1

HIGHLAND HEALTH & SOCIAL CARE GOVERNANCE COMMITTEE Report by Directors of Operations

The Board is asked to:

 Note that the Highland Health & Social Care Governance Committee met on Thursday 3 May 2018 with attendance as noted below.  Note the Assurance Report and agreed actions resulting from the review of the specific topics detailed below.

Present:

Melanie Newdick, Board Non-Executive Director – In the Chair James Brander, Board Non-Executive Director Val Gale, Third Sector Interface Georgia Haire, Deputy Director of Operations (Mid Division)(Videoconference) Tracy Ligema, Deputy Director of Operations, North and West Joanna Macdonald, Director of Adult Social Care Deirdre MacKay, Board Non-Exec Director Margaret MacRae, Staffside Representative (Videoconference) Adam Palmer, Board Non-Executive Director(Videoconference) David Park, Chief Officer, The Highland Partnership Ann Pascoe, Board Non-Executive Director Gaener Rodger, Board Non-Executive Director Kenny Rodgers, Interim Head of Financial Planning(Videoconference) Michael Simpson, Public/Patient Representative Cllr Nicola Sinclair, The Highland Council

In Attendance:

Arlene Johnstone, Complex Case Manager(Videoconference) Donellen MacKenzie, Area Manager (Adult Social Care)(Videoconference) Brian Mitchell, Board Committee Administrator John Skouse, Link Care Inspector Simon Steer, Head of Strategic Commissioning(Videoconference)

Apologies:

Shirley Christie, Staffside Representative Ann Clark, Board Non-Executive Director Norman Houston, Carer Representative Alison Hudson, Area Clinical Forum Representative Cllr Ronald MacDonald, The Highland Council Donna Mitchell, Public/Patient Representative Cllr Kate Stephen, The Highland Council Dr Chris Williams, Area Medical Committee Representative Mhairi Wylie, Public/Patient Member Representative – Voluntary Sector 2

AGENDA ITEMS

 Assurance Report from 1 March 2018  Sub Committee and External Group Reports  Operational Units Report  Director of Adult Social Care Report  Summary Financial Position as at 31 March 2018  Update on Caithness Maternity Services  Monitoring the Delivery of Adult Social Care Contracted Services  Highland Learning Disability Day Centres/Services  Finance Performance Sub Committee Terms of Reference  Committee Annual Report 2017/18

DATE OF NEXT MEETING

The next meeting will be held on Thursday 5 July in the Board Room, Assynt House, Inverness. 3

1 WELCOME AND DECLARATIONS OF INTEREST

At the commencement of the meeting the following Declarations of Interest were received:

 Melanie Newdick – Family members in receipt of care.  Ann Pascoe – Chair of Dementia Friendly Communities (Helmsdale).  Nicola Sinclair – Founder member of Caithness Health Action Team (CHAT).

The Committee so Noted.

2 PERFORMANCE AND SERVICE DELIVERY

2.1 Assurance Report from Meeting held on 1 March 2018

There had been circulated draft Assurance Report from the meeting of the Committee held on 1 March 2018.

The Committee Approved the circulated draft Assurance Report.

2.2 Matters Arising

There were no matters discussed in relation to this Item.

2.3 Sub Committee and External Group Reports

Finance and Performance Sub Committee

The Chair spoke to the circulated Note of Meeting held on 21 March 2018 which provided an update on the matters considered in detail at the meeting, and associated action points. Comments on the format of the circulated report format were invited, along with notification of those areas where members would wish further detailed consideration. It was noted the Sub Committee would continue to meet on a monthly basis.

Care and Clinical Governance Sub Committee

G Rodger advised as to future Sub Committee reporting arrangements in relation to both the Clinical Governance Committee and the Health and Social Care Committee. Administrative support had yet to be provided, although it was noted that the administrative role had just been advertised.

North Highland Local Partnership Forum

D Park advised the Local Partnership Forum had met twice, with an update to be presented to the next meeting. Administrative support had yet to be provided, although it was noted that the administrative role had just been advertised.

ACTION: Agreed update be presented to next meeting - D Park

Adult Social Care Strategic Commissioning Group

J Macdonald advised relevant governance arrangements were under review at that time and undertook to circulate to members the original Group Role and Remit for consideration.

ACTION: Agreed Role and Remit be circulated to members – J Macdonald/B Mitchell 4

After discussion, the Committee:

 Noted the Note of meeting of the Finance and Performance Sub Committee.  Noted the position in relation to the Care and Clinical Governance Sub Committee.  Noted the position in relation to the North Highland Local Partnership Forum.  Noted the position in relation to the Adult Strategic Social Care Commissioning Group.

2.4 Operational Units Report

D Park spoke to the circulated report, providing Operational Unit Divisional updates in relation to People (Recruitment and Selection, Staff Experience, Sickness Absence), Quality and Safety (Improvement Activity, Waiting Times, Infection Prevention and Control, Patient Safety), Care (Service and Delivery) and Finance. Mr Palmer took the opportunity to advise the iMatter Survey would go live for all NHS Highland staff with effect from 28 May 2018.

During discussion, specific updates were provided in relation to the following:

Florence (Technology Enabled Care) - There was reference to the funding position for the Florence system post September 2018. Mr Rodgers confirmed this matter was being considered and an update would be provided to the next meeting.

ACTION: Agreed an update on the Florence funding position post September 2018 be provided to the next meeting – K Rodgers

Care Home Gradings – On the point raised, it was advised that a Service Improvement Lead had been allocated to Invernevis House and that a permanent manager had now been appointed. More generally, NHS Highland sought Quality Gradings of Level 4 and above, was sighted on all areas where Gradings were at Level 3 or below, and provided a network of support where this was required. It was reported that a number of Care Homes in Highland were demonstrating Gradings of Level 5 and above in some areas. With regard to the decision by the relevant operator to close the Achvarasdal Care Home it was confirmed that the relocation of residents, within the wider Caithness area, was being taken forward. The Chair added that the NHS Highland Board was to consider a Place of Care Strategy at their meeting to be held in May 2018 and that this Committee would then be asked to consider the same in relation to North Highland.

Overnight Care Service (Inverness) – G Haire confirmed three independent sector providers were successfully operating the service within the Inverness area and that the existing contract had been extended for a further year in recognition of their flexible and responsive service based on ‘as and when’ requirements. The weekend service had not been recommissioned. It was emphasised the same service level model could not be replicated in all other areas although it did provide an effective service while operating a limited capacity. A Johnstone stated a redesign of the current service for younger adults was being considered, taking advantage of new technology to provide an alternative to an on-site overnight presence, with a First responder service to be piloted within the Inverness area.

Noting the role to be played by new technology, members expressed an interest in holding a Development Session on the wider use of such new technology within healthcare provision in Highland.

ACTION: Agreed consideration be given to the holding of a development session on the use of new technology in NHS Highland – M Newdick/D Park 5

Care at Home (including Commissioning) – D Park advised discussion was ongoing with providers, and Scottish Care, with regard to the potential for introducing 3 separate tariff rates for urban, remote and rural areas. This would reflect the actual costs of service provision and recognise an ever increasing demand. If implemented, any transition arrangements would require appropriate management. This remained a work in progress.

Advanced Nurses and Advanced Paramedics – On the point raised, T Ligema advised as to the nature of Advanced Practice and stated the £23,500 to be received by NHS Highland would solely be for the purpose of enhancing the training and development of such Advanced Practice to meet the requirements of the Scottish Government and their stated aim of supporting an additional 500 Advanced Nurse Practitioners across Scotland. The resource would not be available for the recruitment of additional staff members.

After discussion, the Committee otherwise:

 Noted the detail of the Operational Units Report.  Noted the circulated exception reports.

2.5 Director of Adult Social Care Report

J Macdonald spoke to the circulated report providing an update in relation to the implementation of the Inner Moray Firth 14 to 25 Joint Transitions Team with effect from June 2018, arrangements for closer working between Deaf Services and Sight Action, and a review of Dietetic and Nutritional activity in Care Homes.

ACTION: Agreed updates on the activity of the Joint Transitions Team be provided to future meetings – J Macdonald

The Committee Noted the content of the circulated report.

2.6 Summary Financial Position as at 31 March 2018 (M12)

K Rodgers spoke to the circulated report advising as to the draft Highland Health and Social Care Partnership year-end financial position, projecting a potential projected out-turn overspend of £13.1m. Overall, £2.6m of savings remained unidentified, £6.5m of previously identified savings had not been realised and £4m of additional cost pressures had been factored in. The report provided subjective analysis of the position by Operational Unit, highlighted aspects relating to pay and non-pay budgets, and outlined actual progress on savings plans. Finalisation of the Annual Accounts for NHS Highland was underway.

There followed discussion in relation to the matter of proposed brokerage for NHS Highland. It was reported the Scottish Government had requested NHS Highland develop a three year plan for achieving financial balance, with the assumption that any final brokerage figure for 2017/18 being liable for repayment after that had been achieved. Final discussion had yet to be held with the Scottish Government. D Park emphasised the financial challenge being faced by the NHS Board, in relation to which successful savings plans would be essential.

The Committee:

 Noted the M12 year to date position of a projected overspend of £13.1m.  Noted the forecast comprised £6.5m of savings unachieved, £2.6m of savings unidentified and £4m of additional cost pressures. 6

2.7 Update on Caithness Maternity Services

There had been circulated a report summarising a number of approaches for gaining service user feedback since the move to establish a midwife-led Community Maternity Unit in December 2016, and the responses received to date. It had previously been recognised NHS Highland could no longer sustain a Consultant-led maternity Unit in Caithness given known recruitment issues mirrored across the country and with the relatively low caseload not providing sufficient patient throughput to maintain appropriate clinical skill levels. This reflected the national context, relating to which “Best Start - Five Year Plan for Maternity & Neonatal Services in Scotland” is signalling a move to developing local Community Maternity Hubs, with CMU and Home Birth options for low risk pregnancy. The Chair urged the wider local community to acknowledge and support this clinically proven safe model of care. Members expressed concern at the relatively low response rate of 24% and highlighted matters relating to both accommodation at Raigmore Hospital and wider communication issues as requiring further consideration. Members heard that additional accommodation facilities had recently been made available.

During discussion, N Sinclair stated more should be done to further understand the personal and financial impact on patients of having to travel to Inverness to give birth. In particular, the reasons for first time mothers choosing to travel to Inverness rather than give birth in Caithness, when clinically assessed as healthy, should be further investigated and understood. The current role of the Maternity Liaison Officer should be enhanced and arrangements for patient transfer and accommodation could be improved.

She suggested a risk assessment of transport arrangements could establish if the most appropriate method of travel was being adopted in all cases, with learning possibly to be taken from similar Maternity Units in Argyll and Bute, and Lochaber. In its first year the Caithness Unit had seen comparable local birth numbers, maternity and neonatal transfers to the other Highland CMUs. The distances travelled by expectant mothers were also similar to the other Units and it was noted, over a five year period, there had been no increase in the maternal road or air transfers undertaken by the Scottish Ambulance Service. There had been a marked decrease in neonatal retrievals by air. Members had heard, in the earlier Development Session, all travel decisions were taken in the context of appropriate care pathways and based on the individual clinical risk assessment at the time. Clinical risk criteria and assessment was undertaken against the clinical evidence base provided by NICE and RCOG Guidance. Members had heard, across the UK, only 47% of women had a BMI within the normal range, with increasing numbers of expectant mothers presenting with complex health conditions. In Caithness, approximately 80% of expectant mothers were placed on the Red Pathway given their individual medical presentation. T Ligema emphasised the importance of promoting a healthy Highland population and healthy communities. Clinical risk remained the primary concern for all healthcare professionals and would always take priority over matters of convenience.

On the matter of ensuring improved communication and feedback, whilst staff were trying to be creative in this area there was agreement that this was a two way process. It was emphasised that negative press and social media commentary not only affected staff but patients also, with NHS Highland having an overarching duty of care in that regard. The Chair asked that all members, and wider groups including Caithness Health Action Team, encourage the public and service users to actively complete the survey and provide relevant feedback. D Park stated NHS Highland welcomed appropriate feedback and urged the public to communicate around matters where realistic improvement can be made for the benefit of patients and/or staff, such as in relation to the issue of access to accommodation. The aim of a local, safe and effective service was one shared by all concerned. 7

After discussion, the Committee:

 Noted the feedback from service users following the move to establish a midwife-led Community Maternity Unit.  Noted matters relating to access to accommodation would be considered further.

2.8 Monitoring the Delivery of Adult Social Care Contracted Services

There had been circulated a report summarising outcomes from 38 contracts monitored during Q4. A further 4 monitoring visits were undertaken for The Highland Council. Monitoring of the payment of the Living Wage for care staff remained a priority. It was noted contract monitoring activity regularly highlighted issues and concerns requiring follow up action and review. Nine main areas had been identified and acted upon, including in relation to management/staffing, service delivery and quality, financial viability and actions around withdrawal and transfer of service. The Chair advised further consideration would be given to future reporting arrangements in light of changes to the function of the Committee and the introduction of associated Sub Committees.

The Committee:

 Noted the outcomes from fourth quarter reviews and progress made in resolving issues highlighted in previous reviews.  Noted consideration would be given to future reporting arrangements.

2.9 Highland Learning Disability Day Centres/Services

There had been circulated a report describing the existing day centre provision across North Highland and presented the case for change, highlighting a range of challenges in striving to ensure safe, efficient and effective delivery of person-centred services that reflect an asset based approach to meeting identified needs that are affordable and sustainable. The report outlined the national and local strategic and legislative context. In this regard it was noted that across Highland there had been a gradual decline in the number of people with learning disabilities attending day centres and an increase in the number of adults with learning disabilities with alternative day opportunities. It was advised that the new post of Head of Service (Learning Disabilities and Autism) would lead on the development of a Highland Learning Disability Strategy in partnership with people with a learning disability. The key challenges being faced in Highland were outlined and it was confirmed that NHS Highland had committed to ensuring that the voice of people with learning disabilities was included in decision making. It was stated that a number of options, outlined in the report, would be discussed with a wide range of stakeholders including those with a learning disability, advocacy, third sector partners, families, and other interested parties. The need to ensure an early process change had been recognised and in that context a detailed and costed options appraisal was to be completed by July 2018. Relevant appraisal feedback, including in relation to consultation with staff, on the various options would be reported back to this Committee in due course.

The Committee:

 Noted the need for change and redesign in relation to in-house and commissioned day centres, services and opportunities for people with learning disabilities across Highland to ensure increased choice, control and opportunities as approved at the NHS Highland Board meeting of 27th March.  Noted the recommendations identified in the report, in particular that all day support opportunities for people with learning disabilities should be person-centred and asset based, in keeping with the recommendations of The Keys to Life (2013). 8

 Recognised the requirement for a consultation and engagement process to co- produce an options appraisal to identify how best to meet the needs and aspirations of people with a learning disability living in Highland, and to ensure that solutions are person-centred, sustainable and affordable.

3 COMMITTEE FUNCTION AND ADMINISTRATION

3.1 Terms of Reference – Finance and Performance Sub Committee

The Chair introduced the circulated draft Terms of Reference for the Finance and Performance Sub Committee and sought the wider views of the Committee. She confirmed that active consideration was also being given to issues relating to the wider NHS Board governance structure and existing timelines for data production and submission.

Noting that Operational Units were also in the process of considering their respective governance and decision making structures to ensure a clear direction of travel, members emphasised the need to ensure appropriate levels of scrutiny were maintained, with clear lines of assurance reporting to this Committee.

The Committee otherwise Approved the circulated Terms of Reference.

3.2 Committee Annual Report 2017/18

There had been circulated an Annual Report for the Highland Health and Social Care Committee in 2017/18. It was advised this would be submitted to the Audit Committee as part of the governance aspect of the NHS Highland Annual Accounts process.

The Committee Approved the circulated Annual Report.

4 ANY OTHER BUSINESS

There were no matters discussed in relation to this Item.

5 DATE OF NEXT MEETING

The next meeting of the Committee will take place on Thursday 5 July in the Board Room, Assynt House, Inverness and is to be chaired by A Pascoe (Vice Chair).

The Meeting closed at 2.15pm 9 Feedback to Health and Social Care Committee From Finance and Performance Sub Committee Monday 18th June

Present:

Ann Clark, Non-Executive Director Ann Pascoe, Non-Executive Director George McCaig, Planning and Performance Manager Georgia Haire, Deputy Director of Operations, South & Mid Operational Unit Karen Underwood, Head of Finance, Raigmore Katherine Sutton, Deputy Director of Operations, Raigmore Kenny Rodgers, Interim Head of Financial Planning Kim Corbett, Programme Manager Melanie Newdick, Non-Executive Director - Chair Ros Philips, Head of Finance, North & West Operational Unit Simon Steer, Interim Head of Financial Planning

Apologies:

David Park, Chief Officer, NHS Highland Frances Gordon, Interim Finance Manager, South & Mid Division Joanna MacDonald, Director of Adult Social Care Tracy Ligema, Deputy Director of Operations, North & West Operational Unit

Comments from the Committee: Nothing specific other than comments below

Finance Figures  This showed 767,000 in cost pressures (overspend) and 1.065m in unachieved savings giving gap between forecast position and actual position of £1.83 million. Finance Trajectory  There was a need for operational units to keep a close eye on pressures and savings. It was too early to draw conclusions on progress so far and Kenny was optimistic about improvement in the next figures. Operational Units  Each updated on their plans and challenges. There were some issues highlighted around Medacs not being able to supply enough locums.  The negotiations in the care at home tariff had caused some providers to stop taking referrals until the situation was clarified (early July). This will likely have an impact on delayed discharge situation.  Raigmore detailed their recent budget rebasing exercise and the measures in relation to budget holders taking control of their budgets. The feedback from budget holders had been positive. Delayed Discharges  There was a thorough discussion around delayed discharges, the implications and opportunities for improvement as well as a look back at performance over the last 5 years. Trauma & Orthopaedic Performance  The committee looked at the performance in this area. 10

Action Points:  Feedback to be given on Medacs and availability of locums across operational areas, particularly North and West.  Operational areas to reflect on how those in community and hospitals could better understand how systems work to avoid delays caused by lack of understanding.  Operational area colleagues to bring back to next meeting suggestions for areas where rules could be broken to improve performance and the potential benefits of such activities. 11 DRAFT

Strategic Planning Group (Adult Services) (formerly Adult Services Commissioning Group) OVERVIEW Description  The Strategic Planning Group (SPG) is the principal integrated locus for the strategic discussion of the Highland population’s need; models of care that meet/don’t meet need; and available resource.  It is the role of the SPG to ensure that this discussion and subsequent actions adhere to the principles of equity; engagement and fairness enshrined within the Highland Quality Approach to collaborative commissioning.

Purpose  Discharge of the relevant responsibilities in terms of the Public Bodies (Joint Working) (Scotland) Act 2014, principally the development, production and delivery of the Strategic Commissioning Plan.  Oversight of the total commissioning process as below:

Operation  Delegated, on behalf of Health and Social Care Committee (HSCC), to exercise authority to provide strategic direction on need; models of care; performance; investment/disinvestment across sectors at Highland; community and operational levels.  Receives and interprets activity, outcome and performance, information and oversees the translation of this into commissioning intentions and actions.  Establish and oversee the operation of task and finish groups as required.

