weeks 9 192

referral to to Board Improvement treatment for committee Psychological Therapies from December 2014

Psychological Therapies HEAT target - admin and clinical time

Mental Health Deliver faster Additional admin Employment of a fixed term Mental Health LDP access to mental hours will assist in Band 2 post for 10 hours redesign is currently (CAMHS) health services ensuring reception per week to supplement the being undertaken to Heat (mental health) by delivering 26 cover is in place current admin team for assess is more weeks referral to which allows the CAMHS. appropriate skill mix treatment for Band 4 members alignment can take p specialist Child of the team to Raigmore senior lace to ensure that and Adolescent utilise their skills management team this is not required on Mental Health appropriately to oversees actions and a recurrent basis Services support the clinical reports to Waiting times without re provision (CAMHS) from team as opposed access group which in turn elsewhere March 2013; to using Band 4 reports to Board reducing to 18 hours to cover a Improvement committee weeks by reception role. December 2014; and 18 weeks

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referral to treatment for Psychological Therapies from December 2014

CAMHS HEAT Target

Mental Health Deliver faster The Helensburgh Employment of a 6 month Data held on helix will LDP access to mental based CAMHS fixed term 0.5 WTE Band 2 be up to date prior to (CAMHS) health services team transferred to post to supplement the the transfer to Heat (mental health) by delivering 26 NHS Highland from current part time secretary trakcare/PMS weeks referral to NHS GG&C in for the Helensburgh treatment for 2012. Due to delay CAMHS team specialist Child in appointing to the and Adolescent part time admin Mental Health posts there is a Services significant backlog (CAMHS) from of work in March 2013; transferring data on reducing to 18 to the helix system. weeks by This work need to December 2014; be completed and 18 weeks before the move referral to across to trakcare/ treatment for PMS later in the

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Psychological year. Therapies from December 2014

CAMHS HEAT Target

Mental Health Deliver faster Each of the Employment of 2 x 6 month This will mitigate the LDP access to mental CAMHS teams in fixed term 0.5WTE Band 2 reduced availability of (CAMHS) health services Argyll & Bute, Admin posts to supplement admin support to the Heat (mental health) by delivering 26 based in the current CAMHS teams during the data weeks referral to Helensburgh and secretaries in Lochgilphead migration ensuring treatment for Lochgilphead, have and Helensburgh that clinical staff can specialist Child 1 secretary to focus on direct patient and Adolescent support the teams. care without the need Mental Health As a result of the to undertake Services transfer from Helix additional admin (CAMHS) from to Trakcare/PMS duties March 2013; later this year, reducing to 18 there is expected weeks by to be a period of December 2014; increased demand and 18 weeks on those staff as referral to data is migrated treatment for across resulting in Psychological a loss of direct Therapies from admin support for

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December 2014 the clinical staff. This in turn will result in clinical CAMHS HEAT staff spending more time on Target admin duties rather than on direct patient contact.

Mental Health Deliver faster 0.5 WTE Band 4 Employment of a fixed term Mental Health LDP access to mental admin hours are 0.5WTE Band 4 Admin post redesign is currently (CAMHS) health services required to backfill to supplement the current being undertaken to Heat (mental health) by delivering 26 similar within the CAMHS admin team. assess is more weeks referral to CAMHS Team to appropriate skill mix treatment for allow work which Raigmore senior alignment can take p specialist Child has been management team place to ensure that and Adolescent discussed to be oversees actions and this is not required on Mental Health progressed around reports to Waiting times a recurrent basis Services quality access group which in turn without re provision (CAMHS) from improvement work reports to Board elsewhere March 2013; which will improve Improvement committee reducing to 18 processes for the weeks by admin team which December 2014; will have an impact and 18 weeks on the clinical referral to team. Without treatment for backfill we are not 13 196

Psychological in a position to Therapies from progress the work December 2014 we have discussed. CAMHS HEAT Target

Mental Health Deliver faster Both CAMHS and Employment of a fixed term, Building capacity and LDP access to mental Psychological full time Band 5 post shared capability for quality (CAMHS &, health services Therapies in North between CAMHS and Adult improvement in the Heat (mental health) Psychological by delivering 26 Highland are Psychological Therapies to services is a key part HQA Improvement services) weeks referral to planning to start, or facilitate LEAN/KAIZEN of the Highland Science treatment for continue existing events for both services in Quality Approach. Methodology specialist Child DCAQ, LEAN and tandem with the planned This post is short term and Adolescent other service DCAQ in Psychological funding to enable Patient centred care Mental Health improvement work. therapies training and Services This work will have development to be (CAMHS) from a natural link to the Mental Health Operational undertaken March 2013; SPSP MH Group oversees actions reducing to 18 Programme in which reports to Mental weeks by terms of reduction Health Steering group December 2014; in risk by Waiting times access group and 18 weeks streamlining patient also oversees and reports referral to flow. to Board Improvement treatment for committee Psychological Therapies from

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December 2014

Psychological Therapies and CAMHS HEAT Targets - efficiency and productivity; SPSP MH Programme

General Highland Quality Cultural shift, Development and roll out of Building awareness, Reduce harm, waste Capacity and Approach Training and standard workshop capacity and and managing Capability (Leadership & Communication capability for quality variation Building Culture) across all NHS HQA leadership group improvement in the Highland oversees and reports to services is a key part Leading the way managers NHS H Board of the Highland workshops Quality Approach.

General Highland Quality Cultural shift, Development and roll out of Building awareness, HQA Capacity and Approach Training and standard training capacity and Capability (Leadership & Communication programme capability for quality Leadership & Building Culture) across ALL NHS improvement in the Culture, workforce Highland staff HQA leadership group services is a key part development. "Beauly Porter" oversees and reports to of the Highland Reduce harm, waste training for all NHS H Board Quality Approach. and managing staff variation

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General Highland Quality Concentrated focus Significant learning has HQA database is Reduce harm, waste Capacity and Approach on delivery of key been gained over the past established for all and managing Capability (Leadership & quality 12 months, following visits Quality Improvement variation Building Culture improvement to Virginia Mason Medical work. Managed by Improvement initiatives Centre and to Tees, Esk each of the Patient centred care Mental Health Science embracing the and Wear Valleys NHS operational units. Safe working Acute Flow Methodology & whole Foundation Trust and it is Focus & now clear that a different Evidence from Delivery) approach is required. previous Quality Departments within improvement work Development of corporate support functions has shown that Quality Hub including Public Health, informal (corporate eHealth, Planning, Finance, arrangements services) HR, Research and receiving support from Development, Clinical corporate functions Advisory Group, Risk such as E health and Management and Clinical Public Health work Governance will now be well but are asked to provide dedicated dependent on a resource to ensure that degree of goodwill specialist skills and and networks. expertise is made available Establishment of the to deliver successful Quality Hub mirrors change and service that of the National improvement. Quality Hub and allows a more formal, HQA leadership group dedicated 16 199

oversees and reports to arrangement to be NHS H Board developed this encouraging a “standard work “ approach to the quality improvement work

General Highland Quality Clinical In addition a critical key to There is significant Reduce harm, waste Capacity and Approach engagement and success is the provision of evidence that strong and managing Capability (Leadership & leadership of overall Clinical Leadership Clinical leadership is variation Building Culture Quality for the Quality Hub and key to implementation Improvement Improvement dedicated clinical leadership and sustaining of Patient centred care Science Initiatives resource is now required. quality improvement Safe working Methodology & Funding from existing Focus & resources in the form of a Our strong links with Delivery) Public Health Clinical Lead Virginia mason and has now been confirmed. Tees Esk and wear Development of To enhance clinical valley have also Quality Hub engagement and leadership shown us the benefit (clinical fellows) and appropriate challenge of a physician and more widely however, it is clinical compact in proposed to establish a shifting culture from Clinical Fellowship performance, through Programme which will improvement and on comprise of 4 clinicians with to co production a dedicated 2 days per 17 200

week to the Quality Hub. Recruitment for these posts will be for 1-2 years and it is hoped that this will be recognised as a prestigious post for clinicians to hold. In addition work on developing a Physicians/Staff Compact needs to be progressed to ensure that our staff are fully engaged in the quality improvement agenda moving forward.

HQA leadership group oversees and reports to NHS H Board

General Highland Quality Building stable At the centre of the Quality This is a stepped Reduce harm, waste Capacity and Approach infrastructure for Hub will be the Quality change for NHS and managing Capability (Leadership & Quality Improvement Office, Highland and a key variation Building Culture Improvement (currently the Quality part of our work is in Improvement leadership and Improvement Support now building capacity Patient centred care Science support Team), led and managed by and capability for all Safe working Methodology & the Director of Quality improvement Focus & Improvement and staffed by methodologies within

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Delivery) a number of Senior Quality NHS Highland. The Improvement practitioners team will provide Development of (3 x Band 8a), Quality leadership, training Quality Hub Improvement Practitioners and development and (Quality (3.6 x Band 7), Trainee will ensure through a Improvement Quality Improvement process of mentorship Office) Practitioner (1 x Band 6) and training that the and Administrative support skills are cascaded (1.5 x Band 3). It is anticipated that the posts will support all of the Quality Improvement Methodologies. However dedicated support for SPSP will continue and the Programme will benefit from the overall enhancement of resources.

HQA leadership group oversees and reports to NHS H Board

General Highland Quality Building stable A programme of coaching, Reduce harm, waste Capacity and Approach infrastructure for training and experiential and managing Capability (Leadership & Quality learning has been variation Culture Improvement developed and

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Building Improvement leadership and implemented to build Patient centred care Science support internal capacity and Methodology & capability for Quality Focus & Improvement within NHS Delivery) Highland. To assist with this the NHS Highland Development of Bench which was Quality Hub established two years ago (Quality and brought together a Improvement number of staff with Bench) expertise, energy and some time to work on allocated quality improvement projects will be reinvigorated. This will ensure that the quality improvement process and systems are embedded and sustained within NHS Highland. The intention is that all staff will have some training and Quality Improvement experience; however learning from other organisations has shown that there are two phases to

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this cultural shift. · · Awareness raising and engagement and Standard Implementation. Having focussed primarily on awareness raising and the engagement phase, we now need to move to the standard implementation phase.

HQA leadership group oversees and reports to NHS H Board

General Highland Quality Building stable The Scottish Patient NHS Highland has a Reduce harm, waste Capacity and Approach infrastructure for Safety Programme (SPSP) strong and positive and managing Capability (Leadership & Quality started in 2008 and is history with SPSP. variation Building Culture Improvement currently bringing about a Improvement leadership and range of local The programme is Patient centred care Acute Flow Science support improvements, including being rolled out to include Mental Health, Safe working Mental Health Methodology & dedicated initiatives relating Focus & to sepsis, primary care, Primary care, Primary care Delivery) paediatric care, mental Maternity, paediatric health and maternity care. and neonatal care and Integrated working Spread and The aim is to deliver an Community hospital, Unscheduled and Sustain Scottish integrated and sustained as well as continuing

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Patient Safety programme for patient with the Acute phase emergency care Programme safety improvement that will 1 and phase 2 and support boards across all early years the key initiatives and in line collaborative. All with Scottish Government programmes are ambitions. The SPSP is being brought under being implemented in every the HQA leadership acute hospital in the group, reporting to the country. The initial goals Board and developing were to drive improvements Board dashboards to in leadership, critical care, ensure governance, medicines management visibility and and peri-operative care. continuous The SPSP is now well improvement are embedded in NHS Highland maintained and the Board have been sighted on the success and the challenges. The programme is rolling out over all sites and is extending to other clinical areas in including Maternity Services and General Practice. The enhancement of resource in the Quality Hub and particularly in the

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Quality Improvement office will support the roll out of the SPSP.

HQA leadership group oversees and reports to NHS H Board

General Highland Quality Rapid Process See attached workplan This focuses on the Reduce harm, waste Capacity and Approach Improvement WHAT in the HQA and managing Capability Workshops HQA leadership group and the attached is a variation Building (Focus & oversees and reports to small representation Delivery) NHS H Board of the calendar of Patient centred care Acute Flow Various improvement work Safe working Mental Health which is underway for the current year. All Primary care work follows a tier 1, 2 and 3 reporting Integrated working structure and report Unscheduled and outs are written up emergency care and on occasions filmed to ensure that Cancer care as many as possible can participate. Report outs are attended by many executives, and board

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members who empower staff to make the changes required to improve patient care

General Highland Quality Virginia Mason Virginia Mason. 3 staff It is important that we Reduce harm, waste Capacity and Approach Lean leader members received maintain the rigour and managing Capability (Leadership & accreditation Advanced Lean Leadership and integrity of the variation Building Culture Training in Seattle last year methodology whether Improvement and continue to be it is LEAN or SPSP. Patient centred care Science supported through to In order to ensure Safe working Methodology) certification by Virginia there is no slippage, Mason Institute. This will we have committed to Unscheduled and Building Capacity involve staff from the learning from as close emergency care & Capability. Institute visiting NHS to source as we can in Training for the Highland this calendar year, order to ensure that Cancer care different levels of to assist with the delivery of the purity of the Improvement has 4 Rapid Process methodology is and will be Improvement Workshops maintained. provided from a (RPIWS), which are number of expected to deliver This is the only sources significant service benefits, approach which is staff engagement and approved by NHS awareness and certification Highland Board who as Advanced Lean Leaders have fully endorsed it and are holding the

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for the 3 staff members. senior management team to account for HQA leadership group maintaining the oversees and reports to integrity and for NHS H Board sustaining the improvements made

General Highland Quality Tees Esk & Wear The Trust is accredited by It is important that we HQA Capacity and Approach Valley lean leader Virginia Mason Institute to maintain the rigour Capability (Leadership & accreditation deliver accredited training to and integrity of the Leadership & Building Culture Advanced Lean Leader methodology whether Culture, workforce Improvement level. As a result we can it is LEAN or SPSP. development. Science source an appropriate level In order to ensure Reduce harm, waste Methodology & of training within the UK. there is no slippage, and managing Focus & NHS Highland have had we have committed to variation Delivery) three senior staff (Cohort 1), learning from as close Patient centred care trained by TEWV’s and they to source as we can in Training for the are at a similar stage to order to ensure that Safe working different levels of those staff who have been the purity of the Improvement has trained by Virginia Mason, methodology is Unscheduled and and will be in that they are about to be maintained. emergency care provided from a supported through 3 RPIWs Cancer care number of to achieve their This is the only sources accreditation. We are approach which is satisfied that the training approved by NHS and support TEWV’s offer is Highland Board who have fully endorsed it 25 208

comparable with that of and are holding the Virginia Mason institute. An senior management additional 12 staff members team to account for of staff (Cohort 2) will be maintaining the participating in Advanced integrity and for Lean Leaders Training in sustaining the April and May, with RPIWs improvements made in late summer and autumn and a 3rd & 4th Cohort is being considered for January and August 2014

HQA leadership group oversees and reports to NHS H Board

Enhanced Enhanced The benefits are Main workstreams are NHS Highland ERAS HQA recovery Recovery better patient Steering Group in outcomes and Orthopaedics place Reduce harm, waste and managing satisfaction and Colorectal reduction in length The group is variation of developing metrics to ENT Patient centred care stay……releasing monitor ERAS e.g. bed days. Urology ALOS, readmissions, Safe working morbidity, Gynaecology mobilisation, Cancer care catheterisation rates,

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Breast pain scores etc.

Vascular will come on line NHS Highland with the appointment of the attended the ERAS additional 3rd vascular National Event in surgeon in August 2013 March 2013 and from this we have contacts Each specialty has a lead in other boards to consultant designated. share and learn. The Anaesthetics has consultant output of the ERAS representation. group is reported to Main support required is the Operational release of clinical time to Programme Board. support project.

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APPENDIX 2

LEAN LEADERS TRAINING

Date Value Stream Location

13 – 17 May Radiotherapy Breast Raigmore Hospital Cancer 3 – 7 June Colorectal surgery Raigmore Hospital

5-9 August Community Mental Health A&B CHP

26 -30 August Pre Op assessment Raigmore Hospital

2 – 6 September Radiology Results Raigmore Hospital reporting 2 – 6 September Unscheduled Care Belford Hospital, Fort William (Belford) 7 – 11 October Care at Home South and Mid Operational Unit 7 – 11 October Primary Care Services A&B CHP

14-18 October Chemotherapy Raigmore Hospital 28 October – 1 November Primary Care Services South and Mid Operational Unit 28 October – 1 November COPD Raigmore Hospital/ South and Mid Operational Unit 28 October – 1 November Chronic Pain services Caithness General/Golspie

25 – 29 November Stroke Services Raigmore Hospital

25 – 29 November Microbiology Raigmore Hospital

19-13 December Unscheduled care Raigmore Hospital

3 – 9 February Community Hospitals North West Operational

3 – 9 February Radiology scheduling Raigmore Hospital

3 – 9 February Scheduling Emergency Corporate, Inverness Surgery 211 Highland NHS Board 13 August 2013 Item 4.3

NHS HIGHLAND WORKFORCE DEVELOPMENT PLAN 2013/14

Report by Pamela Cremin, Workforce Planning and Development Manager and Judith McKelvie, Head of Learning and Development, on behalf of Anne Gent, Director of Human Resources

The Board is asked to:

1 INTRODUCTION

Members of the Board are familiar with the iterative approach taken and the format and content for the Board Workforce Plan on an annual basis. The format for Board workforce plans has been clarified by CEL(2011)23 Revised Workforce Planning Guidance 2011. NHS Highland iterative Board Workforce Plans has followed the process set out in the CEL since 2006, being an early adopter of the Skills for Health/National Workforce Projects ‘6 Steps to Workforce Planning’ methodology, which is outlined in the revised CEL, therefore the format of the workforce plan remains the same as in previous years. However, NHS Highland incorporates its Learning and Development Plan into the Workforce Plan on an annual basis to deliver an integrated Workforce Development Plan. This approach has been underpinned by the close working between the Workforce Planning and Development Sub Group and the Learning and Development Sub Group of Highland Partnership Forum – assuring that the Workforce Development Plan for 2013/14 has been developed in a partnership approach.

2 NHS HIGHLAND WORKFORCE DEVELOPMENT PLAN 2012/13 – KEY COMPONENTS

In its Local Delivery Plan for 2013/14, the Board outlined its key workforce risks and challenges, which are largely unchanged from previous years. The vulnerability and sustainability of Rural General Hospitals continues to be a key issue for the Board – evidenced by significant recruitment and succession planning challenges in medical staffing, including on-going high medical locum use in both trainee and trained grades. There are also workforce sustainability issues in GPs with a number of vacancies across rural GP practices. Recruitment and succession planning for small specialties (for example, AHP specialist roles and health care scientists) are becoming more of a challenge in both urban and rural areas, exacerbated by national shortages in some professions. The workforce is also ageing. In support of the implementation of NHS Highland Quality Objectives and Strategic Framework, the Workforce Development Plan 2013/14 comprises 3 Sections as follows:  Section 1: Six Step Workforce Plan, set out in the format required by CEL(2011)23 Revised Workforce Planning Guidance 2011  Section 2: Workforce Plan Rolling Action Plan for 2013/14  Section 3: Learning and Development Plan 2013/14. 212

The content is as follows:

Section 1: Workforce Plan commences with the Introduction and Purpose and Scope of the Workforce Plan. Progress against the Workforce Plan Rolling Action Plan is outlined form page 8. Drivers for Workforce Change are described from page 11. An Overview of the Current Workforce is set out from page 12 and leads into two sections describing Workforce Supply (page 16) - recruitment and retention issues and challenges; and Workforce Demand (page 21) – population, health and health care needs, taking into account findings from the NHS Highland Annual Report of the Director of Public Health. NHS Highland Strategy is outlined form page 26, focussing on the Strategic Framework and Highland Quality Approach. The Workforce Plan then goes on to outline how the future workforce should be designed to meet the workforce requirements arising from NHS Highland Local Delivery Plan, Operational Unit Delivery Plans, Asset management Plan and Single Outcome Agreements with Local Authorities. The document then leads into Section 2, at page 37: Workforce Plan Rolling Action Plan for 2013/14.

Section 2: Workforce Plan Rolling Action Plan 2013/14, from page 37, identifies 6 workforce actions to be taken forward in the Short (1 year) Medium (1-3 years) and Longer term (3-5 years). Some workforce actions are specific to Board delivery; other work streams are part of regional and national workforce work streams and workforce development strategies. The Rolling Action Plan will be overseen by the Workforce Planning and Development Sub Group of Highland Partnership Forum and reported to and monitored by the Staff Governance Committee on a quarterly basis – thus providing assurance to the Board about the continual focus on the workforce demand to support and sustain health and social care service delivery for NHS highland.

Section 3: Learning and Development Plan 2013/14, from page 42. As already stated, there has been a conscious effort to integrate the Learning and Development Plan into the Workforce Plan to support workforce planning and development aligned to the delivery of the Strategic Framework and Highland Quality Approach for 2013/14 and beyond and provides an explicit approach about how we develop our current and future workforce to support service redesign and future service sustainability.

2.1 Working with partners to deliver workforce solutions

Working in partnership to design and deliver workforce plans is key to addressing workforce challenges. The Board recognises that partnership working is key in all workforce planning and development activities and values the importance of working with partner agencies, and its partnerships, including:  Staff Side Organisations;  Scottish Government;  Patient and Public Involvement;  Essential alignment with Local Authorities;  Voluntary Sector and Communities;  Scottish Ambulance Service;  Regional Planning Groups;  Neighbouring Health Boards;  National Shared Services;  NHS Education for Scotland;  Skills for Health;  The Remote and Rural Implementation Group; and  The Remote and Rural Healthcare Education Alliance (RRHEAL).

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2.2 Workforce Projections for 2013/14

Workforce projections have been developed in response to those workforce requirements arising from the Local Delivery Plan and NHS Highland Operational Unit Delivery Plans for 2013/14. In line with the requirements of CEL(2011)23 Revised Workforce Planning Guidance 2011, a workforce projection template has been agreed in partnership and forwarded to Scottish Government on 28th June 2013. All NHS Scotland workforce projections will be published by Scottish Government on 29th August 2013 as a national document that supports the analysis of workforce projections submitted by all NHS Scotland Board. This approach supports Scottish Government in establishing future student intake numbers for commissioned training programmes in medical, dental and nursing and midwifery; and to work in partnership with education institutions to meet the needs of Allied Health Professional, Pharmacy, Health Care Science and other NHS workforce demand, to ensure that NHS Scotland has future workforce capacity matched to health care demand.

3 CONTRIBUTION TO BOARD OBJECTIVES

Systems are in place for quarterly monitoring of workforce projections and Workforce Plan Rolling Action Plan 2013/14. This monitoring will be overseen by the Workforce Planning and Development Sub Group, reporting to HPF. This approach will provide the assurance of the workforce planning function to the Staff Governance Committee and the Board throughout 2013/14.

Adherence to the process for integrated workforce planning will provide assurance to the Board that quality, patient safety, engagement, consultation and risk management, have all been considered and addressed. This will be delivered by implementing monitoring process around workforce plans, in response to Operational Unit Delivery Plans with the Directors of Operations and ensuring staff engagement at operational unit level, in work place settings and in local partnership fora.

4 GOVERNANCE IMPLICATIONS

NHS Highland Workforce Development Plan 2013/14 supports workforce alignment to the Board’s Quality Objectives and Strategic Framework and compliance with other existing NHS Highland policies including Patient Access, Quality and Patient Safety, the Framework for Communications, and Staff Governance and PIN policies.

 Staff Governance – workforce planning and development are key components of the staff governance standard and staff engagement is integral to the workforce planning process and the agreement of workforce plans.

 Clinical Governance – In support of Board’s Quality Objectives and Strategic Framework, the workforce planning function ensures recruitment and development of a workforce that has the right skills and competencies to deliver high quality, safe and effective health and social care services that underpins the Board’s successful delivery of the triple aim (better health, better care, better value), clinical quality, patient safety and clinical governance. Workforce is key to the delivery of quality and safety and the delivery of learning. Development initiatives, leadership and management training and the investment in new technology will support staff to overcome geographical challenges to delivering health and social care services across NHS Highland.

 Financial Impact – The Workforce Plan 2013/14 underpins the delivery of the Board’s Local Delivery Plan 2013/14 and Operational Unit Delivery Plans.

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Through an integrated approach to financial, workforce and service planning, there are in place a number of workforce plans that respond to service redesign and service improvement programmes. In addition, specific measures have been developed to scope and monitor the workforce cost base in terms of 1) staff utilisation; 2) workforce efficiency and productivity; and 3) service redesign and skill mix review (see page 32 of the Workforce Plan 2013/14 which outlines these approaches in detail).

5 RISK ASSESSMENT

Risk Assessment is an integral part of the workforce planning process. Workforce risks are identified as part of the plan and are also a specific action in the Workforce Plan Rolling Action Plan. A recent Capacity Planning Audit set an action that workforce risks should be identified with plans to mitigate against these. The Board is currently reviewing its overall approach to risk management and the workforce risks with explicit actions to mitigate against such risks will be illustrated in the Workforce Plan Rolling Action Plan in line with the Board prescribed format.

6 IMPACT ASSESSMENT

The NHS Highland Workforce Development Plan 2013/14 has undergone Planning for Fairness assessment throughout and in conclusion of its development.

Pamela Cremin Judith McKelvie Workforce Planning & Development Manager Head of Learning & Development Corporate Services Corporate Services

2 August 2013

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Workforce Development Plan 2013/14 NHS Highland Workforce216 Development Plan 2013/14

Table of Contents

Page(s)

Glossary of Key Terms 4

SECTION 1: Six Step Workforce Plan

Introduction and Purpose 6

Scope 7

Progress made against Workforce Plan Rolling Action Plan 2012/13 8

Drivers for Workforce Change 11

Overview of the Current Workforce 12

Workforce Supply 16

Workforce Demand 21

NHS Highland Strategy 26

Designing the Future Workforce 29

Workforce Projections (to be confirmed on 29th August 2013) 34

SECTION 2: Workforce Plan Rolling Action Plan 2013/14 35

SECTION 3: Learning & Development Plan 2013/14 40

List of Figures and Tables

Figure 1: Workforce Planning Approach 6

Figure 2: NHS Highland Workforce Planning Cycle 7

Figure 3: NHS Highland Workforce Staff Group Pie Chart (staff in post by 13 staff group Headcount %)

NHS Highland Workforce Development Plan 2013/14 2 NHS Highland Workforce217 Development Plan 2013/14

Figure 4: NHS Highland Age Profile (Headcount) 13

Figure 5: NHS Highland Use of Flexible Workforce (Replacement) (WTE) 14

Figure 6: NHS Highland Annual Sickness Trend and Breakdown 15

Figure 7: Figure Components of population change by administrative area 21 NHS Highland: 1999-2009

Figure 8: Projected Population Change Numbers by Age Group and Gender, 22 NHS Highland Area, 2008, 2023 and 2033

Figure 9: Projected Population Change Percentage Change by Age Group, 23 NHS Highland Area, 2008 to 2033

Figure 10: The Highland Quality Approach (HQA) 27

Table 1: NHS Highland Staff in Post as at 31st March 2013 by WTE 12 Table 2: Workforce Productivity and Efficiency Contribution to Quality 32 2013/14

NHS Highland Workforce Development Plan 2013/14 3 NHS Highland Workforce218 Development Plan 2013/14

Glossary of Key Terms

AfC Agenda for Change AFFI A Force for Improvement AHP Allied Health Professional AT-L AT Learning System BC Better Care BH Better Health BV Better Value CEL Chief Executive’s Letter CHP Community Health Partnership CPD Continuing Professional Development CRES Cash Releasing Efficiency Savings DGH District General Hospital EFM Estates and Facilities Management EPA Extra Programme Activity (in the Consultant Contract) eESS (electronic) Employee Support System eKSF Electronic Knowledge and Skills Framework EWTD European Working Time Directive GP General Practitioner GRO(S) General Register Office for Scotland HAI Healthcare Associated Infection HC Headcount HCHS Hospital and Community Health Service HCS Healthcare Science HCSW Healthcare Support Worker HEAT Health Efficiency Access and Treatment Targets HDL Health Department Letter HPF Highland Partnership Forum HR Human Resources ICH Integrating Care in the Highlands IPG Integrated Planning Group IRF Integrated Resource Framework ISD Information and Statistics Division (NHS Scotland) IT Information Technology KPI Key Performance Indicator KSF Knowledge and Skills Framework LDP Local Delivery Plan LTC Long Term Condition MH Mental Health MMC Modernising Medical Careers (now SMT) NRRP National Recruitment and Retention Premia NES NHS Education for Scotland NHS National Health Service NHSH NHS Highland N&M Nursing and Midwifery NMC Nursing and Midwifery Council

NHS Highland Workforce Development Plan 2013/14 4 NHS Highland Workforce219 Development Plan 2013/14

NoSPG North of Scotland Planning Group NWAHP Nursing and Midwifery & Allied Health Professional OOH Out of Hours PA / PAs Physician Assistant(s) P4I Planning for Integration PIN Partnership Information Network QIS NHS Quality Information Scotland QUEST Quality and Efficiency Support Team RGH Rural General Hospital RRHEAL Remote and Rural Health Education Alliance RRIG Remote and Rural Implementation Group SAAT (Staff Governance) Self Assessment Audit Tool) SEHD Scottish Executive Health Department (now known as SGHD) SGHD Scottish Government Health Department SGDP Salaried General Dental Practitioner SMT Scottish Medical Training SOA Single Outcome Agreement SPA Special Programme Activity (in the Consultant Contract) SSSC Scottish Social Services Council SSTS Scottish Standard Time System ST Specialty Training (in terms of medical trainees) STBs Specialty Training Boards (in terms of medical trainees) SVQ Scottish Vocational Qualification SWISS Scottish Workforce Information Standard System WTE Whole Time Equivalent

NHS Highland Workforce Development Plan 2013/14 5 NHS Highland Workforce220 Development Plan 2013/14

Introduction and Purpose

NHS Highland Board is committed to improve the health of the Highland population and develop high quality health care and adult social care services that deliver Better Health, Better Care, and Better Value to the people of Highland.

Workforce planning is an important task for all NHS Boards. In order to deliver the requirements set out by the government in Better Health, Better Care: Action Plan1, the Board must ensure it has a committed, well prepared, dedicated workforce that has the right knowledge, skills and behaviours, in the right place, at the right time, to respond to and deliver health and social care services now and in the future.

Figure 1: Workforce Planning Approach

Source: Centre for Workforce Intelligence 2012

NHS Highland workforce plans are integrated with service and financial plans through the development of annual its Local Delivery Plan to deliver a three dimensional (integrated service, financial and workforce) approach, building on the iterative workforce plans developed in previous years.

Making sure that the workforce planning function is integrated with financial and service planning functions ensures that staff have the capacity and capability to deliver safe, efficient, high quality health and social care services. Workforce planning must also be delivered in partnership with staff and trade unions to ensure that workforce solutions are fully debated, understood and implemented for the benefit of Highland population and service users.

1 Scottish Government, 2007. Better Health, Better Care: Action Plan. Edinburgh: SGHD NHS Highland Workforce Development Plan 2013/14 6 NHS Highland Workforce221 Development Plan 2013/14

Scope

NHS Highland publishes a workforce plan every year. The workforce plan informs the Board of the future workforce requirements for the organisation and provides workforce analysis and workforce projections aligned to health and social care demand, integrated with service and financial planning systems. NHS Highland’s Workforce Planning process / cycle encompasses 6 stages in line with the Six Steps Methodology to Integrated Workforce Planning2, as defined by CEL(2011)323, and is shown dramatically as follows: Figure 2: NHS Highland Workforce Planning Cycle

STEP 1: Define the Workforce Plan and its objectives

STEP 6: Implement. STEP 2: Identify Monitor and Review Workforce Demand progress quarterly and Drivers for Workforce Change

STEP 5: Develop an Action Plan and STEP 3: Identify confirm Monitoring / mechanisms to Governance respond Workforce arrangements Demand and Drivers STEP 4: Develop the for Workforce Change Workforce Plan, identifying key workforce plans, key policy links, and key partner agency relationships

Workforce planning arrangements within NHS Highland are facilitated by a partnership approach, engaged operationally with staff side representatives and Highland Partnership Forum (HPF). Specifically, workforce planning function is identified as part of the Staff Governance Standard and therefore accountable through the Staff Governance Committee to NHS Highland Board. A Workforce Planning and Development Sub Group of the HPF oversees the development of the workforce plan and its links with the service and financial planning agenda as well as its links with external partners.

2 Six Steps Methodology to Integrated Workforce Planning. Workforce Projects Team / Skills for Health. Available from: www.healthcareworkforce.nhs.uk

3 CEL(2011)32Revised Workforce Planning Guidance 2011. Available from: http://www.sehd.scot.nhs.uk/mels/CEL2011_32.pdf

NHS Highland Workforce Development Plan 2013/14 7 NHS Highland Workforce222 Development Plan 2013/14

Progress made against Workforce Plan Rolling Action Plan 2012/13

1 Develop plans to mitigate against workforce risks  Workforce risks in small specialties identified and working with national workforce planning group to address these.  Informed the Migration Advisory Committee Shortage Occupation List of difficult to recruit to posts.  Locum Policy updated and compliance monitored.  Regional and National banks being progressed, but out with Board control re timescales.

2 Reduce senior management posts by 25% by 2015, in line with SGHD guidance  NHS Highland agreed its baseline with Scottish Government as 79.4 WTE senior managers, which translated into a reduction of 18.5 WTE to 60.5WTE by the end of this parliamentary term.  As at 31st March 2013, the total number of posts reduced is 5.0 WTE, which represents just under a third of the target achieved.

3 Workforce Productivity and Efficiency Contribution to Quality  Staff Utilisation: work has been taken forward to clarify capacity and demand and this is reflected in Operational Unit Delivery Plans with the workforce demand addressed in the Workforce Plan 2013/14; Job Planning reviews are ongoing to ensure current capacity meets demand; vacancy management approach is in place and continues to be effective in underpinning job redesign as a result of quality improvement and natural turnover.  Reducing workforce costs and increasing workforce productivity: continued focus on managing the workforce cost base in relation to supplementary staffing; the reduction of agency locum costs remains challenging due to long tern vacancies in medical staffing, particularly in the RGHs; Waiting Time Initiatives are at a minimum; continuing to manage staff absence and employee friendly leave in line with PIN Policies. These approaches have now been extended to adult social care staff.  Service Redesign and skill mix review: establishment reviews are in place across all AfC staff groups using nationally validated workload measurement and workforce planning tools (where available) – at lease once per year in each setting  Governance systems have been strengthened to provide assurance that NHSH establishment review principles are being applied – in partnership

4 Workforce development to support integrated health and social care  Workforce development needs are being scoped within integrated teams.  The Board is implementing the role of Health and Social care Co-ordinator across Highland. A job description has been finalised and funding has been agreed. NES are also supporting workforce development in this area by funding visits to Torbay NHS Trust, where this role has been fully implemented and evaluated.  The Board is also being supported by NES and Scottish Social Services Council (SSSC) to support role development. NHS Highland Workforce Development Plan 2013/14 8 NHS Highland Workforce223 Development Plan 2013/14

 Workforce data set has been incorporated into routine workforce information reports and all adult social care staff are migrated onto NHS Highland payroll – completed as at 31st March 2013.  The migration will provide a baseline and integrated workforce data to enable trend reporting and support future workforce and succession planning.

