Highland Health & Social Care Committee 1 March 2018 Item 3.5

NORTH HIGHLAND OPERATIONAL UNIT – Chief Officer’s REPORT

1. Introduction

This report will provide an overview of activity in North Highland and will highlight areas of focus as well as areas of further opportunity.

South & Mid Division

2. People 2.1 Recruitment

We continue to be challenged by recruitment to mental health services, in particular medical and registered nursing posts and are looking at new workforce models that are sustainable in the future.

2.2 Sickness Absence

Sickness absence in the division was 5.66% in December 2017 with an annual trend of 5.31%.

There is an improving position in East Ross with monitoring system implemented from the recent RPIW.

3. Quality Safety 3.1 Improvement Activity

SPSP in Community Hospitals

Leadership meetings are now taking place quarterly to provide a leadership system that supports the improvement of safety and quality in all Community Hospitals across NHS Highland. Priorities include falls reduction, Catheter Associated Urinary Tract Infection (CAUTI) prevention, early recognition of deteriorating patient, prevention of hospital acquired pressure ulcers, promotion of improvement culture and use of Quality Improvement (QI) methodology.

Value Management

New Craigs and the Royal Northern Infirmary (RNI) are participating in value management. They report out weekly on their box score which contains a mix of financial, performance and capacity measures.

Improving systems and process Neighbourhood Teams

The Inverness Neighbourhood teams have completed extensive mapping to refine processes in preparation for introduction of Morse IT system.

1 Rapid Process Improvement Workshop (RPIW)

A discharge planning RPIW will New Craigs Hospital taking place 26th February – 2nd March.

3.2 Redesign Initiatives

Prescribing Budget Position

Data from PRISMS to end November 2017 shows the following budget positions:

Area Allocation Expenditure Difference Percentage year-to-date year-to-date difference EastRoss £2,803,535 £3,103,272 +£299,737 +10.69 InvernessEast £5,696,469 £6,107,354 +£410,885 +7.21 InvernessWest £3,782,748 £3,885,960 +£103,212 +2.73 MidRoss £2,825,761 £2,911,127 +£85,366 +3.02 Nairn, Badenoch & £3,419,711 £3,493,439 +£73,728 +2.16 Strathspey South & Mid Division £18,528,224 £19,501,152 +£972,928 +5.25 Totals

In the above table a negative value in the "Value YTD" and the "Percentage YTD (%)" columns denotes an underspend against allocation, whereas a positive value in these columns denotes an overspend against allocation

A significant number of medicines are currently in short supply and, as a result, their price has increased. We are tracking the impact of the top 13 of these and, comparing the first eight months of 2017/18 to the first eight months of 2016/17, we have seen an increase in expenditure for these 13 medicines of over £854,300.

3.2.1 Psychology

Waiting list improvement work continues with no waiting times for people with personality disorder in the Inverness area awaiting Systems Training for Emotional Predictability and Problem solving in Borderline Personality Disorder (STEPPS).

A planning day for introducing the Computerised Cognitive Behavioural Therapy (cCBT) for Highland is scheduled for end of February.

3.2.2 Drug & Alcohol Recovery Service

NHS Highland continue to have challenges in meeting the HEAT A11 Standard. However, improvement work carried out in June 2017 has resulted a test of a new service model within Osprey House (the biggest service with highest referral rate). In the 6 months since this has been implemented, Osprey are consistently meeting the HEAT A11 standard with over 90% of clients on treatment within 3 weeks of referral being received. This model is only just being rolled out to community services in Inner Moray Firth. Wider issues have impacted on the NHS Highland achievement, particular long waits in Caithness and Lochaber as a result of staff vacancies. Caithness is now back at full capacity and waits will reduce as a result. The Lochaber area is seeking to reappoint a senior practitioner as a result of a recent change to the team.

2 3.3 Health Improvement

South & Mid Health Improvement Team has secured premises in Merkinch area of Inverness to deliver Health Improvement Services and it is anticipated that this local premises will provide a local hub for other health care services.

The Vaccination Transformation Programme at Highland level has started scoping the process for various different vaccination schedules to inform the development of service models for delivering a cradle to grave vaccination service in the Inner Moray Firth.

3.4 Control of Infection

The South & Mid division has seen a number of different flu outbreaks in both hospital and Care Home settings from the middle of December to date.

Compliance with standard infection control precautions continues to achieve above 95% in all Hospital and Care Home settings.

4. Care Service and Delivery 4.1 Care at Home (including commissioning)

One provider has started piloted involvement in one of the seven Inverness Neighbourhood Teams with further discussions having taken place regarding the next phase of this project. The Inverness Overnight Service is coming towards the end of its first year and discussions are due to commence on how this can be taken forward. Development work is also ongoing on creating standard care packages for Step Up, Step Down and Transfers to Daytime Providers are also being developed.

The transformational change programme is not yet completed with the organisational change process ongoing for some staff.

For both community divisions, discussions are ongoing regarding achievable efficiency savings and the development of proposals that encompasses additional capacity planning across the whole of the North Highland Area within a collaborative tariff structure.

3 4.2 Care Homes

Care Homes (Including Commissioning)

Work continues to progress to develop an internal position regarding a place of care strategy to determine what model of care is required into the future, where it is required, how much of it is needed and how it will be delivered. Three internal sessions have now taken place with operational directors, clinicians, public health, finance and commissioning staff, to review available data, understand the current position, flow and current projections into the future. A briefing was provided to a board development session in October 2017 in order to facilitate a shared understanding by Board Members of the issues and challenges. Following on from the second session, a short and accessible summary of the key points from the data wall is in preparation, to assist communicate the messages of and challenges around this work with wider stakeholders. The third session took place on 12 February 2018, which looked to articulate the Board’s proposed strategy and delivery plan. Following this, it is intended to engage with the sector during March 2018.