Relationships  Provide advice and recommendations to HSCC on commissioning agenda.  Actions tasks set by HSCC.  Acts as the conduit to interpret and implement national and local commissioning policy and acts as the conduit to communicate the implementation and the implications of the strategic commissioning plan through communications and relationships with Operational Units, communities, and populations of interest (eg care group/service/geographic)

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Strategic Planning Group (Adult Services) (formerly Adult Services Commissioning Group)

Role, Remit and Operating Procedures – JUNE 2018 (V0.2)

1.0 Objective

a) To discharge the legislative requirements of the Public Bodies (Joint Working) (Scotland) Act 2014, in relation to the establishment of a “Strategic Planning Group” and preparation of a “Strategic Commissioning Plan” in respect of adult primary and community health and social care services.

2.0 Remit

a) To develop and finalise a three year Strategic Commissioning Plan for adult primary and community health and social care services, monitor and review its progress, and report on its activity.

b) To ensure the questions as undernoted are considered throughout the commissioning process, and embodied in the development, monitoring, reporting and review of the Strategic Commissioning Plan.

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3.0 Deliverables

a) Provide proposals about matters the Strategic Commissioning Plan should contain.

b) Provide views on a first draft of the Strategic Commissioning Plan.

c) Comment on a second draft of the Strategic Commissioning Plan.

d) Develop a final draft, taking into account views obtained through consultation on the second draft.

e) Develop a communication and engagement plan, workforce, market facilitation, procurement and implementation plan to support the implementation of the Strategic Commissioning Plan.

f) Publish of full and detailed final Strategic Commissioning Plan.

g) Publish an easy read, over-arching summary of the Strategic Commissioning Plan.

h) Publish an annual performance report to measure progress and benchmark performance against stated objectives.

i) Publish an annual financial statement which sets the total resource to be allocated under the provisions of the plan.

j) Review the plan at least every three years, to include a clear recording and measurement framework.

4.0 Members

a) The membership of the group will comprise the undernoted representatives, as required by the Act.

Name Organisation / Membership Designation Status Users of health and social care Iain McNamara HSCN Member Carers of users of health and Donald MacLeod Connecting Carers Member social care Commercial providers of health TBC GP Representative Member care Commercial providers of social TBC Chair, Scottish Care Co-Chair care Chris Allan Chair, Scottish Care Member Non-commercial providers of Mhairi Wylie Third Sector Interface Member health and social care Non-commercial providers of David Goldie Highland Council Member social housing Housing Representative Third sector bodies carrying out Mhairi Wylie Third Sector Interface Member activities related to health or social care Social care professionals Joanna Director of Adult Social Member H:\Committees\Governance Committees\HH&SCC - Health & Social Care Committee\Circulated Reports\2018\18 07 05\2.3b - SPG Role Remit and Operating Procedures-GG-V0.2-for SCG.docx 14 DRAFT

Name Organisation / Membership Designation Status Macdonald Care Health professionals David Park Chief Officer Member

Georgia Haire Depute Director of Member Operations Tracy Ligema Depute Director of Member Operations Boyd Peters Medical Director Member

Hugo Van Director of Public Member Woerden Health Gill McVicar Director of Quality and Member Transformation Simon Steer Head of Strategic Co-Chair Commissioning Adam Palmer Employee Director Member

Gillian Grant Team Leader Member (Contracts) Other Stakeholders Isobel Murray Highland Council Member Representative

5.0 Operating Procedures [*Required under the Act]

a) Chairman

The SPG will be co-chaired by the NHS and a sector representative. The appointment of the Co-Chairs will be determined by the Health and Social Care Committee and reviewed every three years, aligned with the publication of the Strategic Commissioning Plan.

At least one Co-Chair must be present at all meetings.

b) Appointment of Members*

Members will be nominated to attend the SPG by their parent organisation.

The appointment of members will be formally confirmed to members by the Co- Chairs of the SPG.

In accepting their appointment on the SPG, Members will be required to confirm that they agree to adhere to the group’s stated values and behaviours and to agree to declare any interest at the start of each meeting.

Membership of the group will be reviewed annually in March by the Co-Chairs.

c) Removal of Members*

Members may be removed in the event they no longer hold the post as denoted in the membership list or following a review of membership by the Co-Chairs.

Confirmation of removal will be issued by the Co-Chairs and an updated membership provided to the HSCC.

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d) Resignation of Members*

Members may resign from their appointment upon written confirmation to the Co- Chairs.

e) Delegates

Where a member is unable to attend, apologies should be submitted to the meeting administrator and arrangements made for a briefed substitute to attend in their place.

No additional members or permanent changes to membership can be made outwith the appointment process noted above.

f) Commissioning Values Behaviours

[Discussion: to develop and include?]

g) Declaration of Interests

Members must declare any interests at the commencement of each SPG meeting.

h) Expenses and Allowances

The process and procedure for payment of any expenses and allowances for non NHS employees, will be in accordance with NHS Board procedures.

i) Governance and Reporting

The SPG will report to the HSCC through the issue of Minutes/Assurance Reports and an assessment of the performance of the SPG will be undertaken annually and presented by way of an Annual Report to the HSCC.

j) Administrative Arrangements

The Committee will be serviced within the NHS Highland Committee Administration Team and minutes will be included within the formal agenda of the HSCC.

Any amendments to the role and remit of the SPG will be submitted to the HSCC for approval following discussion within the committee.

k) Meeting Arrangements

The SPG will meet a minimum of five times per year. Meetings will take place on a Wednesday, commencing at 10.00am.

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The calendar of dates for the succeeding financial year will be confirmed to members no later than the previous January.

Meetings will be scheduled to optimise reporting to and from the HSCC.

Additional meetings may be scheduled, subject to approval by the Co-Chairs, by providing a minimum of 10 working days notice to members.

l) Agenda and Minutes

The Co-Chairs of the SPG, supported by the Commissioning, Contacts and Compliance Manager and representative of the NHS Highland Committee Administration Team, will prepare a draft agenda, and request reports for forthcoming SPG meetings.

The representative of the NHS Highland Committee Administration Team will issue the agenda and papers for the SPG no later than 5 working days prior to the SPG meeting.

The standard agenda for each meeting of the SPG will contain the following areas:

[Discussion: to be agreed]

The representative of the NHS Highland Committee Administration Team will be present to record the meeting and will prepare a minute on behalf of the Co- Chairs, to be submitted to the next ensuing meeting of the SPG for approval, as a record of the meeting and thereafter submitted to the HSCC for noting.

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Highland Health & Social Care Committee Report

Chief Officer’s Report

1. INTRODUCTION

This report provides an overview of operational activity across the three Divisions in North Highland and highlights areas of focus for improvement as well as areas of development and further opportunity.

Community Divisions including Hosted Services

2. PEOPLE 2.1 Recruitment and Selection

South & Mid Division We continue to be challenged by recruitment and retention issues, particularly in mental health services, both in nursing and medical posts. We are advertising nationally and looking for opportunities to recruit in other arenas such as job fairs as well as redesigning services to support a more sustainable model. The contingency plan that reduced adult admission and drug and alcohol detoxification beds remains in place. Attendance at four Jobs Fairs has only produced one successful recruitment of a Registered Mental Nurse. A number of Learning Disabilities qualified nurses have expressed interest in working in Highland and the older adult service is exploring how these Registered Nurses could join the team.

New posts are being developed in a number of fields. We have redesigned our physiotherapy service to create two new First Contact Physiotherapy Practitioner posts which will support musculo-skeletal patients in primary care.

We have a number of staff on redeployment due to organisational change. At present this is mainly due to the Care at Home Service redesign. Vacancy meetings now include a Human Resources Advisor so that we can identify at an early stage potential candidates for redeployment before any posts are advertised.

The Rebalancing of Primary Care Dental Services has resulted in a number of fixed term employment contracts as the rebalancing programme progresses. Staff have been identified for redeployment.

North & West Division

Nurse staffing in Caithness is particularly challenging with contingency plans in place to support community hospitals. District nurse staffing in Caithness is also problematic. Posts have been advertised and applications received.

An Advanced Physiotherapy Practitioner Post has been recruited to.

In Sutherland there are recruitment difficulties in Social Work and mental health nursing in Migdale Hospital and these services are currently experiencing difficulties in running a full service.

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Domestic staffing in Portree remains problematic although it is anticipated this will improve over the next month. Recruitment is an ongoing challenge and there remains a concern around sustainability of services in Skye. The administration team across the District is under pressure at the moment due to absences and vacancies. This will potentially impact on hospital reporting, coding and back office support. There has been successful recruitment into the five Care at Home posts in North Skye that were recently advertised.

There are vacancies within the Rural Support Team for Skye and West Ross, which may necessitate continued use of agency and locum cover as required to fill service gaps in order to keep an out of hours / urgent care centre operational in North Skye. Even with these efforts some shifts have proved impossible to fill, resulting in consolidation of the Out of Hours service to a single site in Broadford.

Surgical staffing in Belford Hospital remains a challenge with all consultant posts being covered by locums. A Highland wide approach is being progressed and the posts will be re-advertised on that basis in the near future.

There has been a good response to the job adverts for the Telford Centre and internal shared bank is now in place. There are a number of vacancies in June at the Mackintosh Centre. However, internal temporary transfer of staff between the integrated care home staff has provided an in- house solution with no need to request Agency expected.

There is currently a vacancy within the Substance Misuse service in Lochaber. This will have an impact on the waiting time for initial assessment however nursing support from elsewhere has been identified to work with the team.

2.2 Staff Experience 2.2.1 Learning and Development

The opportunity presented by the redesign of the Human Resources (HR) Directorate to have a lead manager for learning and development is welcomed by the Divisions.

Plans for team development will link with the i-matter team results.

2.3 Sickness Absence Sickness absence figures do show a decline although we are not reaching the standard of 4%. Long term sickness remains a challenge (at 3.11% in South and Mid Division) and we are monitoring that the learning from the Rapid Process Improvement Workshop in East Ross is being applied.

Mar 2018 % Apr 2018 % Cumulative Annual % at 30 April 2018

South & Mid 5.18% 4.60% 4.60% Division North & West 4.87% 4.54% 4.94% Division

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3. QUALITY & SAFETY 3.1 Improvement Activity

3.1.1 Value Management Royal Northern Infirmary (RNI) has built on their work to reduce falls with the introduction of a process for early identification and management of delirium. In the past five months they have successfully identified and managed over 50 people with early signs of delirium. They are now progressing to focus on preparation for discharge and will link with the Daily Dynamic Discharge work.

3.1.2 Rapid Process Improvement Workshop (RPIW) There has been a Continence Assessment RPIW in April 2018. Progress has been made on establishing a patient experience baseline measure, developing a NHS Highland-wide referral criteria and a reduction in lead time.

There has been testing of a ‘virtual ward’ with GP Quality Cluster B in Inverness and Merkinch where a number of named patients are proactively case managed to prevent a deterioration in their condition or home circumstances.

In terms of communication the Formstream e-health initial referral form is now in place which automatically pulls personal information from SCI store reducing the risk of recording errors, reducing paper usage and makes the process more efficient.

In relation to the provision of community equipment ELMS 2 now allows us to track and assess stock quickly and efficiently and this programme will be rolled out. A central budget has now been created for the equipment store in the South and Mid Division which reduces the financial risk to individual districts in the Division and will allow us greater control and scrutiny of the equipment spend. Further work is now being undertaken to review the equipment store processes to maximise efficiency for staff across the service. Invergordon equipment store is currently being decommissioned following successful transfer of all equipment store, personnel and stock to a single store in Inverness which will release efficiency savings from next financial year. There is however financial risk associated with high de-commissioning costs in the current year and we are working with Estates colleagues to minimise the pressure.

3.1.3 Daily Dynamic Discharge (DDD) As part of the National 6 Essential Actions to Improve Unscheduled Care, Daily Dynamic Discharge (DDD) is to be rolled out to community hospitals and Rural General Hospitals across North Highland. It was agreed that this would sit within the NHS Highland Community Hospitals Scottish Patient Safety Programme (SPSP) framework to support the governance and sharing of learning and reduce duplication and overlap with other initiatives. An initial launch was held at a WebEx session with further sessions held in March, June and another planned for early December 2018 to share learning and monitor progress.

It is recognised that DDD has an important role in supporting patient flow in busy acute wards and that the principles are transferrable to the community hospital setting. However, in order to maximise effectiveness in community hospitals the SPSP leadership group agreed a set of nine activities / outcomes to support flow and improve overall discharge planning. It will be the aim of the project to identify the areas where the nine actions are not fully embedded and when implemented will provide a valuable role in improving flow and supporting discharge.

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The community hospitals in South & Mid Division have been engaged with the DDD approach since 2016 with additional focus in 2017. The RNI are engaging with DDD to support their implementation of Value Management.

Lawson Memorial Hospital are taking forward some of the elements of DDD which are not currently embedded and is building on the success of the Sutherland RPIW.

The plan is to have all areas, including the two Rural General Hospitals involved by October 2018. DDD is supported by monthly information from the Planning & Performance Department which demonstrates where improvement work is having an impact on numbers of discharge and length of stay.

3.2 WaitingTimes 3.2.1 Out-patients

Out Patient Department:  Surgical – 1 patient breaching the Treatment Time Guarantee.  Ophthalmology – backlog of return patients by consultant under review by Raigmore.  All other local specialties within the Treatment Time Guarantee

 Outpatients – local specialties within Treatment Time Guarantee dates.  General Medicine referrals and return patients continue to be affected. Physicians at Belford Hospital are not able to undertake clinics when they are on-call.  There are insufficient new patient appointments with pressures in gynaecology, dermatology and ophthalmology where referrals have had to be sent to Raigmore.

3.2.2 Treatment Time Guarantee (TTG)

Dental Services Ongoing difficulties in accessing sufficient theatre capacity to meet TTG are reported.

Caithness General Hospital  Surgical – 51 patients on the waiting list, 1 patient breaching the TTTG with an average wait of 11 weeks.  Chronic Pain – 20 patients on waiting list for CGH, 23 patients on waiting list for Lawson with an average wait of 8 weeks.  Gynaecology – 27 patients on waiting list, 7 patients breaching the TTG and 11 week wait.  Cataract – 75 patients on the waiting list, 45 patients breaching the TTTG and an 8 month wait.

Belford Hospital There are a number of patients transferred to Belford waiting list from Raigmore who had breached their TTG date before the transfer. All but two have been given dates for admission at Belford.

3.2.3 Key Diagnostic Tests

Caithness General Hospital Endoscopy  Endoscopy at Caithness General Hospital currently has 1 patient unbooked for Urgent

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Suspected Cancer.  Urgent 6 patients un-booked with a 2 to 3 week wait time.  Routine endoscopy – 4 patients currently un-booked with a 3 to 4 week waiting time.  Return Endoscopy patients – 1 patient on the return waiting list should have been seen in 2017; 14 patients on return waiting list should have been seen in 2018.  Following changes to the bowel screening test, referrals have increased from 2 per week to 4. Currently managing the increase within existing capacity.  Radiology – plain film – no waiting lists to appoint other than normal delay in time to post / receive appointment.  CT Scan – no waiting time other than post/receive letter, small delay if awaiting blood test results for contrast examinations.  Radiology reporting – delays across NHS Highland in line with shortage of radiologists – some imaging is out-sourced at financial cost however many are still waiting some weeks to be reported.

Non-Obstetric Ultrasound Sonography  Routine outpatient referrals – 136 – with a 10 week wait.  2 patients are protocolled as ‘soon’ and will be seen within 5-6 weeks.  77 patients are on the long stop pending list and are due to be scanned at specific timed intervals.  Urgent cancer referrals are seen within 2 weeks.  Currently 10 ultrasound sonography sessions per week available, however 4 sessions per week are dedicated to obstetrics leaving 6 sessions for all others.  Staffing shortage.

Belford Hospital Endoscopy  We have 4 patients who waited 1 to 3 days beyond breach date for a new endoscopy appointment. This was due to full endoscopy lists with no space on cutting lists.  Problems with capacity for all Bowelscope Screening (BoSS) colonoscopies and referrals from Skye GPs for endoscopy.  Limited number of Consultants available to undertake endoscopy sessions.  Return endoscopy patients: 3 patients from February still awaiting appointment dates; 6 from March, 4 from April and 3 from May (16 in total).

3.2.4 Musculo skeletal (MSK)

South & Mid Division

Waiting times for MSK physiotherapy are not generally within the 4 week target. Inverness waits are 9-10 weeks with Dingwall and Invergordon 8-9 weeks. This is due to a change in staff and vacancies which are being advertised.

Both Nairn and Badenoch and Strathspey are meeting the 4 week target.

The introduction of First Contact Physiotherapy Practitioner posts, achieved through service redesign, is expected to reduce referrals to the service.

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3.2.5 Psychology

A further planning meeting took place with NHS 24 to implement the primary care based Beating the Blues system in North Highland. All is now ready to start when funding for the required administrator is confirmed.

The first testing of the Near Me system to conduct mental health assessments between New Craigs and Caithness General Hospital using videoconferencing took place successfully. Further testing over June and July will now take place and will then be reviewed with a view to expanding to other areas.

An additional clinical Associate for Applied Psychology is to be recruited from the NHS Education Scotland allocation for improving access to psychological therapies. This post is currently being advertised. Funding allocation for another post is to be granted in January 2019.

3.2.6 Emergency Department (ED) 4hr Compliance

Both Caithness General and Belford Hospitals continue to consistently achieve the required standards for ED waits.

Belford Hospital is currently achieving 97.3%, compliance as at 3 June 2018.

Belford Hospital are experiencing extremely high numbers of presentations due to tourist numbers, the school break and a major mountain bike event.

Caithness General Hospital is currently achieving 96.6% compliance as at 3 June 2018.

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3.4 Infection Prevention & Control

South & Mid Division

All inpatient ward areas and care homes remain compliant with monthly hand hygiene and standard infection control precaution audits.

From April 2018 to date, there have been 3 cases of Clostridium Difficile, all of which have been reviewed for learning in terms of preventable factors and compliance with best practice.

There have been no cases of Staph Aureus Bacteraemia reported.

North & West Division

Clostridium Difficile Cases (C Diff) Since 1 April 2018 there have been 6 cases of Clostridium Difficile (CDI). There does appear to be an increasing incidence of CDI in the community.