5 Integrating workforce planning and development function with HQA approach  More explicit and planned way of identifying and prioritising workforce plans  Workforce planning and development requirements outlined in LDP for 2013/14. Operational Units have drafted their Delivery Plans and workforce plans have been scoped from these – identified from a “bottom up” approach.  The workforce planning function in Board is aligned to the QuIST and picking up the workforce aspects identified by HQA approach, which can be prioritised and progressed.  There is engagement with operational units to ensure workforce redesign, efficiency and productivity is applied to all quality improvement and service redesign process. There is a focus on pan Highland consistency and outcomes / benefits realisation.  This work is on-going, will become mainstreamed and will continue to be developed and progressed throughout 2013/14 and beyond.

6 Reshaping Medical Workforce (and the contribution of Clinical Workforce)  On-going. NHS Highland is working closely with NoS Regional Boards and NES to implement the national reduction in medical trainee numbers. The process has been reviewed for 2013 and the reduction in numbers paused in a number of frontline specialties including acute medicine; paediatrics; anaesthetics; and emergency medicine.  The total reduction in posts for 2013 has been agreed by the Cabinet Secretary & 24 posts will be disestablished nationally.  2 of these will be from the North Region; 1 each from Old Age Psychiatry & OBGYN.

7 Rural General Hospital Workforce Planning  On going. KTP has concluded. A number of discussions are taking place both within NHSH and at national level regarding the vulnerability and sustainability of RGHs, which remains a key workforce challenge for the Board. Recruitment challenges remain unchanged.  A workshop has been arranged for 27th September for all RGHs and NES to further discuss workforce development needs.

8 Remote and Rural Workforce Sustainability (links to Actions 1 and 7 above)  Experiencing significant current GP recruitment issues in remote and rural areas. Plans in development for sustainable workforce; inclusive of discussions with key partners and engagement with local communities.  Board has been funded to progress a R&R Healthcare test pilot, but this will take time to implement and deliver solutions.  AfC workforce sustainability in remote and rural areas, especially in higher bands in AHP, Pharmacy and Nursing.

NHS Highland Workforce Development Plan 2013/14 9 NHS Highland Workforce224 Development Plan 2013/14

9 Workforce Development and New Roles  Physician Assistants: job descriptions for PA roles at intern and fully qualified level have been banded and there are plans to appoint 3.) WTE in 2013/14. We continue to offer placements for PA’s in training with St Georges University in London. Plans are in place to offer internships from Aberdeen University PA’s.  A policy to support NMAHP HCSW role development has been completed  Links in place with NES, RRHEAL, Local Authorities in Highland and Argyll and Bute and SSSC to support development of new roles  NHS Highland has an in-house SVQ centre to support education delivery, including Modern Apprentice roles  Currently developing Modern Apprentices for administration posts.

10 Nursing, Midwifery and AHP (NMAHP) Workforce Planning and Development Plan  Review of establishments have been undertaken using validated workforce and workload tools where available. Establishment review outcomes are agreed in partnership.  Governance systems have been developed to track workforce establishment changes in line with the use of workload measurement tools and linked to financial systems.  Internal Audit Report on Nursing and Midwifery Vacancy Management was completed in September 2012.  Further work has been done in response to patient acuity and ensuring all establishments are budgeted for supplementary workforce.  Supplementary staffing is continually being monitored in line with agreed budgets and establishments.  Nurse interns and NMAHP flying start programmes are mainstreamed.  Integration of Health and Social Care is a key focus for development. Further integration has take place for Speech and Language and Dietetics services.

11 Implementation of Health care support Workers (HCSWs)  Monitor the compliance with HCSW standards and codes for new starts  Systems are also in place to record compliance and progress against standards and codes; being overseen by L&D team working with recruitment team and operational managers. Data recorded appear to be lower than appointed posts and work is currently underway to confirm whether or not many more have achieved both the standards and code but they have not yet been recorded; and to confirm that managers understand what they are required to do in terms of new starts.  Policy in place to ensure new and existing staff can meet the NHSS HCSW mandatory induction standard and code of conduct and SSSC code of practice.

NHS Highland Workforce Development Plan 2013/14 10 NHS Highland Workforce225 Development Plan 2013/14

Drivers for Workforce Change

The demand for health and social care services:  Increasing life expectancy and an ageing population, with marked decrease in the proportion of young people4;  Growth in chronic diseases and long term illness;  The prevalence of health inequalities;  Increasing emergency hospital admissions;  Future lower levels of investment than has been seen in recent years;  Developments in technology, medicines and new treatments; and  Changes in National Policy and Standards.

As a consequence, the provision of services needs to change and respond to:  The impact of quality improvements already in place  A focus on improving health and preventing illness;  Greater responsiveness to the population’s needs and expectations;  More use of care pathways, multi-professional and multi-disciplinary working;  More diversity in, and a changing balance between community and hospital based services – integrated health and social care and more care in the community;  The introduction of new technologies; and  The increasing health and social care costs with reduced financial uplifts for the foreseeable future.

At the same time workforce changes are focused on:  Quality improvement and service redesign outcomes and organisational change, particularly the integration of health and social care;  Working smarter, not harder – supported by technology, automation and self care and self management approaches;  Workforce redesign across systems – not just focussed on professional silos or operational areas; and the requirement for role development, new and extended roles and skill mix review across teams and across agencies;  Reshaping Medical Workforce (and the contribution of clinical workforce)  Shape of (Medical) Training review and modernising clinical careers and other health and social care professional careers;  Maintaining the requirements of EWTD for all workforce groups;  Assessing the impact of an ageing workforce and succession planning to small workforce groups that tend to be specialist rather than generalist in their service delivery.

NHS Highland is not immune to these challenges and drivers for workforce change and solutions lie in how the organisation assesses workforce risks and designs, develops and plans its workforce in the most efficient and effective way, whilst maximising talent and making the best use of financial resources.

4 See NHS Highland Population analysis in the next section. Population analysis (sourced from GRO(S); provided by NHS Highland Health Intelligence Unit. NHS Highland Workforce Development Plan 2013/14 11 NHS Highland Workforce226 Development Plan 2013/14

Overview of the Current Workforce

NHS Highland has developed robust systems that monitor workforce trends. Detailed workforce information is provided on a quarterly basis to the Board, its formal committees and operational units. The following figures and graphs, illustrate NHS Highland workforce profile analysis in whole time equivalent (WTE) for 2012/13 (year to 31st March 2013).

Table 1: NHS Highland Staff in Post as at 31st March 2013 by WTE

Staff Group Staff in Post 31st March 2013 WTE Medical* 443.1 Dental 79.1 Medical and Dental Support 221.7 Nursing and Midwifery 2961.6 Allied Health Professional 577.2 Other Therapeutic Services 181.3 Healthcare Science 246.9 Personal and Social Care 876.8 Support Services 830.2 Administration Services 1471.9 Senior Management (non AfC) 54.5 Total 7890.0

Source: Publication Summary, ISD5 * Medical data does not include doctors in training.

5 NHS Scotland Information Statistics Department Workforce Data as at 31st March 2013 Report. Available from: https://isdscotland.scot.nhs.uk/Health-Topics/Workforce/Publications/2013-05-28/2013-05-28- Workforce-Report.pdf?69784182311

NHS Highland Workforce Development Plan 2013/14 12 NHS Highland Workforce227 Development Plan 2013/14

Figure 3: NHS Highland Workforce Staff Group Pie Chart as at 31 March 2013 (staff in post by staff group Headcount %) (Source NHS Highland extracted from SWISS)

Staff Breakdown (headcount) Other Therapeutic Nursing/Midwifery 2.15% (Unqual) 9.23%

Personal and Social Care 12.00% Nursing/Midwifery (Qual) 27.91%

Medical and Dental Senior Management Support 0.55% 2.83%

Support Services 11.54% Medical 5.49% Administrative Services Healthcare Sciences 17.71% 2.67%

Dental Allied Health Profession 0.78% 7.13%

Figure 4: NHS Highland Age Profile as at 31 March 2013 (Headcount) (Source NHS Highland extracted from SWISS)

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NHSH Allied Health Profession Medical Nursing/Midwifery Healthcare Sciences

NHS Highland’s workforce age profile reveals an ageing workforce with the majority of staff in the 50-54 age group, closely preceded by 45-49 age group and 55-59 age group (figure 4). This will have significant impact for NHS Highland in the coming years as the workforce ages and retires.

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Figure 5: NHS Highland Use of Flexible Workforce (Replacement) (WTE) as at 31 March 2013 (Source NHS Highland extracted from SWISS)

250.00 Bank figures scaled for clarity, value (WTE) shown next to line

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316.58 200.00 299.14 295.49 291.32 277.96 282.09 282.79 280.20 271.69 265.33 266.84

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Excess Basic Hours Overtime Agency Consultant Locums Bank

The Board continues to use flexible workforce for a number of reasons:  Using excess basic hours and bank staff to fill gaps arising from service demand or staff absence as a first response – to maintain service quality and stability.  Overtime is used in circumstances where excess basic hours and bank staff are not available; or where particular grades of staff are not available, for example Band 5 and above nurses or AHP or specialist staff in particular professions. This is also the case for agency staff use.  Waiting time initiatives can require an increase in flexible workforce across all grades, particularly in the approach to the last quarter of the financial year (December onwards).  Consultant Locums are in place particularly in the rural general hospitals and in some specialties, where there are recruitment challenges or long term absence, including maternity leave.  Flexible workforce is also used to support quality improvement and service redesign programmes, as a short term measure to support change  The Board has a continued focus on flexible workforce, with monitoring on a monthly basis in the form of regular reports for each operational unit that provide a breakdown of flexible workforce and cost trends. The HPF is informed of such reports by regular financial and workforce reports, so that underpinning rationale can be discussed and understood. Flexible workforce trends are also monitored by the Staff Governance Committee on a quarterly basis, via the Workforce Plan Rolling Action Plan.

NHS Highland Workforce Development Plan 2013/14 14 NHS Highland Workforce229 Development Plan 2013/14

Figure 6: NHS Highland Annual Sickness Trend and Breakdown as at 31 March 2013 (Source NHS Highland extracted from SWISS)

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Apr 12 May 12 Jun 12 Jul 12 Aug 12 Sep 12 Oct 12 Nov 12 Dec 12 Jan 13 Feb 13 Mar 13 Monthly (SWISS) 4.58 4.87 4.62 4.27 4.22 4.65 5.03 5.43 5.23 5.87 5.23 4.91 Annual (SWISS) 4.60 4.66 4.68 4.67 4.83 4.89 4.67 4.72 4.76 4.84 4.88 4.89

The NHS Highland sickness absence trend has risen slightly over the last 12 months.

In March 2012, the sickness absence figure for NHS Highland was 4.45% with an annual trend of 4.44% compared to the Scotland annual trend figure of 4.63%.

Figure 10 illustrates that in March 2013, the sickness absence figure for NHS Highland was 4.91% with an annual trend of 4.89%, compared to the Scotland annual trend figure of 4.80%.

The increase has been identified at least partly, as a result inheriting a higher level of long term sickness absence for local authority staff, transferred to NHS Highland following the integration of health and social care from 1st April 2012.

Continuing efforts to reduce long term sickness absence are directed towards individual case management and supporting rehabilitation strategies. A regular audit of long term cases is undertaken to ensure early and appropriate interventions to assist people back to the workplace.

More recently, agreement has been reached to provide occupational health services to adult social care staff from April 2013 and there is a proactive approach and a plan to review all cases and ensure that health status of absent staff is understood and that the organisation is able to support staff to return to work or address other aspects in line with organisational policies.

There are a number of health improvement initiatives in place and a specific piece of work has been developed, overseen by the HPF, Staff Governance Committee and Health and Safety Committee, to support staff health and wellbeing.

Although sickness absence was a HEAT Target to achieve 4% absence figure by the end of April 2008, it remains a standard for NHS Scotland to achieve 4% and NHS Highland is continuing to make progress in a downward trajectory. NHS Highland Workforce Development Plan 2013/14 15 NHS Highland Workforce230 Development Plan 2013/14

Workforce Supply

NHS Highland has recruitment challenges, which result in hard to fill posts for various reasons such as the ability of the Board to attract staff to fill specific posts particularly in remote and rural areas or national shortage of staff and / or skills for specific posts.

To address recruitment challenges, the Board has to rely on locum staff to maintain service delivery, especially in remote and rural medical specialties in the Rural General Hospitals, Primary Care GP’s and some specialist nursing and AHP posts.

Primary Care: GPs: There are a number of GP vacancies (current and retirement pending) across the Board area with various locum doctor solutions in the short term to fill vacancies. A number of single handed GP practices are vacant which has led to practices under temporary arrangements and the onus on NHS Highland to manage the practices in this situation. This reflects ongoing challenges around the recruitment of GPs to single- handed and small practices.

A robust approach to GP workforce planning is currently underway with NES, SAS and wider partners (across the UK) to address supply issues, recruitment process and marketing issues to attract candidates to Highland and sustain GP services. A move to rotational GP appointments rather than single handed GPs is also desirable to sustain future services. Skill mix review including contribution of NMAHP and other workforce requires to be progressed. Age profiling and retirement intentions need to be undertaken and monitored. Engagement with communities will be important if the Board has to look at alternative ways of providing primary care services.

A number of initiatives are underway to make rural practice more attractive, such as the development of a Scottish National rural-track Programme for GPST training to address supply issues and the Board is developing a new model for the delivery of primary care services, involving local communities in agreeing solutions to current workforce challenges.

Small Specialties: Some specialist areas have recruitment issues as the knowledge and skills for particular service delivery can only be gained within the NHS, for example, clinical scientists in specialist areas or decontamination technicians – it is challenging to recruit staff in these areas as the specialist skills are not known to those out with the NHS. Specific recruitment challenges exist in:

Medical Physics: Principal Clinical Scientist, Treatment Planning (District General Hospital (DGH)); Consultant Physicist, Equipment & Dosimetry, Radiotherapy Physics (DGH) Radiology: Consultant Radiology (DGH) Radiography / Sonography (Rural General Hospital (RGH)) Clinical Child Psychologists

The Board is participating in a number of workstreams that are being nationally led to understand and address recruitment issues in small specialties – for example in health care science, pharmacy and AHP professions.

NHS Highland Workforce Development Plan 2013/14 16 NHS Highland Workforce231 Development Plan 2013/14

Medical Specialties: Medical staffing continue to experience the following problems, that are not new, but are long standing as follows:  Consultant Physicians (RGH)  Consultant Surgeon (RGH)  Consultant Rheumatology (DGH)  Consultant Diabetes (DGH)  Consultant Gastroenterologist (DGH)  Consultant Haematology (DGH)  Specialty Doctor Psychiatry (New Craigs Hospital, Inverness)

Performance against national cancer waiting times remains of concern both at Board level and at national level. These results are due in part due to increasing pressure in radiotherapy planning, resulting in an international recruitment process aimed at supporting and increasing capacity in Radiotherapy Physics staffing. Further detailed work is also ongoing to review the processes in place to oversee the delivery of cancer waiting times in line with quality improvement and agreed milestones. The Board is also working with regional planning groups to secure workforce solutions for specialist cancer services.

Whilst the Board is projecting an increase in Consultant medical staff, there remains the on-going challenge that the projected increase is identified to address demand and capacity, but recruitment challenges persist and are exacerbated by national shortages in some specialties. On-going engagement with the National Medical Reshaping Programme is in place and NHS Highland makes a key contribution around remote and rural workforce challenges and contribution to solutions. The Reshaping programme is also looking at a number of specialties where growth may be required to meet future demand.

A Board wide medical workforce risk assessment exercise is currently underway in NHS Highland in conjunction with colleagues in the North Region to clearly identify areas of high risk in terms of; • Demographic workforce changes • Single handed practice • The impact of CEL 28 • Recruitment difficulties • Sustainability of current models of service delivery

Nursing and Midwifery: There are retention issues with Nurse Practitioners in the DGH and RGHs. The Board is considering the Physician Assistant role to promote consistency in the delivery of care and the care team. The Board is projecting to add 3.0 WTE Physician Assistants to NHS Highland in 2013/14.

The Board has a healthy nurse bank to fill gaps and newly qualified nurses are on the bank in addition to internship posts – so plenty coming in at Band 5 / newly registered levels. We are seeing a pattern that nurses wish to work flexibly and want to work on the bank for this reason.

Our nursing and midwifery workforce are ageing with most in the 46-54 age group (see Figure 4 on page 13).

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Domestic Staffing: There are on-going retention problems in domestic staffing, which creates an added challenge in terms of the loss of the investment that is continually applied to new staff in post, only to lose them to other competing employment, especially the tourism industry in the summer months. However, recent analysis of exit interview data illustrates that just under half of those who resigned, stayed in the NHS – moving internally to other posts as a result of their development in line with the HCSW standards and code; KSF and Career Framework interventions that are facilitating staff and career development. However, sustainable recruitment remains and on-gong challenge.

Support Services: also experience challenges in recruiting staff mainly due to competition with the private sector wages for estates staff: works and trades staff: painters, joiners, electricians, maintenance staff etc. The development of national guidelines on payment of national recruitment and retention premia (NRRP) for estates staff were seen as tool that might have addressed recruitment challenges in estates workforce. RRP is improving the number of applicants, however recruitment remains challenging and we have invested in modern apprentice’s development to grow the workforce specifically required.

Competition with private sector wages is on-going and a number of recent new or refurbished off shore installations has impacted on retention of fitters and electricians.

Estates Officers are also becoming difficult to recruit – longer term sustainable options need to be addressed, both at local level and nationally.

Remote and Rural Workforce Challenges: The vulnerability and sustainability of Rural General Hospitals continues to be a key issue for the Board – evidenced by significant recruitment and succession planning challenges in medical staffing, including high locum use. The Board is progressing Rural General Hospital medical workforce planning, working in partnership with Boards, NHS Education for Scotland (NES) and North of Scotland Planning Group, taking forward the residual work of the Remote and Rural Implementation Group. A workshop is planned to take this forward in September 2013.

From time to time, the Board does have short term recruitment problems in remote and rural areas for a range of generalist posts. These recruitment problems can be resolved through the opportunities that a tightening labour market and some over supply in some professional areas bring – the outcome is that workforce are more willing to migrate to remote and rural areas to gain employment. However, this also brings a set of concomitant challenges such as available housing for incoming staff and retention of these staff in the future pending changes in the labour market or economy.

There are a number of initiatives in place to address recruitment challenges, for example:

 The Board continues to ensure it has the right staff to deliver a safe and quality service, within the resource envelope. There are a number of workforce initiatives in place in line with the quality improvement and service redesign agenda. In an effort to ensure that the Board makes the best use of its workforce resource, there is a continual approach to maximising the use of the skills available to meet current and future health care demand, monitoring establishments and workforce deployment and keeping to a minimum the need for, for example, locum agency spend (particularly in medical posts), enhanced payments associated with unsocial hours and waiting time management.

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 An integrated approach to financial, workforce and service planning and the development of the Board’s Quality Objectives and Strategic Framework, provides the opportunity to reshape the size and skill mix of the workforce to respond to drivers for change. This requires on-going workforce analysis of the local and wider labour market to ensure that the organisation is proactive in anticipating and addressing recruitment challenges.

 NHS Highland became an integrated health and social care organisation on 1st April 2012. 2012/13 has been a year of transition and the opportunity to review the balance and the interface between health and social care support roles, registered practitioners and advanced practitioners and develop workforce development and education solutions to support a shift in the balance of care to the community, with a focus on horizontal integration and the development of skills across agenda for change bands and across professional boundaries. The Board is being supported in this work by NES and SSSC. o As the integration model emerges in Argyll and Bute CHP, the workforce planning and development agenda can be further streamlined to respond to all aspects of health and social care workforce planning and development approaches.

 Workforce development, particularly education solutions, take time to develop, deliver and realise their benefit. This can potentially conflict with service redesign outcomes. There are service pressures related to the additional time required to release existing staff for training and mentoring roles. Both these aspects potentially place risks in addressing the Boards ability to develop the workforce for the future. Learning and Development activity is prioritised by statutory and mandatory training needs in the first instance. Further work is been undertaken to match L&D capacity to demand; return on investment and the focus on developing those staff in line with service needs and service sustainability.

 Some services are reliant on single handed (and in some cases, remote and rurally isolated) practitioners with any vacancies having the potential to disrupt service delivery. This is very evident in GP workforce at present. Plans need to be developed to manage succession planning and avoid person-dependent ways of working. This will include an approach to team based development, horizontal integration approach, robust vacancy management and not replacing like for like. Workforce development emerges as a key requirement for the Board to reshape the workforce to meet service need.

 NHS Highland communicates its hard to fill posts to Scottish Government for inclusion in the National Shortage Occupational List. This list is then considered by the Migration Advisory Committee (MAC), who compiles a list of shortage occupations that can be sensibly be filled by non-EEA migration under Tier 2 of the UK Government’s Points Based System for Immigration. The process is undertaken on an annual basis.

 There has been some development of generalist practitioners by developing staff to take on tasks and work in a more integrated way. NHS Highland has reviewed NMAHP advanced practice and specialist roles and undertaken skill mix review, to support the workforce to work in a more generalist way and define specialist

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contribution of NMAHP at all AfC band levels. Principles for establishment setting, underpinned by nationally validated workforce and workload planning tools (where available), have been agreed in partnership and are mainstreamed.

 Growing our own staff. For example, broadening our traditional health care careers events to include and promote social care careers, so that school pupils can be “grown” into social care workforce roles in terms of pathway into higher education for health and social care SVQ qualifications and are ready for work in NHS Highland. Modern Apprentice schemes and SVQs are in place across many workforce groups – support services, pharmacy, administration, NMAHP, Healthcare Science, and Adult Social Care.

Working in partnership to design and deliver workforce plans will be key to addressing workforce requirements arising from service plans and addressing workforce supply challenges. NHS Highland recognises and values the importance of working with partner agencies, and its partnerships, including:  Staff Side Organisations  Professional Regulatory and Registration Organisations;  Scottish Government;  Patient and Public Involvement;  Essential alignment with Local Authorities;  Voluntary Sector and Communities;  Scottish Ambulance Service;  Regional Planning Groups;  Neighbouring Health Boards;  National Shared Services;  Skills for Health;  NHS Education for Scotland (NES); and  NES Remote and Rural Healthcare Education Alliance (RRHEAL).

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Workforce Demand

Population Trends

Key messages:

 The population is projected to increase by around 10% over the next 20 years.  The population of very elderly people is projected to increase more rapidly in the same time.  Life expectancy is increasing, in line or better than the rest of Scotland, but it is still poor compared to parts of Europe.  Inequalities in health are not reducing.

NHS Highland covers an area of 32,500 square kilometres, just over 40% of the land mass of Scotland, but only 310,500 people (6%) of the Scottish population live in the area. This headline population is an increase of 630 people on the previous year and a continuation of the trend in growth that has seen a 3% increase in the total Board area population since 1999. This estimate is based on the last Census in 2001, adjusted for births, deaths and migration, but may undergo considerable revision after the next Census in 2011.

The main influence on population growth in recent years for Scotland as a whole has been inward migration, rather than an increase in births or reduction in deaths, but population movements across Europe have made it increasingly difficult to provide accurate estimates and projections of future growth. The recent pattern of population growth dependent on net migration gain has not been evident across all NHS Highland and while the Highland population has increased by over 5% the population of Argyll & Bute has fallen by 1.7% over the last 10 years.

Figure 7: Components of population change by administrative area NHS Highland: 1999- 2009

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Assuming the continuation of recent high net migration gains off set an established pattern of negative natural population change, the NHS Highland resident population is projected to continue to grow over the medium term to potentially 340,000 people by 2030.

Over 75% of the NHS Highland population lives in a remote or rural location, including 35 inhabited islands. Geographical barriers such as extensive coastline and mountains and climate contribute to the physical aspects of remoteness, but social aspects such as low incomes, poor transport and small but ageing populations contribute to disadvantage in our most remote and rural areas. In contrast, other areas of NHS Highland are rapidly developing with rapid housing growth. There is a need for health care planning to be considered in both contexts.It is also important when designing new developments, that the new environment provides support for healthy lifestyles. Social changes include a move towards more single occupancy households, and fewer multi-generational households. If this trend continues, the number of single person households in the NHS Highland area is expected to increase from 48,920 in 2008, to 74,900 in 2033. Of these, 37,360 are expected to be people aged 65 years or older living alone.

Figure 8: Projected Population Change Numbers by Age Group and Gender, NHS Highland Area, 2008, 2023 and 2033

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Assumptions about migration affect younger people in the main, so estimates of the number of older people are likely to be more reliable. Figure 8 shows the most likely population changes for 2023 and 2033, compared to 2008. Assuming that migration does not change this, by 2033 the single largest age group in the area is likely to be people aged 65 – 69 years.

The predicted percentage change by age group is shown in Figure 9. Taking a longer view, compared to 1980, the number of people aged 65 years and over will have increased from approximately 43,000 people in 1980 to over 103,000 people in 2033.

Figure 9: Projected Population Change Percentage Change by Age Group, NHS Highland Area, 2008 to 2033

According to the last census, only around 0.5% of the population in NHS Highland are from an ethnic minority background; again estimates of this proportion are likely to increase following the next census. No single ethnic minority group is predominant in the area and people are distributed widely across geographical communities. Inward migration from Europe, largely Eastern Europe, has accounted for substantial changes in the ethnic minority population in recent years.

Health and Health Care Needs in NHS Highland

Long Term Conditions (LTCs): The prevalence of LTCs is increasing as a result of the ageing population and improving survival from previously fatal conditions such as cancer. There are increasing numbers of fit younger elderly people; but there are also increasing numbers of frail very elderly people, requiring a fresh approach to prevention and management of Long Term Conditions. Long Term Conditions and undefined symptoms represent a high proportion of GP consultations and hospital bed use.

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Dementia: The term dementia includes a variety of diseases that result in impairment of brain function, reduction in intellectual ability and personality change. Alzheimer’s disease is one form of dementia. Prevalence rates are difficult to calculate, but do rise with advancing age, so a likely effect of the ageing population will be an increase in dementia prevalence. Currently, about 5,000 people in NHS Highland are estimated to be suffering from dementia. Many people with dementia have other co-existing long term conditions, such as circulatory disease or arthritis, requiring a holistic approach to clinical care planning and not just a single condition focussed approach.

Cancer: One in three people will develop cancer during their lifetime, and the condition is responsible for approximately 25% of deaths in the UK6. Cancer incidence has been increasing in NHS Highland residents since the mid 1980’s, a trend that is likely to continue. During 2013 – 2017, an average of 2,244 Highland residents are likely to be diagnosed with cancer each year, rising to 2,467 cases a year during 2018 – 20227 (Scottish Cancer Registry). This rising incidence is mostly due to the ageing of the population.

Premature deaths from coronary heart disease and cancer are decreasing.

The prevalence of smoking is slowly reducing, but smoking remains the biggest cause of avoidable mortality.

The prevalence of obesity is still increasing and is likely to halt or reverse the downward trend in premature mortality. More effective interventions are still needed to prevent and treat obesity.

Premature deaths from circulatory disease and cancer continue to decrease, while alcohol-related deaths are still increasing. Life expectancy and healthy life expectancy continue to increase, but the gap between the two is not reducing; while people are living longer and staying healthy for longer, many older people are still tending to spend the last years of their life with one or more chronic long-term health problems. Socio-economic inequalities in health are also not reducing, despite the overall reduction in death rates.

Health care over the next 20 years is likely to be dominated by the growing population of older people, particularly the rapidly increasing numbers of people aged 75 years and over. While many older people remain fit, active and able to live independently, there needs to be a fresh approach to helping and supporting the minority of the elderly population who are frail with multiple long-term conditions. One important health improvement intervention is preventing falls in elderly people, as fractured hips resulting from falls is a major reason for older people being admitted to hospital and being unable to maintain independent living subsequently.

Up to half of all circulatory diseases and cancers could be prevented by major reductions in the prevalence of three common risk factors: smoking, alcohol and obesity. Providing targeted individual and group support to help smokers stop smoking, coupled with wider initiatives such as banning tobacco advertising and smoking in public places and promoting smoke-free homes and cars, have led to a steady decline in smoking prevalence in the adult population. However, around a quarter of the adult population still smoke and these efforts must continue if we are to reduce smoking prevalence further.

6 http://info.cancerresearchuk.org/cancerstats/keyfacts/Allcancerscombined/index.htm 7 information supplied to the Board by ISD (personal communication to Director of Public Health in 2010) NHS Highland Workforce Development Plan 2013/14 24 NHS Highland Workforce239 Development Plan 2013/14

We are now taking the same approach, of both targeting individuals with supportive services and developing healthy environments, to reduce alcohol consumption and obesity levels, but it is too soon to note any encouraging trends in the levels of these risk factors in our population. Nevertheless, it is important to continue with our current health improvement activities to reduce levels in the future.

More detailed information about population, health and health care needs can be accessed from The Annual Report of the Director of Public Health 2012, which is available on the NHS Highland web site: http://www.nhshighland.scot.nhs.uk/Meetings/BoardsMeetings/Documents/Board%20Meet ing%202%20October%202012/4.4%20DPH%20Annual%20Report-APP.pdf

A key challenge for NHS Highland will be to maintain service delivery in rural areas where the population is falling. This will require the Board to work in partnership with the local authority and other agencies to maintain and enhance sustainable community infrastructure and development.

From a workforce perspective it is crucial that the Board has in place workforce plans and workforce development approaches that are aligned to and address the health and social care needs of Highland population. A key focus for the Board is to support staff to see their role as supporting people in maintaining their own health, for example, ensuring front-line staff are aware of the more specialist services available to help with health behaviour change and direct people to them as necessary.

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NHS Highland Strategy

The Board’s vision is: Quality Care to every person every day

Strategic Aims

In order to ensure delivery, NHS Highland has established its overall strategy based on the Triple Aim of: 1. To deliver better health (BH) of our communities through population wide and individually focused initiatives to maximise health and well being and prevent illness. 2. To deliver better care (BC) of our patients through quick access to modern services, in the most appropriate settings and in clean and infection free facilities by well trained professional staff. 3. To deliver better value (BV) for the use of the public money we spend. This is by ensuring there is no waste and inefficiency, where money is spent only on what is needed and has evident therapeutic benefits.

This approach embraces key NHS Scotland policy directives: Healthcare Quality Strategy (2010)8 and its supporting 2020 Vision9 and the recently published 2020 Workforce Vision10.

Quality is therefore at the heart of the Board Vision. NHS Highland believes that a focus on efficiency without attention to quality is unthinkable but equally that promoting quality with no regard for efficiency is unsustainable.

The Board developed its Quality Objectives in 2012 for a 2 year period to support the delivery of the Strategic Framework and to make the link between the Strategic Framework . The Quality Objectives describe the vision to:  Provide quality care at all times;  Support people and communities to maximise their own health;  Develop precision driven services so that when people need our care they experience; timely, focussed, effective services, that minimise the duration and frequency of contact;  Ensure that every health pound spent delivers maximum health gain.

8 The Healthcare Quality Strategy for NHS Scotland, 2010. Available from: http://www.scotland.gov.uk/Resource/Doc/311667/0098354.pdf

9 The 2020 vision is that by the year 2020, everyone is able to live longer and healthier lives at home, or in a homely setting. We will have a healthcare system where we have integrated health and social care, a focus on prevention, anticipation and supported self management.

10 Everyone Matters: 2020 workforce Vision, 2013. Available from: http://www.scotland.gov.uk/Resource/0042/00424225.pdf

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Figure 10: The Highland Quality Approach (HQA)

Key messages:

The Highland Quality Approach puts ‘Quality first to deliver, better health, better care and better value’.

The aim of the NHS Highland Quality Approach is to improve people’s experience and outcome of care while systematically identifying and removing waste. There is considerable national and international evidence that better quality, safer care is more efficient and delivers financial benefits. The focus of the HQA is a continued focus on reducing harm, variation and waste and building on the quality improvement outcomes that have been achieved to date.

Following a year of development and now implementation, the Highland Quality Approach is beginning to be embedded across NHS Highland. The HQA approach identifies priority areas for quality improvement in 2013/14, agreed by the Board as:  Cancer Services;  Patient Flow / Discharge Planning; and  Implementation of the new Patient Management System.

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As part of the work to embed HQA, the Board has been looking at the approaches being taken by successful health and social care providers to gain knowledge and understanding of what methods work best to redesign services to improve the service quality.

The Highland Quality Approach embraces three elements;

 Focus & Delivery (What)  Improvement Science (How)  Leadership & Culture (Who)

Board, Clinical Leadership and staff engagement are critical to the success of implementing the Highland Quality Approach. How the Board recruits and develops its workforce are key to achieving the HQA. The workforce development plan aims to secure the future supply of workforce, in a way that both maintains safe staffing levels for patients, clients and staff, whilst supporting the transformation of services necessary to drive quality improvement (workforce projections).

Service transformation will be driven through a combined set of actions with regard to the numbers, skills and behaviours of the workforce (workforce efficiency and productivity).

A key objective of this approach is to create development across professional groups, between the needs of the current and future workforce, and between volume priorities and skills and behaviours priorities (workforce development).

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Designing the Future Workforce

Workforce demand is driven by a range of drivers – mainly health demand in the population, demographic change and health care policy. NHS Highland has an overall approach to capacity planning for health and social care services, underpinned by the Highland Quality Approach and these are detailed in:  The Local Delivery Plan for NHS Highland 2013/14;  Operational Unit Delivery Plans for 2013/14;  Board Asset Management Plan; and  Single Outcome Agreements with Local Authorities;

Service planning priorities for each operational unit are explicit in the Local Delivery Plan and Operational Unit Delivery Plans and require a focus on workforce planning and development in the following areas:  Integration of Health and Social Care (North Highland Community Health and Social Care Partnership): on-going structural change and embedding of new ways of working, workforce and service redesign – specifically a review of the Care@Home service with specific workforce plan and workforce development interventions and outcomes;  Preparing for health and social care integration in Argyll and Bute Community Health Partnership with Argyll and Bute Council: principles, clinical engagement and organisational engagement.  Scheduled Care:  Unscheduled Care:  Workforce Productivity and Efficiency

Integration of Health and Social Care

North Highland Community Health and Social Care Partnership: Following the integration of health and social care on 1st April 2012, there has been further review of existing cradle-to-grave services in Speech and Language Therapy and Dietetics, which has resulted in the further transfer of AHP staff in these categories to Highland Council on 1st April 2013.

In the past year, there has been much transition activity in NHS Highland mainly as a result of structural change to support new teams and integrated ways of working. We are beginning to identify key areas for development and an new role, Health and Social Care Coordinator has been developed and 4.0 WTE posts will be recruited to during 2013/14.