4.3 Falls Prevention

South & Mid Operational Unit has established a short life working group to test a revised approach to the implementation of the new NHSH Policy for the prevention and management of falls in inpatient settings, including Community Hospitals and New Craig’s Hospital. This group will oversee the implementation of key measures which have demonstrated success in preventing falls in hospital settings. The success of the Multi- Disciplinary Team (MDT) working together to implement measures to reduce falls has been evidenced in the reduction of falls in both the RNI and County Community Hospital Invergordon (CCHI).

4.4 Mental Health and Learning Disabilities

The redesign of the rehabilitation service has been completed. The first phase of the bed re- configuration on the New Craigs site will commence at end of February.

4.5 Support for People with Dementia and their Families

The planning team preparing the Dementia Strategy Implementation Plan led by M Wyllie from the 3rd Sector interface has commenced.

5. Finance

2017-18 has been a challenging year for the South & Mid division given the significantly higher savings targets than allocated in previous years (£3.1m 2016-17 and £8.6m 2017-18) and as such this has been reflected in our year end out-turn of £4.8m as at Month 10. £3.2m of unachieved savings accounts for the majority of this overspend with adult social care pressures of £2.6m also being a factor.

Whilst £4.832m of savings were achieved in 17/18, £3.2m of this was made non recurrently and South & Mid are now in the process of identifying what can be converted recurrently from 18/19.

Prescribing pressures due to short supply and demand accounts for £1.3m of the year end out-turn with non-recurring benefits in Pay/Non Pay offsetting this. Prescribing initiatives in

4 17/18 has released £360k of savings from 1819 and work is ongoing to quantity the remainder of the schemes previously identified.

For the remaining two months of the financial year it is imperative that the division contains its expenditure in order to retain the current year end out-turn.

5 North & West Operational Unit

2. PEOPLE AND STAFF MORALE

2.1 Recruitment There are recruitment challenges across the Unit and across all disciplines, the following are examples of this:-

North:

 Nurse staffing in Dunbar Hospital and Town & County Hospital continues to be challenging with long and short term sick leave. Advanced Nurse Practitioner development posts for the Caithness Out of Hours service are being re-advertised. Patient safety remains paramount at Town & County Hospital, therefore the reduced bed numbers remain in place, retaining 6 beds within the hospital. Both sites form part of the Caithness Redesign consultation.

West:  Domestic staffing in Portree remains fragile although it is hoped this will improve over the next month. Every possible avenue is being followed, however there is a high level of concern around sustainability of services in Skye.  On Raasay, the two Health & Social Care Support Worker vacant posts will be re-advertised with a slightly different remit in the hope of attracting candidates. Ideally it would be good to recruit on the island, with training being provided. There have been 3 applicants and interviews have been arranged.  There are currently 5 vacant Care at Home posts in North Skye. These have been repeatedly advertised both in the local paper, Social Media sites and posters. The negative publicity around the Hospital Redesign is not helping the position locally.  The recruitment day went really well with over 30 people venturing out in horrendous weather to come and speak to staff. This has definitely generated interest in posts.  In Portree 2 Whole Time Equivalent posts are vacant in Supported Independent Living in the Community (SILC) which is placing significant pressure on the service for people with a learning disability. This is likely to result in consolidating day services for older people with services for people with a learning disability in order to staff shifts.  There are 2 Whole Time Equivalent vacancies within the Rural Support Team for Skye and West Ross, having managed to recruit to one of the vacancies. However we have continued use of agency and locum cover is necessary 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 problem 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.  Significant staffing and recruitment issues persist within Telford Centre in Lochaber. There has been successful recruitment to the vacant care home manager post within Invernevis House. The new manager commenced in February 2018.  Issues continue with Care at Home staffing, with active recruitment continuing.

2.2 Sickness Absence Average overall sickness absence rates for 2016/17 stood at:

NHS Highland: 4.86%

6 North & West: 5.15% (N: 5.94%; W: 4.38%)

Sickness absence rates for the North had previously reduced over the first quarter of 2017/18 compared to the N&W average rate for 2016/17, but have seen an increase since August. Rates for the West are generally higher than the N&W average 2016/17 rate (except for months July and October). The first months of 2017/18 had initially shown a reducing trend, however, this has not been sustained into the next quarter so far and the picture is mixed. Against a background of an overall downward trend across the organisation absences in North and West areas show unpredictability particularly for the West and an increase for North.

All Sickness Apr 17 May 17 Jun 17 Jul 17 Aug 17 Sep 17

NHS Highland 4.71% 4.90% 4.81% 4.56% 4.60% 4.87%

North & West Areas 5.09% 5.03% 4.85% 4.58% 4.92% 5.38%

North Area 5.13% 4.69% 4.73% 4.74% 4.70% 5.22%

West Area 5.19% 5.46% 5.08% 4.52% 5.24% 5.42%

All Sickness Oct 17 Nov 17 Dec 17 Jan 18 Feb 18 Mar 18

NHS Highland 4.65% 4.89%

North & West Areas 5.16% 5.63%

North Area 5.54% 5.99%

West Area 4.78% 5.27%

In November 2017, in the North area the absence rates were highest in Hotel Services (6.49%) and Caithness District (6.77%). In the same period, in the West area highest absence rates were in Hotel Services (10.81%) and Lochaber District (6.58%).