Antibiotic prescribing is closely monitored and a year-on-year reduction is the target: this aims to minimise both the development of antibacterial resistance and the risk to patients of significant side effects such as CDI. Figures for the quarter October - December 2017 were lower than for the same period the year before and there was peak in January 2018. Information around any outliers in prescribing proton pump inhibitors and / or antibacterials associated with CDI, will be fed to the GP Cluster Quality Leads on a regular basis going forward. Within the hospital setting, the ongoing empirical (local) audits are a more useful reflection of anti-microbial prescribing practice on a daily basis. Point prevalence audits are undertaken on an annual basis

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8

6 s e

d 4 o s i p E . o N 2

0

C diff tox + Trigger (+2SD) UCL (+3SD) CL

Staphylococcus aureus bacteraemia (SAB) Incidence: During the reporting period 2017/18, there were a total of 6 SAB infections in the North Area (Caithness and Sutherland). This represents an increase on last year where we saw a total incidence of 4 cases in the North area. A root cause analysis has been undertaken for each case to determine where improvements can be made and learning identified. A specific working group is also established to review all cases and this group met at the end of May 2018. Three of the cases were community acquired, two were Caithness General Hospital acquired and one case was an inter-hospital transfer between Raigmore, Lawson and Caithness General Hospitals. There is a possibility that the increase may be a result of earlier triggering of the sepsis pathway which requires blood cultures to be taken within one hour of admission. This has resulted in an increase in the identification of SAB. However there is also improvement work required in terms of taking a blood culture to avoid contamination of sample (one case) and 100% compliance with the PVC (Peripheral Vascular Catheter) bundle which is evidence that best practice has been followed in terms of insertion and maintenance of a Cannula. Of the 6 cases studied there were 2 cases where practice could be improved. All cases are also reviewed by a consultant microbiologist. The situation is being closely monitored.

3.5 Patient Safety 3.5.1 Scottish Patient Safety Programme

South & Mid Division

Falls Prevention – In-patients

The focused approach to falls reduction in all in-patient mental health and community hospital wards continues with an emphasis now on sustaining improvements and improving management of falls with harm. The falls prevention work in the RNI has been closely linked to early identification and management of delirium over the last 6/12 and recognising its success, this will be implemented across other sites.

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Medication

The above chart shows trends in number of medication errors for South and Mid Division. The increases in Nov 17 to Jan 18 were as a result of a value management exercise being undertaken in the in-patient wards, Royal Northern Infirmary. Part of this involved nursing staff reviewing and reporting on Datix every medication omission on kardexes. This was a useful learning exercise in that it highlighted the benefit of double checking kardexes at the end of every medication round to ensure that medication administration is recorded properly. The learning from this exercise is informing a resource pack for charge nurses on managing medication errors. This is being developed in conjunction with the Medicines Safety Subgroup of Aare, Drugs & Therapeutics Committee.

Pressure Ulcer Prevention

Community acquired pressure ulcers

The number of community acquired pressure ulcers remain below the control limit, however the number of people who develop a pressure ulcer and are known to care at home services and care not referred to district nursing remains a challenge. Further review and root cause analysis is underway with an improvement plan to be developed.

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Hospital Acquired Pressure Ulcers

The number of hospital-acquired pressure ulcers peaked to just below the upper control limit in April, with analysis identifying that significantly complex presentations and patient choice regarding use of pressure relieving equipment a factor.

In two of the community acquired pressure ulcers, delays in provision of pressure relieving equipment which was acceptable to the patient were cited as factors. The Lead Nurse is reviewing the supply and availability of pressure relieving equipment is working with the Joint Equipment Store Manager to address delays. This is to be added to the South and Mid Division Risk Register until the review is complete.

North and West Division

Tissue Viability

Community: As shown in the table below there has been an increase in incidence since October 2017. There have been five grade 3 pressure ulcers arising in the community since January 2018 (one in Caithness, one Sutherland, two in Lochaber and one Skye, Lochalsh). Root Cause Analysis

10 27 is undertaken for every grade 3 or 4 pressure ulcers to identify any learning or improvements in care required. As a result of this, an improvement action plan has been developed to address the emerging themes which include the need for more robust assessment to identify where a patient is at risk from developing a pressure ulcer, improved communication between services e.g. Care at Home and improved patient information about the importance of using recommended equipment. The Lead Nurse will be taking a report the Highland Tissue Viability Group to ensure the learning is shared across Highland.

As part of this a focused education and training programme is to be undertaken in 2018 with care at home staff. Currently prevention of pressure ulcers are not included within the Care at Home service induction programme and this will be addressed in collaboration with the service.

Table 1: Incidence of pressure ulcers arising in the community excluding Grade 1 to March 2018.

Hospitals: There has been no grade 4 pressure ulcers recorded in our hospitals as of end August 2017 since 2012 and only one Grade 3 in the Belford, 2016.

Table 1, below, Incident of pressure ulcers arising in hospital excluding Grade 1 to March 2018.

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Falls Prevention – In-patients

Table 4 below shows a further sustained improvement in the incidence of hospital falls.

The Quality Improvement Facilitator posts for the North and West Operational Unit in place and the share and spread plan is being rolled out which is being overseen by the Associate Lead Nurses for the North and West Operational Unit. Monthly falls prevention ‘huddles’ have been established and the new falls point of care ‘bundles’ are being introduced alongside other measures to identify individual risk factors, manage any risks without reducing mobility and where a fall does occur to utilise the multi-disciplinary post falls review process to learn and prevent further falls.

Table 4: All Patient Falls – North & West Division sustained improvement.

4. CARE Service and Delivery

4.1 Adult Social Care 4.1.2 Care at Home (including commissioning)

The Chief Officer met with care at home providers in April 2018 to set out the plans to develop care at home services in North Highland. This included a new pricing model which would replace the existing single tariff rate. As part of this task, having listened to feedback from the care at home sector, the proposed reduction in the tariff rate was suspended whilst the new pricing model was further developed. Discussions with the elected spokespeople from the independent sector providers gave constructive feedback about the new pricing model and having a clearer understanding of the challenged faced by NHS Highland, offered to develop their own model which they felt could deliver the required outcomes. At this time the detail and impact of both models are being analysed before a final decision is made.

An alternative provider for the Drumnadrochit area has now come forward and subject to Care Inspectorate approval, the service is scheduled to commence in early to mid July 2018.

Development work has been taking place in Lochaber to create new areas of independent sector provision allowing in-house services to be reallocated. In the North, work is ongoing regarding developing services and appropriate housing provision.

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The Inverness Overnight Care Service has had an extension to the contract term and continues to operate.

For both divisions the current discussions with independent sector providers is impacting on care at home development and the uptake of new care packages. Work is ongoing to develop new models of provision and to reach a solution which is both affordable to NHS Highland and which creates an appropriate framework for growth.

4.1.3 Care Homes

Highland Care Home Strategy

Previous updates confirmed that work continues to progress regarding the development of a care home strategy.

The NHS Board considered a report on care homes at its meeting on 27 March 2018 and following further work is being undertaken to map out a clearer proposed strategy for in house care home provision, a further report would be considered by the NHS Board on 29 May 2018.

At this meeting on 29 May 2018 NHS Board has agreed a vision that will require significant change in the delivery of residential based care services to offer better choices for older people living in Highland; noted that there will not be a published, final plan describing the detail of this vision; but confirmed that there is an agreed direction of travel to enable community based solutions to be able to be progressed to identify solutions for each locality. Work is commencing to progress this confirmed vision.

Achvarasdal House in Caithness has now been closed by the provider.

Fairfield Care Home in Inverness has given notice of closure in August 2018. Work is ongoing by the local operational team to source alternative placements for residents.

4.1.4 Delayed Hospital Discharge

Delayed Hospital Discharge for North Highland hospitals is detailed below.

Hospital Care at Placements Complex Other Total Home DunbarHospitalThurso 0 3 2 0 5 Caithness General Hospital 2 3 1 0 6 Town & County Hospital Wick 0 0 4 0 4 Lawson Memorial Hospital, 1 0 0 0 1 RNI Community Hospital 11 4 0 0 15 Raigmore Hospital 8 10 3 0 21 Town & County Hospital Nairn 3 0 1 0 4 Ian Charles Hospital 1 0 0 1 2 Belford Hospital 0 2 0 0 2 Mackinnon Memorial Hospital 0 1 0 0 1 PortreeHospital 0 2 0 0 2 Ross Memorial Hospital 2 1 1 0 4

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CountyCommunityHospital 1 8 2 2 13 NewCraigsHospital 0 3 7 3 13 Migdale Hospital 0 2 0 0 2 Total 29 39 21 6 95

We continue to be challenged by both care at home and care home capacity as the main reason for delay. Commissioning discussions with the independent sector, care at home providers leaving the market and the need to prioritise residents in care homes that are ceasing to operate for available places are all having an impact.

The delayed discharge reporting system has now moved from EDISON, a stand-alone reporting system to TraKcare PMS, our NHS electronic patient management system. There has been some issues with the data quality which are being addressed. A member of the Service Planning team will now join the weekly Delayed Hospital Discharge monitoring meeting to support the transition.

We anticipate a reduction in the number of delays from August 2018 as care at home and care home capacity increases.

4.1.5 Self Directed Support

See separate Committee paper.

4.1.6 Carers

The Carers (Scotland) Act 2016 came into force on 1 April 2018. The NHHSCP and The Highland Council have been allocated £871,000 to implement the duties of the Act. A strategy and implementation plan will be developed with key stakeholders.

4.1.7 Respite

A review of the delivery of home- based respite is underway. The aim is to provide services to those eligible in a consistent and equitable way. The Carers Improvement Group is revisiting the Respite Review they undertook in light of legislative changes and focus on community led support.

4.1.8 Housing

A half-day workshop was held on 24 May 2018 between NHS Highland and The Highland Council Housing Department. The workshop was well attended by District Managers within South and Mid Division and Mental Health, Learning Disability and Substance Misuse leads/managers, Area Housing Managers and Principal Housing Officers alongside a number of other staff. North & West Division were represented by the Deputy Director alongside a number of her staff. The main purpose of the day was to build strong working relationships and to have a plan going forward for regular communication/meetings at District level that will address all housing related matters, including improved strategic planning. This will then be taken forward by North Highland Health and Social Care Partnership representatives at Housing Development Hub meetings. Feedback from the workshop has been extremely positive and plans to create local housing development plans that reflect agreed NHS priorities are being progressed. Development plans have to be completed by the end of August 2018 to inform Housing Strategic Plans and to ensure appropriate

14 31 prioritisation of housing development monies. Donellen Mackenzie and Hilary Parkey, Housing Policy Officer with The Highland Council continue to work together to support this area of work at District level.

4.2 Hospital Inpatients 4.2.1 Community Hospitals

South & Mid Division

The Ross Memorial Hospital Minor Injuries Unit will now be closed on Wednesday as we prioritise nurse staffing for main general ward. We are still seeing significant success with the unique Senior Charge Nurse/Advanced Nurse Practitioner led model of care on the site.

A review of community hospitals role and function is to take place. A job description for a project manager is currently being developed to support this work across North Highland.

4.2.2 Older People in Acute Hospitals (OPAH)

South &Mid Division

Feedback from the Mental Welfare Commissions visits to community hospitals in the Autumn of 2017 has now been received and there was recognition of the focused work which has been progressed under the direction of the Senior Charge Nurses and supported by a network of Dementia Champions to improve care for people with dementia / cognitive impairment in Community Hospitals. However, there was recognition that in some areas staff needed greater understanding of the legislative framework for Adults with Incapacity and how this impacts on care delivery. In addition, it was noted that whilst physical care needs were well documented in care plans, there needed to be more detailed care plans for mental health. A detailed action plan will be incorporated in the existing Older People in Acute Hospital plan and feedback will be provided to the Mental Welfare Commission in August 2018.

4.3 Integrated Health & Social Care Community Services South & Mid Division

The Inverness neighbourhood team model, which has grouped key health and social care workers into designated small area teams continues to progress.

The Charleston Neighbourhood Team have had an introduction session and training for value management. They are currently working to understand their base line with a focus on communication.

Two new coaches have been identified to support further roll out of the Value Management approach.

The Inverness Neighbourhood Team has held a development day as well as the Mid Ross integrated community team The focus is on team processes, production board and communication a follow on from the meeting 6 months ago looking at areas for improvement.

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4.4 Mental Health & Learning Disabilities and Drug & Alcohol Recovery 4.4.1 New Craigs

The Mental Health Tribunal Service remains on site at the hospital with no immediate solution identified for permanent accommodation. There is an impact on the bed reconfiguration plans.

4.4.2 Community Mental Health Services

700 people from the public and third sector have now been trained in applying The Decider Skills by mental health service trainers across Highland with 15 active groups operating in all areas.

The Associate Medical Director, General Manager and the Personality Disorder Consultant Psychiatrist presented at an event organised by the Highland Council for elected members. Presentations on the range of services provided by the specialist mental health services were delivered and clarifying the various aspects of the service. A further two events are planned.

In Sutherland there is currently a waiting list for Guided Self Help services. There has been no Adult Psychologist support in place across Sutherland since December 2017.

There is currently no adult psychiatry provision for Caithness and North West Sutherland. All psychiatric clinics have been cancelled in June 2018. The post has been advertised and we are actively seeking to recruit a locum.

4.4.3 Learning Disability and Autism Services

The Learning Disability Day Centre and Day Opportunities Review and Redesign is underway. We are currently in Phase 1 involving gathering data and consulting with the people we support and their families.

The night support redesign project continues. The Inverness Overnight Responder Service will be operational from 1 October 2018 to replace existing sleepover arrangements. Tests of change are occurring in other localities.

A ‘Participatory Budgeting’ event to distribute £20,000 to the Autistic community is planned for early September 2018. This is a process of democratic deliberation and decision-making, in which people decide how to allocate part of a municipal or public budget.

There are significant concerns regarding recruitment and retention in the commissioned Support Sector to provide support to individuals with complex support needs.

4.4.4 Support for People with Dementia and their Families

The Highland Dementia Strategy was presented to the Adult Services Commissioning Group and agreed. An implementation plan is to be developed which NHS Highland will participate in.

A partnership conference with housing has led to a proposal to work more closely together and to have a joint approach to support people living with dementia to remain in their own homes as long as is safely possible.

A Project Group is to be established exploring commissioning options with the independent sector

16 33 to provide a specialist care facility working with the Older Adult Mental Health Service.

4.5 Out of Hours

North & West Division

Work continues to progress the redesign plan as outlined in the September 2016 paper to the NHS Highland Board.

The emergency planning exercise held in Glenelg will be replicated in Lochinver and the North Coast using scenarios from local communities.

Discussion is ongoing with communities in the North. In principle it is agreed to move to a team of Advanced Nurse Practitioners and specialist paramedics from Scottish Ambulance Service (SAS) based in Thurso with local urgent primary care provided by crew of Bettyhill ambulance. This has become possible due to changes made by SAS to Wick ambulance station leading to reduced call outs for the Bettyhill ambulance.

“Clinical Guardian” is now live to enable governance, and clinician feedback following Out of Hours (OOH) consultations. This marks a significant step forward in our oversight of OOH. Over 2500 cases have been reviewed mainly ANPs and now agency locums providing reassurance around the staff we have.

The report for North Skye OOH as chaired by Sir Lewis Ritchie has now been published. Work has commenced to establish the team to take this forward and begin discussions with the communities SAS, NHS 24, SFRS and Highland Council. Glenelg are unhappy with the independent facilitator suggested by the North Skye community and we await their suggestion to take that forward.

4.6 Primary Care Services

South & Mid Division

4.6.1 GP Quality Clusters

Six quality clusters have been formed in the area, utilising a bottom-up approach to determine the makeup and location of each cluster. The practices have grouped into clusters which are mostly, but not always geographically linked with some taking account of their common quality objectives and interests.

Cluster work to date has been firmly quality-driven, with areas of focus driven by GPs with support but not direction from board colleagues. Several projects are being taken forward including:

 Catheter Bundles

 Link Workers

 Quality of Patient Discharge

 Reducing Inappropriate Admissions

 SEPSIS NEWS score for primary care

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 Social Signposting

 Specialist Led Clinics working with Secondary Care

 Virtual Ward

A series of workshops linking clusters and community teams are planned to begin to better understand mutual priorities.

4.6.2 Vacant Practice

Cromarty Medical Practice which had been running as a vacant Practice since July 2017 has since 1 April 2018 been operating under ‘17J’ independent contractor status. This has been a successful transition and quality services are being delivered to the community in this area.

4.6.3 Recruitment & Retention

There are currently no GP recruitment and retention issues within the Division. However skill mix has been introduced within many of our Practices which has seen the further development of Advanced Nursing Practitioner and Pharmacy posts, These post are directly employed by the practices.

4.6.4 Primary Care Modernisation Plan (PCIP)

Proposals for a new GP contract were published in November 2017 and agreed in January 2018. The new contract aims to support the development of the Expert Medical Generalist role for GPs with a shift over time of workload and responsibilities to enable this. The priority of this work is to lessen workload and risk for general practitioners. A key enabler for this is investment is a wider NHS Board employed multi-disciplinary team (MDT) in support of general practice. The new contract offer is supported by a Memorandum of Understanding (MOU) which requires:

“The development of a HSCP (Health and Social Care Partnership) Primary Care Improvement Plan, in partnership with GPs and collaborating with other key stakeholders including NHS Boards that is supported by an appropriate and effective MDT model at both practice and Cluster level, and that reflects local population health care needs”.

The MOU has been developed between Scottish Government, the British Medical Association, Integration Authorities and NHS Boards and sets out the principles of redesign. These principles include,

 Responsibilities of the parties to the MOU  Key Stakeholders  Resources  Primary Care Improvement Plan  Key priorities

The North Highland Primary Care Modernisation Group, supported by a Project Team has been developing a plan for North Highland. The plan, which needs to be developed in collaboration with and agreed by the GP Sub-Committee of the Area Medical Committee, is currently in development.

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There are six key workstreams in various stages of development.

 Vaccination Transformation Programme  Pharmacotherapy  Community Treatment and Care  Urgent Care  Additional Roles  Community Links Workers

The PCIP has not been approved by the GP Sub-Committee and further work is required over the next few weeks prior to submission to Scottish Government by the end of July 2018.

This is the beginning of a three year transition plan with investment available over the period. GPs in North Highland wish to continue to provide a wide range of general medical services as close to the patient as is practical and safe to do so.

The Highland Health and Social Care Committee will receive the plan in due course.

4.6.5 Premises

Our large and geographically dispersed area means that, in order to provide access to primary care medical services, we have a large, dispersed and, in places, old primary care estate. This ranges from large, purpose build modern health centres to older branch surgeries that are not fit for purpose. Several of our practice premises, including in our urban areas, do not have the additional space required to meet the needs of primary care now and into the future. Associated MDT professionals have already been required to move out of general practice premises due to the lack of space as a result of the increasing patient list sizes and demand.

Work is underway to fully understand the size and condition of the estate, including GP-owned and third-party leased buildings, to support the prioritisation process relevant to the GP Premises Sustainability Fund.

Premises are a key enabling factor for our future sustainability and are an important factor in developing and maintaining new ways of working and creative solutions.

Work is underway with several of the Practices to establish their needs, and identify any issues which can potentially allow quick resolution.

4.7 Midwifery - Community Midwifery Units

4.7.1 Caithness Community Midwifery Unit

There was a visit from Scottish Government Chief Medical Officer and Chief Midwife on the 21 May.

Caithness maternity survey continues to run with the response rate so far sitting at around 24%.

The new shortened midwifery programme at University of the Highlands & Islands, starting February 2019 has had interest from prospective candidates.

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Service development continues with the use of video conference consultation and the aim of using Near Me technology for some antenatal clinics and the specialist diabetic clinic.

4.7.2 Skye & Lochalsh Midwifery Service

The local birth service Out of Hours (OOH’s) remains suspended due to staffing levels and an inability to provide two midwives on call. However midwives have resumed on call OOHs with one midwife, to provide support to Rural Practitioners for unscheduled maternity cases.