Workforce plans and workforce development initiatives continue to support integrating care in the Highlands, such as new roles and role development across traditional boundaries. For example, advanced practice roles (across clinical professions), generic support worker roles (across health and social care); and developing rural generic health care support worker roles (across clinical professions and across health and social care in rural areas). Specifically workforce plans are being developed to support Care at NHS Highland Workforce Development Plan 2013/14 29 NHS Highland Workforce244 Development Plan 2013/14

Home services alongside the reablement agenda and workforce redesign to support the best and most efficient use of resources in terms of hospital beds and care home beds.

Workforce change is being supported through the change fund to rebalance investment in residential and hospital care in favour of increased community capacity.

The reablement agenda is a key focus for the Board and its local authority partners. A joint Reablement Steering Group is focusing on providing support and training for frontline health and social care staff to adopt a reablement approach. Self management and self care approaches are being invested in with Motivational Interviewing / Health Behaviour Change training in place for health and social care staff.

Reshaping Care for Older People will introduce and drive forward changes to clinical pathways and referral pathways and support a shift in the balance of care from hospital to the community. Workforce development approaches are being developed for staff working in all sectors across health and social care including voluntary and independent sector.

In terms of future workforce supply, a new careers event So You Want to Work in Care? has been developed in partnership with sector employers and higher education to encourage school pupils to consider careers in care from a more informed perspective than has been the tradition in the past. It is anticipated that the workforce will be sourced and developed / educated prior to taking up employment and this puts in place safe systems that are underpinned by education and regulation.

Scheduled Care

There are workforce supply issues that impact on scheduled care – in acute, primary and secondary care services. Through the development of Operational Unit Delivery Plans, capacity and demand analysis demonstrates the need to increase medical Consultant workforce, but the ongoing challenge still exists around workforce recruitment and sustainability.

In Cancer Services, Radiotherapy, Radiology and Consultant Oncologist staff are difficult to recruit to. The Board is engaged nationally in addressing medical and medical physics (health care science) and AHP workforce planning to address workforce supply issues. There is a national shortage of specialist staff. Workforce solutions are also being identified working with neighbouring Boards and Regional Planning Groups.

Unscheduled Care

The Board has a Local Unscheduled Care Plan in Place. Workforce issues are as follows:

Out of Hours: In common with the rest of Scotland there are problems recruiting GPs to cover OOH shifts, additionally there are major issues with the sustainability of small remote and rural practices where GPs have continued to provide OOH cover.

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This issue has been flagged separately to Scottish Government in the paper “An Approach to Building Sustainability of Health and Care Services in Remote and Rural Areas - Proposal to Cabinet Secretary for Health and Wellbeing.” Many areas of Highland have already started to utilise a range of clinicians in the OOH/Unscheduled care workforce with Unscheduled Care, Nurse and Paramedic practitioners working within Emergency Departments and Primary Care Emergency Centres across Highland. It is recognised that this multi professional, multi disciplinary approach potentially offers more flexibility and a more sustainable way of providing capacity.

Emergency Department: following notification of the Scottish Government allocation of £100,000 investment the recruitment process has commenced for an additional Consultant is Emergency Medicine, this post will be based in Emergency Department at Raigmore Hospital and will support improved weekend cover in the department and so assist consistent senior decision making at the hospital front door services.

Maintenance of skills levels of GPs, specialist nurses and AHPs, midwives where there are low levels of activity continue to present challenges. The Board is engaged being supported by NES in the development and delivery of programmes such as Clinical Skills Managed Education Network North (CSMEN) Acute Care Competences for medical staff, developed in partnership with NES.

Remote & Rural Acute Physician: This post is an innovative approach to delivering acute medicine in remote and rural environments. The post-holder is based at Raigmore and Belford Hospitals and provides outreach support to the Portree and Dr McKinnon Hospitals on Skye.

Consideration is also being given to the Physician Assistant Role in acute and remote and rural areas that supports team working and continuity of care.

Workforce Productivity and Efficiency

The Board has an overall approach to workforce efficiency and productivity around three key enablers:  The people who deliver services (better working practices; improved attendance; improved skills; flexible workforce)  The processes that drive delivery (reduce duplication and waste; improve rota compliance; job planning; service redesign; streamlined processes; skill mix review and new roles) and  The technology that supports both (mobile devices, eHealth, automation; maximizing the use of technology in standard operating procedures.

These enablers can be operationalised through the delivery of three key interventions outlined in Table 4 below:  Staff Utilisation  Reduce Workforce Costs and Increase Workforce Productivity  Service Redesign and Skill Mix Review.

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Table 2: Workforce Productivity and Efficiency Contribution to Quality 2013/14

Staff Utilisation Reduce Workforce Costs/ Service Redesign and Increase Workforce Skill Mix Review Productivity

 Identify anticipated  Continue to monitor and  Service redesign vacancies in line with reduce workforce cost outcomes, underpinned quality improvement and base in relation to by HQA approach will service redesign plans supplementary identify workforce and skill mix review workforce (bank, redesign in teams, outcomes agency, locum, across services and  Robust, standardised overtime, extra basic across traditional roles vacancy monitoring hours) and traditional process in line with  Reduce Payments to boundaries. vacancy management Existing Staff: paying  Apply Organisational approach less to the staff we have Change Policy  Consistent and rigorous – waiting times process to manage initiatives and extra  Continue to undertake Fixed Term Contracts programme activities establishment review where they are required (medical), on-call and using nationally  Appropriate decision unsocial hours / validated workload making around premium rate payments, measurement and supplementary staffing working hours, travel workforce planning tools  Review Job Plans to (promote the use IT) (where available) – at match service demand, and subsistence lease once per year in capacity and delivery, reduction each setting ensuring, to promote  Releasing Time to Care  Strengthen governance level activity and and Productive Time systems to provide reducing the risks of programme delivery assurance that NHSH waiting time initiatives across all departments, establishment review and associated underpinned by HQA principles are being workforce costs.  Benefits realisation of applied – in partnership interventions including  Establish systems to the e-Health solutions monitor actual staffing that support workforce levels in acute hospital efficiency settings, compared to  Continue to monitor staff planned absence and employee  Implement NMAHP friendly leave in line with advanced practice policy PIN Policies across NHSH, including activity analysis and job planning

Workforce Productivity and Efficiency Contribution to Quality 2013/14 components will be progressed throughout 2013/14 and will be reported quarterly as part of the Workforce Plan Rolling Action Plan and in line with the overall approach to integrated workforce, financial and service planning approach.

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eHealth Delivery and Development

NHS Highland has considered the five high level outcomes set out in the NHS Scotland eHealth Strategy 2011-17 and associated Finance Strategy that is explicit in that rather than focusing on products and technology, the emphasis is instead on benefits and outcomes experienced by the people of Scotland flowing from eHealth enabled service redesign and quality improvement. In this regard, a number of developments are underway and set out in the NHS Highland eHealth Delivery Plan 2011-14. The Board is also undertaking a number of eHealth and IT solutions to support workforce development and workforce productivity and efficiency.

Workforce Aspects:  Implementation of the new Patient Management System – an integrated health record will enable staff to communicate across one system and manage workload more efficiently, for example, with the planned development of Bed Management and Request Reporting (Electronic diagnostic test ordering) components of the system.  Continued expansion of video conferencing network and moving to utilise the network and VC units for direct patient communication allowing centrally based consultants to hold clinics in local areas (improved workforce productivity)  Continued improvements in information systems to enable communications between secondary and primary care to enable staff to work more efficiently with up to date information in community and social care settings, including electronic care records in relation to Key Information Summary and Palliative Care Summary  Further roll out of patient focussed booking systems at Raigmore to enable out patient appointments to run more efficiently (improved workforce efficiency in terms of administration of appointments)  A range of eHealth solutions in relation to promoting self care and self management  Further implementation of automation in laboratories (workforce development; workforce productivity and efficiency)  Further development IT solutions to support development of standard operating procedures (workforce development; workforce productivity and efficiency)  Continued support in the development of blended learning opportunities (workforce development; workforce productivity and efficiency)

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Workforce Projections

In line with CEL(2011)32 Revised Workforce Planning Guidance 2011, detailed workforce projections for all workforce groups are provided via an excel work book, to Scottish Government by 30th June each year. Nationally, Scottish Government will publish high level workforce projections for all NHS Scotland Health Boards, in August. This year publication will take place on 29th August 2013. Thereafter this section will be updated.

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SECTION 2: Workforce Plan Rolling Action Plan for 2013/14

The NHS Highland Workforce Plan Rolling Action Plan 2013/14 has been developed to support the delivery of the NHSH Workforce Development Plan throughout 2013/14. The Action Plan is overseen by the Workforce Planning and Development Sub Group and an update is provided quarterly to Highland Partnership Forum and the Staff Governance Committee.

Key: Status

5 Action complete.

4 Action on track to be completed by agreed date.

3 Action delayed – will still be achieved but may be dependent on variables out with NHSH control to progress the work stream.

2 Action experiencing significant problems in Board.

1 Action unlikely to be met.

Key: Timescale

Short Term: 1 year Medium Term: 1-3 years Long Term: 3-5 years

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Action Who / How Timescale Status Comment m u t i r g d o n e h o S M L 1 Workforce Supply Workforce X TBC Working with a range of partners, across a number of workforce Address recruitment challenges of Planning and work streams at a local, regional and national level to identify hard to fill posts described in the Development and implement solutions – National Medical Reshaping Group; Workforce Supply section of the Sub Group National Workforce Planning Forum. Workforce Development Plan 2013/14. by working with a range Employment Specific RGH workforce event being held on 27th September of partners. Services Team; 2013, in partnership with NES, Boards and other stake holders.

Monitor the identified service HR Teams; Board Risk management Strategy being reviewed. Workforce delivery and service sustainability risks will be added as the format is agreed and populated. – risks arising from reliance of small Links with NES, Action for Workforce Planning Manager and Clinical specialities and single professions partner Boards Governance Manager. / practitioners and develop risk and SGHD. management plans in line with the Communicate hard to fill posts to Migration Advisory Committee Board Risk Management Strategy. to be added to Shortage Occupation List. Report position to the Staff Governance Committee on a Continue to monitor workforce age profile across all groups and quarterly basis. analyse retirement trends to identify when people may plan to retire

Monitor and report progress to HPF and Staff Governance Committee on a quarterly basis. Status to be confirmed at Q2.

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Action Who / How Timescale Status Comment m u t i r g d o n e h o S M L 2 Workforce planning and Director of Adult X 4 Integration of Health and Social Care (North Highland development to support Care Community Health and Social Care Partnership): integrated health and social Directors of care Operations Workforce development needs are being scoped within integrated teams. on-going structural change and embedding of new ways of working, workforce and service redesign – specifically a review of the Care@Home service with specific workforce plan and workforce development interventions and outcomes;

The Board is implementing the new role of Health and Social care Co-ordinator across Highland (4.0 WTE)

Workforce data set has been incorporated into routine workforce information reports and all adult social care staff are migrated onto NHS Highland payroll – completed as at 31st March 2013.

The migration will provide a baseline and integrated workforce data to enable trend reporting and support future workforce and succession planning.

Preparing for Integration of Health and Social Care in Argyll and Bute Community Health Partnership with Argyll and Bute Council: principles, clinical engagement and organisational engagement.

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Action Who / How Time Scale Status Comment m u t i r g d o n e h o S M L 3 Workforce Productivity and Efficiency Directors of X TBC Monitor and report progress to HPF Contribution to Quality: Operations and Staff Governance Committee on 1. Staff Utilisation a quarterly basis. 2. Reducing workforce costs and Workforce Planning Status to be confirmed at Q2. increasing workforce productivity and Development 3. Service Redesign and skill mix review Sub Group

4 Reduce senior management posts by 25% HR Director; X 4 NHS Highland agreed its baseline by 2015, in line with SGHD guidance Head of Personnel with Scottish Government as 74.7 and Development WTE senior managers, which translated into a planned reduction to 56.03 WTE over the next 5 years. The Board has made progress by reducing to 65.9 WTE as at end of March 2013 a reduction of 8.5WTE, which is nearing 50% of the target achieved to date. For 2013/14, the Board aims to reduce senior managers by a further 5.0 WTE, through planned retirements.

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Action Who / How Time Scale Status Comment m u t i r g d o n e h o S M L 5 Workforce Development Head of Learning and X TBC Monitor the uptake of statutory and Development and mandatory training and identify risks Learning Plan incorporated into Workforce Team (such as low attendance due to backfill Development Plan 2013/14. Systems are in Learning and problems) place to monitor course delivery and staff Development Sub attendance. Group (of HPF) Report activity to Staff Governance Committee in February 2014.

Status to be confirmed at Q2.

6 Health care support Workers (HCSWs) Workforce X TBC Policy in place to ensure new and Information Officer to existing staff can meet the NHSS Monitor the compliance with HCSW compile status report HCSW mandatory induction standard standards and codes for new starts and code of conduct. Systems in place Report compliance to to support adult social care staff to meet NHSH Workforce registration requirements of SSSC. Planning and Development Sub Systems in place to record compliance Group, HPF and and progress against HCSW standards SGC and codes for new staff; being overseen by L&D team working with recruitment team and operational managers.

A status report has been prepared for discussion at HPF on 16th August 2013.

Status to be confirmed at Q2.

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SECTION 3: Learning and Development Plan 2013/14

The NHS Scotland Staff Governance Standard provides a framework which is supportive of the three Quality Ambitions outlined in the NHS Scotland Quality Strategy. It sets out what employers are required to do to develop and manage their staff, and to ensure that all staff have a positive employee experience and feel motivated and engaged with their job, team and organisation. The Standard is a framework that sets out the criteria required of all NHS Boards to ensure that staff are:  Well informed;  Appropriately trained and developed;  Involved in decisions;  Treated fairly and consistently with dignity and respect, in an environment where diversity is valued; and  Provided with a continuously improving safe and working environment, promoting the health and wellbeing of staff, patients and the wider community.

The Standard also requires all staff to:  Keep themselves up to date with developments relevant to their job within the organisation;  Commit to continuous and personal and professional development;  Adhere to the standards set by their regulatory bodies;  Actively participate in discussions on issues that effect them either directly or via their trade union / professional organisation  Treat all staff and patients with dignity and respect while valuing diversity; and  Ensure that their actions maintain and promote the health, safety and wellbeing of all staff, patients and carers.

Workforce Planning and Development is a key aspect of Staff Governance.

An annual Staff Governance Action Plan underpins the Local Delivery Plan and Workforce Plan. The Board is expected to ensure that there is a workforce learning and development strategy in place in line with the standard ‘appropriately trained and developed’.

Each year the Board agrees its Workforce Plan which sets out how the workforce will be deployed in the future to support the delivery of the Board’s Quality Objectives and Strategic Framework. To enable the Workforce Plan to take into account the learning and development needs of existing and new staff and identify how learning and development interventions will be delivered consistently across NHS Highland and across adult health and social care services, the Board’s Learning Plan is incorporated into the Workforce Plan NHS Highland Workforce Development Plan 2013/14 40 255 NHS Highland Workforce Development Plan 2013/14 thus supporting the delivery of an integrated Workforce Development Plan. Continuing this approach for future years will enable NHS Highland to ensure its learning and development activities are aligned and prioritised to support the organisation and its Quality Objectives.

Integrating Care in the Highlands

From the 1st April 2012 NHS Highland became the Lead Agency for Adult services and the Highland Council became the Lead agency for Children’s services.

Workforce development strategies, activities and programmes are being developed to support the implementation of integrated health and social care teams. In relation to the statutory mandatory and general learning and development requirements of the Adult social care staff, these are being accessed within NHS Highland. The Highland Council are continuing to provide learning interventions associated with maintaining professional registration with the Scottish Social Services Council, and Highland Council Social Care Team (within Employee Development) will continue to provide Social Care SVQs and PDAs and some additional learning and development programmes. Resources to support the development needs of Adult Social Care Staff now working in NHS Highland are in the process of being transferred.

For Children’s services staff that have transferred to the Highland Council, learning and development will continue to be provided by NHS Highland in relation to their specific clinical professional development requirements.

Learning and Development in NHS Highland

The model for the provision of Learning and Development (L&D) within NHS Highland is complex and provided by a number of teams who are based in Corporate Services. Some teams have staff whose sole role and function is to provide Learning and Development, whilst others have staff for whom Learning and Development is part of their role.

The key Corporate L&D teams comprise:

 Learning and Development  Clinical Skills, Practice Education  Resuscitation

 E-Health  Health and Safety  Medical Education

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Within Corporate Services there are specialist staff who have the development and delivery of L&D as a key part of their role e.g. in Facilities, Public Health, and Equality and Diversity. In addition to the staff within Corporate Services, there are other staff based in the operational units who have L&D as part of their role and will deliver programmes, or support staff development using other interventions on a fulltime basis, a few days per week, to one or 2 hours a month. In Argyll and Bute CHP there are similar L&D teams embedded in the CHP itself.

Additional support and development is available for medical staff and this is overseen by the Director of Medical Education. Other development can be accessed through NES, which is the National Educational Board for Scotland.

Staff development needs are identified and agreed through the various Personal Development Planning and Review processes in place within NHS Highland, and can be classified as Statutory11, Mandatory12 or Core13 to the job role. Development needs are also identified as a result of organisational change, policy, priorities, or developments and by national initiatives.

NHS Highland also supports staff in career progression and Lifelong Learning. This may also be identified through the PDP&R process, but is likely to be supported through non-core Endowment funding rather than from core learning and development budgets.

Statutory and Mandatory Training

NHS Highland has a legal requirement to provide a safe and healthy working environment for their employees (including subcontractors). One way in which it does this is through the delivery of a range of learning and development programmes or interventions to ensure staff are appropriately trained and able to use their knowledge and skills effectively.

11 Statutory Training is the training that NHS Highland is legally required to provide as defined in law and covered by a statutory instrument (e.g. Health and Safety at Work etc. Act 1974 and Display Screen Equipment, Fire Safety, Food Safety, Manual Handling regulations) or where a statutory body has instructed organisations to provide training on the basis of legislation (e.g. training on equalities issues is required because the Equality and Human Rights Commission has interpreted the Equality Act (2010) as saying that training should be provided to meet the legislation.

12 Mandatory Training is a training requirement that has been determined by NHS Highland. Mandatory training is concerned with providing assurance against policies and enabling staff to carry out the requirements of their job role safely & efficiently maintain their competence to required standards e.g. Resuscitation, Blood Transfusion, Child Protection, Clinical Supervision, Induction, Infection Control, Mental Health Act, Vulnerable Adults etc.

13 Core training is the term used to describe training that is required to support staff development for that particular role. Core training needs should be identified within the Personal Development Plan, and marked as such.

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The Learning and Development Subgroup is the forum within which all NHS Highland Learning and Development programmes and initiatives are agreed, developed, supported, monitored and evaluated. In undertaking their duties within that role, they set up a short-life working group to review activity in relation to Induction, Statutory and Mandatory Training which would be the focus for the development and delivery of all Statutory and Mandatory programmes / activities within NHS Highland by:

 Developing and updating a Statutory and Mandatory Training prospectus  Review the resources and methods utilised to ensure effectiveness and efficiency and Return On Investment  Providing reports to the relevant stakeholders on the effectiveness, uptake and identify any risk to NHS Highland

This supports NHS Highland by tackling any WASTE, HARM, and/or VARIATION within and across the Statutory and Mandatory programmes being delivered as well as enabling us to make the most effective use of all our resources.

Development Activities

The following tables outline the role, function and key priorities by the L&D providers within the Corporate Service function of NHS Highland, which support the development of staff. The key programmes being delivered / in development for 2013/14 are fully outlined in the Learning & Development Plan for 2013/14, which can be accessed here

Team Name: Practice Development and Practice Education Teams Role and Function: Support Education and training within the NMAHP workforce. This covers a wide range from clinical skills development to mentorship and professional training

Priorities for 2012-13:  Ensuring training matches service needs and priorities  Ongoing professional training such as clinical skills development, supporting appropriate staff in NHS Highland and appropriate staff in the Highland Council  Supporting the development of NMAHP HCSWs in line with the HCSW educational framework e.g. clinical skills, SVQs etc

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Team Name: Learning & Development Team Role and Function: The Learning and Development Team are based in Inverness and are responsible for the implementation and mainstreaming of KSF (and its associated PDP&R process), the delivery of SVQs, Induction, Leadership and Management Programmes. They are also responsible for the development and delivery of a range of programmes and activities which support the core and specific dimensions of KSF. They also offer sessions on requested topics to meet identified needs.

In addition they manage the Learning Management System (AT-L), LearnPro (e-learning system) and have an overview of the Learning and Development activities across NHS Highland.

Priorities for 2013-14: The courses outlined below are the main programmes offered. The team priorities for 2013-14 are to support.

 To take a lead role in the development of Educational Governance principles and standards within NHS Highland  To support the implementation of HQA within NHS Highland.  To identify and resolve L&D related issues arising from “Integrating care in the Highlands.”  To lead and manage the implementation of OLM within NHS Highland

Team Name: eHealth Role and Function: Provide training in the use of clinical and non-clinical IT systems for NHS Highland staff. Provide training, IT facilitation services and mentoring in IT systems to primary care services.

Priorities for 2013-14:  Training delivery in the new Patient Management System introduced throughout the secondary care sector of NHS Highland. Continued support of existing systems.  Mentoring and facilitation in IT clinical systems for GPs, GDS Independent Dentists, CP Community Pharmacists, HMP Health Centre

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Team Name: Learning & Development (A&B CHP) Role and Function: Encourage and support learning and development in all staff groups across A&B CHP in line with service plans at NHS Highland and CHP level.

In addition, the team provides Coaching and Mediation support.

Priorities for 2013-14:  Activities which support operational staff in achieving efficiency targets  Support for Mental Health Redesign  Support for Leadership Development  Support for Reshaping Care of Older People  Support in and through service change  Support and develop teams and individuals through difficult challenges and service redesign  HR Policy training – awareness/overview and specific to ensure staff with management responsibilities are aware of, and know when and how to implement polices correctly  Managing in Partnership training to help managers to understand the need and benefit of working in partnership with staff side representatives  Implementation of programme of SVQs for NMAHP HCSWs  Implementation of e:ESS and OLM in particular for all training  KSFE/e-KSF embedding, improvement, quality and PDPs  Leadership management and development - ILM, RCOP (in association with external consultant)  Implement service improvement methodologies within own department e.g. LEAN, ROI,

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TeamName: Health&Safety Role and Function: The Health and Safety Team (which includes the Violence & Aggression and Moving & Handling Teams) is based in Inverness, with some managers co-located to Operational Units. The primary role of the Team is to; establish safe systems and procedures, provide technical support and guidance, devise needs and risk based training, investigate serious incidents, undertake inspection and audit, liaise with regulators and work with senior and local management, staff, and contractors to prevent injury and ill health to those at work and those affected by our work activities.

Priorities for 2013-14: The key priorities for improving Health and Safety competence over 2013-2014 are as follows:

 To work with Care at Home officers in the short to medium in order to understand what their priority competency & training needs are and devise an appropriate, and resourced, plan to support this. In particular this includes: Moving & Handling and Violence and Aggression.  Fulfil the priority training development aspects detailed in the Health and Safety Committee’s Work Programme 2013-2015. This includes Competency based Assessment for Moving & Handling, Health and Safety Management training, Sharps Safety for Non-Clinical at risk groups and Mental Health in the Workplace.  Identify and secure a delivery options for First Aid training and a replacement for the existing web based / online DSE risk assessment and training  Deliver Senior Management Health and Safety training, a Board Development Session for Non-Executives, and additional COSHH assessment training.  Undertake a baseline audit of AB CHP Moving & Handling Practice , then plan and rollout the keyworker system in AB.

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Team Name: Resuscitation Role and Function: The department’s function is to:

 Provide evidence based emergency care education, electrocardiograph recognition (ECG) and instructor training based on current national guidelines to clinical staff at a level appropriate to the individual’s employed role through out NHSH.  Provide emergency care education to schools and carers of children with life threatening conditions  Provide Immediate Life Support training to Stirling and Aberdeen Universities nursing and medical students  Organise/instruct on Resuscitation Council (UK) and Royal College of Surgeon advanced adult, paediatric and trauma courses including Generic Instructor Course.  Provide guidance and advice to NHSH clinical staff on new or current emergency equipment  Audit the practice of resuscitation through the use of Cardiac Arrest Audit forms  Develop/implement local and national policy with regards to resuscitation and DNACPR

Priorities for 2013-14:  Maintaining the uptake of training across all clinical areas of NHSH during a time of reduced staffing within the department.  Maintain communication with all Senior Charge Nurses/ team leaders regarding course attendance and training data  Prioritise all activities within the department and optimise places at all teaching sessions across NHSH

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Team Name: Community & Health Improvement Planning Role and Function: Amongst other things, the team supports the organisation to mainstream equalities practice and comply with legislation by developing policies, procedures and supporting implementation. The multi agency Violence Against Women team is hosted by Community and Health Improvement Planning.

Priorities for 2013-14:  Equality & Diversity – training, delivering equalities outcomes and mainstreaming evidence in line with Equality Act 2010, new Deaf communication contracts, new Advocacy Plan, embedding Planning for Fairness, addressing access support needs between primary and secondary care

 VAW - training, embedding MARAC, development of response pathway services for sexual violence, strengthening of perpetrator programme, developing responses to commercial sexual exploitation

Team Name: Medical Education Role and Function:  Appropriate provision for medical staff induction, training, development, mentoring, appraisal and peer review to maximise their effectiveness as teachers.  Development of an educational faculty.  Development and dissemination of best practice and innovative teaching practices within the Board.  Participate in internal and external reviews and quality management visits, as appropriate.

Priorities for 2013-14:  General Medical Council recognition and revalidation of trainers  Measurement of teaching exercise  Identifying medical education (teaching and training) in job plans

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Team Name: Health Improvement Role and Function: The Health Improvement team sits within the Public Health Directorate in Corporate Services. Its role is to create a supportive environment for health improvement and foster a culture of public health practice in Highland, supporting competencies and standards of practice in the specialist and wider badged and unbadged ‘public health’ workforce in NHS Highland and its partner agencies. Its role is also to identify and support evidence based practice and set strategic direction in health improvement, supporting and developing initiatives to take forward the Scottish Government’s priorities for health improvement such as Heat targets or the Health Promoting Health Service. It works closely with NHSH Operational Units and other partners.

The Public Health Network is hosted by the Health Improvement Team and coordinates the planning and delivery of the Health Improvement Learning & Development Programme.

Priorities for 2013-14:  Supporting Integrating Care in the Highlands  Implementation of a person-centred approach to behaviour change across NHSH  Reducing health inequalities  Supporting community action for health  Supporting an asset-based approach to health improvement  Delivery of Scottish Government health improvement priorities (e.g. Heat Targets; Keep Well; Health Promoting Health Service)

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Team Name: Facilities and Estates Role and Function: Within Facilities and Estates there are a range of teams:

 Hotel Services (including Catering, Domestic and Portering Services)  Building Support Staff  Linen Services  Estates (this includes all operational building and engineering services , and delivering the Energy, Water and Environmental management service)  Central Decontamination Unit (of all re-usable medical devices for NHS Highland and Elgin (for NHS Grampian) Some of the development for staff is provided in-house e.g. Food Hygiene, Steam Cleaning whilst other programmes have to be commissioned externally due to the specialist nature of the provision.

Priorities for 2012-13:  Provide comprehensive Food Hygiene training to relevant staff across NHSH commensurate with their roles and responsibilities  Provide Public Peer Reviewer training to public partnership members in connection with their role during independent quality audits on the standards of Domestic Services & Estates monitoring  Provide comprehensive domestic services training to relevant staff across NHSH commensurate to their roles and responsibilities  Training and development of new and existing staff using a range of training techniques including face to face and e-learning programmes.  Provision of in-house Fire Safety Training across NHS Highland

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Team Name: Research & Development Role and Function: To provide governance, monitoring and support for all research and development activities in NHS Highland (in 2012 – 2013 this will relate to 1000 plus studies including clinical trials (drugs), clinical trials (devices), clinical trials (other) and all other research and development projects. Training relates to the training of directly employed R&D staff (30+) and all NHS staff including in any research active capacity. In any year this can be 250+ staff.

Priorities for 2013-14:  To ensure all staff are ICH-GCP trained and to actively promote R&D training to all staff and seek opportunities to include research and development sessions within staff job plans (e.g. consultant level PA’s, specialist nurse sessions and others).  Ensure all directly employed R&D staff are trained appropriately to their different (clinical/governance/administrative) roles.

Team Name: Personnel & Development Role and Function: Provision of professional expertise in ensuring the delivery of NHS Highland corporate objectives. Supporting the achievement of Staff Governance Standards, facilitating service developments and organisational change initiatives; and the implementation of statutory requirements and best practice personnel techniques in maintaining operational services.

Priorities for 2013-14:  Awareness raising of NHS Highland Personnel Policies and Procedures for new team leaders and managers; promoting Dignity at Work and minimising workplace conflict; development of skills and confidence to ensure consistent application in managing staff; guidance and support to senior managers to ensure Staff Governance requirements are met when progressing service changes.

 Three programmes under review: Level 1, Introduction to Personnel; Level 2, Personnel Management Skills Programme; and Level 3 Managing Corporate Risk (Employee Relations & Managing Change)

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Team Name: Infection Prevention & Control Role and Function: To improve infection prevention & control practices, thereby providing a healthcare environment for patients that minimises the risk of HAI.

Priorities for 2013-14: Through the HAI Education Group established in January 2013, ensure Patient/Service Users safety is achieved in relation to Infection Prevention & Control by standardising HAI education and training, targeted at different staff groups across NHS Highland in:

Hospitals Community Care Homes Care at Home Adult Day Care Centres Learning Disability Bank Staff Social Work Staff Volunteers Contractors

Initial Priorities

• To update and further develop NHS Highland Healthcare Associated Infection Training and Development Strategy. • To review the Policy for Staff Core Competencies in Infection Prevention & Control • To identify what is mandatory training and what is not, who will deliver, when, how and where. • To agree learning outcomes for induction training for different staff groups and how it is provided • To agree a strategy for rolling out the Cleanliness Champions Programme • To identify what protected learning time is required for HAI training • To look at barriers to preventing HAI training • To ensure that NHS Highland has a robust system of recording what training has been undertaken

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Team Name: Clinical Governance Role and Function: The Clinical Governance Department of the Board’s Medical Directorate provides appropriate, professional and competent clinical effectiveness, patient safety, risk management, legal claims, complaints and patient experience advice, guidance and support to the NHS Board, its managers and its staff.

The Department is responsible for developing, gaining approval for and monitoring the implementation of a quality and patient safety strategies together with supporting policies, procedures and guidelines.

The Department is also responsible for delivering, maintaining, enhancing a pro-active and positive quality and patient safety culture, which effectively contributes to NHS Highland clinical governance roles, responisiblities and plans.

The Department will assist operational units, Pharmacy, Facilities Management and Corporate Services to plan and deliver their clinical governance agenda.

Priorities for 2013-14:  Complaints and Datix for Care Homes.

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Further information from:

Anne Gent Pamela Cremin Director of Human Resources Workforce Planning & Development Manager NHS Highland NHS Highland Assynt House John Dewar Building Beechwood Park Inverness Business and Retail Park INVERNESS Highlander Way IV2 3HG INVERNESS IV2 7GE E-mail: [email protected] E-mail: [email protected] Tel: 01463 704865 Tel: 01463 706916 269 Highland NHS Board 13 August 2013 Item 5.1

NORTH OF SCOTLAND PLANNING GROUP ANNUAL REPORT 2012/13

Report by Jim Cannon, Regional Director Planning, North of Scotland Planning Group

The Board is asked to:

 Note the Annual Report for 2012/13  Agree the future direction for NoSPG during 2013/14

1 Background and Summary

The Annual Report of the North of Scotland Planning Group (NoSPG) summarises regional achievements throughout 2012/13 across the range of projects which NoSPG supports on behalf of North of Scotland (NoS) Boards. Progress of inter-regional and national initiatives led by the NoSPG or by the Director of Regional Planning is also reported. NHS Highland is a member Board of the NoSPG and each year NoSPG prepares an Annual Report for submission to the NoS Boards.

In March 2013 the new Director of Regional Planning was appointed and since then there have been significant staff changes within the NoSPG team. Existing projects have continued as planned from the 2012/2013 work plan and the new Director has instigated changes to the way the NoSPG generates the work plan and subsequently reports on that activity.

For 2012/13 it has been agreed by the NoS Chairs and Chief Executives Group that the Regional workplan would be rolled forward, with the acknowledgement that it may require to be altered during the year. New ways of presenting and organising the work plan are currently being trialed through the NoSPG executive and future work plans will be presented annually, after that process and structure is agreed.

The emphasis of the regional workplan during 2012/13 has continued to focus on children’s services, mental health services and acute services, together with those overarching groups that provide support across disciplines.

In September 2011, NoSPG hosted an event focused on ‘Regional Futures: Horizon Scanning and the Implications for Regional Working’. Collaboration was identified as a key theme and has been confirmed by both the NoSPG Executive and the NoS Chairs and Chief Executives Group as an essential aspect of delivering quality healthcare services and supporting the further integration of services with our partners.

As part of a renewed commitment to collaboration and ongoing development of the “Intelligent Region” work, the NoSPG executive has agreed in principle to shift the focus of NoSPG activities from reactive acute sector projects, to a broader agenda where proactive planning across traditional planning silos is the priority. This wider focus aims to engage Boards in longer term planning, with sustainable high quality services in the north as a central theme.

2 One paper is attached: i) Annual Report 2012/13 270

3 Contribution to Board Objectives

The Workplan has been developed to enable NHS Boards to achieve the regional objectives within Better Health Better Care and maintains the aims of the Highland Quality Approach by supporting work aligned to person centred care, reducing waste, reducing harm and managing variation through collaborations across the NoS.

4 Governance Implications

 Patient and Public Involvement Regional working should only be adopted where there is an added benefit to patients by adopting such an approach. Whilst the Annual Report describes the many projects undertaken or supported by NoSPG during 2012/13, there is a section which identifies what benefits patients will see, as a result of each project. This includes improved patient pathways, modern and fit for purpose facilities, improved access to specialist services and sustainable services.

Wide consultation takes place through NHS Board structures in development of project objectives. This includes clinical forums and public consultation where appropriate.

 Financial Impact No additional resources are requested through these documents.

5 Risk Assessment

Risks assessments are undertaken within individual projects where appropriate.

6 Planning for Fairness

An Equality and Diversity Impact Assessment (EQIA) is undertaken within individual projects where appropriate.

7 Engagement and Communication

The NoSPG Annual Report is accepted by the NoSPG executive prior to being submitted at each NoS Board meeting.