Long term sickness absence (LTS) is the main contributor to absence rates for the organisation and this is reflected in the North and West areas with a particular upwards trend over the last three months since May for the West:

All Long Term Sickness Apr 17 May 17 Jun 17 Jul 17 Aug 17 Sep 17

NHS Highland LTS 3.25% 3.50% 3.44% 3.39% 3.34% 3.30%

North & West Areas LTS 3.63% 3.53% 3.26% 3.48% 3.84% 3.86%

North Area LTS 3.73% 3.31% 3.24% 3.58% 3.78% 3.89%

West Area LTS 3.65% 3.84% 3.38% 3.48% 4.01% 3.85%

7 All Long Term Sickness Oct 17 Nov 17 Dec 17 Jan 18 Feb 18 Mar 18

NHS Highland LTS 3.05% 3.18%

North & West Areas LTS 3.94% 4.09%

North Area LTS 4.42% 4.38%

West Area LTS 3.48% 3.83%

There are 38 employees in these areas who have been off for more than 90 days as at 31 December 2017; with 18 of these having been off for more than 6 months (10 in the West, 8 in the North); four employees having been off for more than 12 months (a further reduction from previous month), with 50% each in the two areas; and three for more than 18 months.

With regards to short term absence this is an area which, however, does also require some attention as a considerable number of employees have hit the trigger point of 4 episodes or more within previous 12 month period. In November 2017 the highest short term absence rate was in Hotel Services West with 3.49%; while in the North Sutherland District was the main contributor to short term absence with a rate of 2.14% in the same period.

Short Term Sickness Apr 17 May 17 Jun 17 Jul 17 Aug 17 Sep 17 Oct 17

North & West Areas STS 1.46% 1.50% 1.59% 1.10% 1.08% 1.52% 1.22%

North Area STS 1.13% 1.40% 1.37% 1.49% 1.16% 0.92% 1.33%

West Area STS 1.53% 1.63% 1.70% 1.04% 1.23% 1.57% 1.29%

Short Term Sickness Oct 17 Nov 17 Dec 17 Jan 18 Feb 18 Mar 18

NHS Highland STS 1.60% 1.71%

North & West Areas STS 1.23% 1.53%

North Area STS 1.12% 1.61%

West Area STS 1.31% 1.43%

Sickness absence figures will be scrutinised to identify particular professional or geographical areas of concern with a view to target management support so that further improvements can be made.

A further relevant area of addressing sickness absence is that of prevention. This involves ensuring managers are stress and mental health aware to allow them to spot early signs which may prevent employees having to go off due to ill-health but are supported at the earliest opportunity which may allow them to stay at work.

It is continued to be anticipated that a number of current long term absence cases will, with close

8 management, come to a conclusion in the following months. In addition, encouraging managers to ensure earlier action should lead to an overall reduction in long term absence cases going beyond 12 months.

Ensuring that all employees are dealt with consistently across all areas will ensure that expectations are clear from the outset and managers and employees can rely on being dealt with fairly and in line with procedures. North and West areas continue to work towards a sickness absence rate of 4% in line with the national NHS target. The forecast is that the NHS Highland overall sickness absence rate can be achieved while working towards the national target rate will continue to be challenging.

3.0 QUALITY AND SAFETY

3.1 Improvement Activity

Pharmacy: Quality improvement in community pharmacies continues through the national contract. Quality improvement support packs have been produced and provided to community pharmacies on request: the number of community pharmacies voluntarily participating reached 100% of all community pharmacies in December 2017. It has been announced that a quality improvement bundle based on the NHS Highland bundle will be spread nationally in April 2018.

Primary Care: Learning from Intermountain to reduce clinical variation continues to be tested in two clinical areas: an electronic tool embedded in the GP clinical system for chronic obstructive pulmonary disease (COPD) in one GP practice and for medication review in three GP practices.

3.2 Community Hospitals

Following the Highland wide Community Hospital Patient Safety event where hospitals were able to “show case” some of the work, a formal education framework to support the building of Quality Improvement capability and capacity is now being developed. A draft proposal will be developed by February 2018 for approval. A recent mapping exercise to understand how well embedded SPSP methodology and care bundles are embedded in practice has been undertaken with good results, although audit and measurement data is not yet available.

All 18 Community hospitals in NHS Highland were asked for input to the mapping. The mapping was re-visited in 2017. Again all community hospitals in NHS Highland were asked to input. Results are as per bar chart below: Community Hospital Use of Patient Safety Bundles 2014 and 2017 comparrison

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. NEWS PVC CAUTI Falls TEP Safety SBAR Huddles o

N Bundle Bundle Brief SPSP Safety Budnles

9 Daily Dynamic Discharge As part of the National 6 Essential Actions to Improve Unscheduled Care, Daily Dynamic Discharge (DDD) is to be rolled out to community hospitals. An initial launch was held at a WebEx session with further sessions planned to share learning and monitor progress held in March, June and early December 2018. Further sessions are planned for March 2018.

3.3 Advanced Practice

Advanced Nursing Practice – A key element of the redesign in out of hours services is the introduction of Advanced Nurse Practitioner roles. In order to ensure robust clinical and educational governance, an Advanced Nurses and Advanced Paramedics Competency Framework and Training Toolkit 2017 has been ratified for use across NHS Highland. The Framework includes a ‘validation’ process for those who are in development roles to ensure completion of their core education programme at Masters level and evidence of competencies are achieved prior to practice at Advanced level.

There is also a national transforming roles programme of work led by the Chief Nurse for Scotland. This programme of work aims to provide strategic oversight, direction and governance to the development and transformation of advanced nursing roles to meet the current and future needs of Scotland’s health and care system. NHS Highland’s Framework is in line with the national recommendations.

NHS Highland has been asked to complete an and educational needs assessment for Advanced Nursing Practice and has submitted bids to NES to support practitioners’ education and training needs against the Scottish Government funding of £3 million available for all NHS Boards across Scotland. The Scottish Government have stated that this funding is to support an additional 500 Advanced Nurse Practitioners across Scotland. A North of Scotland ‘Academy’ is also being developed in collaboration with Grampian, Highland, Orkney, Shetland and the Western Isles which is a very exciting development.