Routine midwifery services continue as normal and negotiation and discussions are ongoing with regard to future sustainable on call model and the resumption of a local birth option for low risk women. It is hopeful that resolution will be reached in the coming months.

4.8 Highland Sexual Health

A consultant has been successfully appointed to the Highland Sexual Health Service and will commence her role in Autumn 2018.

The number of patients accessing pre-exposure prophylaxis for HIV prevention since its introduction last year has exceeded the number predicted by threefold. Over 70 discussions have taken place with those who met the eligibility criteria, with 52 currently accessing treatment.

4.9 Technology Enabled Care

4.9.1 Operational Telecare

ELMS2 (Electronic Loan Management System) is now fully embedded within our Telecare Service. We’ve worked closely with the manufacturer Ethitec and our installers, Care and Repair Scotland and Handyperson Services, to tailor the system to meet our unique and specific Telecare requirements. ELMS2 enables us to track and trace all 9,000 assets throughout Highland providing a secure service for telecare clients and NHS Highland. The reporting function of the system also allows our installers to plan annual health checks on equipment automatically through the system, and for NHS Highland to audit progress.

4.9.2 Analogue to Digital Telecare

Telecommunication providers have indicated that analogue phones in the UK will be replaced with a digital telecom service by 2025. Several providers have already initiated this process, eg, Virgin and TalkTalk. As Telecare Services currently rely on analogue technology NHS Highland are working with the National TEC Programme and the Local Government Digital Office to ensure we continue to provide a safe telecare service during this transition period.

The national Analogue to Digital Telecare (A2DT) programme has made significant progress in the past year. 17 Partnerships, including NHS Highland, have worked together and moved from strategic planning to an implementation phase. This implementation phase will provide:

 a clearer understanding of the factors involved in a Digital Telecare Service  guidance on how to safely transition from analogue to digital  a telecare community with increased skills and confidence to make informed decisions.

NHS Highland is working closely with the National A2DT Programme to support a fully digital

20 37 telecare service in the “Fit Homes” in Alness. Ten clients now have digital ready equipment installed in their homes and the calls have been outsourced to Perth and Kinross Council Alarm Receiving Centre. Perth & Kinross have digital ready software already in use at their Alarm Receiving Centre and hope to be fully digital by the end of June 2018. As part of our National A2DT Funding we will work with P&K to March 2019 to have 200 new digital Telecare clients across Highland.

4.9.3 Florence Update – to May 2018

Florence is a text message system that helps patients and health professionals track and or/manage their health and wellbeing. Numbers:

With 120 new patients enrolled on Florence during May the total number of patients who have benefited from Home Health Monitoring using Florence has now reached 2221.

Key Florence protocols: Key Florence Protocols - to May 2018 140 120 100 80 60 40 20 0

Blue = electronic action plans, Red = supported self-managemet, Purple = diagnosis, Turquiose = prevention & early intervention

Five of the key Florence protocols have now passed a key milestone – with over 100 patients having used them:  Asthma – electronic action plan  Mental health courses – supporting learning  Pain management courses – supporting learning  BP monitoring – diagnosis  Foetal movement awareness – prevention/early intervention

There has also been a noticeable increase in the number of patients signed up for:  COPD – electronic action plan  Diabetes – electronic action plan (or simple monitoring) Healthy weight – prevention/early intervention

GP practices are showing a keen interest in using Florence to monitor patients on their hypertension register on an ongoing basis.

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Engagement work with community teams (including mental health, physiotherapy, diabetes and dietetics teams) and with GP practices has been ongoing, with the results of the GP engagement activities shown in the following table.

Current status Number Decision % Trained and using Florence or about to start 18 Accepted 12 for BP monitoring 33% Training booked 4 Accepted Contacted – no decision yet made about a visit 2 Undecided 8% Visited–butnotheardiftheywanttogoahead 3 Undecided Visited – Florence declined after visit 12 Declined Contacted – visit declined at present, may Declined 9 59% reconsider Contacted – visit declined 18 Declined Total GP practices 66

Reasons given for declining Florence (some gave more than one reason):

Reason given No. % Poorsignalinarea 11 28% Toomuchgoingonatthemoment–mightreconsiderlater 9 23% SmallGPpractice–knowallpatientswell 7 18% Use of Florence would not improve current care 6 15% Might reconsider if Florence integrated with clinical systems 6 15% Fewsuitablepatients–e.g.manyelderlywithnophone 5 13% Lack of research evidence of benefits 2 5% Donotwantstafftohavetologintoanothersystem 1 3% Liketofollowratherthanlead 1 3% No reason given 7 18%

4.10 Prison & Custody Services

We continue to experience challenges in providing a Forensic Medical Examiner Service. We are currently advertising nationally.

5. FINANCE

South & Mid Division

The May 2018 financial statement reports a year to date break even position and a £0.5m overspend against an annual budget of £141.8m. The full year overspend is due to Adult Social Care containment schemes slippage.

North & West Division

2018-19 will be another challenging year for the North and West Division despite the savings and containment targets allocated being lower than last year (£8.2m in 2017-18 and £3.7m in 2018-19). Recurring savings for the previous years has been significantly lower than this (£1.1m in 2016-17

22 39 and £1.8m in 2017-18).

The 3 year North Highland plan is well underway for the two divisions with a particular focus on supplementary staffing reductions and containment of Adult Social Care and drugs costs. This plan will drive forward the change necessary to deliver a sustainable service within the available resources to recover financial balance.

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Raigmore Hospital

2. PEOPLE 2.1 Recruitment and Selection

The respiratory service have successfully recruited to a long standing vacancy by partnering with UHI and recruiting to a shared post which offers the successful candidate the opportunity to continue with both research and general respiratory practice.

Challenges are on-going with regards recruitment to general Radiology Consultant posts and also to Interventional Radiology Consultant posts despite significant effort at National and North of Scotland level to recruit to these posts.

Urology, Vascular and Obstetrics and Gynaecology are also challenged with regards to recruitment to vacancies that have been on-going within the teams for some time. Discussions are on-going at Senior Manager and Executive level as to what alternative strategies could be introduced to help improve interest in local vacancies or what alternative affordable options may be available to solve the capacity gap that these vacancies create.

2.2 Staff Experience

IMatter questionnaires have now closed. Responses will be picked up as a part of the action planning next phase.

Value Management continues to deliver good benefits in engaging staff as a part of a standard process at ward and department level.

Plans are being established to introduce a daily management system within Raigmore that will aim to further enhance staff engagement.

2.2.1 Learning and Development 2.3 Sickness Absence

March 2018 % April 2018 % Cumulative Annual % as at 30 April 2018

4.87% 4.60% 4.60%

3. QUALITY & SAFETY 3.1 Improvement Activity

Progress this Month

Value Next phase of roll out to be decided by next accountability meeting. 3A, Management 2C, 7C possibilities. Chief Officer has instructed coaching to come from any certified Lean Leader to increase capacity, with a buddy system in place.

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Discharge Roll out continues in 5C, 3A, 2C, 3B. 6C and 7C started 4/6/18. 5A and Process 7C aware of the work but not been given instructions yet.

HLVS – Post Acute HLVS – Susan MacGregor Project Lead for Raigmore. Wall Hospital, walk to be commenced with data. The Board Nurse Director holds Ambulatory, fortnightly then monthly sponsor meetings to decide priorities for improvement. Post Acute, Home Ambulatory HLVS – Sponsor development session on 6 June 2018.

Post Acute Tracking of post acute patients continues daily. Patients Numbers remain similar. Increased length of stay over the past 3 weeks – majority now waiting on long term care. Capacity in the community remains an issue especially around Care at Home.

Training The Senior Quality Improvement Leads (Lean) will run initial training sessions for anyone wishing to become a value management coach for an area in Raigmore. 2hrs max.

RPIW 1. Children’s Unit RPIW – Planned for 24 September. Scoping meetings have been scheduled to take place in next few weeks. 2. 3 new requests submitted by Raigmore this month to the Kaizen Promotion Office, all approved.

3.2 Waiting Times 3.2.1 Out-patients

As at month ending 31 May 2018, there were 1,588 outpatients waiting over 12 weeks for a first appointment in NHS Highland. The Scottish Government Access Support funding has not yet been fully agreed however there has been a continued focus on reducing the number of patients waiting beyond 12 weeks. The improvement continues through transformational work, new clinic space (Ophthalmology), waiting list validation and additional clinics. The waiting time issues within a number of specialties have been addressed and significant progress has been made to reduce the number of breaching patients. The specialties with the highest number of breaching outpatients are Orthopaedics and Ophthalmology.

Patients waiting over 26 weeks for a first outpatient appointment continues to reduce. As at 31 May 2018, NHS Highland had 342 patients, this number has continually declined for reasons outlined above.

This quarter NHS Highland has been working to Treatment Time Guarantee rules operationally. From 1 July 2018, TTG rules will be reported nationally.

3.2.2 Treatment Time Guarantee (TTG)

As at month ending 31 May 2018, there were 2,060 TTG patients waiting over 12 weeks for treatment with NHS Highland. The Scottish Government Access Support funding has not been

25 42 fully agreed and therefore a limited number of additional sessions have been run. NHS Highland has seen an increase due to additional outpatient activity providing patients with a diagnosis. The specialties with the highest number of breaching TTG patients are Orthopaedics, ENT and General Surgery.

There has been a significant benefit from treating cataract patients in Elgin and the service are now in a manageable position. Other operating specialties are now working on a plan to continue activity throughout the Theatre Upgrade Project. There is a focus on specialties working in a different way to minimise the loss of theatre capacity at Raigmore, this includes working at other Highland sites and Elgin. This has been shared with Scottish Government Access Support Team.

3.2.3 Key Diagnostic Tests

As at month ending 31 May 2018, there are currently 245 Scope patients and 580 Radiology patients waiting over six weeks under NHS Highland.

Endoscopy has been running additional clinics to reduce the breaching number, specifically targeting upper endoscopy patients. There has been a considerable increase in referrals from Bowel Screening Programme which has impacted on the unit’s capacity.

In Radiology there has been an increase in the number of patients waiting for CT scan due to a loss of 10 days activity because of a scanner breakdown. The first MRI scanner has now been replaced with training in place, the next scanner will be due replacement in August.

3.2.4 ED 4hr Compliance

The attendances at ED have increased significantly in all sites – beyond the normal Seasonal increase putting pressure on ED performance across all sites.

Raigmore maintained its performance during May – and whilst there were occasional dips in performance overall for the month the performance was 94.68. This compares well against the national average of 90% for Scotland in April.

Whilst this is the anticipated trend – with significant spikes in attendance over the summer the normal pattern, already the attendances are higher than the busiest period last year.

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3.2.5 Cancer Access & Treatment Times

31 Day Performance – Quarterly to end March 18 and April/May 18

(From “decision to treat” to treatment for all patients regardless of the route of referral)

Chart 1 - Number of Patients Treated and Breached

300

250 31 37 25 200 23 26 27 16 25 13 11 18 13 7 22 9 12 10 21 12 150 13 21

218 100 207 214 191 188 185 181 187 178 178 167 175 171 166 165 174 166 145 153 156 145 5 50 60

0

Breached Treated

31 Day Performance against 95% Standard

Performance against 95% Standard 99.0 97.0 97.3 98.1 95.0 96.396.9 96.4 96.396.896.1 96.0 95.996.0 95.2 95.995.596.0 93.0 95.1 94.994.3 94.3 91.0 93.1 93.1 89.0 91.5 87.0 85.0

As can be seen above, the Board usually meets this Standard on a regular basis unfortunately performance in the latest Quarter and for April and May dipped as a result of the theatre shutdown and the clinical prioritisation of cases deferred. The combined April and May performance is due to difficulties in scheduling an increased number of Breast patients at a time of reduced capacity following the theatre refurbishment. This has been addressed on an on-

28 45 going basis with cancer patients such as these being prioritised for treatment. Other failures tending to be within Urology and Renal in particular.

62 Day Performance – Quarterly to end March 18 and April/May 18

(From date of referral to treatment, for all patients referred urgently with a suspicion of cancer

Chart 3 – Number of Patients Treated and Breached

300

250 31 37 25 200 23 26 27 16 25 13 11 18 13 7 22 9 12 10 21 12 150 13 21

218 100 207 214 191 188 185 181 187 178 178 167 175 171 166 165 174 166 145 153 156 145 5 50 60

0

Breached Treated

Chart 4 – Performance Against 95 Per Cent Standard

62 Day Performance against 95 Per Cent Standard 100.0

95.0

90.0

96.0 85.0 93.8 94.6 93.9 92.7 92.492.8 91.492.2 91.7 91.0 89.7 88.0 88.3 80.0 86.2 86.586.285.586.785.885.6 82.1

75.0

As can be seen above, the performance against the 62 Day Standard continues to be a significant cause for concern, both locally but also Nationally where the 62 Day Performance in

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April 2018 was 84.5 per cent.

The major of the patients who breach continue to be within Urology and its sub specialties. Minimising the number of Urology patients breaching their target would almost certainly ensure that the target was met as a Board.

The numbers of patients breaching within Urology are due to pressures at almost every stage in the pathway but given that this target measures the time from “decision to treat” to treatment it is clear the patients are breaching as a result of delays to both surgery and also Radio Frequency Ablation for Renal Cancer.

An improved level of performance in the last three months has been brought about by the following actions within Urology

 Completion of the dedicated spaced for TRUS Biopsies  This will improve again during August within an additional two PAs per month of TRUS or “decision to treat” clinics as demand dictates. This is made possible as a result of the Nurse Specialist being freed from other duties.

Other immediate actions

 Work is also on-going in order to review the On-call provision within Urology in order to create additional elective capacity.  A laser system for the provision of benign Prostate services in order to free up bed days for cancer patient is also being procured.  Continuing in our efforts to appoint to the vacant 6th Consultant Urologist post.

As reporting previously the emerging pressure as a result of a greater number of patients being referred to Endoscopy following the introduction of the FIT test ( Faecal Immonuchemical Test) test as part of the National Bowel Screening Service in November 2017 is also restricting Endoscopy capacity. This should be a temporary pressure until the thresholds and sensitivity for referral are moderated nationally.

The introduction of FIT testing for the symptomatic service in August 18 is expected to help to some extent with a 14 per cent reduction in scope demand

4. CARE

Service and Delivery

4.1 Adult Social Care 4.1.1 Delayed Hospital Discharge

Delayed Discharge numbers have increased due to lack of care at home capacity within community services over recent months.

4.5 Modernisation of Hospitals and Community Services

Work continues on the introduction of the post acute ward and reduction of surgical bed footprint.

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Work also continues on the Modernising Outpatients agenda.

Plans are being introduced to deliver a more robust management system within Raigmore that will ensure good staff engagement and appropriate prioritisation of initiatives being progressed within the hospital.

Tower block reconfiguration work continues with the medical receiving unit now relocated to the new ward area on the ground floor.

4.11 Technology Enabled Care

NHS Near Me has started to be scaled up. The testing phase was completed in May and a standard process manual published on the intranet. An 8-week plan for clinical services to implement or to scale up NHS Near Me has been defined, and 14 services have planned dates for scaling up by the end of August. Currently this scaling up will be for Caithness patients only as no decision has been made about how the service will he funded across NHS Highland. An audit to inform scheduling of NHS Near Me across Highland took place in w/c 11 June. A national version of the NHS Near Me process manual and branding (as developed in Highland) was launched for use across NHS Scotland by the Scottish Centre for Telehealth & Telecare on 18 June. This is particularly useful for cross-board working (eg, with NHS Greater Glasgow & Clyde, NHS Western Isles and the Golden Jubilee).

5. FINANCE

For the first two months of the new financial year 2018/2019, Raigmore Hospital is reporting an overspend of £910k. This initial Year to Date position is too high by £250k approximately due to the timing of the Scottish Government funds for waiting times & TTG being known - this budget will be drawn down for the next monthly report. There are several notable overspends across the Operational Units including drug costs in Oncology of £318k;

Haematology locums net overspend of £104k; unfunded Surgical beds of £200k; Caithness Labs £42k. The Operational Management have been asked to consider how they will absorb these costs (and any future costs and they do not appear in the forecast for this month whilst talks are ongoing; they are, however, included as red risk.

Raigmore has been through a recurrent re-basing of all of the budgets and alongside the newly issued financial governance framework, this will underpin the budget management for this year and hopefully produce a break-even position for most of the Departments. Savings targets have been devolved, with management input, to the appropriate level to allow the budget managers full control of their budgets

Raigmore has also changed the reporting around vacancy factor by non-recurrently reducing most pay budgets by about 2.7% - this will be much more meaningful for the overall reports that are produced.

Savings - £1.8m targets for housekeeping/procurement have been devolved to the Operational Units at the most appropriate level and the plans are to achieve the total over 10 months rather than 12.

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Plans from each hospital division are at varying stages of completeness but this is part of each of the meetings with the budget managers over the coming weeks. At this stage, we do not anticipate that these savings will not be met and they all noted as amber risk.

Centrally, we are holding £600k for savings to be made from drugs (from Depts./areas) outwith the cost containment plans; this target will be devolved once the full plans are implemented (noted as amber risk).

32 49 Highland Health & Social Care Committee 5 July 2017 Item 2.6

CAITHNESS REDESIGN OF HEALTH AND SOCIAL CARE SERVICES

Michelle Johnstone (Area Manager, North), Eric Green (Head of Estates), Christian Nicolson (Quality Improvement Lead) and Maimie Thompson (Head of Public Relations and Engagement), on behalf of David Park, Chief Operating Officer, North Highland

The Health and Social Care Partnership Committee is asked to:

 Endorse the options development and appraisal process.  Endorse the preferred option.  Recommend to the NHS Board that the changes represent major service change and proposals should be formally consulted upon.

1. Background and Summary

NHS Highland’s Quality and Sustainability Plan and Strategy published in May 2017 describes the national and local context, around the challenges to sustain services. It set out what the board believed to be a compelling case for change and the need to transform services underpinned by a number of principles.

However, in a paper presented to the board on 28th November 2017 specifically about the redesign of services in Caithness it was highlighted that:

“Despite all the efforts to date, NHS Highland appears not to have been successful in communicating the case for change and /or there not being acceptance for the case for change”, and that:

“Going forward there will need to be a clear focus on explaining the case for change and a more inclusive approach as to how together we can design models of care which are fit for the future.”

The Project initiation Document (PID) presented to the board on 28th November 2017 set out the proposed arrangements to oversee a fresh approach to the redesign work in Caithness, including describing the scope, management and governance arrangements for the proposed redesign.

As recorded in the board minutes of that meeting, the Chair referred to: “the passion people felt for health services and felt this was the common ground on which the redesign process would be engaged for the future”, and

The Highland Council representative on the board Deirdre Mackay spoke about the: “breakdown in trust that had occurred between the local community and the NHS. She emphasised the need to draw a line in the sand to move forward cooperatively to ensure safe and sustainable services could be co-designed. This would need a clear programme of work with timescales for any changes based on best available evidence.”