Jim Cannon Regional Director Planning North of Scotland Planning Group

2 August 2013

2 271

NORTH OF SCOTLAND

PLANNING GROUP

Annual Report

2012-13

272

Contents

Page Foreword 2

Introduction 3

Achievements in 2012-13

4 • NoSPG Clinical Planning Groups

• Regional Networks 10 • NoSPG Specialist Planning Groups 25 • National work 26

Finance 27

Priorities for 2013-14 32

Contacts 35

NoSPG Structure 36

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

1 273

Foreword

Regional working remains a strong feature of how the NHS Boards in the North of Scotland collaborate to plan and deliver services to our patients. During 2012 a national review of regional planning was commissioned by the Chief Executives Group, led by Mrs Heather Knox, Director of Regional Planning for the West of Scotland Planning Group and Mr Mark O’Donnell from Scottish Government Health Department. The review reflected positively on the achievements of regional planning nationally and made some recommendations as to how it might be strengthened further in future.

The Boards have continued to face significant challenges over the past year and it will be imperative that regional approaches continue to provide sustainable progress over the year ahead and beyond. The regional team will be led by a new Director of Regional Planning and our thanks go to Mr Peter Gent, Interim Director of Regional Planning and his team for their support over the past year. Our thanks also go to Mr Richard Carey, Chief Executive Officer NHS Grampian, who has Chaired NoSPG for the past few years and will hand this role over to Ms Elaine Mead, Chief Executive Office NHS Highland. Richard has provided strong leadership to NoSPG throughout his tenure and will continue to be an important leader on behalf of his Board for NoSPG in future.

Ian Kinniburgh Chair NoS Chairs & Chief Executives Group

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

2 274

Introduction

This annual report is the fourth that the regional planning office has produced and highlights the continued success and achievements of regional working.

NoSPG is an important vehicle for delivering sustainable services to the populations of the north and is also an important adjunct to the territorial Board planning structures. The remote and rural landscape, constraints on resources, ever increasing public expectation and the emphasis on ‘quality’ pose ongoing challenges for the Boards that often require collaborative ways of working to achieve the best possible outcomes for patients.

The review of regional planning by the Chief Executives Group across Scotland has been a significant process over the past year and sets new standards for strengthening the benefits of planning services together moving forward. The review highlighted a number achievements and successes as well as acknowledging areas of tension and where improvements could be made. Overall however the review was a very positive appraisal of regional planning and we will look forward to building upon this in future.

Examples of achievements during 2012 was the completion of the Medium Secure ‘Rohallion Unit’ in Perth, progression of the CAMHS service in Dundee, the move from recommendations to implementation of the Zoe Dunill Child Health review, completion of the regional Restorative Dentistry business case and development of a regional governance framework to support the new CEL’s concerning specialist cancer services.

We now welcome Mr James Cannon as the new substantive Director of Regional Planning and I personally will be handing over Chairmanship of NoSPG to my colleague Ms Elaine Mead in NHS Highland from June 2013.

Mr Richard Carey Chair North of Scotland Planning Group

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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NoSPG Clinical Planning Groups

NoS Cardiac Services Sub-group Mr Hussein El-Shafei, as Regional Clinical Lead, chairs the North of Scotland Cardiac Services Sub Group. The group is supported by Mr Ken Mitchell, Programme Manager - Acute Services & Workforce and Miss Sandra Hay, Regional Project Manager – Acute Services & Workforce.

Benefits to Patients The delivery of cardiac services across the North provides a regional approach that will ensure consistency of care, and enhanced access to specialist services, closer to patient’s homes.

During 2012-13 the membership of the Cardiac group has been reviewed, with a particular focus on engaging with stakeholders such as the local Cardiac MCNs, to improve the linkages between national, regional and local priorities.

It had become apparent that the direction of travel for cardiac services would benefit from wider discussion to understand local priorities and areas where collaborative working across the region could add value. A planning event was therefore held on 30th October 2012 to enable the development of a North of Scotland Cardiac Services Plan for 2013-2018, which would support delivery of sustainable services across the region.

Further areas of work have included the review and re-costing of the Cardiac Surgery Service Level Agreement to ensure the long-term sustainability of the service; the development of outreach services for Adult Congenital Cardiac Services; a review of Electrophysiology; and the agreement of funding to develop an educational resource for Thrombolysis.

Work is also underway to re-develop the Regional Cardiac Work plan, which will be completed by the end of June 2013.

Child Health Dr Michael Bisset, Consultant Paediatrician, provides clinical and strategic leadership for Child Health across the North. Within that role, Dr Bisset chairs the NoS Child Health Clinical Planning Group (NoS CHCPG). Mr Neil Strachan, Programme Manager for Child Health and CAMHS has provided managerial support to the Child Health Programme.

During 2012/13 the CHCPG has taken strategic direction from the NoS paediatric sustainability review, during this period each participating Board submitted a formal response to the review, which contained both local and regional recommendations. The responses received demonstrate a shared recognition of the requirement

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for Boards to collaborate in order to sustain paediatric services and as such the regional child health work programme is growing. Therefore, the CHCPG has focused on achieving agreement as to prioritising the regional recommendations, which has now been achieved.

The Child Health Clinical Planning Group continues to support the development of regional and pan-Scotland networks ensuring access to a wide range of safe, sustainable, specialist services for children across the North. An essential element of future service delivery for North of Scotland Boards is ensuring that Island Boards and remote communities have access to specialist services. The networks have been providing increased support to staff in remote and rural locations through peer support, utilisation of telemedicine for education and training, as well as for clinical decision-making.

An important link has been retained during 2012/13 in terms of monitoring ongoing additionality brought about by the resources introduced via the National Delivery Plan funding, the use and protection of this funding continues to be overseen by the national Specialist Children’s Services Monitoring group, which the CHCPG is represented on.

Benefits to Patients Through regional approaches and established networks, children and young people in the North will have improved access to specialist paediatric services, including local provision of specialist clinics or tele-medicine links for those in remote areas.

Regional approaches also provide education and training for locally based staff who care for children and will improve outcomes.

With a mandate informed by the agreeing of regional priorities from the sustainability review, these will provide the focus of CHCPG and NoSPG team activity for 2013/14. These priorities include:

• Exploring and describing an Obligate Network model for Child Health in NoS. • Effective cross-board collaboration on identifying service reconfiguration options for paediatrics across the A96. • Delivery and evaluation of a pilot Paediatric Unscheduled Care Project offering a single point of contact to rural practitioners. • Establishing transport requirements for children requiring high dependency care or specialist clinical escort, where care needs do not require transfer to Paediatric Intensive Care units. • Scoping paediatric workforce demographics and upcoming paediatric retrials. • Continuing to ensure the effective delivery of our existing and developing NoS paediatric networks. • Ongoing monitoring of the added value brought by the National Delivery Plan resources.

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Neonatology A regional Neonatal Managed Clinical Network (MCN) will provide a collaborative approach to the delivery of quality, safe and effective neonatal care to the population across the North of Scotland. The level three unit in Aberdeen Maternity Hospital, the level two unit in Raigmore Hospital Inverness and the level one special care baby unit within Dr Gray’s Hospital Elgin will provide specialist care and support to the peripheral units on Orkney and Shetland and the remote and rural areas of the North of Scotland mainland.

The Neonatal MCN has worked collaboratively with NHS Orkney, Shetland, Highland and Grampian to identify the requirements of compliance with the ‘Neonatal Care in Scotland –A Quality Framework’ draft document which has since been published on 5th March 2013. The Neonatal MCN has established specific subgroups to address the work identified within the work plan.

These groups are: Service development and pathways - The MCN is currently engaging in a joint neonatal clinical guidelines group with SEAT colleagues to develop standardised high quality clinical guidelines for new developments in neonatal care and to share current methods of practice across the neonatal community. Work is underway to finalise a pathway for babies born 28weeks and less.

Informatics – This group has developed an audit and clinical governance process, which has been ratified by the steering group. This process will support collection and analysis of data from the neonatal dashboard. The neonatal dashboard is currently under development and will be used in a pilot starting in April 2013. Raigmore Hospital neonatal unit has agreed to trial the dashboard as a unit without the use of the BADGER IT system. The dashboard will be evaluated following a twelve-week trial. The neonatal work stream of the Scottish Patient Safety Programme has been established with representatives from the North attending a skills training event as safety champions. A short life working group has been established to take this work forward across Scotland. The NMCN will co-ordinate a mapping exercise to identify current PS practice and share information across the region on new developments. Neonatal PS data will be analysed through the informatics group via the audit and clinical governance process. Education and Training – a mapping exercise to identify mandatory training currently being carried out in each Board area has been completed. This proved to be very positive with all Board areas delivering very similar programmes. Developments from this exercise have lead to AHP induction being included on the level 2 and level 3 units.

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A training needs questionnaire has been sent to each unit to identify the requirements for a potential national development of learn-pro modules to support neonatal education across Scotland. Discussions are still in the early stages of this project.

Parent Involvement - the NoSNMCN now has a parent representative sitting on the steering group. Work has started to develop a baby diary to inform and support parents through their neonatal unit experience. A desire to investigate some form of social media group for parents has been expressed by the parent representative. Work is currently underway to identify how this may work for the parents in the North

Child & Adolescent Mental Health

During 2012/13 the CAMHS project has taken significant steps forwards in terms of approvals, procurement approach and new appointments. It has been confirmed by Scottish Government that the construction costs of the new 12-bed inpatient unit will be met via national capital slippage monies. The unit remains a hubco ‘design and build’ project, with revenue funding input agreed by the participating Boards, as described in the outline business case (OBC). An OBC addendum with updated timescale and financial information had been requested by SG Capital Investment Group, this was provided and approval for the OBC was granted in full in March 2013. Work is underway to prepare the full business case (FBC), which is on track for the planned construction start in October 2013, with a planned service operational date of February 2015.

The inpatient unit design is well advanced and full planning permission has been granted, the project design team has seen close working between the architects and staff, with continual input from young people. There have been a number of engagement sessions with young people and parents, in relation to the design of the new unit, more are planned but the comments received to date are very positive.

This project has always been about more than inpatient bed provision, and in the latter part of the reporting period, project staff have successfully appointed to a number of ken network roles which will support local CAMHS teams in their ability to manage tier 4 need with a view to fewer, or shorter, admissions. These roles, approved at OBC stage, are led by Mrs Ruth Masson, NoS CAMHS Network Manager. Mrs Masson is supported by an Advanced Nurse Practitioner, 0.5 WTE Consultant Psychiatrist and 3 Network Liaison Nurses. It is envisaged that by end April 2014 all posts will have been appointed to, with Dr Helen Smith taking up the Consultant role in autumn.

Benefits to Patients A regional Network for Child and Adolescent Mental Health will provide specialist care as close to home as possible and provide access to specialist services for those living in the most remote communities. The

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regional inpatient unit will be provided within the context of an obligate network and will ensure that pathways of care are optimised, including liaison and transitional support between different tiers of service.

NoS CAMHS will be supported in their local response to tier 4 CAMHS needs through regular access to experienced network staff, located across NoS.

During 2013-14, the focus for the project team will be on ensuring the preparation of the FBC, on developing robust governance arrangements which reflect the nature of the service and it’s funding, and on operationalising the plans (e.g. workforce plan, ensuring phased increase of inpatient staffing). Construction of the new inpatient unit will commence October 2013 with planned service operational date in February 2015. During this period the opportunity will be seized to embed a network philosophy as far as possible, in advance of the full resource being available.

North of Scotland Secure Care Clinic The new NoS Secure Care Clinic included both a capital development to establish a regional secure care clinic for medium secure patients and an increase in the capacity for low secure care for NHS Tayside, together with the development of regional ways of working through the establishment of a North of Scotland Managed Care Network for Forensic Services. Dr Tom White is the Regional Clinical Lead for Forensic Services, Barbara Wilson was appointed as the Service Manager for the Secure Care Unit in July 2011, and Dave Charles continued to be the Project Director for the capital development until his retirement in August 2012. Ms Sushee Dunn Project Manager managed the final stages of the development of Rohallion thereafter. The Rohallion Unit was opened during August 2012 and marked the end of the development project from the regional office.

Benefits to patients The regional approach to secure care will ensure equity of service and quality of care throughout the North of Scotland, including a patient pathway negotiated with all partner agencies.

North of Scotland Managed Care Network for Forensic Services

Construction and Project Management

The Executive Project Board was chaired by Mr Garry Coutts, Chair of NHS Highland, and membership included representatives from NHS Grampian and NHS Tayside. The Lead Executive was Ms Lesley McLay, Chief Operating Officer, NHS Tayside. The project sponsor for this Mental Health Development was Mr Ian MacDonald Director of Finance, NHS Tayside. Detailed work on a range of issues including training, workforce

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and security is carried out in the Service Modelling, Workforce Planning and Service Migration sub groups was chaired respectively by Dr Tom White; Ms Barbara Wilson, the Regional Service Manager; and Mr Graham Rennie, the Service Development Manager seconded from NHS Grampian. The Finance sub-group was briefed with developments by the Project Accountant, Ms Lynne Hamilton, and the whole Project was overseen by Mr Dave Charles, the Project Director.

Project Timetable The project has been completed and the build element was transferred to NHS Tayside during August 2012.

Rohallion The medium secure ward and department names had been agreed. Like the building name – Rohallion – they are taken from lochs and rivers in the north of Scotland: • Spey Ward – Assessment • Ythan Ward – Acute • Vaara Ward – Rehabilitation • Scapa Activity Centre

Clinical Governance The Forensic Quality & Governance Group will support and develop The North of Scotland Forensic Mental Health Services in satisfying statutory and mandatory obligations to meet national and organisational quality and risk management standards.

To reflect the fact that services at Rohallion are being provided on behalf of the North of Scotland Boards, a core function of this group is to monitor and assure themselves and their Boards that services are delivered effectively and efficiently.

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Regional Networks

Managed Clinical Network for Specialist Paediatric Child Protection Services Building on the baseline assessment of current services in the region carried out in 2011 by the then MCN Clinical Lead, Dr E Myerscough, a clinical specification of services was drafted that proposed a way forward based on a model of an obligate network which contained an element of a pan-regional service. Unfortunately Dr Myerscough resigned at the beginning of 2012 and a replacement Clinical Lead for the network was not available. Consequently elements of the work plan associated with the network could not be taken forward as they relied upon clinical leadership, support for training and provision of a regional service which the Clinical Lead would have provided.

However, Lead Child Protection Specialists from each of the Health Boards have continued to meet together throughout 2012 as a Working Group to concentrate on areas which could still be developed such as peer review, training syllabus, protocols and patient information. This has been supported by Mrs Anne-Marie Pitt, Child Health Network Manager.

An important area of service provision which the MCN Clinical Lead would have provided for the region is child protection tertiary support and advice. This relies on a clinician who has extensive experience who is able to support other child protection specialists in the region with complex and difficult cases. In the absence of a Clinical Lead, the NoSPG have negotiated with NHS Grampian to provide this service (0.5 PAs per week) via Dr Myerscough from July 2012. Dr Myerscough, however, retires at the end of March 2013 and there are no other specialists with the required expertise in the region. Unfortunately this is beginning to be a similar picture for the whole of the country and consequently there are ongoing discussions between the three regional planning groups to ascertain a way forward to provide a sustainable service across the country. These discussions will feed into a wider child protection review by the Scottish Government.

Benefits to Patients Children, young people and their families who may have suffered abuse or neglect can expect child centred effective local services and the provision of expert specialist paediatric child protection services when required.

Regional Paediatric High Dependency Care Network Significant investment has been provided to support paediatric high dependency care throughout the region via the National Development Plan for Children’s Specialist Services funding (NDP). Additionally non-recurrent funding was provided to Health Boards for equipment and education and training. This has resulted in an increased capacity for children and young people to receive more locally provided care.

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A regional network to support high dependency care development across the region has also been established, supported by Mrs Anne-Marie Pitt, Child Health Network Manager. Initial discussions during 2012 show a willingness to share learning, protocols/procedures and training but the most significant area for development is tackling the issue of transferring critically ill children to high dependency units in a safe and effective way. Agreement to include this type of transfer in the Specialist Transport Service for Scotland Review (ScotSTAR) has been reached and the network have been working towards gathering appropriate data to feed into the business solutions of the review.

Representatives from the regional network have also been attending the newly established National Critical Care Steering Group which is concentrating on co-ordinating national standards and nationwide data collection and performance measurements.

Benefits to Patients Children and young people who require high dependency care will benefit by an increased capacity of trained and experienced staff and the establishment of a regional network will help to ensure an equitable and safe service in all parts of the north of Scotland.

Regional General Surgery for Childhood Network NDP investment has been provided to support general surgery for childhood throughout the region via the provision of a paediatric surgeon at the Royal Aberdeen Children’s Hospital and extra sessions for general surgeons at Raigmore Hospital. This has enabled paediatric surgeons to provide various outreach clinics and carry out general surgery for children and young people throughout the region.

However, to increase the effectiveness and sustainability of general surgery for childhood there was an agreement from representatives of general surgeons, who carry out these procedures in district general hospitals and rural general hospitals, that a more formalised networking approach is required. A network has therefore been established, supported by Mrs Anne-Marie Pitt, Child Health Network Manager, which will allow for more formal collaboration, the development of agreed patient pathways, improved training, better peer review and ultimately improved standards of care. Along with the NDP funding there is an expectation that improvements in the service are recorded and quantified through audit and patient feedback so as to demonstrate the added value of this investment.

Benefits to Patients Children and young people who require emergency and elective general surgery will benefit from the provision of safe and sustainable local services that meet national standards.

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North of Scotland Gastroenterology, Hepatology and Nutrition Network (NOSPGHANN) Dr Michael Bisset, Consultant Gastroenterologist continues as Clinical Lead for the regional network as well as NoS Clinical Lead for Child Health. Mrs Carolyn Duncan has supported NOSPGHANN as Network Manager during the year.

National Delivery Plan (NDP) funding is now well embedded in existing paediatric gastroenterology, hepatology and nutrition (PGHN) services in Aberdeen, Dundee and Inverness and has allowed improved outpatient services to be developed in Elgin, Perth and Shetland. These investments promote equitable patient access to the highest quality services as close to patients’ homes as possible. Improved quality of care and equitable patient access has been enabled through the provision of specialist local and regional multi- disciplinary teams of Medical, Nursing, Dietetic, Psychology, Speech and Language Therapy, Occupational Therapy and Pharmacy professionals.

NoSPGHANN has been successful in retaining multi-disciplinary staff and attracting new staff during the year. Dr Shyla Kishore will join the team in Aberdeen as a specialist Consultant in April 2013 which will enable the development of further tertiary clinics and endoscopy investigations and faster access to tertiary specialist advice throughout the region.

Clinics by a Consultant Gastroenterologist and Nurse Specialist in Shetland (twice a year) and Dr Gray’s in Elgin established in 2012 (currently bi-monthly) will be built upon in the coming year. The potential for delivery of a tertiary out-patient service on Orkney will continue to be investigated and established if fitting according to appropriate patient numbers.

Regular multi-disciplinary meetings have been held in Aberdeen, Dundee and Inverness during the year and highlight valuable collaboration and partnership working in furthering the aims of the network. The teams in each of the 3 main centres communicate together regularly to share good practice and to provide a coordinated approach for patients. Four network steering group meetings took place during the year. In addition an excellent network study day took place in Aberdeen in June 2012 to look at topics such as weaning off gastrostomy and psychological therapy, transitional care, biliary atresia, care pathways and audit.

Benefits to Patients Children and young people in the North of Scotland with gastroenterology, hepatology or nutritional problems have timely access to high quality care through a multi-disciplinary team of clinicians. Specialists and general paediatricians work closely together to ensure care is provided as close to the patient’s home as it is safe and appropriate to do.

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Work on the objectives in the current work plan progressed well during the year and while most objectives have been met, the network will continue to update and review the work plan to produce a new plan for 2013-15.

The network is in a very good position to continue to develop, improve and to sustain a first-class secondary and tertiary service to gastroenterology and hepatology patients across the North of Scotland in the year ahead. The dedicated work of the network has been built on through willingness and close collaboration across the North over the past 10 years. It is all carried out by highly motivated, conscientious, well trained staff that are very proud of the quality of care they provide to their patients on a daily basis. Together the network looks forward enthusiastically to developing its work further in 2013/14.

North East Scotland Child & Adolescent Neurology Network (NeSCANN) Dr Martin Kirkpatrick continues to provide clinical leadership for the neurology network, with network support being provided by Mrs Carolyn Duncan, Network Manager.

As with the gastroenterology and respiratory NoS child health networks, National Delivery Plan funding provided additional posts in each of the 3 main NoS centres which are now embedded into local services to ensure equitable access to tertiary and secondary services for patients and families delivered as locally as possible e.g. Medical, Epilepsy Specialist Nurses, Ketogenic Dietician, Neuropsychology, Physiotherapy, Speech and Language Therapy and Occupational Therapy. In addition, NeSCANN now meets many of the recommendations set out by national bodies such as SIGN (Scottish Intercollegiate Guidelines Network), NIHCE (National Institute of Health and Clinical Excellence), the Scottish Government and the ability to deliver SIGN guideline 81 regarding ‘Diagnosis and management of epilepsies in children and young people’. A prominent example by way of evidence is the recently published national “Epilepsy 12” audit in which the audit units within NeSCANN are all well above national averages.

Monthly multi-disciplinary team meetings in Aberdeen (Neurology Open Day) and Dundee (Brainwave), providing forums for discussion on complex cases, developments, brain imaging and neurophysiological investigations have continued during the period. A similar forum operates in Inverness alongside the clinics from the visiting tertiary Neurologists. Three NeSCANN steering group meetings took place during the year discussing topics such as service developments, work plan, IT systems, reporting, training and education, care pathways and guidelines and research and audit.

Specialist clinics delivered by Dr Kirkpatrick in Shetland (2-3 per year) and Dr Jollands in Orkney (2 per year) supported by Grampian clinicians and Epilepsy Specialist Nurses continue to enhance locally delivered patient care. Dr Jollands also carries out follow-up review consultations by video-conference with Orkney patients twice per year which are also supported by ESNs.

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Following the appointment of Dr Alan Webb to the NDP funded Consultant with a special interest in epilepsy post at the end of 2011, Moray specialist epilepsy clinics commenced in January 2012 and continued bi- monthly at Dr Gray’s with the support of Epilepsy Specialist Nurses. Moray patients can now benefit from having EEGs carried out in Inverness as this service is almost immediately available as well as being as close to patients’ homes as possible. At Raigmore there is now a twice monthly epilepsy clinic with ESN support and access to EEG on the same day which has been extremely valuable. There are also epilepsy clinics in both Fort William and Caithness once a quarter.

Benefits to Patients Children and adolescents with complex neurological conditions have improved timely access to specialist neurology and epilepsy multi-disciplinary services provided by skilled, experienced staff as close to their homes as possible.

The Epilepsy Specialist Nurse Training and Education Group completed its excellent work during the year to standardise disease and treatment information provided to patients and families. Information packs were reviewed and the generic standards for the delivery of training provided to families, medical, social care and education staff were also agreed. A comprehensive folder was produced for access by all health professionals in the 3 main centres enabling the setting of network nurse training and education standards.

Work on items in the 2011-13 work plan progressed well during the year. These will continue to be reviewed and added to according to service need next year. Data management and audit and the establishment of a fit for purpose IT system for the benefit of network neurology and epilepsy patients is still high on the agenda. The National Services Division Clinical Audit System in the North is key in moving this forward and discussions continue to take place jointly with the Scottish Paediatric Epilepsy Network and the NSD system developer in order to ensure accurate data collection for the future benefit of the network’s neurology patients.

The network will continue to build on the excellent collaborative work carried out across the region over the past 10 years. The multi-disciplinary teams of conscientious, hardworking, well trained staff continue to make a big difference to improve standards of care for patients with a neurological condition across the North.

North of Scotland Paediatric Respiratory Network Dr Jonathan McCormick, Consultant in Paediatric Respiratory Medicine continues to provide clinical leadership for the regional complex respiratory network, supported part-time by Mrs Carolyn Duncan, Network Manager.

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NDP funding is now embedded into local services and has enabled improvements to the tertiary and secondary specialist service for patients with Cystic Fibrosis and Chronic Respiratory Disease. These investments have increased local access for children and young people with complex and rare, respiratory conditions. Specialist multi-disciplinary teams of professionals including medical, nursing, dietetics, physiotherapy, clinical physiology and pharmacy underpin the improvements in quality of care.

Benefits to Patients Complex respiratory and Cystic Fibrosis patients benefit from equitable and timely access to diagnostic investigations and treatment as close to the family’s home as possible. This has been achieved through increased specialist medical, nursing and AHP staffing across the North of Scotland.

PRISM Network meetings (Paediatric Respiratory Inter-Regional Service Meeting) took place monthly during the year. This forum operates to discuss issues including clinical services for inpatients and outpatients, staffing developments and pressures, the work plan, quarterly clinical data collection for the annual report, the status of physiological testing in the paediatric pulmonary function laboratories, lung function equipment, postgraduate training and teaching and network participation in clinical research. The network was delighted that Elaine Carnegie of Asthma UK agreed to become a member of PRISM from January providing lay involvement in the network.

A large number of specialist and nurse-led clinics have taken place in each of the 3 main centres, as well as in Perth, Skye, Orkney and Shetland during the year. Specialist Respiratory clinics in Highland increased by 50% in 2012 with a consultant in paediatric respiratory medicine joining the Highland CF team for their Isle of Skye CF clinic. Biannual complex respiratory clinics continued in Orkney and a similar clinic has been set up in Shetland with the first clinic taking place in February 2013 (additional clinics are planned for June and October 2013). Monthly flexible bronchoscopy theatre lists in RACH enable diagnostic procedures to be performed for children across the Health Boards by the network’s four trained paediatric bronchoscopists. The lack of post holders for the CF Specialist Nurse and Pulmonary Function Technician posts for both Tayside and Grampian and the CF Dietitian post in Highland are currently contributing to significant staffing pressures.

Video-conferencing is actively used within the network from fortnightly lunchtime respiratory teaching sessions to monthly patient presentations of Cystic Fibrosis annual review. Bi-monthly ‘difficult to treat asthma’ case discussion and learning sessions commenced in February 2013 which are a welcome addition to the educational opportunities for the network, providing fresh ideas for staff when having to tackle very complex, challenging cases.

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The network has been involved in regional discussions with regards the potential use of the NSD Clinical Audit System for NoS complex respiratory patients. However there is already a very good system in place for CF patients in Port CF and it was not felt suitable for NoS respiratory patients as only a selective proportion of patient groups (e.g. asthma) are seen in specialist clinics in hospital.

The objectives in the work plan progressed well during the year and are now being reviewed for 2013/14. Objectives to be developed further in the coming year include:

• Map, develop and agree standardised care pathways/protocols/guidelines. • Develop information for patients and families. • Set up video-conference consultations with patients in remote locations. • Continue to develop an education framework. • Audit clinical care.

The collaborative work of the dedicated multi-disciplinary highly skilled staff involved in the network continues to improve patient care across the region. The drive and enthusiasm of clinicians to further develop the network and to provide high quality services as locally as possible for the benefit of patients and families remains paramount.

Eating Disorders

Benefits to patients Adults across the North with a eating disorder follow an agreed pathway of care, no matter where they live in the region and when an inpatient admission is required, the pathway is as seamless as it can be and retains important links with local clinicians. The Eden Unit offers specialist intervention for both inpatient and day patients within the region, allowing most patients to be cared for within both the region and the NHS.

The North of Scotland Managed Clinical Network for Eating Disorders has continued to focus on a number of core themes consistent with the ethos of Managed Clinical Networks in the North of Scotland. It has continued to remain and develop as a hub for a number of educational and training endeavours including a continued relationship with the Eating Disorders Education and Training Scotland programme, providing administrative support for this vital task in terms of helping professionals develop their skills and ensure consistent knowledge when working with eating disorder sufferers. It provides this opportunity to professionals from a wide range of trainings and bases.

The MCN also has continued to support education in primary care and in the third sector including education sessions to GP practices and other education groups of interested professionals in the community. The MCN also has helped develop education and training through other organisations and events such as the MCN

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Annual Event, supporting the Aberdeen Eating Disorders Conference and its continued close relationship with the Scottish Eating Disorders Interest Group (SEDIG) which ensures good contacts with carers in particular. Another core theme is that of quality assurance and some of the previously mentioned projects contribute to this aim. The institution of the Quality Assurance Group was begun within the MCN in the past year and which over the coming year I’m sure will see further evolution and quality improvement work being guided form it.

In a further linked theme information governance has maintained its high profile within the MCN which is taking an important role in helping develop the Patient Management System, Trakcare, for Mental Health with respect to the electronic patient record development. It has been through regular liaison meetings with eHealth representatives and working on how to convert the information in the current system, Exelicare, to this new system that the MCN is contributing to the development of a new working Electronic Patient Record which will integrate better with the rest of the Grampian services, but also potentially to other areas in the region as well in the future. The current system continues to be put to good use providing meaningful audit and research opportunities.

That brings us on to the continued work of the MCN in supporting the Regional Inpatient Unit in its work and helping clarify the care pathways and structures that support the smooth running of this Unit. The network plays a vital function in facilitating the interface of the unit with the different parts of the region.

Overall, to support its work, The MCN continues to have regular network meetings which have a wide range of representation including the Islands and from the Young People’s Services as well as across the major regional bases.

Finally the network remains committed to working alongside carer and sufferer organisations and as well as SEDIG already mentioned, the link up with the NEEDS local carer and sufferer support group in Grampian is now stronger with the administration portion of that being based within the MCN base. It has also provided continuing support to the Carers Conference that happens annually on a national basis which all parts of the region have access to and benefit from.

Priorities for the MCN will now be developed and grown by a new Clinical Lead in the shape of Dr Jane Morris, current Consultant for The Eden Unit. From her regional perspective in this Unit I have no doubt she will be able to continue the good work of the MCN in the region.

Finally many thanks to Mrs Linda Keenan, Network Manager; Ms Alison Sherriffs Network Secretary; and Ms Brenda Leel, Information Officer for all their hard work and contributions over the last year.

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Neuromuscular Network The role of a regional specialist Neuromuscular care advisor has been progressed well within the North of Scotland (NHS Grampian, NHS Highland, NHS Orkney, NHS Shetland, NHS Tayside and NHS Western Isles) following a commitment by the Cabinet Secretary for Health, Wellbeing and Cities Strategy and the Minister of Public Health public commitment. Funding was secured from the Scottish Government to support the pilot for a two year period, on the basis that there be a positive evaluation of the role and a business case will be developed to secure sustainable funding. Emma Condon was appointed as Clinical Facilitator - Neuromuscular on the 7th January 2013.

To progress the development of the role within the North of Scotland work has been undertaken to develop a working Project Initiation Document (PID). The project initiation document lays out the main objectives to support, enable and promote safe, efficient, effective, timely and person centred care for people, families, carers and the workforce in relation to Neuromuscular conditions for the North of Scotland. Key elements are:

• To establish a Neuromuscular steering group. • Scope current, and agree and develop future pathways, standards and clinics from birth, paediatrics, transition, adult to end of life. • To be a named point of contact for specialised neuromuscular advice information and support to patients, families, carers and the workforce. • Support and establish the role in paediatric and adult Neuromuscular clinics across the North of Scotland. • Support and develop data recording systems to support audit. • Review, commission and / or deliver neuromuscular educational needs – to assess needs and delivery of training to the workforce / patient needs. • Develop and build on innovative models of neuromuscular service care e.g. telecommunication. • Develop a business case to sustain a Neuromuscular Clinical Facilitator role and service improvement for neuromuscular care.

National Services Division have been tasked by the Scottish Government to undertake an independent evaluation of the three posts in Scotland. A key element of this being, the development of a clinical audit system, introduced in March 2013, designed to hold patient information.

Oral Health Network The Maxillofacial, Oral and Dental Health Project Board is chaired by Richard Carey, Chief Executive, NHS Grampian. Mr Ray Watkins, Consultant in Dental Public Health, NHS Grampian has provided clinical leadership and the network is supported by Mr Ken Mitchell, Programme Manager, Acute Services & Workforce and Sandra Hay, Regional Project Manager – Acute Services & Workforce.

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Benefits to Patients The Oral Health and Dentistry Project aims to improve access to specialist oral and dental care and to develop a network approach that will provide care locally by suitably trained practitioners.

The OMF/Oral Surgery Network continues to develop and the quarterly business and education meetings are well attended. During 2012-13, the network completed a regional audit of oral surgery referrals, has established combined clinics in Elgin and has introduced patient focussed booking, which has reduced outpatient DNAs.

During 2012, a Business Case was developed to provide additional capacity within Restorative Dentistry. Agreed by five of the six North Boards, this development will see the joint appointment of two additional Consultants, one based in Aberdeen and one based in Inverness. This additional capacity will enable the North to develop an intermediate care tier of service provision by supporting the development of enhanced skills practitioners, enabling greater access to services as locally as possible.

A North of Scotland network is also developing within Orthodontics, and although embryonic, is looking at the future sustainability of the service and tackling the issue of historically long waiting lists. The group, which consists of hospital and primary care specialists, had been meeting informally since 2010 and has now agreed to progress towards a more formalised network.

Paediatric Dentistry has also been highlighted as a risk for the North of Scotland, and the Project Board will consider how to take this forward during 2013-14.

NOSCAN Cancer remains a national health priority and a major focus for government led improvement plans. The current network office of Mr Richard Carey (Chair), Mr Peter King (Clinical Lead) and Dr Shelagh Bonner- Shand (Interim Regional Manager), supported by a network of colleagues, continue to embrace the national direction and challenges that cancer services bring to the Boards.

Benefits to Patients A regional approach to cancer services allows better integration of care, between local areas and more specialist services, where Boards will work together. A networked approach to service delivery means that patients across the North have optimal access to the same standard of care no matter where they live.

The ongoing shift in emphasis to improve outcomes and the quality of care, embedded in the national Cancer Quality Performance Indicator programme has been a significant area of work for the Boards and the region. The Detecting Cancer Early programme, which will bring with it new performance measures for improving survival impact, is well underway and the regional team have supported the interim Board performance status 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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assessments. We would propose that the regional effort to support the cancer agenda is still important and will continue to be so in the future ahead.

During 2012 / 13 the following is a summary list of the key areas of work:

• Structured visits to the Boards to support the implementation of the key CELs concerning Systemic Anti-Cancer Treatment & Quality Agenda. • Development of a governance structure to support the implementation of the tumour specific Quality performance Indicator Programme. • Rapid roll-out of the programme to develop regionally agreed Clinical Management Guidelines for all of the major tumour types. • Completion of a regional review of Thyroid Cancer services and options for sustainability of this highly specialist service in anticipation of significant retirals expected over the next 2 years. • Pilot of out-of-hours chemotherapy and radiotherapy traffic light and triage system as part of a national programme to streamline treatment related side-effects. Pilot phase completed in Grampian, Orkney & Shetland. • Launch of a regional review of Hepato-biliary & Upper GI Cancers, with completion of an options appraisal. The options predominantly concern surgical services. • Review of tumour specific groups and gaps vis-a vis Clinical Leadership, Management Support & readiness to support the regional elements of the quality agenda. • Early involvement in the national programme for Transforming Care after Treatment, including the establishment of a national programme board and governance structure. Workplan to be developed during 2013/14, reporting to Boards and National Cancer Taskforce group. • Completion of the eCASE development programme and recommendations thereafter for transition to business as usual within Boards.