3.4 Technology

Home and Mobile Health Monitoring (HMHM)

An evaluation of HMHM by the University of Edinburgh was completed in December 2018. The full report is available on the intranet at http://intranet.nhsh.scot.nhs.uk/Org/AdultSocialCare/TechnologyEnabledCare/Pages/Default.asp x

The results are very positive albeit with small numbers. During the evaluation time, there was one COPD patient who had an admission of 106 days-(average length of stay for an admission with acute exacerbation of COPD is 5 days). This has skewed the results. Allowing for that, and without the benefit of a health economist, it appears to have saved unscheduled health care use. The Technology Enabled Care (TEC) Service are exploring whether the National TEC team have access to a health economist for further analysis.

COPD figures (excluding the outlying patient with 106 day admission) Bed days- pre 183 - post 83 Admissions- pre 16 - post 7

Results for asthma and heart failure are also positive- particularly Asthma.

10 This is a startling reduction in admissions and bed days.

44 patients have used Florence (Flo) for COPD. The response has been good, with most completing the 12 weeks. Flo is much simpler than the previous system (Motiva) and isn’t so dependent on clinician time It is designed to encourage self reliance.

NHS Highland’s protocol is based on the COPD self management action plan. It lasts 12 weeks and aims to support self management and reinforce awareness of day to day variation of symptoms associated with exacerbations, to empower patients to anticipate and act.

When asked for feedback the most common word patients use is “connection”. Users like it and say it makes them think and they feel supported, despite the fact that they know it’s not a rapid response service.

Numbers using Florence With 98 patients enrolled on Florence during January the total number of patients who have benefited from Home Health Monitoring using Florence has reached 1639.

Key Florence protocols

The most used Florence protocol is the Electronic Asthma Action Plan for patients with severe asthma. This has resulted in:  An increase in engagement, adherence and medication prescriptions  A reduction in DNAs, clinic appointments, hospital admissions and bed days  In addition, the protocol is being used to monitor patients treated with biologics, who attend the clinic for their injection each month.  During January there has been a noticeable increase in the use of Florence for BP monitoring (by GP practices) and also to support mental health patients attending courses – including Decider Skills and STEPPS.

11 Engagement

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 15 Accepted 12 for BP monitoring 30%

Training date scheduled 4 Accepted

Contacted – no decision yet made about a visit 4 Undecided

Contacted – visit booked 2 Undecided 28%

Visited–butnotheardiftheywanttogoahead 12 Undecided

Visited – Florence declined after visit 8 Declined 42% Contacted – visit declined 19 Declined

Total GP practices 64

Telecare – Deloitte Report, published November 2017

In November 2016, as a response to addressing the variation of telecare provision, the Scottish Government’s Health and Social Care Management Board, and COSLA’s Health & Wellbeing Executive Committee, agreed a feasibility study should be undertaken to examine what a universal approach to the provision of telecare services for the over 75s would look like. This is with a view to supporting older people to remain independent in their own homes, thereby reducing hospital admissions, reducing discharge times and aiding discharge after a crisis.

The full report can be found at https://sctt.org.uk/wp-content/uploads/2017/04/Telecare- Feasibility-Study-Report-FINAL.pdf

Cost and Benefit Analysis Summary from the report:

 Based on the analysis by Deloitte it is estimated Local Authorities/IJBs spend around £39m per annum to provide telecare to 20% of people within the 75+ cohort nationally. Based on analysis Deloitte estimate this generates benefits of around £99m per annum to the Scottish public sector. Around two thirds of benefits accrue to the social care sector and the remainder to NHS Scotland.  The analysis shows that turnover of users has an important impact on the benefit to cost ratio of investment as follows:  Users on the service for 1 year provides an overall benefit to cost ratio of around 1.2:1  Users on the service for 2 years provides an overall benefit to cost ratio of around 1.6:1  Users on the service for 3 year provides an overall benefit to cost ratio of around 1.8:1

12 3.5 Waiting Times/Access Targets/Referral to Treatment (RTT) (See Appendix 1) 3.5.1 Out-patients NORTH: Continue to have challenges with Access Targets/RTT as below

Inpatients:  Surgical - 1 patient breaching, 34 patients on waiting list with an average wait of 10 weeks  Chronic Pain – 1 patient breaching, 20 patients on waiting list for Caithness General Hospital. 3 patients breaching, 36 patients on waiting list for Lawson Memorial Hospital with an average wait of 12 weeks  Gynaecology – 2 patients breaching. 19 patients on waiting list with an average wait of 16 weeks.  Cataract – 75 patients on the waiting list, only 6 sessions available at present. 40 patients who will breach with an average wait of 7 months  Dental – 5 patients on waiting list, 4 patients breaching with an average wait of 16 weeks

Out Patient Department:  Chronic Pain – 0 patient breaching  Medical – 2 patient breaching, 1 waiting for MRI and 1 for King of Hearts, both patients will be seen in February 2018  Surgical – 0 patients breaching  Gynaecology – 0 patients breaching.  Ophthalmology – There is a current backlog of return patients, 180 in total, plus 66 visual fields from August 2017 onwards.

Within the West area Outpatients are currently meeting Treatment Time Guarantee (TTG) dates with no foreseen breaches.

In the north, an improvement is expected in Cataract waiting times following the appointment of a locum ophthalmologist.

In the west the main exception is patients awaiting MRI/ Magnetic Resonance Cholangiopancreatography (MRCP) scans, and there are plans in place to closely monitor this.