This paper is the culmination of a huge amount of work that has taken place since the board approved the Project Initiation Document at their meeting in November. The work has progressed within challenging timeframes as signed off by the board. This could not have happened without the clear commitment and hard work from many including staff, community leaders and representatives in Caithness. 50

1.1 Summary of Key Points

 Since November 2017 between 60 and 70 local representatives have been through an extensive engagement process with NHS Highland. There has been strong local collaboration focussed on designing solutions together.

 The approach has been wide-ranging and included five workshops between March and June 2018 which were independently facilitated (Appendix 1a and 1b).

 At the workshop held on 19th March information was presented on the case for change and summarised in this paper (Appendix 3). This workshop included a panel of senior clinicians who described some of their experiences and reflections on the challenges to sustain services in Caithness, as well as more widely across the country. There was a far greater understanding and consensus from participants of why services were not sustainable now or to meet future increasing demands.

 Following this a further three workshops took place in May (18th, 22nd and 31st) where possible options were developed and a short list of four options agreed, including the status quo.

 The final step in this stage of the process was to score the four options and this took place on 12th June 2018.

 Common to all three proposed change options include strengthening community services, managing end of life care in Caithness and, a multi-million upgrade proposed for Caithness General Hospital.

 A further key element included developing Care Hub/Care Villages in Thurso and Wick both with new build elements.

 It was also highlighted that GP Practices would remain in current towns and villages in Caithness, and the work to roll out NHS Near Me, already underway, would continue.

 For West Caithness the proposed Care Hub/Village would be on the Dunbar Hospital site in Thurso. It would mean some services/ bases moving from Thurso Community Health Centre (Davidson’s Lane) and residents from Bayview Care Home being relocated to a proposed new build facility on the Dunbar site, as part of the Care Hub.

 In Wick, Pulteney House Care Home site was identified as the preferred location for the Care Hub/Care Village. In this option it would mean some services/ bases from Wick Health Centre and Wick Town & County Hospital being relocated to the Hub.

 The main benefits of the preferred option is that it would consolidate day services, community beds (non acute) on two 24/7 sites instead of four, make best use of estate assets, and provide services in modern fit for purpose facilities that would allow staff and services to be strategically co-located.

 When combined with the development of Care Villages the new arrangements would allow more people to be looked after in their own community with less reliance on statutory services. This is going to be necessary for the future where we will have more people to care for but with fewer paid staff to provide the hands on care.

 It is recommended that the preferred option should be subject to wider engagement and consultation. Overall the process has been very constructive and hopefully provides a solid platform to continue to make progress.

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2. Strategic Context

The Health and Social Care Delivery Plan published by the Cabinet Secretary for Health and Sport published in December 2016 brought into sharp focus the urgent need to address the rising demands and other challenges facing the NHS in Scotland. Audit Scotland also prepared a Report ‘‘NHS in Scotland 2017” (October 2017) which further described how the NHS is under pressure with the need for change and longer term planning.

The combined impacts of ageing population, demographic changes and implications for the workforce with increasing costs and demands, mean that the current model of health and social care delivery is not sustainable.

While such pressures are being experienced across the country, and beyond, they are more acute for NHS Highland in general, and in particular, our more remote and rural areas. These pressures have been evident and growing for a number of years yet the pace of change has been slow. This is in part due to resistance to change including a belief by some that the solution is to have more money or to be more innovative around recruitment. Arguably while more money and innovation may assist in the short term it will not address the fundamental challenges to address issues of sustainability.

Health and social care now needs to extend far beyond the classical settings of hospitals, GP practices, and hospices and reach more effectively into a person’s own home and community with communities being more resilient and gearing up for better use of technology. This has in part been facilitated through integration of health and social care which has been ongoing in Highland since 2012.

NHS Highland’s Quality and Sustainability Plan published in May 2017 reflected our local context, around the challenges to sustain and transform services. This included reference to the need to redesign services in Caithness. It also set out a number of goals (Box 1) and principles (Box 2) to underpin any redesign and transformation of services:

Box 1: NHS Highland’s Quality and Sustainability Plan | Goals  Provide services and facilities which meet 21st century health and social care needs

 Provide high quality, integrated and cost-effective services

 Reduce waste and inefficiency across services

 Ensure services are sustainable

Box 2 NHS Highland Quality and Sustainability Plan | Underpinning Principles

 Support for people to stay at home for longer  Supporting people and communities to be more independent and resilient  Increase choice for end of life care and more realistic medicine  Greater integration, co-location and co-ordination of care  Greater Regional collaboration and solutions  Greater use of technology  Reduction the length of time people spend in instructional care  Reduction unnecessary attendances and appointments  Reduction waste, harm and unwarranted variation

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The changes flowing from implementing our strategic vision therefore require us to remodel our care pathways, workforce and our assets. It was highlighted that over time this would bring about a planned reduction in the number of staff working in traditional hospital settings, and that service would be provided from fewer but modern strategically co-located facilities supporting more people being looked after at home or in a homely setting.

2.1 Scope of Redesign of Health and Social Care

The scope of the Caithness redesign includes care at home service, community services, day care services, palliative care, care homes, community hospital services, modernisation of Caithness General Hospital, and use of technology to reduce travel.

The main elements of the redesign are to:

1) support more people to be looked after at home 2) reduce unnecessary travel1 especially out with Caithness but also within Caithness 3) reduce the number of locations currently providing 24/7 services 4) increase strategic co-location, optimisation and developing the estate to meet modern requirements

2.2. Overview of Service Change Process

An overview of the service change process which is required to be followed is summarised (Appendix 1a), including the current status of the Caithness Redesign against the key steps Appendix 1b).

The Chief Executive Letter CEL (2010) 4 provides guidance on “Informing, engaging and consulting people in developing health and community care services”. This document also clarifies the role of the Scottish Health Council which is to ensure that the Boards public involvement activities are in line with the guidance. In particular Boards are required to demonstrate how they:

 work with local people to develop options which are robust, evidence-based, person- centred  services are sustainable and consistent with clinical standards and national policy;  ensure that public stakeholders are involved in developing options and in the process to appraise options;  make sure that the development and appraisal of options is consistent with the approach as outlined in HM Treasury guidance, ‘The Green Book’ and the Scottish Capital Investment Manual.

Any proposed changes which are considered to be ‘major’ is subject to a period of formal public consultation. The Scottish Health Council has published guidance “on identifying major health services changes”. This documents sets out issues to consider when identifying whether a proposed service change ought to be regarded as “major”. They highlight nine key areas to consider:

1. Impact on patients and carers 2. Change in the accessibility of services 3. Impact on emergency or unscheduled care services

1 Recent analysis has revealed significant number of patients travelling for outpatient appointment. Around 10,000 appointments (not patients) are receiving their consultations in Raigmore. Work is underway to reduce the number of people travelling using a combination of approaches including the roll out of NHS Near Me

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4. Public or political concern 5. Conflict with national policy 6. Change in method of service delivery 7. Financial implications 8. Related changes in recent years 9. Consequences for other services

Notably while the Scottish Health Council does not currently have a formal role in processes that are led by Integration Authorities, they do have a role for health services provided under the Lead Agency model and have the ability to make a determination about major service change. However, they don’t have a role on commenting on social care services.

Where major service change is required the guidance is clear that it is a matter for the board to make the final decision.

3. Brief Description of Current Services

3.1 Services

There are 25,807 people registered with General Practices in Caithness of which 11,606 live in East Caithness encompassing Wick and 14,201 in West Caithness including Thurso. The location of services is shown on Map in Appendix 2 and briefly summarised below.

3.1.1 Primary Care and Community-Based Services

The area is served by seven GP Practices, two in Thurso (Riverbank-salaried since 2012) and Thurso and Halkirk Medical Practice (Princess Street); two in Wick (Pearson Practice and Riverview – salaried since 2014). The others are Castletown & Canisbay, Lybster (salaried since 2004) and Dunbeath.

As well as the full range of services provided by General Practice the area has two integrated teams. The teams are split along geographical lines with the East Caithness Integrated Team based in Wick and the West Caithness Integrated Team based in Thurso. They currently work out of a number of different bases.

The Integrated Team include community nursing, community mental health, learning disabilities, physiotherapy, podiatry, occupational therapy and social work.

Palliative and end of life care in Caithness is provided at home and across a range of health and social care settings including care homes and hospitals and is supported by specialists input from MacMillan and the Highland Hospice. The future delivery is informed by a review carried out by the Palliative Care Redesign Group.

Since integration in 2012 NHS Highland manages two care Homes 23 bedded Bayview in Thurso and 18 bed-Pulteney House in Wick. In addition the private sector run three nursing care homes: Pentland View in Thurso and Riverside and Seaview in Wick.

Local communities are also served by Dunbar Community Hospital in Thurso and Wick Town and County in Wick.

Dunbar Community Hospital is a nurse led-unit with six beds currently. Medical cover is provided in hours by a local GP Practice and by agency GPs out of hours. Also located on site is a 24/7 Minor Injuries Unit and out of hours Urgent Centre, outpatient facility which includes physiotherapy and podiatry, community mental health team, vocational support and a modern dental unit.

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Town and County Community Hospital in Wick currently has six beds. Medical cover is provided by Out of Hours General Practitioners every Saturday and Sunday between 08:00- 18:00 and by Consultants at Caithness General out with these times.

3.1.2 Caithness General Hospital

Caithness General is one of NHS Highland’s three Rural General Hospitals. It has 42 inpatient beds, two operating theatres and an endoscopy service. There is an Emergency Department, three high dependency unit beds but no level 2 critical care beds. There is no onsite paediatric service.

It provides a range of outpatient, day-case, inpatient and rehabilitation services. An ambulatory2 care unit provides day case treatment for example dialysis, chemotherapy and medical infusions.

There are a range of outpatient services and clinics including physiotherapy, occupational therapy and radiology providing x-ray, ultrasound and CT scans.

Visiting consultant clinics include orthopaedics, ophthalmology and gynaecology. There is also a rapid access clinic (via the medical ward) for people with chest pain.

The hospital changed to a midwife led community maternity unit in December 2016.

3.2 Case for Service Change

Caithness specific information on some of the challenges relating to sustainability including demography, deprivation, workforce and finance was shared with participants for the workshop held on 19th March and summarised here in Appendix 3.

At this well attended event, participants also had the opportunity to hear from senior clinicians (Table 1) about their perspective on some of the challenges to sustaining local services.

Table 1 Clinical Panel Session, 19th March | Pultneytown Peoples Project, Wick Name Designation Teresa Green Integrated Team Lead for East Caithness and Manager for Mental Health Services in Caithness Dr Martin Wilson Consultant Physician specialising in Care of the Elderly Medicine, based at Raigmore. Provides a visiting service to the north including Caithness General, Care Homes, GP Practice and home visits Dr Alison Brooks GP in Thurso for 29 years, Clinical Lead for the Dunbar and provides Out of Hours Care at weekends (as part of team) Dr Gordon Linklater Consultant in Palliative Care Medicine based at the Hospice in Inverness; a role to provide support and advice to staff in Caithness & Sutherland; see people in the community; meet with the team through fortnightly VC Case Reviews. Michael Loynd Macmillan Advanced Practitioner based at Caithness General; providing care across range of care settings Dr Boyd Peters GP in Badenoch & Strathspey for 20+ years, Clinical Lead in Badenoch & Strathspey, including for major service redesign and Associate Medical Director (Mental Health) with NHS Highand

The clinicians explained:

2 Ambulatory means people are able to walk in for treatment and not confined to a bed.

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o that we will have more people living longer with complex needs but with less people of working age to provide the care

o that already there are staffing difficulties which are made more challenging by having NHS services across multiple sites in particular running 24/7 services across five sites

o the importance of the focus being on the people providing the care not the place of care

o how medicine is also constantly changing and improving and so alongside the rising demands there are also increasing costs

o strong support to use new technologies and other approaches to support more people to be looked after locally

o more people can be looked after in the community when compared to smaller units

o the importance of providing excellent palliative / end of life care across all settings

The Notes of the meeting are available on the NHS Highland website HERE

3.2 Estates

They also heard from Eric Green NHS Highland’s Head of Estates, who emphasised;

o the importance of agreeing the clinical and care strategy first before looking at buildings

o that services and staff are not strategically co-located and some buildings are not fit to deliver modern health and social care standards

Furthermore at the workshop held on 31st May colleagues from Estates shared further information on the condition of some of the buildings (Appendix 4, 4a and 4b), highlighting:

 Parts of hospital buildings don’t meet modern clinical requirements for inpatients  Bayview House Care Home has accessibility issues  Some facilities are not fit for purpose

4. Options Development, Appraisal and Scoring of Options

Since the Board meeting in November 2017 between 60 and 70 local representatives have been through an extensive engagement and options appraisal process. This included a series of five workshops held in Caithness independently facilitated by Higher Ground.

4.1 Benefits Criteria

At the workshop held on 18 May in Pultneytown Peoples Project in Wick, participants agreed seven non financial benefits criteria to assess future options. These were prioritised and weighted in order of importance as follows:

1. Delivering sustainable services 2. Meeting the demographic challenge 3. Patient experience 4. Staff experience 5. Delivering services locally 6. Addressing buildings issues 7 56

7. Caithness as a proposition

4.2 Long List of Options

Following the workshop held on 22 May 2018 a long list of options emerged. This was initially developed by the participants but was then reviewed and completed by Higher Ground. The long list included:

 New build Caithness “combined hospital”  New build Caithness “acute health airport” +/- “Care Hubs”  New build Rural General Hospital in a new (central) location +/- “Care Hubs”

It was through these discussions that the Care Hub/ Care Villages was explored (Box 3).

Box 3 Care Hub / Village Concept

While the principle of ‘Care Hub/ Village’ is starting to get more established, it is clear that a ‘one-size’ does not fit all especially in remote and rural locations. There is an opportunity to co-create something dynamic, inclusive and resilient that currently does not exist, yet, can benefit from the learning from others.

Developing Care Villages | Thurso and Wick

The Care Village element brings together housing solutions, looking after people at home and overall helping to overcome issues relating to social isolation through a range of approaches. This could include the growing support for developing inter-generational approaches across all elements of health and social care.

There would also need to be closer collaboration across Planning Partners and communities to develop a range of suitable accommodation options.

At the point where people require nursing care in a residential setting, it would be necessary to provide services in high quality Care Hub. In the future it is expected that the length of time spent in residential or nursing care would be shorter.

There are already Highland examples of where communities have been developing their own approaches to promoting inclusion and independence are summarised.

Developing Health and Social Care Hubs | Thurso and Wick

The Care Hub element proposed for each location (Thurso and Wick) would form the Hub for the Care Village. They would be slightly different in each area depending on local circumstances, needs, opportunities and constraints. The following is indicative.

In general Health and Social Care Hub would bring together, onto one site/ campus, 24/7 Community Care Beds, Palliative Care, NHS Near Me a base for the Integrated Team and other staff groups and NHS services as appropriate. There would be co-location with Scottish Ambulance Services.

It could potentially bring GP/Primary Care Services into the Hub but the advantages and disadvantages would need to be considered from all perspectives, including access and transport for patients.

The Dunbar and Caithness General Hospital Option would include A&E/Urgent Care and Out Patients being part of the Hub. But for Wick Town and County or Pulteney House it would not.

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4.3 Short List of Options

At the meeting held on 31st May (also in Pultneytown Peoples Project) a short list of options was agreed by the group (Box 4). These options were subject to a more detailed review. Participants were reminded again that the short list must include the current arrangements i.e ‘status quo’. This is to act as the bench-mark against which to compare the three potential change options.

Box 4 Short list of options agreed at workshop held on 31st May 2018 Option Ref Description 1 1 Status quo – current arrangements 2 4b(i) Care Hubs/Villages Dunbar and Wick Town & County 3 4b (ii) Care Hubs/Villages Dunbar and Pulteney House 4 5b Care Hubs/Villages Dunbar and Caithness General Hospital

4.4 Process of scoring the short list of options

A fourth and final workshop, was held on 12th June 2018 in the Norseman Hotel in Wick. This had three important strands to ensure all participants had a clear understanding of:  the status quo  elements common to each change options  elements unique to each change option

First the facilitator guided the participants through assessing and scoring of the status quo – the current arrangements - including an analysis of Strengths, Weaknesses, Opportunities and Threats (SWOT).

After this was done considerable time was spent on understanding the elements which were common to all three change options:

 Primary care services maintained in current towns and villages  Community services (including mental health) enhanced  Palliative care will continue to be delivered in Caithness  Enhancing community services (including mental Health)  Out-patient services delivered from Thurso and Wick plus NHS Near Me  Urgent care centre (minor injuries unit and out of hours) will be maintained in Thurso  Refurbishment of Caithness General Hospital  Voluntary sector and partnership working will be strengthened  The Care Hub/Care Village concept in Wick  Care Hub/Care Village in Dunbar Hospital Site (Box 5)

Box 5 Summary Assessment | Care Hub/Care Village in Dunbar Hospital Site

• Accessibility: Readily accessible by car. Potential to improve bus access. • Size: The site is big enough to accommodate our core care hub elements and future aspirations • Buildings: Likely to require the re-furbishment and change of use of physically but not functionally suitable accommodation at Dunbar. Minimal demolition • Disruption: Some disruption to Dunbar site/operation during construction; significant change to the permanent residence of a number of Bayview residents upon completion • Opportunity: To utilise additional NHS owned land • Challenges: Planning required for substantial additional development. Longer lead time and scheduling critical 9 58

• Contribution: Existing buildings likely to be retained but for different use. Beds likely to be in new build. Maximises use of existing assets • Programming: Presents a number of opportunities for interim arrangements – change could occur before large building developments

The Care Hub/Care Village in Wick

There were three possible options to locate the Care Hub/Village in Wick: Wick Town and County (Box 6a) Pulteney House (Box 6b) and Caithness General Hospital (Box 6c) and each are summarised below:

Box 6a Summary Assessment | Care Hub/Care Village in Wick Town and County Site

• Accessibility: Readily accessible by car. Poor bus access. • Size: The site is big enough to accommodate our core care hub elements but future aspirations/longer term developments would require the purchase of adjacent land • Buildings: Likely to require the demolition of physically, but not functionally suitable, accommodation at Town & County. Largest amount of construction of all options. Largest amount of functionally suitable redundant estate. • Disruption: Minor disruption to a small number of existing in-patient services during construction but significant change to the permanent residence of a higher number of residents upon completion with re-location of Pulteney House • Opportunity: Limited, if any, added value elements • Challenges: Planning required for substantial change of use and scale; longer lead time. Will require replacement of staff residences on the site • Contribution: Options for exterior space/gardens may be limited. Existing buildings and garden area highly unlikely to remain in present locations Programme: Largest number of stakeholders; longest programme; most difficult to deliver; most problematic business case

Box 6b Summary Assessment | Care Hub/Care Village in Pulteney House Site

• Accessibility: Readily accessible by car. Potential to improve bus access • Size: The site is big enough to accommodate our core Care Hub elements and some future aspirations/longer term developments however future site acquisition may be required to minimise loss of green space • Buildings: Existing building retained and extended/added to. Caberfeidh Court integrated with development. Minimal construction. • Disruption: No disruption to existing in-patient services at Town & County during construction. Minimal disruption to Pulteney House residents during re-furbishment / extension • Opportunity: Inclusion of Caberfeidh Court to accelerate Care Village development; ready access to Pulteney Peoplestown Project if appropriate; early realisation of benefits • Challenges: Planning required for extension but with less lead time than other options • Contribution: Options exist for exterior space/gardens, e.g. Multi-generational development using playpark. Buildings will primarily be the existing ones with added space. Services located in a more deprived area • Programme: Quick to deliver. Could be concept pathfinder site? 10 59

Box 6c Summary Assessment | Care Hub/Care Village in Caithness General Hospital • Accessibility: Readily accessible by car and public transport although parking limited. • Size: The site will struggle to accommodate even core hub elements without the purchase of additional land • Buildings: Main block retained and re-furbished; QE demolished to support new developments • Disruption: Significant disruption to CGH site/operation during construction; significant change to the permanent residence of a higher number of Pulteney residents upon completion • Opportunity: Limited, if any, added value building elements • Conflicts with the care hub/care village concept • Challenges: Planning required for extensive change that also requires complex programming. Space/parking will be a challenge. • Contribution: Options for exterior space/gardens will be limited. May feel “more like a hospital” than a care hub due to relative size of CGH

Each change option was then systematically assessed using SWOT analysis in terms of how well each option met the benefits criteria. This was supported by an appraisal on current services issues and future opportunities (provided by Michelle Johnstone), as well as an appraisal of the estates side of things (buildings condition, location, potential to expand), provided by Eric Green. The facilitator encouraged people to consider the unique elements of each option to help distinguish them when scoring.