A significant issue for services that arose during 2012 was the retirement of a senior clinical consultant colleague in Aberdeen and the impact thereafter on specific oncological services, most notably Neuro- Oncology and Paediatric Radiotherapy. An interim networked arrangement was agreed and implemented between NHS Tayside & NHS Grampian for Neuro-oncology support. Paediatric Radiotherapy support was progressed through the MSN for Child Cancer.

The Neuro-Oncology issue however continues to be an ongoing problem and has highlighted a number of sustainability issues for certain parts of the oncological services of the north, and most specifically, a scarcity of Consultant Clinical Oncologists and Physics staffing. This is being taken forward as a matter of extreme priority, supported by the Scottish Government Health Department and key sub-groups i.e. Scottish Cancer Taskforce Group & Radiotherapy Programme Board.

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In addition to the above, the Regional Cancer Office has continued to play its part as core members of the Scottish Cancer Taskforce Group, joint Scottish Government & Regional Managers Group and the Detect Cancer Early Programme and Operational Groups. The office again hosted the annual Breast Audit & Clinical Trials meeting in Dundee and will next move to support the meetings as per tumour specific QPI reporting structure.

North of Scotland Public Health Network (NoSPHN)

Dr Sarah Taylor, Director of Public Health for NHS Shetland led NoSPHN to the end of August 2012. The NoSPHN lead role is shared between the North of Scotland (NoS) Directors of Public Health and rotated on a 2-3 year basis and Dr Margaret Somerville Director of Public Health in NHS Highland was nominated to the Lead role from September 2012. The Lead role and network are supported by the Network Manager, Pip Farman a Public Health Specialist. The work of NoSPHN is guided by a Steering Group comprising the NoS Directors of Public Health, the NoSPG Director of Planning; representatives from regional working groups and programmes; and national bodies e.g. the Scottish Public Health Network (ScotPHN).

Benefits to Patients The NoS Public Health Network ensures that regional initiatives are informed by the best available evidence and identified population need so that we make the best possible decisions within the resources available for the people of the North of Scotland.

NoSPHN supports NoSPG in agreed pieces of work and also develops regional approaches to Public Health services, activities and continuing education. A summary of progress on NoSPHN objectives is highlighted below. Further details of work are available on the NoSPHN website www.nosphn.scot.nhs.uk

Using a logic model approach in NoSPG service planning Ongoing support has been given to the development of a needs and evaluation based approach to the North of Scotland NDP Children’s Specialist Service programme. NoSPHN was initially asked by NoSPG to develop a model to show how added benefit to patients would be demonstrated as a result of investment in Children’s Specialist Services at a regional level (using a logic model approach). Early work focussed on the development and evaluation of the work. Work this year has focussed on applying the logic model approach to other NoSPG programmes of work for example the development of the new NoS Neuromuscular Advisor post and initial discussions with regard the NoS Paediatric Unscheduled Care project evaluation. The logic model approach has been incorporated into the NoSPG project scoping planning tools.

Horizon Scanning NoSPG asked NoSPHN to identify the key factors that would have the biggest impact on the future provision of services across the North of Scotland. NoSPHN colleagues developed a picture of the future from national

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and international research through a literature review and by consulting with a range of stakeholders at local, regional and national levels.

The key message from the work was that we cannot continue to do what we have always done and in the way we have done it if we are to meet the challenges of the future. The work was presented to NoSPG in late 2011 and the work was well received and evaluated. Papers summarising the findings of the work, the event in 2011 and suggested next steps is available on the NoSPG website www.nospg.nhsscotland.com and NoSPHN website www.nosphn.scot.nhs.uk/?page_id=873. One message that appears to have had particular resonance with colleagues is the concept of needing to approach changes within the NHS as like ‘redesigning the plane whilst flying it’1 whilst clearly ensuring we all know the destination to which we are headed. The findings from the event have continued to be discussed over the last year and NoSPHN has focussed its attention on progressing Public Health activities emerging from the work including developing the concept of the ‘Intelligent Region’ and the development of, or improving access to supporting tools.

The concept of the ‘Intelligent Region’ has been developed by Jillian Evans (NHSG), Susan Webb (NHSG), and Pip Farman (NoSPHN) and is based around the concept of the Intelligent Board2. It acknowledges that with a rapidly changing environment, those who are charged with governance of NHS organisations have an increased need for good quality, timely information to set strategy, monitor implementation of strategy and oversee operational delivery. At the crux of this approach is the aim of improving the accessibility of appropriate information for all and that information must be packaged appropriately and intelligently and might include for example a focus on agreed minimum data sets, a clear cycle of strategic and operational business and understanding of delegated authority and accountability. A tiered approach to information needs and management to support this has been proposed. This work is in development and we will be promoting opportunities to debate and develop the approach and understand the potential impacts for regional and Board work. A NoSPG ‘blue print’ for service development, planning or review is also in development. The aim of the blue print is to ensure that appropriate, informed and ‘intelligent’ questions are asked at each stage of service review and developments are informed by Public Health perspectives and some of the thinking emerging from the horizon scanning work.

A year on from the Horizon Scanning event, NoSPHN has also reviewed the initial Horizon Scanning work with colleagues with the aim of exploring and sharing the impacts and challenges of the work and lessons learned.

The review was conducted through questionnaire and interview – the overall response rate was 32% (24/76). 58% of respondents reported that they had used the work (42% of respondents had not used the work) and 83% of respondents indicated that the work had an impact on them as individuals or organisations e.g. their

1 www.internationalfuturesforum.com/ 2 Intelligent Board February 2006 www.drfosterintelligence.co.uk/thought-leadership/intelligent-board/ 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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thinking, decision making or practice (17% of respondents indicated that work had no impact on them). Respondents cited evidence of where the work was being used and/or had an impact.

The feedback and proposed improvements and further work suggest the need to keep the work going and: • ‘Make the work real’ i.e. further translate concepts into practice and apply them. • Revisit and share the work more widely. • Develop further the Horizon Scanning methodologies (methods, terminology etc). • Highlights a number of issues for both NoSPG and NoSPHN to reflect on if the work is to be further supported and progressed – these have which have been supported by NoSPG and will inform the NoSPHN and NoSPG workplans for 2013/14.

Drug and Therapeutics Collaborative approaches to the NoS Area Drug and Therapeutic Committees (ADTCs) have continued to be explored over the year including: • Discussions about community pharmacy input into Detecting Cancer Early; • Work on sharing of Patient Group Directions; • Sharing of Standard Operating Procedures for Patient Access Schemes; and • A meeting also took place between NOSCAN, ADTC leads and clinical staff to determine how best to work together around budget setting, horizon scanning, Scottish Medicines Consortium (SMC) implementation, Individual Patient Treatment Requests, databases and standards for chemotherapy.

Cardiac services NoSPHN supported the Cardiac Surgery review (with health intelligence advice and support) and also the NoS Cardiac Network event in November 2012 which it is intended will guide the development of the network’s work programme for 2013/14.

Other work ongoing • NoSPHN is currently scoping work to understand the evidence for and impacts of low surgical volume and outcomes in relation to the sustainability of regional services. • NoSPHN is supporting the NOSCAN Hepatobiliary Cancer Review Group in particular with the use of an option appraisal tool to assess models of delivery. • NoSPHN health improvement colleagues are reviewing NoS collaborative approaches to the outcomes of the Scottish Centre for Healthy Working Lives Review.

Supporting Regional and National Working Public Health colleagues are nominated to sit on and advise NoSPG groups e.g. NOSCAN, Oral Health and Dentistry and the Cardiac Networks. NoSPHN has continued also to work with other national organisations to maximise engagement with and links to the North of Scotland including NHS Health Scotland, the Scottish Government and Scottish Public Health Network (with whom we now have a Memorandum of Collaboration). 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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NoSPHN has supported where appropriate national working groups for example this year this has included the National Health Protection Stocktake review and has sought to influence national discussions with regards Geographical Information Systems (GIS). One of the main foci of such work is to ensure that the remote and rural aspects of national developments are recognised and addressed, for example work to develop a Health Impact Assessment for off-shore wind farm developments and responding on a NoS basis to national consultations and processes e.g. Detect Cancer Early, anticipatory care mainstreaming discussions, reviews of national groups e.g. the National Services Advisory Group and input to the National Review of Regional Planning in which the work and contribution of NoSPHN to regional working was positively highlighted.

Continuing Professional Development NoSPHN has a role to support or organise continuing professional developments (CPD) events where there is an agreed North of Scotland need and to ensure NoS access to national events and training. In line with national drivers to support the development of asset based approaches for public health, NoSPHN organised an event on the 27th March 2012 to support discussion and debate on the approach (a copy of the event report and all supporting papers is on the NoSPHN website at www.nosphn.scot.nhs.uk/?page_id=1125) and we have been following up local developments arising from the event during the year. A framework for developing and supporting CPD on a NoS basis has also been developed.

Quality improvement As part of its process for continuous quality improvement NoSPHN routinely reviews its activities with stakeholders. Over the last few years we have concluded a number of pieces of work which were individually and then collectively reviewed for lessons learned which has informed the further development of the scoping processes for new pieces of work for NoSPHN and improving guidelines for the delivery of NoSPHN work.

Acknowledgements NoSPHN would wish to record their thanks for the significant support Dr Sarah Taylor has given to NoSPHN in her period of leadership. Sarah will continue to represent NoSPHN on the North of Scotland Planning Group.

For more information or to discuss NoSPHN and its work contact: Dr Margaret Somerville, North of Scotland Public Health Network Lead [email protected] Pip Farman, North of Scotland Public Health Network Co-ordinator [email protected]

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NoSPG Specialist Planning Groups

Integrated Planning Group Mr Peter Gent, Interim Director of Regional Planning chaired this group, which meets virtually. This group has met regularly throughout the year and continue to provide business management support to the NoSPG Executive Group, through a strategic approach to the regional workplan and performance management of projects.

North of Scotland Medical Workforce Group Dr Annie Ingram continues to chair the group and support is provided from Sandra Hay, Regional Project Manager – Acute Services and Workforce.

The Medical Workforce Group has been in existence for a number of years, although since 2009 the main focus has been to oversee the regional reshaping process, ensuring that there is a clear audit trail of the decision to reduce the number of doctors in training. The group ensures that the service implications of these changes are clearly understood and implemented in such a way as not to destabilise systems and that opportunities to redesign services on a regional basis that supports service sustainability are identified and plans developed for progression.

The views of NoS Boards and the relevant Deaneries are represented at the National Medical Reshaping Project Board and supporting Working Group.

Workforce Planning and Development Group

The Workforce Planning Learning Network continues to meet bi-monthly to enable sharing of knowledge and ideas across the region.

Benefits to Patients A consistent, collective approach to workforce planning across the North of Scotland will support workforce sustainability, ensuring the provision of a safe and affordable workforce and consistent delivery of safe standards of patient care.

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National Work

Throughout 2012/13, a number of national projects were commenced involving members of the Regional Planning Office. Whilst not exclusively north focused, they are worth noting for their national engagement and involvement of regional colleagues: • National review of Trauma Services across NHS Scotland - due to report back to NPF during 2013/14. • A Better Deal for Military Amputees SLWG – initial review completed and due to report during 2013/14. • National Review of Breast Screening Services – review completed and reporting back during 2013/14. • TAVI working group – recommendation for TAVI service in Scotland and service implemented via NHS Lothian. • Review of Specialist Pain Services – following an initial baseline audit, this review is underway and will conclude to report back during 2013/14.

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Finance

This section reports on funding of regional working and includes reports on funding of the NoSPG core team, which includes, the Director of Regional Planning & Workforce Development, and administrative staff. There are also sections on the Project specific costs.

NoSPG Funding by NoS NHS Boards

The funding of the core NoSPG team has been shared between the six NoS Boards since 2003, although for a number of years, the full cost of the team was offset by funding from other sources, mainly Scottish Government. From April 2010, the full costs of the core team have been shared between the Boards. Table 1 outlines the expenditure for the NoSPG core team as at the end of March 2013.

Table 1: North of Scotland Planning Group Regional Planning expenditure 2012/13 £ Staff Costs 162,992 Non-pay costs 15,741 Total 178,733

Table 2 demonstrates the funding contribution that each of the North partners has made to regional working on the basis of NRAC share. The table demonstrates that a saving of 14% has been made on the forecast expenditure within the year. This has largely been as a result of opportunistic vacancy savings within the core team, continuing use of video-conferencing and reduced travel costs. In addition an annual NoSPG event, although budgeted for, was not held during this financial year.

Table 2: Regional Planning Expenditure 2012/13 NRAC Proposed Actual by NHS Board % £ £ Grampian 36.6 76,677 65,416 Highland 25.4 53,213 45,398 Orkney 1.7 3,562 3,038 Shetland 1.9 3,981 3,396 Tayside 31.4 65,782 56,123 Western Isles 3.0 6,285 5,362 100.0 209,500 178,733

Child Health Funding

The funding for the Regional Clinical Lead for Child Health, Clinical Leads for individual Networks, together with the funding for the NoS Programme Manager, Network Managers and administrative support has been provided on a recurring basis through the National Delivery Plan. Funding for a number of these regionally

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focussed roles has been transferred to the host Board where the Clinical Leader or other member of staff is employed.

2012/13 2013/14 Table 3: Child Health £ £ Funding available Programme Manager 70,552 70,552 Support Costs 21,983 21,983 Clinical leader - Gastroenterology 18,162 18,162 Clinical leader - Neurology 18,162 18,162 Clinical leader - Respiratory & CF 18,162 18,162 Clinical leader - Infrastructure 18,162 18,162 Clinical leader - Child Protection 23,345 23,345 Gastro/Neurology Network Manager 41,922 41,922 Regional Physiotherapist 41,779 41,779 Child Protection - Network Manager 20,890 20,890 Child Protection - Admin support 11,725 11,725 Remote & Rural 50,240 50,240 Regional Daatetic Support - Ketogenic 20,859 20,859 375,943 375,943 Expenditure Manager 70,552 70,552 Support Costs 21,983 21,983 Clinical leader - Gastroenterology 18,162 18,162 Clinical leader - Neurology 18,162 18,162 Clinical leader - Respiratory & CF 18,162 18,162 Clinical leader - Infrastructure 18,162 18,162 Clinical leader - Child Protection 5,836 23,345 Gastro/Neurology Network Manager 41,922 41,922 Regional Physiotherapist 41,779 41,779 Child Protection - Network Manager 20,890 20,890 Child Protection - Admin support 11,725 11,725 Remote & Rural 50,240 Regional Dietetic Support - Ketogenic 20,859 20,859 308,194 375,943 Underspend transferred to Child Health Slippage 67,749 0

In addition to the regional elements of the NDP funding, the funding for Boards was routed through the regional office to ensure that funds achieved the biggest benefit for children’s services. Due to delays in appointing staff to posts, combined with the late decision on the year 3 allocations, there is significant slippage against the year 3 funds. These funds must be used to the benefit of children’s services and over previous years there has been significant investment in Boards. Debate is required on how best these funds can be used to support NHS Boards. Additionality, which was a precondition of the investment, must be demonstrated.

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2012/13 2013/14 Table 4:Child Health Slippage £ £ Funding available Slippage from 12/13 67,749 Balance from previous years 1,124,316 1,186,502 1,192,065 1,186,502

Expenditure Critical Care Equipment & Training (NHS Tayside) 20,000 Child Protection (NHS Highland) 20,000 Paediatric Unscheduled Care 300,000 Paediatric Sustainability Review Project Manager time 5,563 10,000

5,563 350,000 Slippage carried forward to following year 1,186,502 836,502

Regional Neonatal Network

In early 2010, Scottish Government announced its intention to establish three regional neonatal networks and made funding for a Clinical Leader, Network Manager and administrative support available to all regions. During 2010-11, NoSPG appointed the Clinical Leader, followed by the Clinical Facilitator in June 2011. Expenditure against the SGHD allocation is reported in Table 5 below.

2012/13 2013/14 Table 5: Neonatal Services MCN £ £ Funding available SGHD Funding 131,304 131,304 Slippage from previous year 69,530 95,121 200,834 226,425

Expenditure Lead Clinician (3 PAs) 35,585 36,000 Network Manager 48,932 49,400 Admin Support 11,700 11,800 Travel/Accommodation/Training 4,496 5,000 Misc (Advertising) 5,000 2,000 SIM Training 10,000 SIM Babies & staff backfill 75,000 SIM Evaluation 37,000 105,713 226,200 Slippage carried forward to following year 95,121 225

Child & Adolescent Mental Health Services (CAMHS) Funding

Originally funding for regional staffing in CAMHS has come from two sources, SGHD and matched funding, top-sliced from the NDP funds for Specialist CAMHS. In 2011, the SGHD funding for the Regional Network

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Manager came to an end and the role was subsumed into the role of the Regional programme Manager for Child Health and CAMHS, which was funded substantively through the regional NDP allocation. In the North, the Boards have agreed that a small proportion of the £0.5m should be directed to support the regional project on a recurring basis until the project is complete. Table 6 describes the position in relation to matched funding.

2012/13 2013/14 Table 6: CAMHS Specialist Funding £ £ Funding Available SGHD funding 61,326 61,326 Grampian 22,117 22,117 Highland 15,732 15,732 Orkney 1,020 1,020 Shetland 1,190 1,190 Tayside 19,373 19,373 Western Isles 1,894 1,894 Slippage from previous years 234,458 292,438 357,110 415,090 Expenditure Project Team 21,000 21,000 Clinical Leader 25,997 28,750 Admin (band 4 0.5 wte) 12,192 12,200 Travel/Accommodation & Event 5,483 6,000 64,672 67,950 Slippage carried forward to following year 292,438 347,140

The slippage in previous years related to an allocation made for professional fees, which have now been superseded by funds made available through hub-co.

Regional Neuromuscular Care Advisor Post

Scottish Government has provided funding for a 2 year a Neuromuscular Care Advisor post. During 2012/13 NoSPG appointed the Advisor. Expenditure against the SGHD allocation is reported in Table 7 below.

Table 7: Regional Neuromuscular Care Advisor 2012/13 2013/14 Post £ £ Funding available NHS Board Allocation 57,500 Slippage from previous year 57,500 38,315 57,500 95,815 Expenditure Advisor 9,679 46,200 Travel/Accommodation/Training 787 1,500 Equipment 1,259 1,500 Delivery of Awareness Training 5,090 Training 2,190 2,500 Misc 180 19,185 51,700 Slippage carried forward to following year 38,315 44,115

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Regional CAMHS Development Post

Scottish Government has provided funding for a 2 year a CAMHS Development post, plus set-up costs. During 2012/13 NoSPG appointed the Network Support Officer, expenditure against the SGHD allocation is reported in Table 8 below.

2012/13 2013/14 Table 8:CAMHS Development Post £ £ Funding available NHS Board Allocation 21,500 35,000 Slippage from previous year 35,000 38,456 56,500 73,456

Expenditure Network Support Officer 10,687 32,400 Travel 2,411 5,000 Equipment 4,946

18,044 37,400 Slippage carried forward to following year 38,456 36,056

Financial Commitments Table 9 describes the projected expenditure for 2013/14 to be shared by NoS partner Boards, which represents a 7.6% reduction on the projected costs for 2012/13.

2013/14 Table 9: 2013-14 Projected Costs £ Director 95,300 Executive Assistant 29,400 PA Support 44,800

Travel 12,000 Event 8,000 Misc 4,000 193,500

Table 10 summarises the projected cost shares by NoS NHS Board.

Table 10:Projected Cost Shares for 2013/14 by NoS Board Grampian £71,363 36.88% Highland £48,936 25.29% Orkney £3,290 1.70% Shetland £3,715 1.92% Tayside £60,372 31.20% Western Isles £5,824 3.01% £193,500

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Priorities for 2013-14

Clinical Governance Continue to develop a practical yet fit for purpose framework or guidance to support regional working, and to influence the HIS development of self-evaluation frameworks for governance that take account of the challenges of regional working.

Child Health Clinical Planning Group Continue to focus on maintaining and improving quality of services under the influence of the regional networks, to drive any mandated response to the NoS Child Health Review and to continue to develop information systems fit for the purpose of multi-Board working.

Child and Adolescent Mental Health Services The priorities for the CAMHS Project Board will be progress towards timely completion of the project, with a continued focus on regional collaboration, formalisation of referral pathways and operational procedures etc.

North of Scotland Public Health Network NoSPHN will continue to progress ongoing developments from the 2012/13 workplan and deliver an agreed programme of regional and national Public Health activities as appropriate including: • To develop and deliver work in response to the findings of the Horizon Scanning review. • To support the delivery of the Cardiac Services Regional Delivery Plan and improve understanding of projected need and the impact on service capacity and accessibility. • Develop a coordinated programme of work to support health service improvement at regional and local levels e.g. the planning blue print and the ‘Intelligent Region’. • To organise and support appropriate professional development opportunities in response to local and regional needs. CPD and development events in planning include support to ongoing asset based approaches work, developing the concept of the Intelligent Region, exploring the use of Geographical Information System (GIS) tools across the North; a workplace planning session to understand collective NoS Public Health workforce challenges and how new ways of working may support future needs and interests and planning for the next Scottish Public Health Faculty Conference which will be held in the North in 2014.

• Further supporting collaborative approaches to Drug and Therapeutics across the NoS (for example implementation of the output of national review of ADTCs; implementation of the Scottish Government output of national review of IPTRs and develop support for staff unfamiliar with processes; work together on systems/ processes required to implement the New Rare Medicines Fund and forecast potential spend; and to consider how the North of Scotland as a region can work with: MSPs; the Pharmaceutical industry and to understand impact of integration agenda).

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• Continued support to the NOSCAN Hepatobiliary Cancer review group. • Scope and develop a project to review small volumes / outcomes and sustainability in the NoS. • Implementation of the national Health Protection Stocktake and any related regional work. • Develop a regional approach to NoS Dental Public Health. • To coordinate health improvement activities where it is agreed there is an added value in doing so at a NoS level including collaborative work with regards the Scottish Healthy Working Lives scheme and maximising health improvement opportunities across the NoS.

Cardiac The priorities for the Cardiac sub-group will be driven by the 2012 regional meeting and resultant action plan. Issues such as TAVI, regional workload and workforce reviews will continue to shape the regional level planning requirements.

Maxillofacial, Oral and Dental Health Project Board The priorities for 2012/13 will include ongoing support OMF and Restorative Dentistry networks, the development of an electronic referral system and the continued development of intermediate care networks.

Vascular Progression of the vascular framework across the NoS, and establishment of the regional MCN for implementation of the vascular implementation plan.

Neonatal network

The regional Neonatal Managed Clinical Network (MCN) will continue to provide a collaborative approach to the delivery of quality, safe and effective neonatal care to the population across the North of Scotland, building upon existing work, including the collaboration with SEAT, implementation of the Neonatal informatics dashboard and development of training & education needs.

NOSCAN The priority areas will be: • a regional strategic visioning review of Oncology services, driven by the current service sustainability difficulties challenging each of the cancer centres. • Stabilisation of the regional Neuro-oncology service which is now a regional issue / pan-Scotland problem. • Implementation of the regional cancer governance structure to enable reporting of cancer quality information at Board and regional levels as per CEL. • Ongoing review of NOSCAN and associated structures to maximise the productivity of the regional network effort. • Transition of eCASE development from national project board to business as usual at Board level.

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• Completion of the regional Clinical Management Guidelines programme across all tumour types. • Completion of the NoS review of HPB & Upper GI cancers and presentation of recommendations back to the Regional Cancer Advisory Group & NoSPG.

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North of Scotland Planning Group Contacts

Mr Richard Carey (Chair) Mr Ralph Roberts Chief Executive Chief Executive NHS Grampian NHS Shetland Summerfield House Brevick House 2 Eday Road South Road Aberdeen AB15 6RE Lerwick Shetland ZE1 0TG

Tel: 01224-558508 Tel: 01595-743063 [email protected] [email protected]

Mrs Cathie Cowan Ms Elaine Mead Chief Executive Chief Executive NHS Orkney NHS Highland Garden House Assynt House New Scapa Road Beechwood Park Kirkwall Inverness Orkney KW15 1BQ IV2 3HG

Tel: 01856 888223 Tel: 01463-704838 [email protected] [email protected]

Mr Gordon Jamieson Mr Gerry Marr Chief Executive Chief Executive NHS Western Isles NHS Tayside 37 South Beach Road King’s Cross Stornoway Clepington Road Isle of Lewis Dundee DD3 8EA

Tel: 01851-708005 Tel: 01382-424049 [email protected] [email protected]

Mr James Cannon Mr Peter Gent Director of Regional Planning Interim Director of Regional Planning NoSPG Office (April 2012-March2013) Kings Cross Clepington Road Rosehill Annexe Dundee DD3 8EA Forresterhill Aberdeen AB25 2ZN Tel: 01382-425673 Tel: 01224 552745

[email protected] [email protected]

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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North of Scotland Planning Group Structure CAMHS Project Board

Child Health Clinical Planning Group

Cardiac Services Network

NOSCAN North of Scotland North of Scotland Chairs and Chief Planning Group – Executives Group Executive Group (NoSPG) Eating Disorders Network

Medium Secure Care Clinic Project

NoS Oral Health and Dentistry Project

Bariatric & Obesity North of Scotland North of Scotland North of Scotland North of Scotland Management Workforce Planning & Medical Directors Integrated Planning Nurse Directors Development Group Group Group Group Public Health Network (NoSPHN)

Remote and Rural Implementation Group

Scottish Neonatal Transport Service

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

36 308 309 Highland NHS Board 13 August 2013 Item 5.2

NHS SCOTLAND RESILIENCE – PREPARING FOR EMERGENCIES: DRAFT GUIDANCE FOR NHS SCOTLAND

Report by John Burnside, Business Continuity Manager, on behalf of Elaine Mead, Chief Executive

The Board is asked to:

1 Background and Summary

The guidance promotes actions around raising the awareness of the role and responsibilities of the NHS in preparing for, responding to and supporting recovery from major incidents and emergency situations.

A Health Inequalities Impact Assessment scoping exercise highlighted three key issues that need to be considered by Health Boards when preparing for emergencies and deploying resources in emergency situations these are: i) Communications, ii) Access to services and, iii) Staff training in equalities and human rights.

Preparing for Emergencies Guidance is principally aimed at NHSScotland Chief Executives, Executive Directors, senior managers and staff responsible for resilience planning of health services. It should, however also be of interest to NHS partners involved in integrated emergency management

2 Purpose of the Guidance

The purpose of the guidance is to:

 enhance the resilience of NHSScotland and ensure there is a coordinated approach to resilience planning across the NHS;  enable NHSScotland Chief Executives, Executive Directors and resilience planning leads to understand both their own and their Board’s roles and responsibilities under the Civil Contingencies Act 2004 and other key legislation  ensure that NHS Board’s comply with the relevant duties in preparing for, and recovering from major incidents and emergencies  ensure consistent approaches and standards of practice across NHSScotland in relation to responding to major incidents and emergency situations  promote continuous improvement of emergency preparedness across NHSScotland 310

2.1 Ensuring preparedness

This guidance requires Chief Executives to be able to demonstrate that the area covered by the Board:

 is fully compliant with its statutory duties under the Civil Contingencies Act 2004 and all subsequent regulations

 has clear and effective leadership, delegation of responsibility and lines of accountability for preparing for, and responding to major incidents. As a minimum requirement, an Executive Director of the Board should be the designated lead for Emergency Preparedness and for Business Continuity and they should ensure effective linkages and consistency between the organisation’s business continuity and major incident plans.

 has clear governance arrangements in place throughout the organisation to oversee emergency preparedness and business continuity. These must include a resilience committee, chaired at least by the Lead Executive Director, which will report to the Board on emergency preparedness, training, exercises, resourcing and any gaps in capability or capacity. Reporting should be at least annually.

 has active and effective links between the organisation’s Emergency Preparedness and Business Continuity arrangements

 has suitably experienced and qualified Lead Officers for Emergency Preparedness and Business Continuity. These officers are responsible for supporting the Executive Director with lead responsibility for advising the resilience committee and facilitating the delivery of the required capabilities and plans throughout the organisation.

 has an up-to-date Major Incident Plan that has been endorsed by the Board. This plan should be based upon the principles of assessment (adopting an all risks approach), reflect integrated emergency management and complement the organisation’s arrangements for business continuity. Other agencies must be made aware of any assumptions in relation to their services.

 has adequate and proportionate resources allocated, in line with the assessed need, to developing and maintaining emergency preparedness and the resilience of the organisation, including staffing equipment, training and exercising.

3 Contribution to Board Objectives

Improvement and Change – the Guidance draws on the most current research evidence, “Lessons Learned” and is intended to support NHS Chief Executives to fulfil their duties under the Civil Contingencies Act 2004, and to promote continuous improvement of emergency preparedness across NHSScotland

Promoting Community Responsibility – implementation of the Guidance will support the principle that sharing information is an integral part of civil protection and NHS bodies should share their major incident plans with the public. This will provide reassurance that planning has taken place as well as allowing the community to further develop resilience plans of their own.

Delivering Safe and Effective Services – in the event of an emergency/service disruption implementation of the guidance will support NHS Highland’s resilience and provide a rehearsed method of restoring its ability to supply its core services to an agreed level within an agreed timeframe and to prioritise and deploy resources efficiently, effectively and safely.

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Delivering Efficient Services – implementation of the guidance will support clear reduction in costs by assisting in identifying, managing and preventing disruptions to services.

4 Governance Implications

 Staff Governance – an on-going training programme, including training in equalities and human rights in emergency situations will be delivered and evaluated through the direction of the Highland Emergency Planning and Business Continuity group.

 Patient and Public Involvement – The following groups were consulted on the guidance: All Health Boards, Special Health Boards, Police Scotland, Scottish local authorities, Strategic coordinating groups, Red Cross and Scottish Health Council.

 Clinical Governance – Major Incident and Business Continuity plans benefit an organisation because they help to maintain Clinical Governance thus providing assurance that the organisation has systems and processes to maintain services and delivery in the event of an emergency.

 Financial Impact – As in “delivering efficient services” will produce clear cost benefits by assisting in identifying, managing and preventing disruptions in advance can reduce costs to an organisation in terms of financial expenditure and management time.

5 Risk Assessment

There are significant risks associated with not complying with the guidance including non – compliance with CCA 2004 which subjects all category 1 responders to the full set of civil protection duties, and the Health and Safety at Work Act 1974. All operational units should have any non – complete Major Incident /Business Continuity plans entered into their Operational Unit Risk Register.

6 Planning for Fairness

A Health Inequalities Impact Assessment scoping exercise of the guidance has been completed by NHS Scotland Resilience; a local EQIA has not yet begun but will be undertaken through the Highland Emergency Planning and Business Continuity group when the final guidance is published in August 2013.

7 Engagement and Communication

All Operational units have an Emergency Planning and Business Continuity Group that meets on a quarterly basis and this guidance will be circulated to all the groups for inclusion on their agendas. It is intended to publish the guidance on the Highland Emergency Planning and Business Continuity website and to publish on the NHS Highland website.

John Burnside Business Continuity Manager Clinical Governance and Risk Management

2 August 2013

3 312 313 Highland NHS Board 13 August 2013 Item 5.3

FINANCIAL POSITION AT 30 JUNE 2013 (MONTH 3)

Report by Nick Kenton, Director of Finance

The Board is asked to:

 Note the forecast out-turn of break-even overall.  Note the requirement of a £9.8m improvement to achieve this.

1 Introduction

This paper highlights the financial forecast and progress on savings plans, based on the first quarter of 2013/14.

2 Key Messages

 An overall break-even position forecast by 31/3/13  The current reported overspend forecast at £9.8m  This is an adverse movement of £1.6m on month 2  The current overspend is split between;

. Savings to be identified - units £3.0m . Adult Social Care (mainly S&M) £3.7m . Pressures less offsetting benefits £6.3m . Non-Recurrent Benefits Expected (£2.6m)

 The Month 3 forecast in the previous year was an overspend of £10.1m

3 Financial Position Overview

As highlighted above, the position at the end of June (Month 3) shows a forecast of financial breakeven, recognising that this depends on the delivery of savings targets together with successful management of emerging, in-year cost and service pressures.

The position to date is detailed in Table 1 (attached) and this is being addressed through a range of management actions, both local and Highland wide, which lead to the projection of financial breakeven. As it stands, the current forecast can be broken down into the following components; Fig 1

Breakdown of Month 3 Forecasts Operational Unit N&W S&M Raigmore ASC HQ Tertiary Others HSCP A&B Corp. Central Total Heading £m £m £m £m £m £m £m £m £m £m £m

Savings Operational Savings not yet achieved/identified (2.6) (0.1) (2.7) (0.3) 2.6 (0.4) In year non-recurrent benefits applied 0.0 0.0 Pressures Adult Social Care (0.1) (4.4) 0.8 (3.7) (3.7) In-year cost pressures (1.0) (0.5) (5.1) (0.4) (7.0) (0.5) (7.5) Offsetting underspends/benefits 0.2 0.5 0.3 1.0 0.8 1.8 Actual Out-turn (0.9) (4.4) (7.7) 0.8 0.0 (0.2) (12.4) 0.0 0.0 2.6 (9.8)

Previous Month - month 2 (0.7) (4.4) (6.4) 0.9 (0.2) (10.8) 0.0 0.0 2.6 (8.2)

Change (0.2) 0.0 (1.3) (0.1) 0.0 0.0 (1.6) 0.0 0.0 0.0 (1.6) 314

Although Month 3 is still relatively early in the financial year, a £9.8m forecast overspend does give some cause for concern, albeit is broadly in line with the previous two years.

Delays in identifying recurrent savings could result in further reliance on non-recurrent resources in-year and these needs to be avoided in order to meet the Board’s commitment for the removal of the reliance on non-recurring resources, over a three year period.

The adult social care forecast needs to be considered as a whole, as well as a part of South and Mid’s forecast, as the Unit positions are distorted by the removal of Care at Home budgets to a central area, for the initial part of the year. This resulted in the removal of prior year underspends in South & Mid and overspends in North & West.

The usual financial tables are attached as follows;

 Table 1 presents the overall income and expenditure position, inclusive of adult social care funding transferred in from Highland Council and excluding funding transferred out to Highland Council relating to children’s services.

 Table 2 provides more detail on the overall expenditure position. The budgets for South & Mid Highland and North & West Highland operational units are now integrated budgets inclusive of adult social care relating to their areas.

 Table 3 shows the same information but excluding Adult Social Care.

 Table 4 shows the total position on adult social care alone.

 Table 5 summarises the position against savings. This highlights the fact that there is still significant work required to identify sufficient savings to deliver the financial plan.

 Table 6 summarises the position with regards capital expenditure.

4 Operational Performance

In summary, the breakdown of the position by unit is:

 Raigmore £7.7m  South & Mid (ASC) £4.4m  Adult Social Care - Central (£0.8m)  North & West £0.9m  Forecast non-recurrent benefits (£2.6m)  Others £0.2m

Specific issues within operational units are as follows;

4.1 Argyll & Bute CHP – Breakeven A&B CHP is currently forecasting a breakeven position although the Unit has still to identify fully around £0.3m of savings, which there is a high degree of confidence in delivering. In addition to this the CHP requires to manage a number of new and existing pressures, the most significant of these relate to medical and surgical locums of around £0.2m.