3.5.2 8 Key Diagnostic Tests Endoscopy - (See Appendix 2)

North – Caithness General Hospital currently have no Urgent Suspected Cancer patients waiting for appointments. There are 4 patients un-booked with a 2 -3 week wait time. There are 24 routine endoscopy patients current un-booked and these patients will be seen within a 4-6 week waiting time.

West – Belford Hospital - there are currently no patients waiting beyond breach date for a new endoscopy appointment.

A successful trial of capsule endoscopy has concluded in Skye and Ullapool, with a view to this being extended to support the roll out across Highland.

3.5.3 8 Key Diagnostic Tests: Non Obstetric Ultrasound: Caithness General Hospital (See Appendix 3)

Challenges continue with Ultrasound Sonography in the North. Currently there are 94 Out Patient Referrals with an 8 week wait. Urgent cancer referrals are routinely seen within 2 weeks.

13 At present there is no capacity to provide additional Ultrasound sessions within the diagnostics team due to the on call commitment. One sonographer is due to commence maternity leave in March 2018. The remaining sonographer on site is required to multi skill in Xray, CT and on-call in addition to AAA screening and management which will further impact on the Ultrasound Sonography waiting list. Patients are offered Sonography appointments at Lawson Memorial Hospital in Golspie if deemed urgent and there is no capacity at Caithness General Hospital.

All scan referrals are vetted by a Sonographer to approve justification of scan, and to ensure that destinations of referrals are appropriate. Staff are in regular liaison with GP Practices in the area to ensure that they are aware of the capacity issues within the service, and to ensure that clinical information contained within the referral is categorised appropriately at point of referral.

Staff development in Ultrasound Sonography remains a priority but this will be challenging to progress. Ultrasound Sonography waiting lists are expected to increase with sonographer maternity leave and competing demands on remaining sonographer.

3.5.4 Mental Health Services

West Within Skye, Lochalsh & West Ross district, the team are now at full establishment. However, there is currently long term sickness in North Skye addictions service. This is being managed in house at present with support from Osprey.

North The North continue to have difficulty in consistently maintaining the HEAT A11 3 week target mainly due to vacancies and sickness within the team, and the increase in drug use referral continues in particular opiate based substances. There is currently only one Non Medical Prescriber (NMP) running two Opiate Replacement Clinics across Caithness. There is also a noted recent increase in use of New Psychoactive Substances (NPS) being traded as Zanax.

3.5.5 Emergency Department (ED) 4hr Target Compliance (See Appendix 4)

Both Caithness and Belford Hospital continue to consistently achieve the required standards for ED waits. However the charts show that the increased pressure on beds and the presence of influenza in the community has resulted in decreased performance at times, particularly in Belford Hospital.

3.5.6 Cancer Access and Treatment Times

The main concern is the endoscopy performance in Caithness General Hospital, however there are currently no patients waiting for appointments for Urgent Suspected Cancer.

3.5.7 Muscular Skeletal Waiting Times Report (See Appendix 5)

North & West mean compliance was 68% against NHS Highland’s overall 59% compliance. East Sutherland is the only District which has repeatedly reached above 90%.

Introduction of a First Contact Practitioner (advanced Physiotherapy Practitioner) within Caithness will offer greater support to transition of GP services, enabling all MSK conditions to

14 be directly managed by physiotherapy from first contact with the practice to discharge, thus reducing the GP caseload. This will be monitored with the aim of further such developments elsewhere in N&W as we learn from this change in practice.

Interestingly First Contact Practitioner referrals are exempt from reports to the Scottish Government, but this will change once they have evolved beyond early testing across Scotland. We are liaising with the national Primary Care Lead AHP to agree metrics for evaluation of the current role.

The first role of this kind in N&W will cover Riverview, Riverbank and Lybsyter Practices as well as linking with the mainstream physiotherapy service in Caithness.

All Districts are applying appropriate waiting list management processes including standard triage into urgent and routine categories. The main apparent differences between districts’ waits relates to changes in staffing levels, reflected recently in both Caithness and Skye (the latter is ongoing) where small changes within small teams have significant impact on waits.

Physiotherapy staff have worked very hard to implement the PMS system and revised waiting list business processes and should be commended for their ongoing efforts to support cover of services due to staff absences and periods of vacancy. In Skye, in particular long standing under resourcing of the service continues to place sustained pressure on the local physiotherapy team and this is apparent from their average 50% compliance with the MSK HEAT target.

Continuing Actions to address MSK Waiting List Management:  Implementation of triage based on DCAQ approach  Centrally managed patient focused booking  All MSK referrals managed on PMS with regular reporting of data.  In addition work to improve MATS (Musculoskeletal Assessment and Triage Service (NHS 24) ) continues in liaison with National AHP Lead at NHS 24.

Further actions aimed at improving waiting times:  NHS “Near Me” to be tested in Caithness as digital (video) consultation for patient reviews could save considerable time for staff and patients as well as travel costs. An Orthopaedic Consultant at Raigmore will work remotely with the patient and MSK Physio attending at CGH.  Further development and implementation of specific MSK pathways by Physiotherapy and podiatry professionals across N&W to promote standard working. Being progressed via Physiotherapy Professional Forum

3.6 Control of Infection

3.6.1 Clostridium Difficile Cases (C Diff)

Since the start of the new reporting period (April to October inclusive), there has been a total of 17 cases of toxin-positive Clostridium difficile infection in the Operational Unit: 9 in the North, 8in the West Area

3.6.2 Staphylococcus aureus bacteraemia (SAB) Incidence:

Since the start of the new reporting period for 2017/18, there have been 3 SAB infections in the North and West Operational Unit (2 in Caithness General Hospital and 1 in Belford Hospital).