Individuals and groups then privately scored each option in turn, before the scores were amalgamated to arrive at an overall score for each option with the earlier weightings applied (Box 7).

Box 7 Summary of scores for each option short listed Option Ref Description Score3 Rank Status 1 Status quo – current arrangements 277 4 Carry forward 2 Care Hubs/Villages Dunbar and Wick 683 2 Carry Town & County forward 3 Care Hubs/Villages Dunbar and Pulteney 783 1 Preferred House 4 Care Hubs/Villages Dunbar and Caithness 510 3 Reject General Hospital

4.7 Conclusion of Options Appraisal

The status quo (Option 1) received a low score confirming that participants did not feel it was a good fit to address the challenges for the future.

3 An account of how the group work was organised, wider discussion and process for scoring is not included here but the presentation and write up is available on the NHS Highland website. It should be noted the number of workshops and the pace of delivery was, in part, determined by the participants. Initially four workshops over three days were planned. However at the event held on 31st May a further workshop was requested to ensure there was sufficient time to understand, debate and score the options. Moreover participants wanted to score the short list of options at the start of a session when fresh as opposed to the end of a session when tired.

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Option 3 was a clear preferred option scoring 783 with Option 2 the next best option scoring 683.

At the conclusion of the workshop on 12th June it was highlighted that the Operational Unit, with advice from Head of Public Relations and Engagement, would be recommending that the proposals represented Major Service Change. It is proposed to consult on the preferred option but views would also be sought Wick Town and County as potential for the location for the Care Hub in Wick as the option that scored second highest. The status quo also has to be included.

There was a general feeling from participants that having the Care Hub / Care Village at Caithness General Hospital was not a practical option as reflected in the lower score. The operational unit is therefore recommending that this option is not included as part of the public consultation.

4.8 Further issues to consider

Further detail will be required as part of the business case process including a more in-depth site appraisal, work force plans and affordability. The future use of any buildings vacated would also need to be considered. Ongoing impact assessments will be required with respect to any change in location of services.

There will also need to be agreement around how to manage fragile services in short-term and options for how best to manage any transitional arrangements. Some buildings would need to be converted in both Thurso and Wick. For example it would not be possible to convert Dunbar with everything in it and so some interim solutions would be required.

5 Contribution to Board objectives

Despite the best efforts of staff the current arrangements fall short of meeting the draft board objectives as set out under People, Quality and Care for 2018. However being able to redesign services that would allow implementation of new models that fit with the boards Quality and Sustainability Plan would allow objectives to be more readily delivered going forward.

This redesign provides significant opportunities to maximise the potential of integration and deliver services which are more geared up for the future with more sustainable staffing models.

Quality

To improve access to and co-ordination of care by:  Developing local services that are sustainable for the future  Increasing the number of services supporting people through the use of new technology  Improving timely access to the right person who can best meet the needs of an individual through new models of care

Care

To improve the experience of care and caring for people by:  Minimise the time that individuals have to be away from home and their families to receive care  Supporting more individuals and families to make informed choices about their care

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People

To attract staff and improve our staff experiencing working for NHS Highland by:  Making NHS Highland the employer of choice with opportunities for self development  Ensuring staff are proud to work as part of a team delivering safe and effective care  Increasing the number of staff who feel engaged and valued as part of our team

Governance implications

 Staff governance4

Current arrangements and models of care are fragile, often person dependent and mostly not sustainable for the future. The NHS Scotland Staff Governance Standard requires Boards to demonstrate that staff are provided with a continuously improving and safe working environment, promoting the health and wellbeing of staff, patients and the wider community.

Many staff have also worked in the same clinical areas / services for a long time, and while the redesign will not result in any loss of jobs, it will almost certainly mean that some staff will need to think and work quite differently including flexibly across care settings. This will need excellent leadership, management, staff side support and full and full involvement in any changes. This will support to achieve the staff governance standards of ensuring staff are well informed, involved in decisions and appropriately trained and developed.

As in any change process it can be unsettling for staff but this has been particularly challenging in Caithness where the delivery of health services has become high profile, often political receiving very negative coverage. As well as negative coverage being demoralising it counts against presenting a positive image to attract and retain staff to the area, which in turn adds to the challenge. The Staff Governance Standards require Boards to demonstrate that staff are treated fairly and consistently, with dignity and respect, in an environment where diversity is valued.

The work which has taken place since last November has significantly helped to improve this. Local management have been active in supporting, informing and involving staff and this will need to be ongoing. Staff-side is fully engaged and has included drop-in events with further planned.

As part of the business case process a work-force plan will need to be fully developed which will require to be realistic, sustainable and affordable, and an appropriate match for the proposed changed services going forward. Contingency plans and transitional arrangements will also be very important to debate and plan for.

 Clinical5 governance

The staffing challenges described above mean that there are clinical governance issues to be managed. While there are mechanisms in place to achieve this, more sustainable models of care, with a more permanent workforce, and greater use of technology would deliver improved governance. There is a balance to be struck between delivering safe care with services which can be delivered locally. This was reflected in the benefits criteria agreed and weightings by the participants at the workshops.

Pilot work is planned to provide a clinical framework for the delivery of end of life care.

4 In this context staff is used in the broadest term and includes GP and practice staff 5 For the avoidance of doubt clinical refers to health and social care 13 62

 Financial impact

New models need to be designed which can be staffed and which will see more people cared for in the most appropriate environment and with less reliance on hospital beds and institutional care. Supporting more people at home would provide an improved service and should be more cost effective (Table 2).

At this stage in the process participants were expected to asses options on non financial benefits criteria. Therefore a financial appraisal has not yet been carried out. Information was provided to participants on costs on current arrangements and budgets.

Table 2: Indicative weekly costs associated with place of care

Place of care Cost per week Rural General Hospital £4,200

District General Hospital £3,500

Community Hospital £2,500

NHS Highland Care Home £1,000

Private Care Home £649

Care at Home £200

6 Risk Assessment

The Project Initiation Document set out the approach to identifying and managing risks going forward and stated:

“The decision to pause and reset was based on the judgement that that the current process was unlikely to gain acceptance from the public and some staff. In order to deliver more radical and innovative change then a wider, co-ordinated and concerted effort is required with appropriate governance and management support. There was a balance to be struck between taking more time to build confidence versus the real ongoing operational pressures to be managed and the risk that services ‘collapse’ before new arrangements are in place.

7 Planning for Fairness

A Planning for Fairness document has been refreshed to reflect the preferred option agreed and is available HERE Some initial analysis has taken place to look at two elements:

1. The Riverbank Medical Practice to relocate to a healthcare hub at the Dunbar Hospital site in Thurso.

2. The Riverview Practice to relocate to a proposed Wick Healthcare Hub as an integrated part of a development on the site of Pulteney House in Wick.

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The work highlighted that average walk and the drive times for the patients currently registered with the two practices would increase slightly if services are moved to the proposed new sites. . Moving the Riverbank Medical Practice in Thurso to Dunbar Hospital Care Hub increases the average drive time of patients to the service by two minutes and the walk time by six minutes. Similar increases in average access time would be experienced by the patients registered with the Riverview Medical Practice in Wick if the service moved to Pulteney House

Having the Care Hub in Pulteney House site would allow more services to be located in a more deprived part of Wick. There is some evidence from a recent Scottish study which shows that those who live in SIMD 1 are significantly less likely to attend their GP appointments (Ellis et al Dec 2017). A wider review of the literature is underway. These elements would also be subject to public consultation.

Further detailed work will be required as the process develops to look at any access issues.

8 Engagement and Communication

It was highlighted in the Project Initiation Document that it was going to be:

“Critical to the process that the approach this time around will need to be quite different.”

And

“Greater Involvement of clinical leaders and other influences would help with explaining why changes are required and wider collaborative approach is likely to yield more innovative solution.

Significant engagement took place in 2017 (Appendix 5) yet it was the workshop with the clinical panel on 19th March which appears to have had greatest impact. It yielded a turning point around gaining a consensus to address challenges with sustainability. There has been consistent input from local front-line staff and managers and this will need to be maintained.

A Caithness Palliative and End of Life Care Sub-Group has been up and running for some time and this has included completing a Service Review to inform future delivery of care.

Time and effort was also taken to explain the process that NHS Highland is required to follow in order to develop business case to secure resources. A range of approaches were used including preparing an animation. Members of the public also provided comments on draft materials which was extremely beneficial. They will also be invited to comment on draft consultation materials and agreeing consultation plan.

While there can be no room for complacency the change in atmosphere and more rapid progress has been somewhat transformational. Some have described it as ‘seismic’ and there has been a positive shift in how the redesign process is being conveyed locally.

If the preferred option is to become a reality there are still challenges to be overcome including gaining wider public support, securing capital investment and agreeing a fitting future for buildings where change in use is required.

It is the firm belief of the Project Team that the decision to ‘pause’ was a wise one and that the approach taken, supported by expert facilitation, has generated creative options and a more constructive and positive working relationship with all concerned.

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Scottish Health Council feed-back on the process to date to date is still awaited. This was based on their attendance at meetings, assessment of materials and feed-back from participants at the workshop.

8.1 Public Consultation

It is the view of the Head of Public Relations and Engagement that the proposals should be considered as ‘Major’ not least because of the recent history and some long standing concerns by local people. Moreover it is very important to get the next steps right and the period of public consultation offers the opportunity to test out the options with the public, hear wider views and ideas and make adjustments as appropriate.

Consultation documents and a draft consultation plan will be available in time for the board meeting on 21st July 2018.

Other materials would be used during the consultation period including media releases, social media, articles to be included in local bulletins and publications. A section on the NHS Highland website has also been prepared. Consultation documents would be available in alternative formats with the option of additional support, or information where required or requested. Part of the plan would be to send the summary consultation document to every home in the area.

The main emphasis of the consultation activities, however, will be through public events and face to face meetings with local groups, community councils and elected members.

Specific focussed discussions will be required with residents, families and staff directly affected by the residential care element of the proposed changes.

8.2 Next Steps

Subject to Highland Health and Social Care Committee endorsement then a paper will be considered by the board of NHS Highland at their meeting on 24th July with a recommendation to move to formal public consultation in mid-August.

The exact dates would be confirmed after the Board meeting to allow time to respond to any queries and finalise materials. Following the consultation, a recommendation would be brought to the Health and Social Care Committee and the board hopefully early in 2019.

Maimie Thompson Head of PR and engagement

26 June 2018

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Appendix 1a Flow chart service change process for Caithness

Overview of Key Steps in NHS Service Change Process STEP 1 – (Complete) Undertake pre-engagement activity with key stakeholders STEP 2 – (Complete) Agree the need for service change with stakeholders ‘Case for Change’ STEPS 3 & 4 (Complete) Development of Options

STEP 5 Appraisal of Options and Scoring

STEP 6 Proposed change considered major? (we are here)

No Yes

Step 7 Step 7 Undertake Community Undertake formal public Engagement consultation

Step 8 Board Decision

Appendix 1b the key steps in the service change process for Caithness

Step Process Status 1  Pre-engagement  Completed  2017 - Appendix 2  Case for change  Completed  19 March 18 3  Agreeing benefit criteria  Completed  18 May 18 4a  Development of long list of options  Completed  22 May 18 4b  Agree short list of options  Completed  31 May 18 5  Appraisal of short list of options  Completed  12 June 2018 6a  Highland Health and Social Care  We are here Partnership on preferred way forward  5 July 6b  Board decision on preferred way forward  24 July including major service change 7  Community Engagement and Public  Pending | Aug - Nov Consultation 8a  Board Decision  Pending | Jan 19

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Appendix 2 Overview of Current Health Services in Caithness 67

Appendix 3 – Summary of Case for Change as presented in March 2018

General

 Medicine is always evolving in the face of demographic changes and responding to new treatments, drugs and technological advances.  These advances are positive and mean more people are living independently for longer.  Advances in medicine and workforce issues will continue to influence the place of specialist care and costs of care  Increased use of technology will support provision of more local care and support more people to be independent  More people can be looked after in the community than in small units  Sustainability of safe services, affordability and workforce are linked. Striking the appropriate balance is key

Age-related demographics in Highland and Caithness

 One in five of the population in Highland is aged over 65 years old  By 2035 it will be one in three aged over 65, with more than one in ten over 80  More people will need care and more of them will live alone  The impact of this age-related demographic is more advanced in our remote and rural areas  In Caithness the over 85 age group is projected to increase by 136 percent.

Deprivation and Health of the Population

 23.1% of children (aged 0-17years) in Caithness are living in the 10% most deprived small areas in Highland  Percentage of the Population in receipt of out of work benefits: o Caithness – 14% o Highland – 11% o Scotland – 13.5%  The reported prevalence of chronic diseases (%) including Hypertension, Asthma, Diabetes, Coronary Heart Disease, Chronic Kidney Disease, Stroke & TIA are all higher in Caithness than in other parts of Highland and Scotland  Standardised admission rates relating to an alcohol issue indicate a significantly higher rate for admissions from the Wick South area compared with that for the rest of Caithness and for Highland. 68

Workforce and Recruitment

 NHS Highland employs around 10,000 staff across the board area  In Caithness NHS Highland employs around 600 staff, of those around half are aged 50 or older  Last year in Caithness we advertised 170 posts; 39 were full-time permanent posts and 65 were part-time permanent posts, 48 were full-time temporary posts and 18 were temporary part time posts.  Around six out of ten posts in total were filled on first advert.  However for nursing and midwifery that figure fell to around five in ten (Caithness General) and three in ten (community)  There will be less people of working age to provide paid hands on care  Heavy reliance in locum and agency staff for some areas and some specialities is not affordable or sustainable  In some areas it has not even been possible to get locum, bank or agency staff  Across the NHS Highland board area there are currently 30 consultant posts and 21 GP posts vacant.  Therefore we already have problems with sustainability and have been looking at innovative solutions which appears to have brought some degree of success e.g. recruitment of five senior doctors (Rural Practitioners) to Caithness General Hospital

Money

• NHS Highland budget for 2017/18 was £810m • We are forecasting a savings of £32m but we faced a target of £47m • Therefore we are forecast to overspend by £15m • Even with our £15m overspend some services including in Caithness have been disrupted due to staffing shortages • We spent £15m on medical locums in 2017/18 • And £19.5m on supplementary staffing • Spend on Adult Social Care has increased from £92m in 2012/13 to £125m in 2017/18. This includes additional investment of £12m in Care at Home • In Caithness the annual budget for 2017/18 is £41m and forecasting an overspend of £2.5m • We have invested over a million in adult social care in Caithness since 2012/13

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Appendix 4 NHS Highland Caithness | Assessment of Facilities Condition: Status and Suitability V3_June 2018 Building Status: Is based on a summary assessment of the existing condition, state of building repair and space

Building Functionality Suitability: determines how effectively a building (or part of a building) supports the delivery of the existing service. The aim is to hold space that is functionally appropriate to the current and (known) future clinical and requirements for any service

It is split by Wick (4a) and Thurso (4b) below.

Building Map Building Facilities Existing Condition Functional Code Status Suitability Caithness General Hospital, Wick In good repair, requires some mid-life investment to H1 make the hospital fit for the next 25 years from a Green Amber functional suitability perspective.

Not Old Medical Centre, Wick Situated within Caithness General Hospital grounds. Housing marked mental health team and the corporate team. Building unfit Poor Poor on map for purpose. Functionally poor. In excellent repair although most of the building is empty. Town & County Wick l

a It does not provide the required 50% single en-suite t

i H2 Green Amber

p rooms, and would be difficult to make that work with s o investment. H Dunbar Hospital, Thurso Mostly in good repair (heating system to be replaced, blockwork re-pointing needed) but is poor from a quality H3 Amber Amber and functional suitability score for inpatients, and cannot really be improved by investment. Bayview House (Care Home), In excellent condition, building is on 3 floors C1 Thurso contributing to accessibility problem. Also suffers Green Amber with staffing issue. e

m Pulteney House (Care Home), In excellent condition, generally fit for purpose, requires o C4 Green Green H Wick minimal investment. e r

a Thor House (L&D Day Centre), C Shared with children services, inefficient staffing model. Green Green C5 Thurso Halkirk Surgery (Thurso & Halkirk Building in reasonable condition, functionally poor, HC1 Green Poor Medical Practice), Halkirk space very cramped. Princess Street Surgery (Thurso & Building in good condition. HC2 Halkirk Medical Practice), Thurso Green Green

Riverbank Medical Practice, Building requires maintenance, space becoming cramped. HC3 Amber Amber Thurso Dunbeath Health Centre,

e HC4 Building in good condition, functionally suitable. Green Green r

t Dunbeath n

e Canisbay Surgery (Canisbay & Building in good condition, very cramped. C

h HC5 Castletown Joint Medical Practice), Green Amber t l

a Canisbay e

H Castletown Surgery (Canisbay & Building in good condition, very cramped. HC6 Castletown Joint Medical Practice) Green Amber

HC7 Lybster Medical Centre, Lybster Building in good condition, functionally suitable. Green Green Riverview Medical Practice, Wick Building in reasonable condition, functionally poor. HC8 Green Poor

HC9 The Pearson Practice, Wick Building requires maintenance, space becoming cramped. Amber Amber Thurso Community Health Building unfit for purpose, requires replacement. HC14 Centre, Thurso Poor Poor 70

Appendix 4a NHS Highland Wick | Ownership, Status and Suitability

Building Building Facilities Ownership Functional Status Suitability Caithness General Hospital NHS Highland Green Amber Wick Town & County Community Hospital NHS Highland Green Amber

Pulteney House (Care Home), The Highland Council Green Green

Old Medical Centre NHS Highland Poor Poor Riverview Medical Practice NHS Highland Green Poor The Pearson Practice, Wick Pearson Practice Amber Amber

Grant Street Accommodation The Highland Council Green Green Caberfeidh Court Cairn Housing Association Green Green

Appendix 4ba NHS Highland Thurso | Assessment of Facilities Condition: Status and Suitability

Building Facilities Ownership Building Status Functional Suitability Dunbar Hospital NHS Highland Amber Amber Bayview House (Care Home) The Highland Council Green Amber

Thor House (L&D Day Centre) The Highland Council Green Green Princess Street Surgery (Thurso & Halkirk NHS Highland Medical Practice) Green Green Riverbank Medical Practice NHS Highland Amber Amber Thurso Community Health Centre NHS Highland Poor Poor

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Appendix 5 Summary of Engagement 2017 and 2018, as at 25th June 18

The meetings listed below are the main activities. There have been a range of one-off meetings plus meetings with individual patients and public re various aspects of the redesign plus regular media briefings. A website has also been developed.