4.2 North and West Unit – £0.9m Overspend N&W is currently projecting an overspend of £0.9m which is made up of two main components – medical locums within the Rural General Hospitals (£0.4m) and Out of

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Hours, primarily in West Ross, totalling £0.5m. The unit also faces pressures as a result of vacant GP practices.

North & West Unit is forecasting full achievement of savings targets.

In terms of adult social care, N&W is currently predicting a £0.1m overspend although this is subject to the qualifications in 3 above.

4.3 South and Mid Unit – £4.4m Overspend South and Mid are projecting break-even within the NHS components on the budget and the overspend relates entirely to the Adult Social Care element, which needs to be considered as a whole to fully understand the movements.

In terms of Adult Social Care, the overall savings target is currently forecast to be delivered and the £4.4m is made up of an increase in expenditure over 2012/13 as follows;

 New care packages £1.2m  Prior vacancies likely to be filled £0.9m  2012/13 Non-recurrent budgets underspends £0.7m  Previous year accounting adjustments £1.3m

This is offset by an underspend of £0.9m within the central Adult Social Care budgets.

4.4 Raigmore Hospital – £7.7m overspend The most significant overspend relates to Raigmore and can be broken down into three elements;

 2012/13 non-recurrent carry forward £2.6m  Increase expenditure to meet TTG/Access targets £1.4m  Other in year cost pressures £3.7m

In terms of the carry forward, the Local Delivery Plan (LDP) assumed that Raigmore would require time to deliver a balanced budget and that it was unlikely to significantly improve its achievement against this target. The under-achievement on this savings target is therefore not unexpected and is offset within the NHS Highland overall bottom line on a non-recurrent basis.

Treatment Times Guarantee (TTG) initiatives were highlighted to the Board in June and are considerable. Additional resources will become available to offset against this pressure, but these are yet to be confirmed.

The most significant other cost pressures within Raigmore relate to locum costs particularly in dealing with challenging capacity issues within Oncology, Haematology and Radiology.

The Raigmore Management Team have been tasked to produce a plan which provides both short and longer term improvements over a period of time and progress on this matter will be reported to the Board.

4.5 Others – £0.2m overspend This is entirely within Facilities and primarily relates to an overspend on Energy.

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5 Capital

The capital plan was approved at the June Board and expenditure in the first quarter is lower than budgeted for although this is expected to pick up as the year progresses. Table 6 (attached) provides a breakdown. Key budget holders have been tasked with presenting an expenditure profile to the Asset Management Group to improve the management of expenditure over the course of the year.

6 Conclusion

Month 3 is still relatively early in the financial year, however a requirement to improve the position by £9.8m to deliver break-even is significant and actions are required to bring this back into line.

The Raigmore Senior Management Team are seeking to identify measures to reduce costs within Raigmore to bring their overspend down to the level expected. Work will also be required to improve the forecast within Adult Social Care and these actions will be reported through the relevant Groups and Committees and ultimately to the Board.

7 Governance Implications

Accurate and timely financial reporting is essential to maintain financial stability and facilitate the achievement of Financial Targets which underpin the delivery and development of patient care services. In turn, this supports the deliverance of the Governance Standards around Clinical, Staff and Patient and Public Involvement.

8 Risk Assessment

Financial risks, including the potential failure to deliver the necessary Financial Targets are included on the Corporate Risk register and managed accordingly.

9 Planning for Fairness

A robust system of financial control is crucial to ensuring a planned approach to savings targets – this allows time for impact assessments of key proposals impacting on any changes to services.

10 Engagement and Communication

The majority of the Board’s revenue budgets are devolved to operational units, which report into two governance committees that include staff-side, patient and public forum members in addition to local authority members, voluntary sector representatives and non-executive directors. These meetings are open to the public. The overall financial position is considered at the full Board meeting on a regular basis. All these meetings are also open to the public. The overall financial position was described in “Health Check” which was sent to every household in Highland.

Nick Kenton Director of Finance

2 August 2013

4 NHS Highland317 TABLE 1 Income & Expenditure Report as at JUNE 2013

Annual Plan Position to Date Forecast Outturn Prev month Initial Current Plan Actual Variance Forecast Variance from Forecast Movement Plan Plan Summary Funding & Expenditure to Date to Date to Date Outturn Current Plan Variance in month £000 £000 £000 £000 £000 £000 £000 £000 £000

509,790 509,811 SEHD -Baseline Funding 117,738 117,738 0 509,811 0 0 0 6,802 - Recurring Supplemental Allocations 1,700 1,700 0 6,802 0 0 0 6,066 - Non Recurring Supplemental Allocations 1,516 1,516 0 6,066 0 0 0 509,790 522,679 Sub total - SGHD Core RRL 120,955 120,955 0 522,679 0 0 0

0 0 -NonCoreFunding 0 0 0 0 0 0 0

509,790 522,679 SGHD Funding as at July 2012 120,955 120,955 0 522,679 0 0 0

24,992 24,992 -FHSNonDiscretionary 6,248 6,248 0 24,992 0 0 0 55,697 56,299 -FHSGMSAllocation 14,075 14,075 0 56,299 0 0 0 25,734 18,887 - Recurring Pending allocations 4,722 4,722 0 18,887 0 0 0 12,174 6,398 -NonRecurringPendingallocations 1,600 1,600 0 6,398 0 0 0

628,386 629,255 TOTAL SGHD Funding 147,599 147,599 0 629,255 0 0 0

85,966 86,227Add-AdultSocialCareQuantunFunding86,227 Add- Adult Social Care Quantun Funding 21,557 21,557 0 86,227 0 0 0 (7,710) (7,710) Less - THC Childrens services Transfer (1,928) (1,928) 0 (7,710) 0 0 0

706,642 707,771 Funding 167,228 167,228 0 707,771 0 0 0

Health & Social Care Partnership

108,421 108,697North&WestOperationalUnit 26,903 27,411 (508) 109,569 (873) (677) (196) 145,611 145,932South&MidOperationalUnit 38,414 39,183 (770) 150,320 (4,388) (4,387) (1) 20,969 21,990 Adult Social Care - Central 6,343 6,337 6 21,240 750 895 (145) 132,417 133,798Raigmore 34,337 36,125 (1,788) 141,527 (7,728) (6,382) (1,346) 19,812 19,836Facilities 4,644 4,650 (5) 20,088 (252) (261) 9 4,823 4,858 Integrated Pharmacy 1,209 1,291 (82) 4,834 24 24 0 4,380 9,221ehealth 1,331 1,334 (3) 9,221 0 1 (1) 19,119 19,119 Tertiary 4,655 4,755 (100) 19,119 0 0 0 14,483 14,465OtherHCP 3,544 3,552 (8) 14,464 1 (1) 2

470,034 477,917 TOTAL H&SCP 121,380 124,637 (3,257) 490,382 (12,466) (10,788) (1,678)

179,644 179,684 Argyll & Bute CHP 43,619 43,819 (200) 179,684 0 0 0

Cental Services 17,257 17,394 Corporate Services 4,120 4,143 (23) 17,388 7 3 4 39,706 32,777 Central Costs & Reserves (1,891) (2,008) 117 30,157 2,620 2,620 0

706,642 707,771 Total Expenditure 167,227 170,591 (3,363) 717,611 (9,839) (8,165) (1,674)

Manangement Planned Actions 0 (9,839) 9,839 8,165 1,674

0 0 Surplus/Deficit Mth 3 0 3,363 (3,363) 0 (0) 0 0 Finance - Monitoring 5.3 Area Finance Rept to 30 06 13-APPs.xlsx Total Summary 31/07/2013 14:25 Income & Expenditure Report as at JUNE 2013 Table 2 318 Annual Budget YTD Position Forecast Outturn Prev month Initial Current Summary Plan Actual Variance Forecast Var From Forecast Movement Plan Plan Health & Social Care Partnership to Date to Date to Date Outturn Current Plan Variance in month £000 £000 £000 £000 £000 £000 £000 £000 £000

North & West Operational Unit 32,739 32,893 North Area - Caithness District 8,220 8,433 (214) 33,554 (661) (735) 74 17,753 17,836 - Sutherland District 4,478 4,436 42 17,746 90 60 30 20,703 20,766 West Area - S,L, & WR District 5,208 5,524 (317) 21,611 (845) (643) (202) 28,026 28,183 - Lochaber District 7,170 7,190 (20) 27,690 493 460 33 5,441 5,259 North & West Area Mgt 863 838 25 5,192 67 201 (134) 104,662 104,938 North & West Operational Sub Total 25,938 26,421 (483) 105,793 (856) (657) (199) 3,759 3,759 N & W Hosted Services 965 990 (25) 3,776 (17) (20) 3 108,421 108,697 Total North & West 26,903 27,411 (508) 109,569 (873) (677) (196)

South & Mid Operational Unit 21,030 21,188 South Area - Inverness West District 5,325 5,670 (345) 23,013 (1,825) (1,481) (344) 27,459 27,568 - Inverness East District 6,955 7,122 (167) 27,921 (353) (634) 281 25,053 25,107 - NABS district 6,298 6,266 32 25,101 6 (165) 171 3,334 3,332 - South Other services 837 747 90 3,338 (6) (18) 12 15,733 15,573 Mid Area - Easter Ross District 3,913 4,107 (194) 16,792 (1,219) (1,105) (114) 17,286 16,896 - Mid Ross District 4,184 4,483 (299) 18,337 (1,441) (1,358) (83) 3,604 4,309 - Mid Other services 1,075 1,059 16 4,352 (43) (62) 19 2,912 3,088 South & Mid Unit Central 384 426 (42) 2,650 438 400 38 116,411 117,062 South & Mid Operational Sub Total 28,971 29,881 (910) 121,504 (4,442) (4,423) (19) 18,124 17,983 Adult Mental Health 4,388 4,349 38 17,982 1 0 1 1,214 1,206 Learning Disabilities 295 274 21 1,183 23 16 7 1,755 1,574 Substance Misuse 187 164 23 1,547 27 17 10 8,107 8,107 Dental Services 4,572 4,514 57 8,104 3 3 0 29,200 28,870 Sub Total SE CHP Hosted services 9,442 9,302 140 28,816 54 36 18 145,611 145,932 Total South & Mid 38,414 39,183 (770) 150,320 (4,388) (4,387) (1)

20,969 21,990 Adult Social Care - Central 6,343 6,337 6 21,240 750 895 (145)

Raigmore Operational Unit 49,547 50,236 Surgical & Anaesth. Divison 12,440 14,165 (1,725) 54,620 (4,384) (3,535) (849) 73,889 74,475 Medical & Diagnostics Division 18,484 19,327 (842) 75,697 (1,222) (690) (532) 2,044 2,033 Raigmore Hotel Services 513 530 (17) 2,165 (132) (123) (9) 3,132 3,322 Patient Support Division 778 891 (113) 3,598 (276) (280) 4 2,023 1,681 Raigmore Central 1,717 780 937 3,415 (1,734) (1,760) 26 130,635 131,747 Raigmore Divisions 33,932 35,693 (1,761) 139,495 (7,748) (6,388) (1,360) 416 420 Research & Development 76 115 (39) 405 15 3 12 1,365 1,632 ACT - Additional cost of Teaching 329 317 12 1,627 5 3 2 132,417 133,798 Total Raigmore 34,337 36,125 (1,788) 141,527 (7,728) (6,382) (1,346)

Other H&SCP Services 19,812 19,836 Facilities 4,644 4,650 (5) 20,088 (252) (261) 9 4,823 4,858 Integrated Pharmacy 1,209 1,291 (82) 4,834 24 24 0 4,380 9,221 e health 1,331 1,334 (3) 9,221 0 1 (1) 19,119 19,119 Tertiary 4,655 4,755 (100) 19,119 0 0 0 14,483 14,465 Other HCP 3,544 3,552 (8) 14,464 1 (1) 2 62,617 67,499 15,383 15,581 (198) 67,726 (227) (237) 10

470,034 477,917 Total Health & Social Care Partnership 121,380 124,637 (3,257) 490,382 (12,466) (10,788) (1,678)

18,737 18,930 A & B CHP- Oban, Lorn & Isles 4,663 4,864 (201) 19,212 (282) (218) (64) 16,869 17,000 Mid Argyll, Kintyre & Islay 4,175 4,180 (4) 17,080 (80) (65) (15) 7,320 7,340 A&B MH In-patient Services 1,713 1,715 (2) 7,340 0 0 0 12,508 12,619 Cowal & Bute 3,128 3,211 (83) 12,919 (300) (300) 0 4,857 4,882 Helensburgh & Lomond 1,219 1,174 45 4,832 50 0 50 9,231 9,251 Other clinical services 1,983 1,989 (6) 9,262 (11) (30) 19 15,404 15,404 GMS 3,786 3,858 (72) 15,517 (113) (50) (63) 17,075 17,075 Prescribing 4,151 4,125 26 17,075 0 0 0 7,781 7,781 FHS Non Disc. Services 2,089 2,089 0 7,781 0 0 0 49,437 49,437 HCP - Glasgow & Clyde 12,111 12,122 (12) 49,483 (46) (46) 0 4,074 4,074 HCP - Other 998 1,001 (3) 4,069 5 5 0 4,603 4,658 Resource Transfer 1,165 1,165 (0) 4,658 0 0 0 11,748 11,233 Central & Corporate 2,439 2,326 112 10,456 777 704 73 179,644 179,684 Total A&B CHP 43,619 43,819 (200) 179,684 0 0 0

Central Services 17,257 17,394 Corporate Services 4,120 4,143 (23) 17,387 7 3 4 39,706 32,777 Central Costs/Reserves (1,891) (2,008) 117 30,157 2,620 2,620 0

706,642 707,771 Total Net Expenditure 167,227 170,591 (3,363) 717,610 (9,839) (8,165) (1,674)

Finance - Monitoring 5.3 Area Finance Rept to 30 06 13-APPs.xlsx Fin Position 31/07/2013 14:25 Income&ExpenditureReportasat JUNE2013 Table 3 319 Annual Budget YTD Position Forecast Outturn Prev month Initial Current Summary Plan Actual Variance Forecast Var From Forecast Movement Plan Plan Health excluding Adult Social Care to Date to Date to Date Outturn Current Plan Variance in month £000 £000 £000 £000 £000 £000 £000 £000 £000

North & West Operational Unit 26,058 26,197 North Area - Caithness District 6,537 6,677 (140) 26,543 (346) (335) (11) 12,843 12,917 - Sutherland District 3,240 3,193 47 12,881 36 1 35 15,438 15,470 West Area - S,L, & WR District 3,854 4,225 (371) 15,904 (434) (400) (34) 20,749 20,859 - Lochaber District 5,315 5,489 (174) 20,941 (82) (106) 24 4,646 4,462 - West Area Mgt 663 692 (29) 4,368 94 111 (17) 79,735 79,905 North & West Operational Sub Total 19,610 20,276 (667) 80,637 (732) (729) (3) 3,759 3,759 N & W Hosted Services 965 990 (25) 3,776 (17) (20) 3

83,494 83,664 Total North & West 20,575 21,266 (692) 84,413 (749) (749) 0

South & Mid Operational Unit 12,985 13,013 South Area - Inverness West District 3,277 3,270 6 13,104 (91) (37) (54) 16,707 16,826 - Inverness East District 4,261 4,285 (24) 16,837 (11) (3) (9) 17,379 17,428 - NABS district 4,353 4,344 10 17,590 (162) (163) 2 3,334 3,332 - South Other services 837 747 90 3,338 (6) (18) 12 11,009 10,790 Mid Area - Easter Ross District 2,715 2,620 95 10,871 (81) (65) (16) 10,595 10,254 - Mid Ross District 2,509 2,471 38 10,354 (100) (89) (11) 3,604 4,309 - Mid Other services 1,075 1,059 16 4,352 (43) (62) 19 728 905 South & Mid Unit Central (166) (58) (108) 466 439 402 38 76,340 76,858 South & Mid Operational Sub Total 18,861 18,738 123 76,912 (54) (36) (18) 18,124 17,983 Adult Mental Health 4,388 4,349 38 17,982 1 0 1 1,214 1,206 Learning Disabilities 295 274 21 1,183 23 16 7 1,755 1,574 Substance Misuse 187 164 23 1,547 27 17 10 8,107 8,107 Dental Services 4,572 4,514 57 8,104 3 3 0 29,200 28,870 Sub Total SE CHP Hosted services 9,442 9,302 139 28,816 54 36 18

105,540 105,728 Total South & Mid 28,303 28,040 262 105,728 0 1 (1)

382,286 390,690 Sub Total 98,598 101,013 (2,416) 397,362 (8,704) (7,367) (1,337)

Central Services 17,257 17,394 Corporate Services 4,120 4,143 (23) 17,387 7 3 4 39,706 32,777 Central Costs/Reserves (1,891) (2,008) 117 30,157 2,620 2,620 0

618,894 620,545 Total Net Expenditure 144,446 146,966 (2,522) 624,590 (6,078) (4,745) (1,333)

Finance - Monitoring 5.3 Area Finance Rept to 30 06 13-APPs.xlsx Health 31/07/2013 14:25 Income & Expenditure Report as at JUNE 2013 320 Table 4 Annual Budget YTD Position Forecast Outturn Prev month Initial Current Plan Actual Variance Forecast Var From Forecast Movement Plan Plan Summary Adult Social Care to Date to Date to Date Outturn Current Plan Variance in month £000 £000 £000 £000 £000 £000 £000 £000 £000

North & West Operational Unit 6,681 6,696 North Area - Caithness 1,683 1,757 (74) 7,011 (315) (401) 86 4,910 4,920 - Sutherland District 1,238 1,242 (5) 4,865 55 59 (4) 5,264 5,296 West Area - S,L, & WR District 1,353 1,299 54 5,707 (411) (243) (168) 7,276 7,324 - Lochaber District 1,855 1,700 155 6,749 575 566 9 796 797 North & West Unit Central 199 146 54 824 (27) 90 (117) 24,927 25,032 Total North & West 6,329 6,145 184 25,156 (123) 71 (194)

South & Mid Operational Unit 8,045 8,175 South Area - Inverness West District 2,049 2,400 (352) 9,909 (1,734) (1,444) (290) 10,753 10,743 - Inverness East District 2,694 2,837 (143) 11,084 (341) (631) 290 7,674 7,678 - NABS district 1,944 1,922 22 7,511 167 (2) 169 4,723 4,782 Mid Area - Easter Ross District 1,198 1,487 (288) 5,921 (1,139) (1,040) (99) 6,691 6,642 - Mid Ross District 1,675 2,012 (338) 7,983 (1,341) (1,269) (72) 2,185 2,183 South & Mid Unit - Central 550 484 66 2,184 (1) (1) 0 40,070 40,204 Total South & Mid 10,110 11,143 (1,033) 44,592 (4,389) (4,387) (2)

20,969 2,485 Adult Social Care - Central 1,414 987 427 1,518 967 803 164 16,114 - Care at Home 4,081 4,526 (445) 16,419 (305) 36 (341) 3,391 - Business support 848 824 24 3,303 88 56 32 20,969 21,990 6,343 6,337 6 21,240 750 895 (145)

85,966 87,227 Total Net Expenditure 22,782 23,625 (843) 90,988 (3,762) (3,421) (341)

Finance - Monitoring 5.3 Area Finance Rept to 30 06 13-APPs.xlsx Adult Social Care 31/07/2013 14:25 NHS Highland 321 Savings 2013/14 Position as at JUNE 2013 Table 5

Savings Target Position to Date Forecast to achieve In Year Next Year B/fwd New N/R Achieved YTD Forecast Balance Forecast Outstanding Target Target Target Total Savings REC Non Rec REC Non Rec To Achieve FYE 2013/14 C/Fwd £000 £000 £000 £000 £000 £000 £000 £000 £000 £000 £000 H&SC Partnership

252 1,352 1,604 North & West Operational Unit 365 1,238 0 0 197 1,543 1,740 South & Mid Operational Unit 325 888 527 0 888 1,935 1,797 3,732 Adult Social Care 1,000 1,000 1,732 0 2,732 2,595 2,478 5,073 Raigmore 1,280 792 410 2,591 3,001 0 365 365 Facilities 112 253 0 0 63 77 140 Integrated Pharmacy 32 108 108 109 85 194 e health 99 95 0 95 5,151 7,697 12,848 Sub Total H&SC Partnership 2,114 1,888 3,909 2,237 2,699 0 6,824

312 2,088 2,400 Argyll & Bute CHP 934 1,166 300 300 2,000 2,000 Central Costs & Reserves 2,000 2,600 (2,600) 0 122 1,000 1,122 Corporate Services 461 127 534 0 41 620

5,585 10,785 2,000 18,370TotalCashEfficiencySavings 3,509 4,015 5,076 5,371 399 41 7,744

Finance - Monitoring 5.3 Area Finance Rept to 30 06 13-APPs.xlsx CRS 31/07/2013 14:25 Capital Income & Expenditure Report Month322 3 - 30th June 2013 Table 6

Annual Plan Position to Date Forecast Outturn Original Current Plan to Actual to Variance Forecast Variance from Plan Plan Summary Funding & Expenditure Date Date to Date Outturn Current Plan £000's £000's £000 £000 £000 £000 £000

FUNDING 5,892 5,895 NHS Highland Capital Allocation (Formula) 1,474 1,474 0 5,895 0 1,589 1,525 Radiotherapy replacement 381 381 0 1,525 0 896 896 Oban Dental 224 224 0 896 0 1,000 1,000 NDB Hub Dingwall 250 250 0 1,000 0 4,000 4,000 Raigmore Endoscopy 1,000 1,000 0 4,000 0 1,300 0 Raigmore C.I.F. 0 0 0 0 0 200 0 Revenue to Capital Virement 0 0 0 0 0 700 700 Raigmore Biomass 175 175 0 700 0 1,520 1,520 CEEF Eco Hospitals 380 380 0 1,520 0 110 0 Retained Capital Receipts 0 0 0 0 0 (304) 0 UK GAAP Capital 0 0 0 0 0 162 0 Tain Sub Debt 0 0 0 0 0 91 Detecting cancer Early 23 23 0 91 0 1,024 Raigmore C.I.F. 291 291 0 1,024 0

17,065 16,651 Allocation Letter June 2013 4,198 4,198 0 16,651 0

304 304 - Non Core Funding IFRS 0 0 304 0

17,369 16,955 SGHD Funding 4,198 4,198 0 16,955 0

- Pending allocations 200 Revenue to Capital Virement 0 0 200 0 74 Lochgilphead MHU 0 0 74 0 480 Allocation as per SG 0 0 480 0

17,369 17,709 Total SGHD Capital Funding 4,198 4,198 0 17,709 0

Expenditure/Commitments 1,679 1,704 Oban Dental 426 934 (508) 1,704 0 1,589 0 Radiotherapy replacement 0 0 0 0 0 0 0 Greater Inverness Masterplan 0 0 0 0 0 1,000 1,500 Dingwall Health Centre 375 24 351 1,500 0 1,959 1,959 CEEF Schemes 490 368 122 1,959 0 1,216 2,817 Raigmore Biomass 704 13 691 2,817 0 3,550 2,800 Raigmore Endoscopy 700 16 684 2,800 0 0 750 LIDGH/CGH/Belford E.D.U. 188 0 188 750 0 1,300 975 Raigmore C.I.F. Tower Block 244 12 232 975 0 242 242 Lifecycle Costs ERPCC 61 61 0 242 0 62 62 Lifecycle Costs Mid Argyll 16 16 0 62 0 50 50 Capital Salaries 13 0 13 50 0 162 162 Tain Enabling Works 41 130 (90) 162 0 74 Lochgilphead MHU 19 0 19 74 0 505 Reversionary Interest

13,314 13,095 Commitments 3,274 1,572 1,702 13,095 0

Rolling Programmes 1,985 2,200 Estates Backlog Main. 444 483 (40) 2,200 0 530 530 Medical Equipment 133 0 133 530 0 582 582 eHealth Replacement 146 0 146 582 0 837 837 Radiology 209 22 187 837 0

3,934 4,149 Rolling Programmes 931 506 425 4,149 0 Other 100 5 Raigmore SSD washer/disinfectors 1 4 (2) 5 0 91 Detecting Cancer Early 23 0 23 91 0 200 200 Revenue to Capital Virement 50 122 (72) 200 0 100 100 Dental Equipment 25 18 7 100 0 0 9BelfordFoodTrolleys 2 0 2 9 0 (279) (430) Contingency (108) 0 (108) (430) 0 839 128 NBV Disposals 128 0 128 128 0 0 490 Other 0 1 (1) 490 0 960 593 122 143 (22) 593 0

18,208 17,837 Gross Capital Expenditure 4,326 2,221 2,105 17,837 0

(839) (128) NBV Disposals (128) (128) 0 (128) 0

17,369 17,709 Net Capital Expenditure 4,198 2,093 2,105 17,709 0

0 0 SURPLUS/DEFICIT MONTH 3 0 2,105 2,105 0 0 323 Highland NHS Board 13 August 2013 Item 5.4

FORRES, WOODSIDE TAIN (FWT) BUNDLE PROJECT – FULL BUSINESS CASE ADDENDUM

Report by Nick Kenton, Director of Finance

The Board is asked to:

 Agree the Full Business Case Addendum for the FWT Bundle Project.

1. Aim

The aim of the paper is to present to the Board the Full Business Case (FBC) Addendum for the FWT (Forres, Woodside and Tain) Bundle Project.

This Addendum outlines briefly the changes since the FBC was presented to the Boards of NHS Grampian and NHS Highland on 5 February 2013, in particular it details the financial changes recorded at Financial Close and their variance from the figures in the Full Business Case.

The Full Business Case Addendum is submitted to the Board for approval prior to submission to the Capital Investment Group (CIG) at the Scottish Government Health Directorates (SGHD) for information.

2. Strategic Context

NHS Grampian and NHS Highland are committed to improving access to services for the public and therefore a need to provide investment in appropriate building infrastructure in the community to help achieve these objectives, with greater levels of need addressed in community settings and an increased emphasis on anticipatory care, self-care, re- enablement and health improvement.

The Full Business Case (FBC) includes the redevelopment of three health centres in Aberdeen, Forres and Tain. Planning of the proposed health centres has been taken forward in line with relevant national policy, local strategy and NHS guidance.

3. Key Milestones

1. The FBC was approved by the two Boards on 5 February 2013 and by the Scottish Government on 22 March 2013. The approval set an affordability ceiling for the Unitary Charge (UC) for the project of £1.852 million.

2. The Boards of NHS Grampian and NHS Highland respectively on 26 February and 5 March 2013 approved delegated authority to the Chief Executives, the Directors of Finance and their nominated deputies to sign the contract at Financial Close (FC). The certified minutes of these meetings were two of the documents presented at FC.

3. The delegated authority was conditional on the affordability of the Unitary Charge within the FBC not being exceeded. 324

4. Financial Close was planned for week commencing 25 March 2013. This deadline was not achieved as a number of specific contract documents were not completed or signed and the funder AVIVA had not concluded their due diligence and outstanding land valuation by James Lang Lasalle on behalf of AVIVA, as a consequence of the decision to move to a leaseback funding model in February 2013.

5. On 28 March 2013, in the offices of Pincent Mason at 141 Bothwell Street, Glasgow, the participants’ delegated officers signed the Project Agreement and a number of associated documents. During the subsequent 14 working days all of the remaining contract documents were signed by all parties. Financial Close was achieved on 18 April 2013.

6. The overall Unitary Charge has reduced at Financial Close by £0.285 million as demonstrated in the table below. This is well within the delegated authority provided by the Boards on approval of the FBC at the respective Boards meetings on 5 February 2013 when the not to be exceeded limit on the Unitary Charge was £1.852 million.

4. Contribution to Board Objectives

This project will contribute to achievement of “Better Health, Better Care, Better Value” in the Tain area by providing the facilities to assist clinicians improve the health of the population. The new facilities will enhance the experience of care for individuals. The new building will be more energy efficient and cost effective to operate than the two buildings it will replace.

5. Governance Implications

5.1 Staff Governance

Staff working in the current premises have been fully consulted and involved in the design of the new facility

5.2 Patient and Public Involvement

The Head of Public Relations & Engagement is a member of the local project group and a communications plan is in place to keep stakeholders informed including the general public and their representatives. A patient representative is a member of the local project group.

5.3 Clinical Governance

Local clinicians are members of the project group and have been involved in Benefits Realisation workshops.

5.4 Financial Impact

The financial impact is detailed in the FBC; additional costs have been identified and will be funded by local savings.

6. Risk Assessment

The project has its own Risk Register which is contained as Appendix 2j to the FBC.

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7. Planning for Fairness

An Equality and Impact Assessment was completed in early 2009.

8. Engagement and Communication

The project has an established governance structure with the Director of Finance as the Senior Responsible Officer. The local project group is chaired by the Director of Operations, South & Mid Operational Unit and includes representatives of both Tain medical practices, community and dental staff as well as a patient representative. The Head of Public Relations & Engagement is also included and a communications plan is in place to inform stakeholders including the general public and their representatives.

9. Conclusion

The FWT Bundle Project has completed the procurement process in compliance with European and Scottish Government guidance, and has closed at a Unitary Charge of £1.382million, £0.285million within the affordability limit agreed at FBC. It has successfully completed Key Stage Review 3 and the contract has been signed by all partners and the funders (AVIVA) to achieve Financial Close on 18 April 2013.

10. Recommendation

The Board is asked to agree the Full Business Case Addendum for the FWT Bundle Project.

Nick Kenton Director of Finance

2 August 2013

3 326 327

Boards of NHS Grampian and NHS Highland July / August 2013

NHS Grampian and NHS Highland

Forres, Woodside Tain (FWT) Bundle Project

Forres Health and Care Centre

Woodside Fountain Health Centre

Tain Health Centre

Full Business Case Addendum

July 2013 328 Forres, Woodside, Tain (FWT) Bundle Project Full Business Case Addendum

Aim

The aim of the paper is to present to the Grampian NHS and Highland NHS Boards the Full Business Case (FBC) Addendum for the FWT (Forres, Woodside and Tain) Bundle Project.

This Addendum outlines briefly the changes since the FBC was presented to the Boards of Grampian NHS and Highland NHS on 5 February 2013, in particular it details the financial changes recorded at Financial Close and their variance from the figures in the Full Business Case.

The Full Business Case Addendum is submitted to the two Boards for information prior to submission to the Capital Investment Group (CIG) at the Scottish Government Health Directorates (SGHD) for information.

Strategic Context

Discussion

Background

3. The delegated authority was conditional on the affordability of the Unitary Charge within the FBC not being exceeded.

5. On 28 March 2013, in the offices of Pincent Mason at 141 Bothwell Street, Glasgow, the participant’s delegated officers signed the Project Agreement and a number of associated documents. During the subsequent 14 working days all of the remaining contract documents were signed by all parties. Financial Close was achieved on 18 April 2013.

2 329 Forres, Woodside, Tain (FWT) Bundle Project Full Business Case Addendum

Unitary Charge

UNITARY CHARGE FBC Stage FBC Movement Addendum £m £m £m Unitary Charge Total 1.852 1.567 -0.285 Unitary Charge NHS Grampian 0.054 0.054 -0.000 Unitary Charge NHS Highland 0.131 0.131 -0.000 Unitary Charge SGHD 1.667 1.382 -0.285

Within the Financial Model the following inputs have changed and contributed to the reduction in UC.

MODEL INPUTS FBC Stage FBC Movement Addendum Reference Rate 2.85% 2.37% -0.48% Reference Rate Buffer 0.50% 0% -0.50% MLA & Margin 4.09% 2.10% -1.99% Construction Costs £13.602m £13.574m £-0.028m

The gilt rate (Treasury 6% 2028) at FC was 2.37%. During the weeks preceding FC, the gilt rate movement was monitored on a daily basis. As a consequence, a decision was made on Thursday 11 April by key members of the FWT Project Board, in discussion with our financial advisors, to pre-book the rate in anticipation of a FC within the 7 day limit of the pre-booking facility. This was enacted in order to provide certainty regarding financing and the Unitary Charge value. The buffer of 0.50% was removed at FC.

The overall lending rate achieved at FC is significantly lower than the rate identified in the FBC. This is due to the change of the preferred lender from the Co-op to AVIVA and the resulting improved financial terms.

A small saving of £0.028m has also been achieved on the construction costs of the project compared to the cost identified at FBC.

The net impact of these adjustments is a reduction in the baseline Unitary Charge of £0.285 million.

The NHS Boards’ notional contributions have not changed, since the reduction in lending rates and construction cost do not impact on the elements of the Unitary Charge that they will be paying.

Other Revenue Costs

7. There is no change to the estimated net recurring revenue costs associated with the project.

3 330 Forres, Woodside, Tain (FWT) Bundle Project Full Business Case Addendum

FBC Stage FBC Movement Addendum £m £m £m Net Recurring Running Costs - NHSG 0.118 0.118 0 Net Recurring Running Costs - NHSH 0.057 0.057 0 Non-recurring Advisors Fees 0.339 0.256 -0.083

The non-recurring cost of Advisors fees has decreased by £0.083 million. The figure in the FBC of £0.339m has proved to be an over-estimate. The revised figure is based on prudent estimates from the Advisors to the end of their involvement with the project. A significant decrease in input has been required from the Advisors, particularly Technical and Legal as a result of NHS Officers undertaking a greater element of the work than was originally planned.

Capital Costs

8. Capital costs have reduced by £0.029 million. A reduction in the fee costs for the purchase of the Woodside site in Grampian and a reduction in the forecast cost of the access road for Tain in Highland are partially offset by an increase in the fee cost associated with the purchase of the Tain site.

FBC Stage FBC Movement Addendum £m £m £m NHS Grampian Land & Fees 0.620 0.597 -0.023 Equipment 0.492 0.492 0

NHS Highland Land & Fees 0.322 0.327 0.005 Access Road 0.090 0.079 -0.011 Equipment 0.319 0.319 0 OBC Preparation 0.277 0.277 0

Total 2.120 2.091 -0.029

Sub Debt Injection

9. At FBC stage, the NHS Grampian and NHS Highland participation in the sub debt was estimated at £0.689m collectively. This has reduced to £0.402m at Financial Close, primarily due to the change of the preferred lender from the Co-op to AVIVA and the resulting improved financial terms. This payment was made in the last week of March 2013 to a holding account with the Boards’ Legal Advisor, Pinsent Masons, and subsequently paid into Sub-hubco’s account on achieving FC.

FBC Stage FBC Movement Addendum £m £m £m NHS Grampian 0.484 0.282 -0.202 NHS Highland 0.205 0.120 -0.085 Total 0.689 0.402 -0.287

4 331 Forres, Woodside, Tain (FWT) Bundle Project Full Business Case Addendum

Affordability

10. There is no change in the recurring revenue cost to the Boards’ from the figures provided in the FBC.

The non-recurring cost of the advisors fees has decreased by £0.083m, being a reflection of the considerable input by NHS Officers in undertaking a proportion of the Advisors’ roles.