15 3.7 Tissue Viability

Community: As shown in the table below there has been an increase in incidence since October 2017. 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.

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 2, below, shows incidence across all the Operational Units including North and West. All grade 3 and 4 pressure ulcers are subject to detailed root cause analysis so that any improvements required are identified and learning can be shared across Highland. In order to improve compliance with this requirement the Tissue Viability Leadership Group for NHS Highland has developed a Standard Operating Procedure

Table 2:

16 3.8 Falls Prevention

In line with the Scottish Patient Safety Programme (SPSP) we are aiming for; 1. 25% reduction in all falls as defined by SPSP by Dec 2017 2. 20% reduction in falls with harm as defined by SPSP by Dec 2017

To achieve this there has been significant effort in testing the Falls care ‘bundle’ which requires an initial risk assessment and continuous attention to detail in terms of reducing the risk of falling, ‘cohorting’ at risk patients, providing individual support where required and balancing risk of falls with the need to maintain mobility and promote enablement.

Table 4 below shows a sustained improvement

The Quality Improvement Facilitator posts for the North and West areas are 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 areas. 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 – 2nd Sustained Improvement

4. CARE (SERVICE AND DELIVERY)

4.1 Older People in Acute Hospitals (OPAH)

The updated Healthcare Improvement Scotland’s (HIS) Care of Older People in Hospital: Standards (2015) work contains 16 standards. NHS Highland has completed an OPAH Self Assessment in advance of a visit by an Inspector from the Quality Assurance Directorate of HIS who visited Highland in September, to review the Board’s Self Assessment. North and West has a comprehensive 40 page ‘action plan’ which sets out the priorities in order to meet the requirements of the 16 standards. The action plan is based on the initial gap analysis

17 undertaken following the publication of the new standards in June 2016.

On October 4th, Belford Hospital received an unannounced Health Improvement Scotland (HIS) Inspection. The final report is public and NHS Highland has submitted a 16 week update on progress to HIS in response to nine areas for improvement cover. The Head of Quality Care, Healthcare Improvement Scotland said all the patients were positive about the care they were given in the Belford Hospital. They were happy with the care received, staff were polite and caring. It was noted that staff ensured they were comfortable and happy and were treated with respect. There were eight areas of good practice identified in the report.

Person centred care planning was highlighted as a requirement and this remains a priority for improvement across Highland with the development of nursing assessment and care planning documentation which supports nurses to deliver high standards of care across Highland and avoid over processing. The roll out of the revised nursing assessment and care planning documents which includes a short stay version, a mandatory nursing assessment booklet and the development of evidence informed core nursing interventions to support care planning is complete in all sites across North Highland, Argyll & Bute and in progress within Raigmore Hospital. The Lead Nurse is also working with the Patient Management System Clinical Lead to integrate the documentation and assessment tools within TrakCare.

4.2 Care at Home

As mentioned in the last report both the West and North Care at Home Services have now completed their Inspection cycles. Published reports detail that the strengths of these Services are now outweighing their areas for improvement with services graded as Good in the important areas of “Care and Support”.

Given the significant improvement seen in these Services their Managers now wish to build on this period of equilibrium to deliver changes to their Services that will see Care at Home more closely aligned to the Integrated Teams in a way that they can deliver flexible, high quality and complementary Social Care. Managers see the introduction of a new Job Description and a move to “Agenda for Change” as a prerequisite to developing the skilled, flexible and motivated staff base that will be required to deliver the change. Currently, however, finding agreement over the Job Description is encountering a significant ‘headwind’ from particular partners.

Planning is also well underway to help the workforce meet its new Registration and Qualification requirements. Again, in itself we hope, a significant valorisation of the role of Care at Home.

4.3 Care Homes

Current published grades for our in-house Registered Care Home Services in North & West are shown in Table 1 below

Service Name Town Publication Gradings of Quality Areas of Latest Grading Care & Environment Staffing Management & Support Leadership

An Acarsaid Isle of 12/04/2017 5 4 5 5 (Care Home) Skye

18 Bayview House Thurso 18/12/17 4 4 4 4 (Care Home)

Caladh Sona Lairg 14/04/2017 4 3 4 3

Dail Mhor (Care Acharacl 24/03/2017 4 4 4 4 Home) e

Invernevis Fort 13/02/2018 2 4 3 3 House (Care William Home)

Lochbroom Ullapool 28/02/2017 5 5 5 5 House (Care Home)

Mackintosh Mallaig 09/05/2017 4 4 4 4 Centre (Care Home)

Melvich Thurso 07/04/2017 5 4 5 4 Community Care Unit (Care Home)

Pulteney House Wick 26/04/2017 5 5 5 5 (Care Home)

Seaforth House Golspie 14/02/2017 5 5 5 5 (Care Home)

Strathburn Gairloch 26/01/2017 5 4 5 5 (Care Home)

Telford Centre Fort 28/06/2017 5 4 4 5 (Care Home) Augustus

4.3.1 Care Homes

The development of appropriate care home capacity is a developing key workstream. Significant work is underway to internally understand what care home provision we need, where we need it and how much of it we need.

There are ongoing discussions with Crossreach regarding a placement trajectory at Achvarasdal (North) and future alternative community models; and with Abbeyfield Ballachullish (West) regarding maximising access to the Integrated Care Beds.

Invernevis House: The service has recently received an Inspection report which identifies Care and Support as “Weak”. This Grade reflects significant weaknesses in some our care practices in relation to medication administration and across our care-planning. It is understood that difficulties in recruitment – leading to high levels of agency staffing – have contributed to discontinuities of care.