Anything specifically relating to maternity services is NOT listed

Month Activity 2018 June June 25th Staff Briefings June 20th CHAT visit to Pulteney House June 18th Informal monthly meeting with Caithness Councillors June 13th Careers Event, Thurso High School June 12th Option Appraisal: Workshop 4 7th June Caithness Rural Transport May May 31st Option Appraisal: Workshop 3 May 29th Staff Briefings May 22nd Option Appraisal: Workshop 2 May 21st Informal monthly meeting with Caithness Councillors May 21st Chief Medical Officer attends CGH incl. demo of NHS Near Me May 18th Option Appraisal: Workshop 1 May 9th Caithness Community Planning Partnership May 3rd HH&SCC plus Highland Councillor demo of NHS Near Me April April 24th Staff Briefings April 23rd Staff Briefings April 18th Meeting with families at Achvarasdal April 18th Meetings with staff at Achvarasdal April 18th Caithness Older People's Groups Get-together, Thurso April 17th Staff Briefings April 16th Informal monthly meeting with Caithness Councillors April 16th Meeting with Community Planning Partner (HIE) April 12th Meeting with Cllr Nicola Sinclair April 12th Meeting with North Highland College April 11th Meeting with Befriend Caithness and Secondary Pupils April 10th Caithness General Patients Council April 10th Staff Briefings March March 27th Combined Caithness District/CGH Management Meeting March 19th Stakeholder Event: Case for Change March 19th Member of Public attended Demo of NHS Near Me March 5th – 9th Staff Briefings February February 23rd Gail Ross visiting NHS Near Me Clinics February 23rd Meeting with NHSH CEO, Chair and CHAT reps, Caithness February 23rd Meeting with Caithness & North Sutherland Regeneration February 21st Meeting with MSPs, Edinburgh February 19th Informal monthly meeting with Caithness Councillors 72 February 14th & Boyd Peters (Associate Medical Director) various meeting including with staff 15th (Mental Health, GPs, End of Life and CHAT reps) February 14th & The Schools Taster events , Thurso Campus 15th February 14th Caithness Community Planning Partnership February 13th Caithness General Patients Council February 10th Caithness “Jobs & How to Get Them, Wick Academy February 7th Meeting with Cab Sec, CHAT reps and NHSH, Edinburgh January January 29th Caithness & North Sutherland Regeneration Partnership meeting January 22nd First meeting of Project Team January 18th Caithness [weekly] Highlight Report issued January 17th Meeting with CHAT reps re Palliative Care and Social Media Comments January 16th Final Meeting of Redesign Programme Board January 15th Vice Chair of CHAT Demo of Attend Anywhere: NHS Near me January 15th Informal Monthly Meeting with Councillors plus demo of Attend Anywhere: NHS Near Me January 11th Highland Health & Social Care Partnership January 8th Wick Community Council 2017 December December 21st Informal monthly meeting with Caithness Councillors December 18th Caithness [weekly] Highlight Report issued December 14th NHSH Chair Meeting with Vice Chair CHAT December 14th NHSH Chair Meeting with Befriending Caithness December 5th Caithness Association of Community Councils November November 28th NHS Highland Board Meeting, CHAT present November 28th Caithness [weekly] Highlight Report issued November 20th Informal monthly meeting with Caithness Councillors November 14th Spiritual Care Meeting November 13th Staff-side representatives meeting with staff in Caithness November 10th Caithness [weekly] Highlight Report issued November 9th Highland Health and Social Care Partnership November 8th Meetings with North Highland College November 2nd “Reference Group” / Stakeholder Event, Halkirk November 1st Meeting with MSPs, Edinburgh October 2017 October 31st Caithness Association of Community Councils October 30th Informal monthly meeting with Caithness Councillors October 26th Caithness [weekly] Highlight Report issued October 17th Caithness [weekly] Highlight Report issued October 12th Highland Senior Citizens Network October 10th Caithness Redesign Programme Board October 9th Caithness General Patients’ Council September September 8th Highland Health & Social Care Partnership September 5th Meeting with Association of Community Councils August August 28th Stakeholder/ “Reference Group”, Halkirk August 14th Caithness General Patient Council August 4th Summit meeting with local councillors, MSP, MP with NHSH CEO and Chair. Agreeing way forward including consultation on bed strategy July

24 73 July 11th Caithness Redesign Programme Board (confirming consultation on bed strategy and developing options) July 6th Highland Health & Social Care Partnership June June Improvement Event in Caithness General to improve patient flow. Involved public member of Programme Board June 12th Caithness General Patients’ Council June 6th Caithness Association of Community Councils May May 30th NHS Highland Board Meeting – Update on Maternity Service May 23rd Reference Group: Update on work streams and opportunity to feed-back ongoing concerns. Feed-back on why process taking so long and want to know what the options are May 24th Meeting with Gail Ross MSP to update on range of issues and proposed next steps Meeting with MSPs Caithness General Patient Council May 4th Highland Health and Social Care Partnership April April Meeting with Rhoda Grant MSP who requested visit to Dunbar April 10th Caithness General Patients’ Council March March 14th SNP Branch Meeting, Wick March 14th Caithness Association of Community Councils March 10th Caithness Community Planning Partnership March 7th Caithness Redesign Programme Board March 6th Berridale & Dunbeath Community Council (General update on challenges etc) March 2nd Highland Health & Social Care Partnership February February Meeting with Secretary of Association of Community Councils February 6th Caithness General Patients’ Council January January 18th Caithness Community Partnership January 18th Caithness Redesign Programme Board January 16th & “Caithness Delayed Hospital Discharge Kaizen Event” 17th January 5th Meeting with MSP and MP January 5th Highland Health & Social Care Partnership

25 74 Appendix 6 Letter from Scottish Health Council on Optional Appraisal Process

26 75 Appendix 7 – Draft Summary Consultation Document

27 76 77 HHSCC Finance & Performance Sub Committee 18th June 2018

The Committee is asked to:

 Confirm it is content with the accuracy of the financial position as set out in this report  Consider the financial position of the HHCCP for month 2 which shows a potential overspend of £19.4m, in line with AOP forecast position of £19m - £23m  Note savings position including £19m unidentified savings as reported in the AOP

Overall Position – Forecast Month 2 May 2018

Further detail on the forecast position is shown below.

Month 2 (April – May 2018) Further Details

Year to Date Year to date at month 2 is an £4.8m overspend, the majority of which is unachieved savings, this includes the £19m (£3.2m YTD) of unidentified savings that was reported in the AOP.

Table 1 – 2016-17 – 2018-19 Overspend Trends

Operational Forecast at month 2 The operational forecast for month 2 has been compiled following a budget rebasing exercise as part of the budget setting exercise, along with plans to contain spend to 2017-18 levels in 3 main areas of spend, Adult Social Care, Hospital Drugs and Prescribing. 78 The figures by unit can be seen in Table 2 below

Table 2 - Operational forecast

In addition to the analysis by unit shown above, it is also helpful to consider the position by type of spend, as this indicates key themes that cut across the organisation which may be relevant when seeking efficiencies. Table 2a presents information by type of expenditure;

Table 2a - Subjective 79 Trajectories to AOP

Table 3a and 3b show the trajectories, in relation to HHSCP, to month 2 compared to the AOP

Table 3a

Table 3b

Savings HHSCP required a savings target of £43.5m when completing the AOP to deliver a balanced position. £24.5m was identified in plans leaving an unidentified amount of £19m that no plans to deliver this was discussed with SG that the position was not expected to improve and that assistance would be required to bridge that gap.

The tables below show the progress on savings 80 Table 4a - Savings

Table 4b – Savings by Unit

Risks Risks held outwith the forecast are shown in the table below; 81 Conclusion

The HHSCP financial position at month 2 is broadly in line with the position reported to the Board and Government in the Annual Operational Plan (AOP), circa £21m.

Delivery of the forecast position is predicated on the achievement of £31.7m of savings and containment plans with many schemes forecast to be achieved in future months. As at month 2, savings schemes are behind trajectory and containment programmes are overspending.

Careful monitoring is required by operational managers to ensure that savings delivery meet the planned trajectory and it is anticipated that months 3 and 4 will be key in identifying the success of the savings programme for 2018-19. Highland Health and Social Care Expenditure82 & Savings (£000's)

Month 2 May 2018

% of total Achieved Current Forecast Savings Achieved Non % of area Health & Current Spend Variance as at Forecast Out- % of local Recurrent % of savings Annual Budget Budget to Variance to Target for the Rec Savings to local budget Social Care to date month 11 turn budget savings to achieved date year end year month 2 Budget month 2 £000's £000's £000's £000's £000's £000's £000's £000's £000's £000's South and Mid 208,394 100.0% 34.4% 34,483 34,551 (67) 208,766 (372) 2,690 1.3% 40 (100) -2.2% Easter Ross 19,392 9.3% 3.2% 3,187 3,261 (74) 19,799 (407) Mid Ross 19,606 9.4% 3.2% 3,224 3,269 (45) 20,141 (535) Inverness East 34,765 16.7% 5.7% 5,710 5,928 (217) 35,225 (459) Inverness West 25,192 12.1% 4.2% 4,149 4,275 (126) 25,863 (671) Nabs N&A 13,581 6.5% 2.2% 2,230 2,296 (66) 13,706 (125) Nabs B&S 14,165 6.8% 2.3% 2,332 2,362 (30) 14,570 (405) S&M Central inc Management 10,992 5.3% 1.8% 1,674 1,592 82 9,093 1,899 South Area Other 1,666 0.8% 0.3% 267 253 14 1,621 45 Care at Home 15,793 7.6% 2.6% 2,630 2,687 (57) 15,795 (2) Comm Mental Health 9,823 4.7% 1.6% 1,632 1,744 (112) 10,364 (541) Adult Mental Health* 17,848 8.6% 2.9% 2,967 2,837 131 17,859 (11) Dental Services* 19,100 9.2% 3.2% 3,405 3,067 338 18,241 858 Learning Disabilities* 3,730 1.8% 0.6% 621 594 28 3,694 36 Drug & Alcohol Recovery Service * 2,742 1.3% 0.5% 455 385 69 2,795 (53)

South & Mid Health 126,463 60.7% 20.9% 21,040 20,617 424 126,333 130 South & Mid Social Care 81,931 39.3% 13.5% 13,443 13,934 (491) 82,433 (502)

Raigmore 166,963 100.0% 27.6% 27,729 28,639 (911) 167,294 (331) 3,615 2.2% 0 0 0.0% Surgical Specialties Division 67,589 40.5% 11.2% 11,373 11,916 (544) 67,588 1 Medical Division 46,354 27.8% 7.7% 7,757 7,736 21 46,354 (0) Cancer Services 12,943 7.8% 2.1% 2,120 2,546 (426) 13,287 (344) Raig Senior Mgt & Central Cost 3,837 2.3% 0.6% 466 501 (35) 3,837 (0) Clinical Support Division 30,757 18.4% 5.1% 5,313 5,357 (44) 30,755 2 Quality & Safety Division 6,604 4.0% 1.1% 1,040 1,003 36 6,593 11 ACT * (1,120) -0.7% -0.2% (339) (420) 81 (1,120) 0

North and West 141,811 100.0% 23.4% 23,458 23,431 27 142,266 (455) 900 0.6% 207 0 23.0% Lochaber 34,991 24.7% 5.8% 5,878 6,019 (141) 35,689 (698) Skye, Lochalsh & W Ross 30,479 21.5% 5.0% 5,089 5,045 45 30,526 (48) Caithness Acute 13,291 9.4% 2.2% 2,183 2,161 23 13,224 67 Caithness District 28,795 20.3% 4.8% 4,798 4,843 (45) 29,714 (919) Sutherland 22,472 15.8% 3.7% 3,751 3,791 (40) 23,180 (708) NW Management 7,305 5.2% 1.2% 1,011 859 152 5,453 1,853 Sexual Health * 1,687 1.2% 0.3% 282 242 40 1,622 64 Highland Hub * 872 0.6% 0.1% 145 145 (0) 889 (18) Chronic Pain Service * 345 0.2% 0.1% 58 74 (17) 462 (117) Highland Hospice * 1,574 1.1% 0.3% 262 253 10 1,506 68

North West Health 93,878 66.2% 15.5% 15,315 15,381 (66) 93,144 734 North West Social 47,933 33.8% 7.9% 8,143 8,050 93 49,122 (1,189)

Other North Highland 88,646 100.0% 14.6% 9,045 12,861 (3,815) 106,886 (18,240) 36,273 100.0% 1,738 50 4.9% Adult Social Care - Central (3,108) -3.5% -0.5% (627) (1,118) 491 (4,064) 956 300 0.8% 0.0% Facilities 23,136 26.1% 3.8% 3,714 3,802 (88) 23,459 (323) 664 1.8% 293 44.1% Integrated Pharmacy 4,855 5.5% 0.8% 812 771 41 4,855 0 130 e health 9,781 11.0% 1.6% 1,518 1,515 3 9,775 6 300 0.8% 50 16.7% Tertiary 21,621 24.4% 3.6% 3,604 3,665 (61) 21,521 100 0 Other 2,289 2.6% 0.4% 372 371 1 2,284 5 0 Central services ** 30,072 33.9% 5.0% (347) 3,855 (4,202) 49,056 (18,984) 34,879 96.2% 1,445 4.1%

TotalHHSCP 605,814 100.0% 94,715 99,482 (4,767) 625,212 (19,398) 43,478 1,985 (50) 4.5% * Hosted service ** Cental holding the £19m oof unidentified savings 83

Care Inspectorate Summary: 1 April 2017 - 31 March 2018

Care Homes in Highland Care Inspectorate NHS Highland

NHS Highland Service Name Service Town SubtypeIn-House or Number of Last Inspection GradesComplaints Enforcements Requirements Action Plan Action Plan Received by NHSH (as of Operational Independent Registered Date Quality of Quality of Quality of Quality of 2017/18(Up 2017/18 2017/18* Requested by 31 Mar 2018) Unit Sector Places Care and Environment Staffing Mgmt & held or NHSH (as of 31 Support Leadership Partial) Mar 2018) West Abbeyfield Ballachulish (Care Home) Ballachulish Older People Independent 30 10/10/2017 6 6 6 6 No South Ach-an-Eas (Care Home) Inverness Older People NHS Highland 24 20/09/2017 5 5 4 4 No North Achvarasdal (Care Home) Thurso Older People Independent 28 01/02/2018 3 3 4 3 Yes Notice served on contract South Aden House (Care Home) Inverness Older People Independent 24 07/02/2018 4 2 3 2 Yes Yes Yes West An Acarsaid (Care Home) Isle of Skye Older People NHS Highland 10 15/03/2018 5 4 5 5 No South Ballifeary House Inverness Older People Independent 24 20/04/2017 6 6 6 6 No North Bayview House (Care Home) Thurso Older People NHS Highland 23 27/11/2017 4 4 4 4 No South Beechwood House Inverness Alcohol & Drug Misuse Independent 15 30/01/2018 5 5 4 4 No South Birchwood Highland Recovery Centre Inverness Mental Health Problems Independent 23 13/11/2017 6 6 6 6 No South Bruach House Nairn Older People Independent 22 09/08/2017 4 3 5 3 No West Budhmor House (Care Home) Portree Older People Independent 29 06/06/2017 5 5 5 5 No North Caladh Sona Lairg Older People NHS Highland 6 16/03/2018 4 3 4 3 No South Cameron House (Care Home) Inverness Older People Independent 30 25/01/2018 4 4 4 4 No South Carolton Care Nairn Older People Independent 20 02/10/2017 4 4 5 4 No Mid Castle Gardens Care Home Invergordon Older People Independent 40 06/11/2017 5 4 5 5 No Mid Catalina Care Home Alness Mental Health Problems Independent 27 20/03/2018 3 3 3 4 Yes South Cheshire House (Care Home) Inverness Physical and Sensory Impairment Independent 16 22/06/2017 5 6 6 5 No South Cradlehall Care Home Inverness Older People Independent 50 23/11/2017 5 5 6 6 No West Culduthel Care Home** Inverness Older People Independent 62 01/06/2017 3 3 3 3 Yes Requirements carried over from previous provider

South Dail Mhor (Care Home) Acharacle Older People NHS Highland 6 28/02/2017 4 4 4 4 N/A Mid Elmgrove Care Home Inverness Older People Independent 27 11/01/2018 3 2 3 3 Yes Yes Yes South Fairburn House Muir of Ord Learning Disabilities Independent 40 21/11/2016 5 5 5 4 N/A Mid Fairfield Care Home (Inverness) Limited Inverness Older People Independent 35 06/10/2017 3 3 3 3 2 1 Yes Ongoing dialogue; Breach of Contract; Suspended admissions (notice now served) Mid Fodderty House Dingwall Older People Independent 16 01/02/2018 4 5 6 5 No South Fram House Beauly Learning Disabilities Independent 5 12/01/2017 5 5 5 5 N/A South Grandview Nursing Home Grantown-on-Spey Older People Independent 45 27/09/2017 5 5 4 5 No North Grant House (Care Home) Grantown-on-Spey Older People NHS Highland 20 21/02/2018 5 5 5 5 Yes South Hebron House Nursing Home Ltd Nairn Older People Independent 22 16/03/2018 4 4 4 4 No South Highview Care Home Inverness Older People Independent 83 19/07/2017 4 4 4 5 1 No West Hillcrest House Nairn Mental Health Problems Independent 23 31/08/2017 5 5 5 5 No Mid Home Farm Care Home Portree Older People Independent 40 08/12/2017 4 5 4 4 No West Innis Mhor Care Home Tain Older People Independent 40 26/01/2018 4 5 4 4 No West InvernevisHouse(CareHome) FortWilliam OlderPeople NHSHighland 32 12/12/2017 2 4 3 3 2 Yes South Isle View Care Home Achnasheen Older People Independent 25 05/09/2017 4 4 4 4 No South Isobel Fraser Inverness Older People Independent 28 05/05/2017 4 4 4 4 N/A South Kingsmills Nursing Home Inverness Older People Independent 60 30/05/2017 5 5 5 5 No Mid Kinmylies Lodge Inverness Mental Health Problems Independent 18 01/05/2017 5 5 4 5 No West Kintyre House (Care Home) Invergordon Older People Independent 41 20/03/2018 5 5 5 5 No West Lochbroom House (Care Home) Ullapool Older People NHS Highland 11 21/03/2018 5 5 5 5 No South Mackintosh Centre (Care Home) Mallaig Older People NHS Highland 8 27/04/2017 4 4 4 4 No South Main's House Newtonmore Older People Independent 31 20/07/2017 4 4 4 4 No South Maple Ridge (Care Home) Inverness Learning Disabilities Independent 18 04/12/2017 5 5 6 6 No South Mayfield Lodge Inverness Learning Disabilities Independent 12 07/02/2018 5 5 5 5 No South Meallmore Lodge Inverness Older People Independent 94 19/06/2017 3 4 3 3 3 Yes North Melvich Community Care Unit (Care Home) Thurso Older People NHS Highland 6 20/03/2018 5 4 5 4 No West Mo Dhachaidh Care Home Ullapool Older People Independent 21 26/03/2018 4 4 4 5 No West Moss Park Nursing Home Fort William Older People Independent 40 23/08/2017 4 4 4 4 No Mid Mull Hall (Care Home) Invergordon Older People Independent 42 20/10/2017 5 5 4 5 1 No North Oversteps (Care Home) Dornoch Older People Independent 24 05/02/2018 3 3 3 3 Yes Ongoing dialogue North Pentland View - Highland Thurso Older People Independent 50 30/03/2018 5 4 4 5 No North Pulteney House (Care Home) Wick Older People NHS Highland 18 29/03/2018 5 5 5 5 No Mid Redwoods (Care Home) Alness Older People Independent 42 07/03/2017 4 5 4 5 N/A North Riverside House Care Home Wick Older People Independent 44 13/09/2017 5 4 4 5 No North Seaforth House (Care Home) Golspie Older People NHS Highland 15 27/03/2018 5 5 5 5 1 No 84