The capital cost has reduced by £0.029m as outlined in section 8.

All of the costs of the project are within the affordability limits set in the FBC and within the budgets incorporated in the Boards’ capital and revenue plans on an ongoing basis.

Value for Money

11. A small overall saving of £0.028m has been identified in relation to the construction costs from those identified at FBC stage. These costs have been benchmarked by the Boards’ Technical Advisors and confirmed by them that for the project as a whole, they represent value for money.

The significant improvement in the lending rates from those identified at FBC also provide further evidence of value for money having been obtained for the project in terms of the financial deal with AVIVA. The Boards’ Financial Advisors have confirmed that the deal is representative of what can be expected in the market place.

Commercial Issues

12. Since the Board meetings on the 26 February (NHSG) and 5 March 2013 (NHSH) the Project Agreement has been completed. In finalising the agreement there were a small number of changes and revisions, however these are considered to be more of a drafting nature and do not alter the balance of risk previously agreed between the parties.

Risk

13. The risk register for the project is included as appendix 2j of the FBC. Of the 63 open risks included in the FBC Risk Register, 42 are now closed and 21 are still open and are being managed. Since the FBC was submitted 9 new risks have been identified, all are assessed as low or medium risks and are being managed by the joint project team.

Accounting Treatment

14. There has been no change to the accounting treatment described in the FBC.

Timetable

15. The table below outlines the key programme dates.

Financial Close 18 April 2012

Start on Site w/c 29 April 2012

FBC Addendum to NHSG Board, for information 6 August 2013

FBC Addendum to NHSH Board, for information 13 August 2013

5 332 Forres, Woodside, Tain (FWT) Bundle Project Full Business Case Addendum

FBC Addendum to SGHD for information 16 August 2013

Handover 25 April 2014

Bring into Operation May 2014

Project Management

16. The project management structure is outlined in Section 6 in the FBC and is being implemented to guide the three projects through build, commissioning and bring into operation in 2014.

Stakeholder Involvement

17. The stakeholder involvement for the Forres, Woodside and Tain Projects are summarised in appendix 2l, 2m and 2n of the FBC. Staff, local communities, public and patient representatives have been involved in shaping all three projects at a number of key stages over recent years including e.g. site selection and concept design. There is strong stakeholder support for all three projects. A number of issues and concerns have, however, been raised by neighbours surrounding the Forres site since construction commenced, they relate mainly to construction noise, dust and vibration in the early days of the development and about boundary issues e.g. trees and fences etc. A six hour drop in event for neighbours was held in June 2013 and was very well attended. Neighbourhood queries have now been responded to where possible.

Conclusion

Recommendation

1. The Grampian NHS Board and Highland NHS Boards are asked to note the Full Business Case Addendum for the FWT Bundle Project

Executive Lead

NHSG - Mr Alan Gray, Director of Finance NHSH - Mr Nick Kenton. Director of Finance

Mr Ross Davidson Mrs Jackie Bremner Finance Lead Project Director 15 July 2013

6 333 Highland NHS Board 13 August 2013 Item 5.5

NFECTION PREVENTION & CONTROL REPORT

Report by Liz McClurg, Infection Control Manager and Dr Jonty Mills, Consultant Microbiologist, on behalf of Heidi May, Board Nurse Director & Executive Lead for Infection Control

The Board is asked to:

 Note the performance position for the Board.  Note the progress to keep infection under control.

1. Aim The purpose of this paper is to update Board members of the current status of Healthcare Associated Infections (HAI) and Infection Control measures in NHS Highland.

2. Contribution to Board Objectives One of the Board key objectives is “to reduce to an absolute minimum the chance of acquiring an infection whilst receiving healthcare and to ensure our hospitals are clean”. This report presents a comprehensive view of HAI data and activities for scrutiny and feedback from the Board.

3. Summary Table 1 NHS Highland Infection Prevention & Control targets and performance data Group Target NHS NHS Highland Scotland Clostridium Age 65 and 39.0 28.4 20.8 Green difficile over (100,000 April 12 - April 12 – OBDs) March March 2013 2013.

Clostridium Age 15 and New 26.4 Green difficile over Target April – 25.0 June 2013 (100,000 (not OBDs) to validated) be Please achieved note* by 03/15 below Staphylococcus Age 15 and 26.0 29.8 21.8 Green aureus over (100,000) April12 – April 12 – bacteraemia AOBDs March March 2013. 2013.

Hand Hygiene 95% 95% 98% Green

Cleaning 90% 95% 95% Green

Estates 90% 97% 96% Green

Antimicrobial Hospital- 95% AMAU Amber prescribing based 94% Empiric (8 case prescribing notes out 334

Group Target NHS NHS Highland Scotland of 122)

Ward 4A Green 96%

Surgical Compliant New audit Amber antibiotic process prophylaxis for Colorectal Surgery not fully compliant.

Primary Care Less than 7% Amber empirical 5% prescribing

Source: - Health Protection Scotland/ISD/Local data.

* Please note that NHS Highland Local Delivery Plan Target Trajectory for Clostridium difficile cases in patients aged 15 and over at June 2013 is 34 per 100,000 OBDs.

4. Achievements

NHS Highland has met the HEAT targets for Staphylococcus aureus bacteraemia (SAB) and Clostridium difficile in patients aged 65 and over as at March 2013.

5. Challenges

 To influence the prevention and reduction of Clostridium difficile infections acquired in the community in the 15 – 64 age group.  To reduce MSSA bacteraemias by engaging all clinical staff in hospitals and the community in initiatives to prevent and reduce device/healthcare related infections.  To deliver Infection Prevention & Control support and HAI education in care homes and adult social care settings.  To address the need for risk assessment and screening for Multi-Drug Resistant bacteria (Carbapenemase producers) in light of recent Interim Guidance from Health Protection Scotland.

6. Risks

The lack of qualified Infection Prevention & Control Nurse resource in North Highland to ensure that all disciplines of staff have access to specialist infection prevention & control advice and guidance has been challenging, however an experienced Infection Prevention & Control Nurse has been appointed to the vacant post in Skye, Lochaber & Wester Ross. She takes up post in September 2013.

Jonty Mills – Consultant Microbiologist & Lead Infection Control Doctor

Liz McClurg – Infection Control Manager

2 August 2013

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NHS Highland Healthcare Associated Infection Report – March 2013

Section 1 – NHS Highland Board Wide Issues

1. Staphylococcus aureus (including MRSA)

Staphylococcus aureus is an organism which is responsible for a large number of healthcare associated infections, although it can also cause infections in people who have not had any recent contact with the healthcare system. The most common form of this is Meticillin Sensitive Staphylococcus Aureus (MSSA), but the more well known is MRSA (Meticillin Resistant Staphylococcus Aureus), which is a specific type of the organism which is resistant to certain antibiotics and is therefore more difficult to treat. More information on these organisms can be found at: Staphylococcus aureus : http://www.nhs24.com/content/default.asp?page=s5_4&articleID=346 MRSA: http://www.nhs24.com/content/default.asp?page=s5_4&articleID=252 NHS Boards carry out surveillance of Staphylococcus aureus blood stream infections, known as bacteraemias. These are a serious form of infection and there is a national target to reduce them. The number of patients with MSSA and MRSA bacteraemias for the Board can be found at the end of Section 1 and for each hospital in Section 2. Information on the national surveillance programme for Staphylococcus aureus bacteraemias can be found at: http://www.hps.scot.nhs.uk/haiic/sshaip/publicationsdetail.aspx?id=30248

1.1 Staphylococcus aureus bacteraemia target NHS Highland has met the HEAT target of 26.0 cases per 100,000 acute occupied bed days or lower by year ending March 2013. The annual rate, April 2012 – March 2013, is 21.8 per 100,000 acute bed days (55 cases).

From April 2013, NHS Boards are required to further reduce healthcare associated infections so that by year ending March 2015, Staphylococcus aureus bacteraemia (including MRSA) cases are 24.0 cases or less per 100,000 acute bed days. For NHS Highland that means no more than 60 cases.

1.2 Trends National data published by Health Protection Scotland identifies that NHS Scotland Staphylococcus aureus bacteraemia rate January – March 2013 was 30.1 per 100,000 acute occupied bed days. NHS Highland rate for the same period was 21.7 per 100,000 acute occupied bed days (14 cases).

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Figure 1 Funnel plot of S. aureus bacteraemia rates for all NHS Boards in Scotland against acute occupied bed days (x100, 000), January – March 2013.

HG = Highland

April – June 2013 rate (not yet validated by HPS) was 27.93 per 100,000 acute bed days (18 SABs). This is an increase in the quarterly rate, which in part may be due to seasonal variation. The rate for the same period last year was 30.3 per 100,000 acute bed days. The SABs were caused by a variety of sources some of which were preventable.

Figure 2 Staphylococcus aureus bacteraemia (MRSA and MSSA) cases per 100,000 occupied bed days, all ages, with 95% confidence interval (vertical lines), linear trend (Black line) and target (Red line) = 26, CI = Confidence Interval (January 2010 – March 2013) New Target from April 2013 (Blue line) = 24.

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1.3 Current Initiatives

A new strategy for Root Cause Analyses has been implemented to improve the time taken to feedback and learn from any Staphylococcus aureus bacteraemias

2 Clostridium difficile

Clostridium difficile is an organism which is responsible for a large number of healthcare associated infections, although it can also cause infections in people who have not had any recent contact with the healthcare system. More information can be found at: www.nhs.uk/conditions/Clostridium-difficile/Pages/Introduction.aspx

NHS Boards carry out surveillance of Clostridium difficile infections (CDI) and there is a national target to reduce these. The number of patients with CDI for the Board can be found at the end of section 1 and for each hospital in section 2. Information on the national surveillance programme for Clostridium difficile infections can be found at: www.hps.scot.nhs.uk/haiic/sshaip/ssdetail.aspx?id=277

2.1 Clostridium difficile Target

NHS Highland has met the HEAT target of 39 cases per 100,000 total occupied bed days or lower in patients aged 65 and over by year ending March 2013. The annual rate, April 2012 – March 2013 is 20.8 cases per 100,000 OBDs (40 cases).

National data published by Health Protection Scotland identifies that NHS Scotland Clostridium difficile infection rate in patients aged 65 years and over, January – March 2013 was 24.2 cases per 100,000 bed days. NHS Highland rate for the same period was 10.3 cases per 100,000 bed days (5 cases). 5 338

National data identifies that NHS Scotland Clostridium difficile infection rate in patients aged 15 – 64 years, January – March 2013 was 28.4 cases per 100,000 bed days. NHS Highland rate for the same period was 43.9 cases per 100,000 bed days (7 cases).

Figure 3 Funnel plot of CDI incidence rates in patients aged over 65 years for all NHS boards in Scotland, January to March 2013. NHS Orkney and NHS NWTC overlap, as does NHS Ayrshire & Arran and NHS Tayside.

HG = Highland

Figure 4 Funnel plot of CDI incidence rates in patients aged 15 – 64 years for all NHS Boards in Scotland, January – March 2013. NHS Borders, Orkney and NWTC overlap.

HG = Highland

Figure 5 Clostridium difficile cases per 100,000 occupied bed days, 65 years and over, with 95% confidence interval, linear trend and target (January 2010 – March 2013).

6 339

From April 2013, NHS Boards are required to further reduce healthcare associated infections so that by year ending March 2015, the rate of Clostridium difficile infections in patients aged 15 and over is 25.0 cases or less per 100,000 total occupied bed days. For NHS Highland that means no more than 70 cases.

2.2 Trends

April – June 2013 rate (not yet validated by HPS) of Clostridium difficile infections in patients aged 15 and over is 26.4 cases per 100,000 total occupied bed days, 17 cases of which 6 were in hospital and 11 were out of hospital. Figure 6 shows the rate of Clostridium difficile infections in patients aged 15 and over from April 2012 in NHS Highland

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2.3 Antimicrobial Management

Table 2 shows NHS Highland progress against the 3 national indicators.

Antimicrobial Indicator NHS Highland progress

Hospital-based empirical prescribing Ward AMAU – Non-Compliant In acute admission areas, antibiotic A variation in results over the last two months prescriptions are compliant with the local has seen median compliance from April 2011 antimicrobial policy and the rationale for - June 2013 drop to 94%. (8 medical notes treatment is recorded in the clinical case note out of 122) Appropriate treatment choices in above 95% of sampled cases. were made, however the reasons for varying from guidelines were not fully documented in the medical notes. Real time feedback on the learning points is given to the individual clinical team on unexplained variation from guidelines.

Ward 4A - Compliant Data for the last 15 months shows median compliance at 96%.

Surgical antibiotic prophylaxis Colorectal Surgery – non-compliant Duration of surgical antibiotic prophylaxis is For colorectal surgical prophylaxis, previous less than 24 hours and compliant with local audit data looked at only two simple process antimicrobial prescribing policy in above 95% measures - correct antibiotic choice and of sampled elective colorectal and urological single dose given. surgical cases. In March 2013, a more detailed audit looking at 5 separate process measures was introduced. The team are working towards the target of 95%. Real time feedback on significant variance is provided to the consultant anaesthetist and surgeon when unexplained variation from guidelines is identified. Collated feedback is circulated at the end of each month.

Urological Surgery Data collection for elective urological procedures commenced in March 2013. As a robust data collection method has not yet been identified, no data is available.

Primary care empirical prescribing Non-Compliant. Seasonal variation in Quinolone use Quinolone prescribing increased in the winter (summer months vs. winter months) is less months of 2012/13 by 7% when compared to than 5%. the summer months of 2012.

For seasonal quinolone variation, the national measure is based on actual quantity of antibiotic prescribed with no adjustments for population or activity. Use in the most recent winter months Oct 12 – March 13 is lower than the previous winter months October 11 – March 12 however use in the summer months of 2012 was at the lowest so 8 341

far measured since 2008 hence the variation of 7%. NHS Highland prescription rate for quinolones is below the national average for 2012/13.

Management of Infection Guidance Updates The Scottish Antimicrobial Prescribing Group has published good practice recommendations on the use of antibiotics in the frail elderly. This has been incorporated in the NHS Highland Formulary introductory section on principles of antibiotic treatment as the majority of elements apply to all patient groups, not just the frail elderly.

The revised national vancomycin and gentamicin policies have been updated for use in NHS Highland, including the national gentamicin prescribing chart and online calculators. New elements include safety features to reduce the length of prescribing of gentamicin, improved awareness of potential adverse effects and warnings on the online calculator when extreme values for age, height and weight are used.

Raising Antimicrobial Awareness – A Q&A Document for Ward Staff The Antimicrobial Management Team has endorsed the widespread circulation of this useful document across the board area. Developed by pharmacists in South East and Mid Operational Unit, the information is aimed at ward staff and covers where to find the antibiotic prescribing policy, how variation from guidelines is monitored and managed and recommended training courses on prudent antimicrobial use. The document has been cascaded via the Lead Nurses and added to the local handbooks and induction for junior medical staff.

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3 Hand Hygiene

Good hand hygiene by staff, patients and visitors is a key way to prevent the spread of infections. More information on the importance of good hand hygiene can be found at: http://www.washyourhandsofthem.com/ NHS Boards monitor hand hygiene and ensure a zero tolerance approach to non compliance. The hand hygiene compliance score for the Board can be found at the end of section 1 and for each hospital in section 2. Information on national hand hygiene monitoring can be found at: http://www.hps.scot.nhs.uk/haiic/ic/nationalhandhygienecampaign.aspx

3.1 Trends

NHS Highland Hand Hygiene Rolling Monthly Audit Programme continues across all clinical areas sustaining 98% compliance in May and June 2013

The July 2013 National Hand Hygiene Audit report shows NHS Highland compliance as 98%, National compliance was 96%.

3.2 Initiatives

Hand hygiene audits continue to be undertaken monthly by all clinical areas, the results displayed and any non compliance addressed.

4 Cleaning and the Healthcare Environment

Keeping the healthcare environment clean is essential to prevent the spread of infections. NHS Boards monitor the cleanliness of hospitals and there is a national target to maintain compliance with standards above 90%. The cleaning compliance score for the Board can be found at the end of section 1 and for each hospital in section 2. Information on national cleanliness compliance monitoring can be found at: http://www.hfs.scot.nhs.uk/online-services/publications/hai/

Healthcare environment standards are also independently inspected by the Healthcare Environment Inspectorate. More details can be found at: http://www.nhshealthquality.org/nhsqis/6710.140.1366.html

4.1 Current Rates

The monthly cleaning and estates audits as per the National Cleaning Services Specification demonstrated 95% compliance in May and 94% in June 2013 for domestic monitoring and 97% for estates monitoring in May and 95% in June 2013.

When cleaning was monitored in the Belford hospital in June 2013, compliance was found to be 85%. Following rectification of the issues, the area was re monitored and achieved 100% compliance.

5. Outbreaks/Incidents

There have been no outbreaks during June and July 1013.

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6. Surgical Site Infections (SSI)

Colorectal Surgical Site Infection

NHS Highland was the first Board in Scotland to develop a colorectal surveillance programme. This has proved extremely challenging as the nature of the surgery may involve more than one wound which can be readily contaminated with body fluids, or the patient may present with a perforated bowel. By necessity the surveillance required is also very complex. As an example, previous audit data for surgical prophylaxis looked at only two simple process measures namely correct antibiotic choice and single dose given. The audit now looks at correct choice according to policy (which is now 3 drugs), timing of administration in the 60 minutes prior to knife to skin, single dose administration unless long operation or high blood loss. For a long operation, the redosing of correct antibiotic combination at the right time is checked and for high blood loss, redosing of the correct antibiotic combination is also checked. This amounts to five separate measures.

The Colorectal and Infection Prevention & Control Teams continue to review all aspects of care to reduce the number of avoidable infections. Root cause analysis is carried out on elective SSIs. All wound dressings are now carried out in the refurbished clinical treatment room in Ward 4C. The variation in the type of wound dressings and the length of time dressings remain in situ is being reviewed. The Antimicrobial Pharmacist continues to support antibiotic prescribing (see page 7)

Orthopaedic Surgical Site Infections There was a rise in surgical site infections post repair of neck of femur January-March 2013, with a rate of infection of 4.5%, 4 cases (National rate 1.5%). All cases have been reviewed jointly by the Infection Prevention & Control Team and the Orthopaedic department. As a result a review of wound dressings has been implemented together with a renewed focus on care of invasive devices post-operatively, particularly urinary catheters. The rate of infection post hip arthoplasty was 0% (National rate 1%).

Caesarean Section Infections The recently published Health Protection Scotland Surveillance of Surgical Site Infection Annual Report for procedures carried out from January 2008 – December 2012 reported that NHS Highland was one of 3 Boards who were above the 95% confidence limit for caesarean section surgical site infections detected during inpatient stay and until day 10 post operatively, January – December 2012 with a rate of 4.4% (National rate 2%).

There has been a significant decrease in the rate of infections since October 2012 when the practice of leaving the abdominal wound dressing insitu for 7 days post operatively was introduced. January – March 2013 NHS Highland rate was 0.6% (National rate 1.3%)

Table 3 shows the number of Caesarean Section SSIs September 2011- June 2012 and October 2012- May 2013.

September 2011- June 2012 October 2012- May 2013 260 Elective procedures, 13 SSIs, Rate 5% 184 Elective procedures, 1 SSI, Rate 0.5%

281 Emergency procedures, 15 SSIs, Rate 224 Emergency procedures, 5 SSIs, Rate 5.3% 2.2%

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Healthcare Associated Infection Reporting Template (HAIRT) Section 2 – Healthcare Associated Infection Report Cards

The following section is a series of ‘Report Cards’ which provide information for each acute hospital (Raigmore, Caithness General, Belford and Lorn & Islands), and the community hospitals within each Operational Unit/CHP. The information includes the number of cases of Staphylococcus aureus blood stream infections (also broken down into MSSA and MRSA) and Clostridium difficile infections as well as hand hygiene and cleaning and estates compliance.

The out-of-hospital infections report card identifies infections as having been contracted from outwith hospital.

The information in the report cards is provisional local data and may differ from the national surveillance reports carried out by Health Protection Scotland and Health Facilities Scotland. The national reports are official statistics which undergo rigorous validation, which means final national figures may differ from those reported here. However, these reports aim to provide more detailed and up-to-date information on HAI activities at local level than is possible to provide through the national statistics.

Understanding the Report Cards – Infection Case Numbers

Clostridium difficile infections (CDI) and Staphylococcus aureus bacteraemia (SAB) cases are presented for each hospital and the community hospitals within each CHP broken down by month. Staphylococcus aureus bacteraemia (SAB) cases are further broken down into Meticillin Sensitive Staphylococcus aureus (MSSA) and Meticillin Resistant Staphylococcus aureus (MRSA). Data is presented as both a graph and a table giving case numbers. More information on these organisms can be found on the NHS24 website:

Clostridium difficile : http://www.nhs24.com/content/default.asp?page=s5_4&articleID=2139§ionID=1

Staphylococcus aureus : http://www.nhs24.com/content/default.asp?page=s5_4&articleID=346

MRSA: http://www.nhs24.com/content/default.asp?page=s5_4&articleID=252§ionID=1

For each acute hospital and community hospitals in each CHP, the total cases for each month are those which have been reported as positive from a laboratory report on samples taken more than 48 hours after admission. For the purposes of these reports, positive samples taken from patients within 48 hours of admission will be considered to be confirmation that the infection was contracted prior to hospital admission and will be shown in the “out-of-hospital” report card.

Understanding the Report Cards – Hand Hygiene Compliance

Good hand hygiene is crucial for infection prevention and control. More information can be found from the Health Protection Scotland’s national hand hygiene campaign website: http://www.washyourhandsofthem.com/

Hospitals carry out regular audits of how well their staff are complying with hand hygiene. The first page of each hospital/CHP report card presents the percentage of hand hygiene compliance for all staff in table form.

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Understanding the Report Cards – Cleaning Compliance

Hospitals strive to keep the care environment as clean as possible. This is monitored through cleaning and estates compliance audits. More information on how hospitals carry out these audits can be found on the Health Facilities Scotland website: http://www.hfs.scot.nhs.uk/online-services/publications/hai/

The Report Cards show the hospitals’ cleaning compliance percentage in table form.

Understanding the Report Cards – ‘Out of Hospital Infections’

Clostridium difficile infections and Staphylococcus aureus (including MRSA) bacteraemia cases are all associated with being treated in hospitals. However, this is not the only place a patient may contract an infection. This total will also include infection from community sources such as GP surgeries, care homes and the community itself. The final Report Card report in this section covers ‘Out of Hospital Infections’ and reports on SAB and CDI cases reported to a Health Board which are not attributable to a hospital. Given the complex variety of sources for these infections it is not possible to break this data down in any more detail.

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Abbreviations

AOBD Acute Occupied Bed Days AMAU Acute Medical Admissions Unit CDI Clostridium difficile Infection HAI Healthcare Associated Infection HAIRT Healthcare Associated Infection Reporting Template HEAT Health Improvement, Efficiency, Access, Treatment HEI Healthcare Environment Inspection HPS Health Protection Scotland ICU Intensive Care Unit ISD Information Service Division KPI Key Performance Indicator MSSA Meticillin Sensitive Staphylococcus Aureus MRSA Meticillin Resistant Staphylococcus Aureus OBD Occupied Bed Days PICC Peripherally Inserted Central Catheter SAB Staphylococcus aureus Bacteraemia SSI Surgical Site Infection

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Staphylococcus Aureus Bacteraemia (SAB) criteria

 Staphylococcus aureus isolated from blood, and Contaminated Blood  SAB diagnosis incompatible with clinical picture, i.e. no or Culture minimal clinical signs and symptoms indicating SAB.

 Staphylococcus aureus isolated from blood cultures taken 48 Hospital Acquired hours after admission or within 48 hours of discharge, and, Infection  The presence of clinical signs and symptoms indicating SAB

 Positive blood culture obtained from a patient within 48 hours of Healthcare admission to hospital and fulfils one of the following criteria Associated Infection  Attended a hospital clinic or seen by a healthcare worker at home (HCAI) or in a GP surgery within 30 days prior to the positive blood culture being taken.  Was hospitalised overnight in the 90 days prior to positive blood culture being taken.  Resides in a nursing, long term care facility or residential home.

 Positive blood culture obtained from a patient within 48 hours of Community Infection admission to hospital who does not fulfil any of the criteria for a HCAI.

Non hospital  If the SAB is not hospital acquired, but unable to determine if it is acquired infection community or HCAI. (NHAI)

15 348 349

Quarterly rolling year Clostridium difficile Infection Cases per 1000 total occupied bed days for HEAT Target Measurement

0.45

0.40

0.35

0.30

0.25

0.20

0.15

0.10

0.05

0.00 Apr 10 - Jul 10 - Oct 10 - Jan 11 - Apr 11 - Jul 11 - Oct 11 - Jan 12 - Apr 12 - Mar 11 Jun 11 Sept 11 Dec 11 Mar 12 Jun 12 Sept 12 Dec 12 Mar 13

Apr 10 - Jul 10 - Oct 10 - Jan 11 - Apr 11 - Jul 11 - Oct 11 - Jan 12 - Apr 12 - Mar 11 Jun 11 Sept 11 Dec 11 Mar 12 Jun 12 Sept 12 Dec 12 Mar 13 Actual Performance 0.34 0.26 0.26 0.22 0.28 0.30 0.29 0.29 0.21 Target 0.39 0.39 0.39 0.39 0.39 0.39 0.39 0.39 0.39

Quarterly rolling year Staphylococcus aureus Bacteraemia Rates per 1000 Acute Occupied Bed Days for HEAT Target Measurement

0.30

0.25

0.20

0.15

0.10 . 0.05

0.00 Apr 10 - Jul 10 - Oct 10 - Jan 11 - Apr 11 - Jul 11 - Oct 11 - Jan 12 - Apr 12 - Mar 11 Jun 11 Sept 11 Dec 11 Mar 12 Jun 12 Sept 12 Dec 12 Mar 13

Apr 10 - Jul 10 - Oct 10 - Jan 11 - Apr 11 - Jul 11 - Oct 11 - Jan 12 - Apr 12 - Mar 11 Jun 11 Sept 11 Dec 11 Mar 12 Jun 12 Sept 12 Dec 12 Mar 13 Actual Performance 0.21 0.21 0.21 0.21 0.20 0.24 0.23 0.22 0.22 Target 0.26 0.26 0.26 0.26 0.26 0.26 0.26 0.26 0.26 350

Pan Highland Total Staphylococcus aureus Bacteraemia Cases (all ages)

0 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13

Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Hand Hygiene Monitoring Compliance (%) 3 3 2 2 5 6 2 8 4 7 7 4 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 98 98 98 99 98 98 98 98 99 98 98 98 MRSA Bacteraemia Cases - (all ages)

12 Cleaning Compliance (%) 10 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 8 96 96 96 96 96 96 96 96 96 96 95 94 6 4 2 Estates Monitoring Compliance (%) 0 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 97 97 96 97 96 97 98 96 97 97 97 95

Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 0 0 0 0 1 2 0 2 0 1 1 0 Clostridium difficile Cases (ages 15 and over) MSSA Bacteraemia Cases (all ages)

18 12 10 13 8 8 6 4 3 2 -2 0 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13

Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 9 9 5 6 5 8 4 4 5 3 6 8 3 3 2 2 4 4 2 6 4 6 6 4 351

Raigmore Hospital Total Staphylococcus aureus Bacteraemia Cases (all ages)

12 10 8 6 4 2 0 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13

Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Hand Hygiene Monitoring Compliance (%) 2 1 1 0 1 1 0 1 3 2 1 2 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 98 96 99 95 99 99 98 99 99 99 99 99 MRSA Bacteraemia Cases - (all ages)

12 10 Cleaning Compliance (%) 8 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 6 93 94 93 94 96 96 95 94 94 94 97 96 4 2 0 Estates Monitoring Compliance (%) Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 98 98 96 96 97 97 97 97 97 97 98 95 0 0 0 0 0 0 0 0 0 0 0 0

Clostridium difficile Cases (ages 15 and over) MSSA Bacteraemia Cases (all ages)

18 12 13 10 8 8

3 6 4 -2 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 2 0 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13

Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 5 0 2 4 2 3 0 1 2 0 1 2 2 1 1 0 1 1 0 1 3 2 1 2 352 Caithness General Hospital Total Staphylococcus aureus Bacteraemia Cases (all ages)

0 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13

Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Hand Hygiene Monitoring Compliance (%) 0 0 0 0 0 0 0 0 0 1 0 0 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 100 100 98 100 99 99 99 99 100 99 98 98 MRSA Bacteraemia Cases - (all ages)

Cleaning Compliance (%) 10 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 8

96 99 96 95 96 95 97 97 96 97 97 97 6

2 Estates Monitoring Compliance (%) 0 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 96 98 96 97 97 97 99 99 96 99 100 96 Jul-12 Aug-12 Sep-12 Oct-12 Npv-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13

Jul-12 Aug-12 Sep-12 Oct-12 Npv-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 0 0 0 0 0 0 0 0 0 0 0 0

Clostridium difficile Cases (ages 15 and over) MSSA Bacteraemia Cases (all ages)

12 18 16 10 14 8 12 10 6 8 4 6 4 2 2 0 0 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13

Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 0 1 0 0 0 2 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 353 Belford Hospital Total Staphylococcus aureus Bacteraemia Cases (all ages)

0 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13

Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Hand Hygiene Monitoring Compliance (%) 0 0 1 0 0 0 0 0 0 0 0 0 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 96 99 100 98 100 98 100 99 100 98 99 98 MRSA Bacteraemia Cases - (all ages)

Cleaning Compliance (%) 10 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 94 97 97 97 98 99 96 97 96 95 95 85 8 6

4 Estates Monitoring Compliance (%) 2 0 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 100 98 96 96 96 98 99 97 100 98 99 98 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13

Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 0 0 0 0 0 0 0 0 0 0 0 0

Clostridium difficile Cases (ages 15 and over) MSSA Bacteraemia Cases (all ages)

18 12 16 10 14 12 8 10 8 6 6 4 4 2 2 0 0 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13

Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 354 Lorn & Islands Hospital Total Staphylococcus aureus Bacteraemia Cases (all ages)

0 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13

Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Hand Hygiene Monitoring Compliance (%) 0 0 0 0 0 0 0 0 0 1 1 0 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 100 98 98 100 99 100 100 100 100 98 99 100 MRSA Bacteraemia Cases (all ages)

12 Cleaning Compliance (%) 10 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 8 98 96 97 99 96 97 98 98 97 97 96 93 6

Estates Monitoring Compliance (%) 2 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 0 96 95 92 98 97 98 97 93 94 98 96 94 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13

Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 0 0 0 0 0 0 0 0 0 1 1 0

Clostridium difficile Cases (ages 15 and over) MSSA Bacteraemia Cases (all ages)

18 12 16 10 14

12 8

10 6 8

6 4

4 2 2 0 0 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13

Argyll & Bute CHP Community Hospitals Total Staphylococcus aureus Bacteraemia Cases (all ages)

Argyll & Bute Community Hospitals include Argyll & Bute Hospital, Lochgilphead, 8

Campbeltown Hospital, Cowal Community Hospital Dunoon, Dunaros Community 6 Hospital, Isle of Mull, Islay Hospital, Mid Argyll Community Hospital & Integrated 4 Care Centre Lochgilphead, Victoria Hospital & Annex Rothesay 2

0 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13

Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Hand Hygiene Monitoring Compliance (%) 0 0 0 0 0 0 0 0 0 0 0 0 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 97 98 97 98 97 97 98 97 97 97 97 98 MRSA Bacteraemia Cases (all ages) 12

Cleaning Compliance (%) 8

Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 6 96 97 97 97 95 95 96 97 97 96 95 96 4

Estates Monitoring Compliance (%) 0 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 97 95 98 96 95 96 98 95 94 97 99 94

Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 0 0 0 0 0 0 0 0 0 0 0 0

Clostridium difficile Cases (ages 15 and over) MSSA Bacteraemia Cases (all ages)

12 18 10 8 13 6 8 4

3 2 0 -2 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13

Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 356 Out of Hospital Infections Clostridium difficile Infection Cases

6 .

0 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13

Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 4 8 2 2 2 2 4 3 3 2 4 5

MSSA Bacteraemia Cases MRSA Bacteraemia Cases

12 12

10 10

8 8

6 6

4 4

2 2

Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 0 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13

Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 1 2 2 2 3 3 2 5 1 3 5 2 0 0 0 0 1 2 0 2 0 0 0 0 357

NW Operational Unit Total Staphylococcus aureus Bacteraemia Cases (all ages)

12 10 The North West Operational Unit comprises Dunbar Hospital, Thurso; Town & 8 County Wick; Lawson Memorial Hospital, Golspie; Migdale Hospital, Bonar Bridge, 6 Ross Memorial Hospital Dingwall, County Community Hospital Invergordon, 4 MacKinnon memorial Hospital, Broadford & Portree Hospital Isle of Skye. 2 0 Jul-12 Aug- Sep- Oct- Nov- Dec- Jan-13 Feb- Mar- Apr- May- Jun-13 12 12 12 12 12 13 13 13 13

Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Hand Hygiene Monitoring Compliance (%) 0 0 0 0 0 0 0 0 0 0 0 0 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 99 99 99 99 97 100 98 99 99 100 100 100 MRSA Bacteraemia Cases (all ages)

12 Cleaning Compliance (%) 10 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 8 97 95 95 96 95 96 96 97 92 95 92 95 6

Estates Monitoring Compliance (%) 2 0 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 96 96 97 98 97 98 99 99 96 94 95 94 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13

Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 0 0 0 0 0 0 0 0 0 0 0 0

Clostridium difficile Cases (ages 15 and over) MSSA Bacteraemia Cases (all ages)

12 10012

10 10 8 80 8 6 60 4 6 2 404 2 0 20 Jul-12 Aug- Sep- Oct- Nov- Dec- Jan-13 Feb- Mar- Apr- May- Jun-13 0 0 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 12 12 12 12 12 13 13 13 13 Jan-00

Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 0 0 0 0 0 1 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 358

South & Mid Operational Unit Total Staphylococcus aureus Bacteraemia Cases (all ages)

10 The South Mid Operational Unit comprises Ross Memorial Hospital Dingwall, County Community Hospital Invergordon, RNI Community Hospital Inverness, 8 Town & County Hospital Nairn, Ian Charles Community Hospital Grantown on 6

Spey, St. Vincents Hospital Kingussie. For the purposes of monitoring New 4 Craigs Psychiatric Hospital is included in this report card. 2

0 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13

Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Hand Hygiene Monitoring Compliance (%) 0 0 0 0 0 0 0 0 0 0 0 0 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 96 95 98 98 98 97 97 96 96 98 98 96 MRSA Bacteraemia Cases (all ages)

Cleaning Compliance (%) 10 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 8 96 95 96 96 97 93 95 94 95 97 95 95 6

Estates Monitoring Compliance (%) 2 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 0 95 96 96 97 95 95 97 97 95 97 97 96 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13

Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 0 0 0 0 0 0 0 0 0 0 0 0

Clostridium difficile Cases (ages 15 and over) MSSA Bacteraemia Cases (all ages)

12 100 12 10 1080 8 608 6 6 40 4 4 2 20 2 0 00 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12Jan-00 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13

Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 0 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 359 Highland NHS Board 13 August 2013 Item 5.6

NHS HIGHLAND 2012/13 KEEP WELL ANNUAL REPORT

Report by Angus MacKiggan, Keep Well Coordinator & Public Health Business Manager on behalf of Dr Margaret Somerville, Director of Public Health and Health Policy

The Board is asked to:

 Note and discuss the content of the report prior to it being submitted to the Scottish Government by 31 August 2013.