19 However NHS Highland’s Improvement Lead for Care Homes (with Clinical and Practice support) has taken on interim Management and Leadership responsibilities to effect significant progress in these areas: including better, more person-centred care planning documentation and more systematic ways of meeting the full-range of Resident’s needs And we are extremely positive about the fact that an experienced Care Home Manager is now in place to consolidate the improvements made. In particular we have seen significant reductions in the levels of agency staff covering shifts. This appears to have been achieved through the deployment of a new systematic.

4.4 Carers

Work is currently under way to ensure that we are in a position to implement the new Carers (Scotland) Act. To raise awareness of the coming changes our partners in Connecting Carers have been delivering training to a broad range of Health and Social Care Professionals in our Integrated Teams. Work will also need to progress quickly to ensure that our new statutory duties are properly incorporated into our existing care planning and resource allocation processes.

4.5 Delayed Discharge (See Appendix 6)

HOSPITAL NO OF DELAYED DISCHARGES

Portree 3

Mackinnon Memorial 1

Belford 0

Caithness General 4

Lawson Memorial 0

Migdale 3

Dunbar 0

Town & County, Wick 2

As at 09.02.2018 the North & West Operational Unit report 13 patients who are delayed in our Hospitals.

Meetings have been arranged to discuss the ongoing issue in the North in relation to Mental Health Officer (MHO) allocation/involvement within Caithness, along with utilisation of Hospital Home Bundle and utilising Code 13ZA where appropriate in relation to Adults with Incapacity. Integrated Teams & hospital staff continue to work to get people out of hospital as quickly as possible and to keep people out of hospital. The expectation is that delays will reduce with the increase in care at home and care home capacity, and further development of the senior health & social care support worker role and daily dynamic discharge.

20 4.6 Self Directed Support

The Social Care (Self-directed Support) (Scotland) Act 2013 places a duty on us to offer people who are eligible for social care a range of choices over how they receive their support: this is to promote the idea that everyone should be in control of their life. SDS aims to allow people, their carers and their families to make informed choices on what their support looks like and how it is delivered, making it possible to meet agreed personal outcomes. To help achieve this we seek to offer recipients of care a flexible choice of a Direct Payment, an Individual Service Fund (ISF), and/or ‘a traditional service’.

As of 22 February 2018 the number of people accessing a Direct Payment across North and West are distributed as follows:

Area Number Total 4 weekly Active payment Caithness 30 £44,483 Skye & 50 £47,001 Lochalsh Wester Ross 19 £13,737 Lochaber 29 £50,731 Sutherland 19 £22,776

The following one-off payments have occurred during 2017/2018:

Area Number Total Payment Active Caithness 7 £9103 Skye & 9 £11,657 Lochalsh Wester Ross 1 £272 Lochaber 7 £4,670 Sutherland 3 £2,517

There are 147 individuals with active Direct Payments amounting to a total 4-weekly payment of £178,730.

5. FINANCE

5.1: The January 2018 financial statement reports a year end overspend of £6.9m against an annual budget of £136.4m. The main pressures from the past three years continue and cannot be addressed until there is a change in models of care. These are being implemented in Caithness General Hospital but this type of change takes considerable time and effort, and double running costs are incurred as new ways of working are embedded. The Senior Leadership Team is currently reviewing options for the provision of care at the three salaried practices in Caithness to relieve the vacant practice pressure there and Highland-wide options to tackle the vacant consultant posts in Belford are being considered.

The pressures remain similar to last year: Adult Social Care (£4.3m), Out of Hours (£1.5m) and additional locum costs for vacant posts (£1.8m) within Caithness General Hospital, General Practices and Belford Hospital partly offset by pressure funding (£2.0m). The Unit has been issued with a savings target of £8.2m and will be unable to achieve £2.9m of this. There are red risks of £0.4m related to various cost pressures.

21 Significant challenges remain due to the ever increasing need for locums. This is as a result of recruitment and retention issues that are impacting on the Unit, in particular the Rural General Hospitals, Out of Hours and vacant practices. There has been an increased use of locums at Belford Hospital over the last year due to vacant posts and this will continue, so savings targets on locum expenditure will again be difficult until a new Highland-wide approach can be agreed. Efforts are being made to reduce the time required to have locums in place but the need for on call makes this challenging. Given that there are only three Consultants of each discipline, maintaining service with short staffing for any significant period is not possible if the current service is to be maintained.

The Senior Leadership Team is continuing to keep a close eye on savings and cost pressures but radical change as well as attention to detail in the key continuous quality improvement areas will be required in order to manage these pressures and achieve additional new savings.

5.2 Prescribing

NSS data to the end of November 2017 show that prescribing costs continue to be hit by sharp price increases to a small number of key generic medicine, which wipe out savings achieved elsewhere (see table below): most recently perindoril, which has added approximately £15,000 per month to expenditure.

2016/17 (ytd) 2017/18ytd Change from last year OLANZAPINE £104,120 £91,822 -£87,635 QUETIAPINE £67,668 £136,867 -£69,199 SUMATRIPTAN SUCCINATE £27,116 £80,619 -£53,503 AMLODIPINE £34,980 £74,997 -£40,017 since July, approx £6,000 extra per month PERINDOPRIL ERBUMINE £28,224 £60,007 -£31,783 since October, £15,000 in a month LEVETIRACETAM £23,469 £51,728 -£28,258 MEFENAMIC ACID £5,161 £26,635 -£21,474 since September, £12,000 per month Sum: -£331,868

Disbursement of primary care rebates from the first quarter of the financial year was £40,000. This is less than expected – the preliminary data suggested the Operational Unit receive £55,000 in rebate payments, but not all money has come through yet. Extrapolating from what has been paid for the whole financial year would give £160,000 to set against the overspend.

Overall, the Operational Unit’s end of year position looks about £100,000 worse this month than last, i.e. an overspend of between £200,000 and £300,000.