Mid Seaforth House Ltd (Care Home) Dingwall Learning Disabilities Independent 22 24/01/2018 4 3 3 3 Yes North Seaview House Nursing Home Wick Older People Independent 42 05/07/2017 5 4 5 4 1 No Mid Shoremill (Care Home) Cromarty Older People Independent 13 27/04/2017 4 4 4 4 No South Southside Care Home Inverness Older People Independent 33 16/02/2018 2 3 3 2 1 Yes Yes Yes South St. Olaf - Cawdor Road Nairn Older People Independent 42 13/02/2018 4 5 5 4 No Mid Strathallan House (Care Home) Strathpeffer Older People Independent 32 21/12/2017 4 3 3 3 1 Yes West Strathburn (Care Home) Gairloch Older People NHS Highland 14 15/12/2016 5 4 5 5 N/A West Telford Centre (Care Home) Fort Augustus Older People NHS Highland 10 26/05/2017 5 4 4 5 No West The Manor Care Centre Nairn Physical and Sensory Impairment Independent 43 16/03/2018 4 5 5 5 1 No South The Meadows (Care Home) Dornoch Older People Independent 40 30/08/2017 5 4 4 5 No North Tigh-na-Cloich Muir of Ord Learning Disabilities Independent 4 11/01/2017 5 5 5 5 N/A Mid Urray House Muir of Ord Older People Independent 40 15/09/2017 4 5 4 4 1 No Mid Wade Centre (Care Home) Kingussie Older People NHS Highland 11 31/07/2017 5 5 4 4 No South Whinnieknowe (Care Home) Nairn Older People Independent 24 15/06/2017 4 4 4 4 No South Wyvis House Care Home Dingwall Older People Independent 50 22/03/2018 5 5 4 5 1 No

* For services with N/A, please note that there was no inspection (to date) in 2017-18. ** Culduthel Care Home replaced Mandaville as of 31 March 2017. *** The Haven ceased operation as of June 2017. ** Isobel Fraser has re-registered as a SCIO (26/03/2018) and all grade history has been erased - grades for last inspection included

Source of data: 31 March 2018 Data taken from the Care Inspectorate Datastore, publicly available here; http://www.careinspectorate.com/index.php/statistics-and-analysis/data-and-analysis 85

Care Inspectorate Summary: 1 April 2017 - 31 March 2018

Care at Home in Highland Care Inspectorate NHS Highland NHS Highland Grades Complaints Action Plan Action Plan Received by In-House or Operational Last Inspection Quality of Quality of Quality of Quality of 2017/18 Enforcements Requirements Requested by NHSH (as of 31 Mar 2018) Service Name Independent Unit Date Care and Environment Staffing Mgmt & (Upheld or 2017/18 2017/18* NHSH (as of Sector Support Leadership Partial) 31 Mar 2018) Pan Allied Healthcare (Inverness) Independent Not active N/A Contract ceased Dec 2017 Buddies Care Service ** Independent New Service N/A North Carr Gomm North Independent 28/04/2017 5 5 5 1 No Pan Castle Care (Scotland) Ltd Independent 02/06/2017 4 3 3 Yes Yes Yes South/Mid Contrast Care Limited Independent 06/04/2017 5 3 4 No West Crossroads Care - Skye & Lochalsh Independent 15/03/2018 6 6 6 No West Crossroads Caring Scotland - Lochaber Independent 09/03/2018 3 3 3 1 No Pan Crossroads Caring Scotland - NWS/ES/Caithness Independent 08/02/2018 4 4 4 No Pan Eildon Limited Support Service - Care at Home Independent 26/05/2017 5 4 4 No Mid/South Fraser Home Care Independent 09/03/2018 4 3 3 No South/Mid H1 Care at Home Independent Not active N/A Contract ceased June 2017 Pan Highland Home Carers Ltd Support Service - Care at Home Independent 27/09/2017 4 4 4 No West Highland Homeless Trust - Care at Home Independent 19/03/2018 5 4 5 No West Home Farm Support Service Independent 08/12/2017 4 4 4 No North Homelink Caithness (Pultneytown Peoples Project) Independent 13/02/2018 4 5 5 No West Isle View Support Service Independent Not active No Contract ceased March 2017 Pan Lifeways Community Care (Inverness) Limited Independent 11/08/2017 5 5 4 N/A Contract ceased Dec 2016 West Lochaber Day and Night Owl Service Ltd Independent 28/03/2018 4 4 4 No West Lucerne ** Independent 11/09/2017 5 3 4 Yes Mid Mears Independent 20/11/2017 4 4 3 No NHS Scotland contract in place. South/Mid Mistral Care at Home** Independent 21/12/2017 4 4 4 No North North Highland Care @ Home Service NHS 10/10/2017 4 4 4 No South/Mid Options for Independence - Scotland North Independent 15/02/2018 5 6 5 1 No B&S South and Mid Highland Care at Home Service NHS 29/03/2018 4 4 3 No South/Mid Strathcarron Project Support Services Independent 05/12/2017 6 6 6 No West The Glenurquhart Care Project Care at Home Service Independent 29/01/2018 5 6 5 No South The Richmond Fellowship** Independent 17/08/2017 4 4 5 N/A West West Highland Care at Home Service NHS 08/11/2017 4 4 4 No Pan White Heather Homecare Ltd Independent Not active N/A Contract ceased March 2017

* For services with N/A, please note that there was no inspection (to date) in 2017-18. ** Mistral Care at Home - contract began with NHSH 10/03/2017 **The Richmond Fellowship Scotland - Spot Purchase Care at Home began with NHSH 14/06/2017 **Allied contract ceased on 11 Dec 2017. Registration with Care Inspectorate terminated in Highland Dec 17 ** Buddies - new service registered on 06/09/2017 and new contract with NHSH from 05/02/2018 ** Lucerne - New contract began on 19/03/2018

Source of data: 31 March 2018 Data taken from the Care Inspectorate Datastore, publicly available here; http://www.careinspectorate.com/index.php/statistics-and-analysis/data-and-analysis 86 87 Highland Health & Social Care Committee 5 July 2018 Item 2.9

UPDATE ON OOH AREAS WHERE CHANGE HAS BEEN MADE

West Sutherland

A new Out Of Hours area operates at weekends with a single GP covering the practice populations of Lochinver, Kinlochbervie, Scourie and Durness (1800 patients). This has been in place since March 2017. A review at 1 year shows 67 patients seen. Concerns raised locally include GPs seeming to be reluctant to see patients at extreme ends of the patch and retriaging calls as advice. The clinical guardian system is now in place so concerns are being picked up and feedback given to doctors involved. There has been one complaint which has been investigated although fortunately the patient did not come to harm. One outcome from this will be a tabletop emergency planning exercise similar to one held in Glenelg. Ongoing challenge about staffing and accommodation but no uncovered shifts.

Glenelg

The service being offered from Broadford since August 2017. There have been 36 calls in the first 7 months. All cases are reviewed after the event by the Clinical Lead for Out Of Hours and then by Boyd Peters, Associate Medical Director to review the process followed to ensure it was safe and timely. There have been staffing pressures in Broadford which have lead to concerns about ability of the service to offer home visits. Glenelg are part of the Sir Lewis Ritchie North Skye review and an independent facilitator has been appointed to take discussions forward. The agreement is that independent evaluation of patient experience will be measured but unfortunately the community have been unable to agree the wording of the questions for the questionnaire so this hasn’t taken place yet.

Clinically this model appears to be safe and with the implementation of the changes recommended by Sir Lewis Ritchie this will become more robust.

Lochaline

The Out Of Hours service was combined with the service offered from Acharacle from August 2017. There have been 6 calls to the service to end March. This is a Nurse Practitioner led model. There have been no concerns raised by either patients or staff about the service.

North Coast

The initial plan was to run the service across the North Coast from Thurso; this was opposed both by local GPs and the community. A trial run in November 2017 proved unsuccessful but has brought a new way of working with the community partnership group. What is now emerging is a combined model using Advanced Nurse Practitioners and Scottish Ambulance Service paramedics based out of Thurso but crucially with back up from the ambulance resource in Bettyhill to respond to urgent primary care calls. We have 1 Advanced Nurse Practitioner in post and several more in training. This is seen as an evolutionary model starting from covering Monday to Thursday by end 2018 and then covering the weekends ultimately with the building of the Hub/Care home there will be a resource in the area again. It is worth noting that this has become possible due to Scottish Ambulance Service changing the service model for the Wick station. Since moving to a shift system from an on call model the Bettyhill ambulance is called out of area less often and is visibly available to the community giving them more confidence in the proposed change. 88

Applecross

There is extensive opposition to delivering Out Of Hours services in Applecross from Lochcarron. This comes from both the public and the local GPs. The GPs in Torridon and Lochcarron were clear that if the model changed they would pull out of providing the service. There is very little potential for financial saving at present and in fact a bigger risk that the subsequent service would cost more. GP Sub Committee and Local Medical Committee were also vociferous in opposing any change.

Antonia Reed June 2018 89

NHS Highland Board 29 May 2018 Item 3.3

Membership of Highland Health and Social Care Committee Report by Melanie Newdick, Vice Chair and Chair Highland Health and Social Care Committee

The Board is asked to: • approve revisions to the membership of Highland Health and Social Care Committee as detailed.

1. Summary

1.1 The Health and Social Care Committee currently comprises members from a variety of roles and organisations across the Highlands. This includes Councillors, lay representatives and third sector representatives. This report proposes a change to the structure of the Committee membership.

2. Background

2.1 The Highland Health and Social Care Committee Terms of Reference were agreed in July 2017, however its membership now needs refreshed so as to directly support the Committee’s renewed role and remit.

2.2 At the time the Committee was established in 2012, membership was designed to reflect a wide variety of views and input. Since July 2017, the Committee has been tasked with implementing the strategies and policies agreed by the Board, and is accordingly responsible for governance of delivery and performance.

2.3 It is now evident there is a need for more clearly defined roles and clinical representation on the Committee.

3. Assessment/options/issues for consideration

3.1 In accordance with the Integration Scheme, local governance is described as follows:

“The Highland Health and Social Care Committee within the Health Board ensures that primary, secondary and social care sit as equal partners around a formal sub-committee of the NHS Highland Board – this committee includes in its membership 3 elected members from Highland Council”

3.2 To support the revised remit of the Committee, it is recommended that members with voting rights should be restricted to the following:

• 6 x Non-Executive one of whom would chair the Committee and one of whom is the Council nominee on the Health Board • 5 x Executive Directors as follows - Chief Officer, Director of Adult Social Care, Director of Finance, Medical Lead and Nurse Lead • 3 Elected Members This voting membership would therefore include all those individuals who hold responsibility for all integrated and acute services in North Highland.

90

3.3 The wider stakeholder and current advisory membership (non-voting) will be as follows:

Staff Side Representative (2) Public/Patient Member Representative (2) Carer Representative (1) 3rd Sector Representative (1) Lead Doctor (GP) Medical Practitioner (not a GP) 2 representatives from the Area Clinical Forum Head of Financial Planning

The Committee shall have flexibility to call on additional advice as it sees fit to enable it to reach informed decisions.

Committee meetings will continue to be held in public, meetings will also continue to be webcast and agendas and all supporting documents available on the internet.

4. Contribution to Board objectives

• Staff governance

The future arrangements will move to provide assurance around the staff governance for all staff in the HHSCC area.

• Clinical governance

The future arrangements will move to provide assurance around the clinical governance for all clinical and care services in the HHSCC area.

• Financial impact

The future arrangements will move to provide assurance around the financial governance for all operations the HHSCC area.

5. Risk assessment

The future arrangements will move to manage the risks identified arising from within the operational areas of the HHSCC in line with the NHS Highland Board criteria and escalating as necessary.

6. Planning for Fairness

The integration of adult health and social care was subject to a full impact assessment. As appropriate all work programmes should have Impact assessment and it will be the responsibility of the committee to ensue this takes place and is monitored. An equality impact assessment is available from the author on request.

7. Engagement and Communication

Report Author: Melanie Newdick

Date: 15 May 2017

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Highland Health & Social Care Committee 5 July 2018 Item 3.2

NHS Highland Health and Social Care Committee Annual Report

To: NHS Highland Audit Committee

From: Melanie Newdick, Chair of Health and Social Care Committee

Subject: Committee Report – 17/18

1 Background

In line with sound governance principles, an Annual Report is submitted from the Health and Social Care Committee to the Audit Committee. This is undertaken to cover the complete financial year, and allows the Audit Committee to provide the Board of NHS Highland with the assurance it needs to approve the Governance Statement, which forms part of the Annual Accounts.

2 Activity 1st April 2017 – 1st April 2018

In response to changes in the Committee’s terms of reference we introduced a year planner to ensure we covered all the aspects of our remit. This planner covers what topics will be looked at in the main meeting as well as the sub committees.

We have also appointed a Vice Chair of the committee.

An online portal was introduced but committee members have not yet been able to access this information.

We carried out development sessions on the role and remit of the committee, understanding performance information and balanced scorecards.

At every meeting we have reviewed operational reports, balanced scorecard, social work and children’s services reports. We have reviewed financial information in all but one meeting.

We have also reviewed/discussed; Care Inspectorate reports Regional planning Advocacy Plan approved Transitions Team approved Palliative Care Sustainability Plan Mental Health High Value Work Streams

We have reviewed exception reports through the year.

We have also met at Invergordon Hospital and during the year.

The performance team have worked really hard to adapt this information for the committee and to help improve understanding of these metrics. They have also introduced a “Quid” which is a one page quick view of 6 key performance indicators and financial performance for the whole of North Highland.

There have been six meetings of Highland Health and Social Care Committee during the year, the Minutes have been submitted to the Board along with reports relating to key items.

The Membership and attendance at meetings is as follows:

Membership from 1 April 2017 – 31 March 2018:

Mrs Melanie Newdick, Chair Chief Operating Officer Dr Paul Davidson, Chair of Professional Executive Committee 92

Ms Janet Spence, Chair of Adult Social Care Practice Forum Dr Gaener Rodger, Non-Exec (from May 2017) Mrs Ann Pascoe, Non-Exec (from May 2017) Cllr Kate Stephen (from June 2017)(was Bren Gormley) Cllr Nicola Sinclair (from June 2017)(was Margaret Davidson) Cllr Ronald MacDonald (from June 2017)(was Hamish Fraser) Ms Shirley Christie, Staffside Representative Mrs Margaret MacRae, Staffside Representative Donna Mitchell, Patient Representative (from June 2017) Mr Michael Simpson, Patient Representative (from June 2017) Norman Houston, Carer Representative (from June 2017) Adult Services Strategic Planning Group Member Ms Mhairi Wylie, Third Sector Representative Dr Chris Williams, GP Representative Joanna Macdonald, Director of Adult Social Care Mr Quentin Cox, Area Clinical Forum Representative (until 31 January 2018) Mrs Alison Hudson, Area Clinical Forum Representative Mrs Gill McVicar (North and West) Mr David Park (Inner Moray Firth) Georgia Haire (South and Mid) Mr David Garden, Head of Financial Planning (to September 2017)/K Rodgers

Attendance from 1 April 2017 – 31 March 2018 (From Terms of Reference): Member 4/5/2017 6/7/2017 8/9/2017 9/11/2017 11/1/2018 1/3/2018 Melanie Newdick, Sub      Chair Chief Op’ing Officer n/a n/a n/a n/a n/a n/a Dr Paul Davidson A A A A A A J Spence/I Thomson AAAAAA Andrew Evennett Sub A  Sub n/a n/a Ann Pascoe Sub      Deidre Mackay n/a n/a n/a n/a   James Brander n/a n/a n/a n/a   Adam Palmer n/a n/a n/a n/a A A Ann Clark n/a n/a n/a n/a A  Joanna Macdonald  A     Cllr M Davidson/ A  A  A  Cllr N Sinclair Cllr H Fraser/ A   AA  Cllr R MacDonald Cllr B Gormley/ A      Cllr Kate Stephen Ms S Christie   AAAA Mrs M MacRae       Mr G Hogg/   A   A Donna Mitchell Michael Simpson       93

Norman Houston,     AA Carer Representative Adult Services AAAAAA Strategic Pl’g Group Ms M Wylie A A Sub Sub Sub A Dr C Williams A  AAAA Mr Q Cox, ACF   A Sub  N/A Alison Hudson, ACF A  Sub    G McVicar (N&W)    n/a n/a n/a Mr David Park (IMF)       Georgia Haire (S&M)   A  Sub  D Garden/K Rodgers      

3 Sub Groups

There have been two Finance and Performance Sub Group meetings which have considered the current financial situation, the Balanced Scorecard and Performance Indicators on which assurance has been reported back to the Health and Social Care Committee.

There is a Sub Group planned for Clinical Governance and a Local Partnership Forum. It is anticipated that these groups will start to meet imminently.

4 External Reviews

No significant external reviews

5 Any relevant Key Performance Indicators

We are responsible for managing key performance indicators relating to North Highland including; Finance Balanced Scorecard Health and Wellbeing Scorecard Adult Social Care Children’s Services

6 Emerging issues and key issues to address/improve the following year

The Committee has now established a Work Plan for 2018 which sets out the reporting sequence for routine reports and issues, as well as specific areas of focus for each meeting. We are planning on having further meetings away from Inverness with one taking place in Wick and another in Fort William.

We are working to resolve the access issues for all members of the Committee to the management performance information available on the Intranet.

7 Conclusion

As the Chair of the Highland Health and Social Care Committee, I can confirm that the systems of control within the respective areas within the remit of the committee are considered to be operating adequately and effectively.

Melanie Newdick Chair Health and Social Care Committee 29 May 2018 94