1 Background and summary

In March 2011, the Scottish Government issued guidance to NHS Boards on the development of plans to extend the Keep Well programme in their local areas. This guidance reinforced the need to identify how the programme would identify, target and engage with target populations as well as developing systems to monitor and report on progress against these proposals.

The arrangements for reviewing the Keep Well programme between April 2012 and March 2015 were set out as follows:

 At national level: through annual target and delivery plan updates and core indicator reporting  At local level: through production of annual reports and compliance with health check core components

2 2012/13 Keep Well Annual Report

A copy of the proposed NHS Highland Annual Report is attached. This has been compiled using the national template and guidance provided. As at the time of writing the report, only provisional data for the quarter 4 (January to March 2013) period is available relating to the number of referrals made following a health check, and where known the number who attend those services on at least one occasion. This only affects a very small part of the report. We are scheduled to report nationally on the quarter 4 data for that by 15th August and so figures in that section of the report may need to be adjusted prior to submission of the report to the Scottish Government. However, it is envisaged that any changes required will only be minimal.

3 Contribution to Board Objectives

Health inequalities continue to widen in NHS Highland, in line with the rest of Scotland, despite life expectancy increasing over time. Through its links with other strands of ongoing work toward reducing inequalities, Keep Well contributes to the better health and better care objectives by helping to ensure that the most disadvantaged groups in society are able to both access health care when it is needed and also to reduce their risk of ill-health and premature death as far as possible, bringing them more into line with more advantaged groups. 360

4 Governance Implications

The impact on all the relevant Governance Standards is described below:

 Staff Governance: all staff involved with Keep Well undergo a tailored induction training programme. Practitioners directly involved in health check delivery are also provided with a toolkit of guidance.  Patient and Public Involvement: the approach calls for communities and people to be at the centre of decisions made affecting them.  Clinical Governance: Keep Well is being implemented in accordance with clinical governance systems and standards.  Financial Impact: the impact of not supporting the targeted groups of people results in additional costs due to disadvantage and life-style-related health problems.

5 Risk Assessment

A risk register has been developed, which is monitored by the Keep Well steering group on a quarterly basis.

6 Planning for Fairness

An impact assessment has been carried out and signed off in line with the Planning for Fairness process.

7 Engagement and Communication

Verbal updates have been provided to local stakeholders involved in the work described above. A communications plan has also been developed using the Highland Health Voices toolkit to ensure that key localised and/or pan Highland messages remain consistent.

Margaret Somerville Director of Public Health and Health Policy

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Draft Version – 25 July 2013

NHS HIGHLAND 2012/13 KEEP WELL ANNUAL REPORT

August 2013 362

Contents

Page

Summary 3

Background 4

Progress in 2012-13 4

Resources Deployed 5

Key Activities and Outputs 5

Outcomes and Results 6

Future delivery plans 10

Implications & Programme Learning 11

Appendix 1: Key principles in the KW mainstream guidance, the Quality Strategy 13 outcomes and the preventative spend agenda

Appendix 2: Keep Well Implementation 2012-15 14

Appendix 3: NHS Highland Keep Well Governance Framework 2012-15 15

Appendix 4: Keep Well National Reporting Indicators 16

Appendix 5: NHS Highland Keep Well Assessment Form 17

Summary Keep Well is a national programme aimed at reducing inequalities in health. NHS Highland has focused on four main outcomes while implementing the national programme: 2 363

 The development of a stand-alone programme to provide cardiovascular health checks to specific population groups, defined both geographically and as vulnerable or hard to reach. The programme has been developed, although implementation has been delayed, with a consequent impact on the numbers of health checks delivered in 2012-13.  Developing an assets-based, participative approach to reducing inequalities Some geographical areas were selected specifically because there was no good history of positive community development work. Thus far we have seen an increase in NHS working with Third Sector and communities; increased public health capacity; and improved relationships and understanding between clinical and health improvement staff which can be built upon.  A culture shift from clinical to more holistic approaches to healthcare There is less tangible evidence on this partly through the drive to provide the health checks which has meant in some areas providing dedicated staff to do this rather than embedded staff as planned  Reaching and engaging those who are hardest to reach (this goes beyond the delivery of a one-off consultation) The first level of our targeting has worked by selecting specific areas through work with health intelligence. Within those areas however staff feel that those attending are those who experience less inequalities.

Key Results: 670 out of a target number of 850 health checks were delivered in 2012-3, representing about 22% of the overall target population in Highland. 40.1% of those who attended a health check were referred to follow-on services; the majority of these referrals were made to encourage and/or support lifestyle changes. Referrals to a GP were less than 10% of those attending for a check. It is understood that 72.2% of these referrals were attended on at least one occasion, but it has proved difficult to track patient journeys across all referral systems.

20.9% of those who had a health check were found to have an ASSIGN risk score over 20, with that increasing to approximately 1 in 4 (27.6%) for carers who had a health check. Carers aged 50 to 64 appear to be most at risk with approximately 1 in 3 (34.8%) who had a health check found to have an ASSIGN risk score over 20 (table 10).

Key findings and learning from this report will be considered by the NHS Highland Keep Well Steering Group with a view to help improve targeting, reach and overall performance of the programme in 2013/14 and beyond.

Background Keep Well is a Scotland wide targeted anticipatory care programme funded by the Scottish Government. The aim of the programme is to increase the rate of health improvement in deprived communities and contribute to reducing the health inequalities gap. The focus of the programme is the primary prevention of cardiovascular disease (heart disease and stroke), through the delivery of the Keep Well Health Check and the offer of follow up support as required. As well as focusing on physical factors, the Keep Well assessment addresses the wider

3 364 determinants affecting health. It also offers the opportunity to target and identify those at increased risk of developing preventable health issues and then to offer appropriate support to modify health related behaviours. The core target population is individuals aged between 40 and 64 who are not already included in practice based stroke, diabetes or CVD disease registers and living in the most deprived communities or geographical localities. Additionally, Boards are also required to target specific vulnerable populations aged between 35 and 64 who are considered to be at increased risk of CVD. Details of the key principles of the national Keep Well guidance, the Quality Strategy outcomes and the preventative spend agenda is attached at Appendix 1.

Work to develop Keep Well in Highland began by building on lessons from Well North, the local pilot programmes which were the northern version of Keep Well pilots that took place in other Boards from 2006. We recognised early on that the Well North pilots worked because of very specific local factors in remote and rural communities that were not easily transferable to larger populations. We therefore developed a methodology based on SIMD to target specific areas within Highland that were deprived. We also noted that health checks were delivered best where there was a history of community development, or where community development was started.

As a result, our Keep Well programme targets geographical populations and population groups with specific characteristics making them more vulnerable to disadvantage. It employs a community development methodology that seeks to influence the wider determinants of health for specific communities. We are targeting in two ways:

 For the general age-specific groups (40-64 year olds), use of geographical targeting based on our most socio-economically deprived areas  For specific vulnerable groups (travellers, substance misuse service users, offenders, carers, the homeless and ethnic minorities), a mainly Highland wide approach is being undertaken

Progress in 2012-13 NHS Highland was set a challenging target of 850 inequalities targeted cardiovascular health checks in 2012/13, of which 670 were delivered. The main reason for not achieving the target was the time taken to develop and implement stand-alone programmes both for inviting the target groups to have a health check and for delivering the health check through community-based teams.

There has been good progress throughout the year with focus on community development, which is central to our work on inequalities generally. Community development activities will precede the introduction of health checks in all our targeted geographical areas and then run alongside them. The phased implementation plan agreed with Scottish Government identified the key areas in Highland to be included and set out the timeframe for the start of community development activities and subsequent health checks (Appendix 2). The community development approach comprises two major strands of complementary work: community engagement and building communities themselves. The community engagement approach uses a variety of communication methods e.g. newspapers, presentations and discussions with local groups and campaign work with other organisations including local authorities.

An important aspect of implementation has been the bringing together of all lifestyle health improvement activities, thus reducing silo thinking of just smoking, alcohol or weight management in isolation of each other. Individuals have found this approach helpful.

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Those who have received a health check also appear to have valued the experience. Data collated for national indicator reporting purposes highlights that the majority of health checks were delivered to those who reside in our most deprived areas. However, there is a feeling by some staff involved in the delivery of Keep Well that it is the most able within those deprived areas who are taking up the offer of a health check with those least able not making any contact with services. An example of positive client feedback received is as follows:

“I had my Keep Well health check in June 2012 and it has inspired me to change my lifestyle choices significantly. It motivated me to take charge of my own health and I’ve gradually made lifestyle changes which 10 months later have produced huge health benefits. I’ve reduced my BMI & cholesterol and increased physical activity from minimal to jogging 2-3 miles four to six times a week”.

The longer appointment time (approx 45 minutes) for the Keep Well assessment has been found useful for both the individual and the practitioner as there is time to get to some of the more complex issues facing people when trying to make lifestyle changes. There is also some belief that the programme has made people think more about their role in relation to prevention and has helped stimulate interest in health inequalities.

Resources Deployed The majority of the £396K funding available was allocated to health check delivery costs in line with agreed local operational unit resource plans. The remaining part of the budget was used for other core aspects necessary to support the programme such as Board coordination; workforce training and development, equipment; eHealth support and development of systems; follow-on services and pump priming community development work. A considerable level of ‘time in kind’ has also been dedicated to the programme by the Director of Public Health, Programme Lead (Public Health Specialist), the Head of Health Improvement and other staff, which has greatly contributed to the local delivery of Keep Well.

An NHS Highland Keep Well steering group has been established, which is chaired by the Director of Public Health. Local steering groups have also been set up in each of the project areas and meet on a frequent basis. A diagram of the NHS Highland Keep Well governance framework is attached at Appendix 3.

Key Activities and Outputs The approach being taken by the Keep Well programme links into many other existing workstreams such as implementing equalities, disability and homelessness legislation and Early Years interventions (parenting, Healthy Start), which are about targeting specific disadvantaged groups, either on a group characteristic basis, such as ethnicity, or geographical population basis, to ensure that they have equitable access to health care. The solutions may include specific services or interventions for these groups, or raising awareness in mainstream staff and services that these groups may need additional support to obtain the services they need.

Examples of key local area activities that have taken place during 2012/13 are as follows:  A communication and engagement plan was developed using the Highland Health Voices toolkit for incorporation into local area plans  Links have been made with Health Improvement targets such as smoking cessation, alcohol brief interventions (ABIs), weight management and the new Detect Cancer Early (DCE) campaign, which are all the focus of HEAT targets with an inequalities element  Staff attended a number of festivals and/or community events across Highland in order to promote Keep Well and provide general health 5 366

and wellbeing information  Very successful partnership working took place with High Life Highland during a ‘Commit 2 Change’ week in January 2013 with 176 Keep Well assessments carried out. High Life staff were very enthusiastic about the Keep Well approach and expressed an interest in delivering health checks in the future  Links have been established with varied partnership agencies and voluntary groups to promote Keep Well and to help develop a collaborative approach to health and wellbeing  A training programme involving Health Behaviour Change and the use of motivational interviewing techniques for staff delivering health checks has been developed and delivered in the local Keep Well areas. This training is open to local practitioners from a range of agencies. Practitioners directly involved in health check delivery are also provided with a toolkit of guidance. Additionally, the training package has been structured to enable staff to become more knowledgeable about community development and its role in developing/enhancing self efficacy. Thirty two members of staff and local enthusiasts in some areas are now volunteering to carry out mail drops and helping to promote health checks as a result of the training

Outcomes and Results The proportion of our total eligible target population for 2012/13 who received a health check was approximately 22%; more exact data will be available in future years when the data systems are more fully developed and access to GP registers may be possible. The national Keep Well reporting requirements are listed in Appendix 4. Additionally, the Scottish Government expects all Boards to carry out and record other core components of the health check to ensure that all eligible patients, regardless of geographical location or delivery setting, have the same opportunity to experience a holistic health check. A copy of the agreed NHSH Keep Well Assessment Form is attached at Appendix 5.

National Indicator 1: Number of health checks undertaken for people expressed as a percentage of the total delivered in 2012/13.

Completed checks SIMD Quintile Actual Percentage 1 – Most deprived 303 45.2% 2 258 38.5% 3 52 7.8%% 4 2 0.3% 5 – Least deprived - - Unassigned 55 8.2% Total 670 100% Notes: 1. The above data includes all individuals regardless of whether in core population or in vulnerable populations. 2. To give a more accurate indication of reach, the above figures have been expressed as a percentage of the total health checks delivered in 2012/13 rather than the local target (850), which national indicator reporting submissions were based on.

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3. Unassigned: Refers to health checks completed, without a postcode attached to them. This could be for a number of reasons, such as health checks delivered to individuals without a fixed abode (homeless, offenders, etc.) or postcode missing at the time of data extraction.

The above data highlights that the majority of health checks were delivered to those who reside in our most deprived areas. However, there is anecdotal evidence from staff that it is the most able within those deprived areas who are taking up the offer of a health check with those least able not making any contact with services. Additionally, although every effort is made to target those in SIMD quintiles 1 and 2 as much as possible, a relatively small proportion of checks were delivered in quintiles 3 and 4 given that targeting of deprivation in our most remote and rural areas is problematic due to the diversity of our populations.

National Indicator 2: Number of health checks undertaken for carers, expressed as a percentage of the total delivered in 2012/13.

Carers Total number of health Number of Percentage Reported checks delivered carers checks National Keep Well Average Total 670 58 8.7% 8.2% Note: 1. To give a more accurate indication of reach, the above figure of 8.6% has been expressed as a percentage of the total health checks delivered in 2012/13 rather than the local target (850), which national indicator reporting submissions were based on.

The above data shows that we were in line with the reported national average for the percentage of health checks delivered to carers.

Details of engagement that took place with specific vulnerable groups in 2012/13 is as follows:

Prisoners: A total of 33 health checks were delivered during 2012/13. The number is fewer than anticipated due to staffing issues.

Gypsy travellers: The gypsy traveller site manager meets with all families that come on to both official and unofficial sites and provides information to all families about the Keep Well health checks. Nonetheless, despite several visits to the official site in Inverness, the offer of health checks was not taken up by travellers. However, some ad hoc visits to unofficial sites in the Easter Ross area resulted in 9 health checks being delivered during 2012/13.

Homeless people: Approximately 55 health checks were delivered at the homeless day centre in Inverness during 2012/13. It has become more difficult to offer this service to homeless people attending due to lack of facilities since the move of the homeless health team to the Royal Northern Infirmary.

Substance misuse: No-one from the substance misuse service has yet taken up the offer of a health check.

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National Indicator 3: Number of those attending for a health check with an ASSIGN risk score ≥20%, expressed as a percentage of the total health checks delivered to patients over 40 years of age.

Population Number of Number of Number of people Reported National Keep people with people with with ASSIGN risk Well Average (ASSIGN completed ASSIGN risk score ≥20% risk score ≥20%) health checks score recorded (%) All Age range: 320 276 51 (a) aged ≥40 and <50 (15.9%) 4% (b) aged ≥50 and <65 301 262 79 (26.2%) 25% Totals 621 538 130 (20.9%) 15%

Carers (included within figures 35 33 8 above): (22.9%) 5% (a) aged ≥40 and <50 (b) aged ≥50 and <65 23 21 8 (34.8%) 26% Totals 58 54 16 (27.6%) 17% Notes: 1. It was agreed nationally that the ASSIGN score indicator for year 2012/13 would reflect only on patients over 40 years of age. Therefore any health checks delivered to individuals from the vulnerable groups under the age of 40 would not be captured on indicator 3. 2. ASSIGN is a cardiovascular risk score developed in Dundee University, Scotland in 2006. Further details can be found at: http://assign-score.com/estimate-the-risk/

National Indicator 4: Number who have had at least one new chronic disease problem identified within 3 months of their most recent health check, expressed as a percentage of total health checks.

Highland have not been able to report on this indicator due to lack of access to GP Practice data for Keep Well purposes.

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Of the 670 health checks carried out in 2012/13, a total of 273 referrals were made. A breakdown of the numbers/proportion of patients referred by type of follow-up service is as follows:

Services Number % of the total number of of referrals health checks delivered (670) Weight Management 32 4.8% Alcohol Interventions 33 4.9% Smoking Cessation 57 8.5% Benefits Counselling 4 0.6% Employment Services 8 1.2% Mental Health 7 1.1% Wellbeing/Health Coaching 13 1.9% GP 64 9.6% Practice Nurse 8 1.2% Dentist 28 4.1% CAB 4 0.6% Sexual Health 1 0.2% Physical Activity 7 1.1% Family Planning 1 0.2% Community Addictions Team 6 0.9% Total 273 40.1%

Note: The above figures involve the use of provisional data for the quarter 4 (January to March 2013) period as we are not scheduled to report nationally on that until 15th August. Therefore, the above figures may need to be adjusted at that stage. However, it is envisaged that any changes required will only be minimal.

Although the referral rate of 40.1% seems relatively high, the majority of these were made to encourage and/or support lifestyle changes. Referrals to a GP were less than 10%. In addition to the above, at least twelve patients had been supported to access bowel screening kits with a further three advised to contact their practice nurse to arrange for cervical screening.

National Indicator 5: Number of patients who have been referred from Keep Well health check providers to internal and external services and who attend those services on at least one occasion.

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Services Number of health Number Number of checks of referrals attendances Weight Management 32 *28 Alcohol Interventions 33 *29 Smoking Cessation 57 *52 Mental Health 7 *7 Wellbeing/Health Coaching 13 *13 Employability 8 *- Others: GP - 64 123 *68 Practice Nurse - 8 Dentist – 28 Benefits Advice - 4 CAB - 4 Sexual Health - 1 Physical Activity - 7 Family Planning - 1 Community Addictions Team - 6 Totals 670 273 *197 Notes: 1. * These figures are based on local intelligence information and are as accurate as we can get them without having access to GP practice data and/or other service systems. NHS Health Scotland and the Scottish Government have acknowledged this. 2. The above figures involve the use of provisional data for the quarter 4 (January to March 2013) period as we are not scheduled to report nationally on that until 15th August. Therefore, the above figures may need to be adjusted at that stage. However, it is envisaged that any changes required will only be minimal.

The above data highlights that 72.2% of referrals made were attended on at least one occasion, but it has proved difficult to track patient journeys across all referral systems.

Future delivery plans To date, primary care in NHS Highland has only been engaged in delivery of health checks in a minority of our Keep Well areas. Discussions are in progress to extend that engagement on delivery of health checks and in terms of access to practice data.

The central data system that has been developed makes it possible to identify eligible targeted patients using CHI numbers and this has enabled the Patient Booking Service to send out invitation letters and follow up reminders, which are expected to boost health check numbers. However, the quality of the CHI data used so far has been raised as an issue, as it has been found that patient information can often be unreliable or outdated, resulting in a low uptake of appointments. Further work to improve quality is in progress

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Although considered to be an issue at the time, making progress with the implementation of Keep Well in the context of major reorganisation with integration of health and social care is now viewed by many in a positive light.

Implications & Programme Learning A brief summary of what is viewed to have worked well in 2012/13 and what hasn’t and/or seen with some negativity is as follows:

What’s viewed to have worked well

a. The fact that the health check covers a range of lifestyle issues and risks and not just one topic is helpful to individuals.

b. The longer appointment time (approximately 45 minutes) is useful for both the individual and the practitioner as there is time to get to some of the more complex issues facing people when trying to make lifestyle changes.

c. Getting relatively well people to think about their lifestyle before they need to access health services as a result of lifestyle related illness.

d. The programme raises awareness with individuals about health risks before they become ill.

e. The programme helps to reduce silo working on several lifestyle topics such as smoking cessation and healthy weight, e.g. looking at the ‘whole’ person rather than just individual behaviours; and generic use of staff supported through training and mentoring.

f. The community development approach is helpful in engaging communities rather than the traditional delivery of health services.

g. Individuals who have received a health check have valued the experience.

h. Delivery that is tailored to local circumstances has been important in getting people engaged.

i. The programme has made people think more about their role in relation to prevention and has helped stimulate interest in health inequalities.

j. Improved links with local voluntary sector and other organisations who support health in its broadest sense e.g. local authorities.

What’s viewed not to have worked so well and/or seen with some negativity

a. Despite targeting deprived areas, there is a feeling that it is the most able within those deprived areas who are taking up the offer of a health check with those least able not making contact with services, thus widening the gap in health inequalities.

b. In some areas lack of local services to signpost or refer people on to (i.e. emerging feeling that onward referral to services has to be very local and not always practical to deliver on this).

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c. The programme is more difficult to implement in remote and rural areas where deprivation is not clustered in the same way as urban areas.

d. It has been difficult to embed the programme within existing structures, often having to rely on funding additional posts for Keep Well rather than being able to build capacity within existing structures, especially in rural areas. This has mainly been due to the short/fixed term and uncertain nature of funding.

e. The programme only goes some way to getting staff to work ‘upstream’ or think preventatively about the wider determinants of health, this still being a very medical model.

f. Engagement with Primary Care

g. Availability of staff to offer more flexible access to health checks.

h. Difficulties experienced in accessing reliable data in the absence of Primary Care data means that fulfilling the requirements of guidance around contact methods is more difficult.

i. The programme cannot be sustained without specific funding. The delivery often relies on a few key people rather than being embedded within services.

j. Communities are getting fatigued by short-term funded projects and it is widely considered that they do more harm than good.

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Appendix 1

Key principles in the KW mainstream guidance, the Quality Strategy outcomes and the preventative spend agenda

The key principles of the Keep Well Extension Programme are that:

 Keep Well is a national programme, which aims to help reduce Scotland’s socio-economic health inequalities.  Whilst Keep Well will operate in all Boards, activity will be focussed in those communities/populations that contribute most to Scotland’s health inequalities with the available national resource allocated accordingly.  In order to reduce socio-economic health inequalities in this way, Keep Well –and the national resource that will be allocated to help deliver the programme must be targeted at the most deprived communities within a Board area.  Within these deprived communities, Keep Well will target those at high risk of cardio-vascular disease. This reflects both the role of CVD in contributing to premature morbidity and mortality in deprived communities, but also the common risk factors shared by CVD and other causes of premature morbidity/mortality.  The Keep Well health check will take a holistic perspective covering CVD risk, but also a range of other clinical and non-clinical factors, including wider life circumstances. Patients will be referred on to follow-on services as appropriate and as agreed with these individuals. In so doing, the approach will be to build on an individual’s strengths as well as supporting the necessary behaviour changes required.  The Keep Well Extension Programme should support a wider culture shift in embedding inequalities sensitive practice across primary care.  The Keep Well Extension programme is established in such a way to allow a robust evaluation of outcomes supported by short, medium and long term success factors.

Six healthcare Quality Outcomes from the Quality Strategy provide a description of the priority areas for improvement in support of the Quality Ambitions. These Quality Outcomes provide a context for partnership discussions about local and national priority areas for action. The six healthcare Quality Outcomes are:

 Everyone gets the best start in life, and is able to live a longer, healthier life  People are able to live well at home or in the community  Healthcare is safe for every person, every time  Everyone has a positive experience of healthcare  Staff feel supported and engaged  The best use is made of available resources

The preventive spend agenda focus is on encouraging joint working across the public sector with a specific focus on adult social care, early years and tackling re-offending.

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Appendix 2 Keep Well Implementation 2012-15

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Appendix 3

NHS HIGHLAND KEEP WELL EXTENSION PROGRAMME

GOVERNANCE FRAMEWORK 2012-2015

NHS Highland Board

Highland Health & Social Senior Management Care Partnership and Team (operational matters) Argyll & Bute CHP Keep Well Steering Group Improvement Committee •Delivery Model (performance monitoring) •Performance Monitoring •Budget Monitoring •Programme Risk Management •Quality Assurance •eHealth •Workforce •Troubleshooting •National Reporting

Argyll & Bute South & Mid Highland North & West Highland Operational Management Operational Management Operational Management Team Team Team

Inverness Easter Ross Kinlochleven Caithness & Sutherland Argyll & Bute Locality Keep Well Locality Keep Well Locality Keep Well Locality Keep Well Locality Keep Well Steering Group Steering Group Steering Group Steering Group Steering Group

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Appendix 4

Keep Well National Reporting Indicators

Core reporting indicators to monitor the delivery of Keep Well across Scotland from April 2012 were approved by the national Keep Well Extension Board on 12 August 2011 as:

1. Number of people who attend appointments expressed as a percentage of the local target.

2. Number of first health checks undertaken for carers, expressed as a percentage of the local target.

3. Number of those attending for a health check with an ASSIGN risk score ≥20%, expressed as a percentage of first and review health checks

4. Number who have had at least one new chronic disease problem (diabetes, CHD, hypertension) identified within 3 months of their most recent health check (either first or review), expressed as a percentage of total health checks.

5. Number of patients who have been referred from Keep Well first or review health check providers to services* and number who attend those services* on at least one occasion, expressed as a proportion of first and review health checks (*services covering weight management, alcohol interventions, smoking cessation, mental health, wellbeing/health coaching, literacy, employability)

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Appendix 5

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Highland NHS Board 13 August 2013 Item 5.7

CHIEF EXECUTIVE’S AND DIRECTORS’ REPORT EMERGING ISSUES AND UPDATES

1 ARGYLL & BUTE MENTAL HEALTH UNIT DEVELOPMENT

Scottish Futures Trust has just completed the Stage 1 Key Stage Review of the Lochgilphead Mental Health Unit development. This review concluded that this project requires to be 'bundled' with another Northern Territory project to achieve value for money. The process of forming this bundle has begun and timescales for the Outline Business Case (OBC) and Full Business Case (FBC) will be put in place when the bundle programme is developed.

2 NHS HIGHLAND ANNUAL REVIEW – 19 JULY 2013

Earlier this month (19 July) NHS Highland was the first Board to take part in the new style of Annual Review – the first under the Cabinet Secretary for Health and Wellbeing, Mr Alex Neil.

The Minister spent the morning with patients, carers and members of the public. He then went on to hear from staff about progress with integration of health and social care services in Inverness. During the day he also met with the Area Clinical Forum, Partnership Forum and the Board.

In his opening address at the open public session held in the Highland Council Chambers, he congratulated NHS Highland and the Highland Council for their commitment to embrace the integration agenda.

Some of the challenges experienced by NHS Highland during 2012/13 were discussed including cancer waiting times, paediatric insulin pumps, failure to deliver some of the targets set out for stroke services and care at home. Recruitment and retention was also raised as an issue.

Formal feed-back will be received in due course and this will be available to the public.

The public session, which took place in the Highland Council Chambers is available to view and can be accessed here – http://www.highland.public-i.tv/core/

3 REGIONAL PLANNING – NORTH OF SCOTLAND AND WEST OF SCOTLAND PLANNING GROUP

A copy of the Briefing from the June 2013 Meeting of the North of Scotland Planning Group is circulated as Supplementary Paper 1 to this update. There is no update this month from the West of Scotland Planning Group. 380

4 RESPONSE TO AUDIT SCOTLAND RECOMMENDATIONS ON IMPROVING COMMUNITY PLANNING IN SCOTLAND

In March 2013, Audit Scotland published a report on improving community planning in Scotland. Its key findings were that Community Planning Partnerships (CPPs) have been unable to show sustained and significant improvement in outcomes for their communities and have not made an impact on reducing inequalities. The report’s recommendations were grouped into five areas: strong shared leadership, governance & accountability, clear priorities for improvement and for use of resources, community engagement & empowerment and improvement support & capacity building.

NHS Highland is a partner in two CPPs: Highland and Argyll & Bute. Each CPP has developed a draft Single Outcome Agreement (SOA) and has had a visit from a nationally organised peer review scrutiny panel which has provided, or will be providing, written feedback. Highland CPP has also undertaken a form of self assessment against the Audit Scotland report and the national guidelines for CPPs and SOAs and is developing an action plan to address the issues arising from the self assessment. Argyll & Bute CPP is to carry out their self assessment following agreement of the SOA and incorporate this with a refresh of their Audit Scotland Health Inequalities response. Final SOAs for each partnership are to be agreed and submitted to Scottish Government by 31 March 2014.

5 UPDATE ON CARERS’ STRATEGY

Connecting Carers, a subsidiary of Highland Community Care Forum are progressing the Adult Carers Strategy as agreed by the Highland Partnership in 2011. This is monitored through a contract with the NHS as Lead Agency for adult services and regular contract monitoring is in place. The work on the Strategy for Young Carers is being led by the Highland Council and is monitored through the same joint contract.

The adult carer strategy work with the independent and voluntary sectors has got off to a good start and the plan of having a draft strategy for the October Board is on schedule with the final strategy to be published in December.

Connecting Carers have reported that they have also made good progress on the other elements of the Contract, completing 96 Carers Support Plans with 68 new Carers being in contact and a total of 144 Carers receiving support from them in the monitoring period. Assurance has been given that the information line is manned everyday between 10.00 am and 4.00 pm and this has been tested out by the contracts monitoring team.

A number of employment issues had arisen and most of these are now resolved.

A Carer Training Plan is being implemented with good feedback on the training completed so far.

Chief Executive’s Office Assynt House

2 August 2013

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NORTH OF SCOTLAND PLANNING GROUP

NHS Board Briefing June 2013

A meeting of the NoSPG Executive was held on 19th June 2013. The following briefing has been prepared to update the North NHS Boards on the outcome of the meeting.

NoSPG Projects

Hyperbaric Services

The paper submitted outlined the preferred options for the north, and was noted. Mr Mark McEwan, Service Planning Lead, NHS Grampian would attend the Directors of Planning meeting on 25th June 2013 to give them a verbal update and inform that a joint options paper (NSD / NoS) would be submitted to NSSC for consideration, prior to forwarding to the NHS Chief Executives Group. Preferred option - from an NHS Grampian and NHS Orkney perspective - is for wider designation to include Orkney chamber.

Paediatric Sustainability Review

Members agreed with the top five priority recommendations which had been identified as the priority work to focus upon from the recommendations contained within the Paediatric Sustainability Review 2011, carried out by Dr Zoe Dunhill, on behalf of NoSPG. The remaining recommendations from the report would be addressed when there was capacity within the NoS Child Health Clinical Planning Group. The five priorities are:

• The NoS to consider the transport requirement for safe transport of children not catered for by the SCOTSTAR (Specialist Transport) review and especially those with high dependency in collaboration with the SG; • The Unscheduled care initiative pilot is supported and implemented by all NoS paediatric units and RGH partners; • An obligate network for Child Health is resourced and put in place with the utmost urgency in the NOS area; • NoS and the 2 Health Boards should review paediatric urgent care across the A96 corridor to explore collaborations and reconfiguration in the best interests of the children of Moray; and • Future scoping upcoming retirals in remote settings across the North Deanery and enabling proleptic appointments should assure a better supply of appointees for these posts (due for retirement).

Child Protection

Members agreed to support the recommendations to move to an interim solution in the immediate term and produce a list of Level 5/6 Child Protection specialists across the country who would agree to be contacted to support other specialists at Level 4/5 for tertiary level advice. There would be the potential to form a panel or seek advice from other colleagues on the list if those called upon did not feel able to advise on a particular case. The regional MCN managers would be available to assist with the practicalities of this, depending on availability. This solution would have the benefit of auditing the nature of advice and number of cases involved as well as determining the training and support required. This was agreed with the understanding a more sustainable model in the future would be 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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needed and that NES / Scottish Government colleagues are key players in taking this work forward with the regional MCNs.

Working Towards an ‘Intelligent Region’

NoSPG gave endorsement to go ahead with the work proposed within the paper submitted. The intention was to: develop a core reporting data set for NoSPG and develop small datasets to inform proactive planning processes across traditional board and internal boundaries. For example by identifying trends and variations in high volume services and working to reduce that variation. Mr Cannon was keen to work up what some of these data indicators might be and submit some worked examples to NoSPG towards the end of 2013 / early 2014 as part of a more formal proposal.

Small Volumes, Outcomes and Sustainability Work

NoSPG gave approval to the paper submitted which had built on the discussion at previous NoSPG meetings and described work which aimed to develop a resource to support understanding and a consistent approach to service reviews, in instances where low volumes had the potential to impact on the sustainability of services. The intention was to better understand the issues, review learning from previous work e.g. HPB and vascular services, conduct a literature review of the evidence, focus on one of the service areas by example, and gather views on which services in particular might be vulnerable, and also informing what might be core provision in the NoS.

CAMHS Update

The project was making good progress. The design work is well underway and planning permission was obtained in January 2013. During the hubco stage 2 process 80% of the work packages for the construction element of this project have now been tendered and this process has raised an affordability issue. The draft stage 2 cost plan was now showing an overspend of £343k against the affordability cap figure. An initial meeting had been held with hubco to establish what savings could be made in order to bring the project back within the affordability cap. This meeting focussed on the mechanical work package and identified £127k of potential savings, leaving a variance of £216k. Further work is being carried out to reduce this affordability gap and at the moment build timescales remain intact.

Oncology Workforce Issues - Neuro-oncology

The paper submitted gave the background to the situation which had been ongoing and challenging for the past 12 months, affecting initially NHS Grampian but more recently also NHS Tayside and NHS Highland. The situation initially arose through a key retirement in Aberdeen during 2012, followed by a scarcity of trained neuro-oncology consultants to recruit into the vacant position. More recently, the impact of maternity and long-term sick leave was leaving significant gaps in the service across the north. The situation had been escalated to national level with input now at Scottish Government level to facilitate a regional/national solution. A formal agreement has been put in place for the short term in Neuro-oncology. The three cancer centres are in the process of mapping out what opportunities there are for longer term and other collaborative opportunities across the oncology workforce, which will be shared with Boards.

National Work Streams

National Update

The update report on national initiatives was noted.

National Planning Forum

The Action Note from the meeting held on 7th February 2013 was noted.

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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NoSPG Business Management

Chair NoSPG Executive

Ms Elaine Mead Chaired her first meeting and members supported Ms Cathie Cowan as Vice Chair of NoSPG.

Review of NoSPG Workplan Reporting

Under the review of the NoSPG Workplan and reporting of regional projects, an Exception Report was submitted. This report was still in the process of being refined in terms of structure as well as content, and members were asked to forward any comments to Mr Cannon.

NOSCAN

The NOSCAN update paper was noted.

NoSPHN

The NoS Public Health Network paper was noted.

Date and time of next meeting

It was agreed to cancel the meeting scheduled for 21st August 2013, therefore the next meeting will be a virtual meeting on Wednesday 16th October 2013 at 10.30 am.

Mr Jim Cannon Director of Regional Planning North of Scotland Planning Group

4th July 2013

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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