6. CAITHNESS GENERAL MATERNITY SERVICES & SKYE AND LOCHALSH MIDWIFERY SERVICE

The midwife-led Community Maternity Unit (CMU) within Caithness General Hospital has now been operational for over a year and is functioning in line with other NHSH CMUs and is showing comparable local birth numbers.

More women are travelling to give birth in Raigmore Hospital however for 2017 there has been no increase in SAS transfers for maternity, with most women travelling in their own transport.

There has been a significant decrease in neonatal transfer rate down to 3 for 2017 as compared to the previous five year average of 8.

22 End of year 2017 Jan – Dec Figures – Caithness CMU

Pregnancy Local Births Raigmore Maternal Neonatal Bookings Births Transfers Retrievals (inter-hospital) 218 19 175 101 3 61 (own transport) 27 (SAS road) 11 (SAS Air) 5 (Taxi)

Service development continues with the use of Near me / video conference consultation for some antenatal clinics and specialist diabetic clinic where women would normally need to travel to Raigmore Hospital.

The team continue to work closely with Raigmore Maternity colleagues and meet regularly on teleconference and video conference for the daily and weekly huddles.

Recruitment to vacant midwifery posts continues to be challenging and in the meantime use of bank midwives and additional hours are being used to cover service.

Skye & Lochalsh Midwifery Service has experienced significant staffing shortages since November 2017 leading to the temporary suspension of Out of Hours Services (1700-0900). The service continues 09.00 – 17.00 hrs 7 days per week including weekends. There is currently an absence of 2.8 Whole Time Equivalent (WTE) – 1.8 (WTE) vacant posts and 1.0 (WTE) sick leave. A full briefing including Press Release has been issued. Training sessions have also been offered to nursing, medical and Ambulance colleagues to ensure appropriate support is available. The caseload is low at the moment with no women due to give birth at MacKinnon Memorial until March 2018 – women due to give birth at Raigmore are aware of the importance of earlier contact with Raigmore colleagues Out of Hours via routine triage systems.

Update as at 20th February 2018 indicates that midwife on sick leave will be returning to work and successful recruitment has taken place with 1.2 WTE filled – a new full time Band 6 Midwife will take up post in on 5th March and an existing Team Member has had an increase of 0.2 WTE to her contract taking her up to full time. Interviews for 0.6 WTE Band 6 hours will take place on 6th March – there are 2 applicants both local. The OOH’s service will remain suspended until new Midwife has completed her orientation this is likely to be around 4 weeks from start date. Depending on outcome of further recruitment process it is anticipated that OOH will resume around the beginning of April 2018.

Negotiation and discussions are ongoing with regard to future sustainable on call model.

7. OUT OF HOURS (Transforming Urgent Care) – (NHS HIGHLAND) HOSTED SERVICE

Following concerns expressed regarding the impact of the Skye, Lochalsh & South West Ross Redesign on the provision of urgent unscheduled care in the north of Skye, an external view of provision was commissioned by NHS Highland with the support of the Scottish Government. This work is being led by Sir Lewis Ritchie who previously carried out the national review of Out of Hours care provision. Sir Lewis and his team made an initial visit to Skye on 2nd February when he had initial introductions to a number of key individuals, including NHS staff, local representatives and elected members. Sir Lewis and his team will be returning to Skye w/c 26th February in order to carry out a full programme of detailed meetings and discussions with

23 stakeholders throughout the week. The report is expected to be delivered by Sir Lewis in April 2018.

8. Skye, Lochalsh and South West Ross

Work has begun on the 1:50 drawings with stakeholders engaged in the process. These drawings detail items which will be in each room and allows the design team to assess the rooms ensuring they are fully equipped and meet all clinical requirements.

A Transition Workshop took place on 20th February. The Transitions Group will work towards implementing a transition plan for all changes which will occur, including, premises, workforce, eHealth, equipment, transport, commissioning and decommissioning.

Designs for the office accommodation for the Integrated Care Team at Broadford Health Centre have begun with input from the teams involved. This will support collaborative working across care teams and will be delivered via a NHS Highland capital project.

Development and design of the Portree Spoke will include day hospital, Portree Medical Practice, Outpatient clinics and base for Integrated Team. The Transitions Group will progress the design. Draft plans for the spoke layout are currently being considered.

The Outline Business Case for the BSSLWR project has now been approved by NHS Highland board and is being considered by Scottish Government. This is an important milestone and sets out the proposed service solution, required investment and workforce plan. If approved this will allow the project to progress to Full Business Case which will finalise the detailed plans.

The Transport Study team have concluded their engagement with regional and local council representatives and patient groups to assess transport options on Skye. The study team has consulted widely with patients, relatives, visitors and community members to inform this research. The draft Transport Survey has been received by NHS Highland and has been circulated across the Project Team and Operational Unit with the comment and amendments received fed back to the authors. The Skye Transport Group has be re-established with the first meeting scheduled for Monday 19th February.

24 Raigmore Division

1. People 1.1 Recruitment

Recruitment remains a challenge across a number of specialities as per previous reports. North of Scotland regional solutions and in some cases international recruitment initiatives are ongoing.

1.2 Staff Experience

Joy at Work is a concept that is embedding via the value management roll out process. These initiatives are aimed at empowering staff to take ownership for identifying and support delivering improvement work to address issues.

1.3 Sickness Absence

Sickness absence levels across Raigmore remain favourable compared to other areas across NHS Highland. The main pressures currently are being seen across the Surgical Division.

Quality Safety 2.1 Theatre Interruption

Elective surgical procedures resumed in the main theatre complex at Raigmore on Monday 19th Feb after all planned operations were cancelled from 08 February after superficial cracks were found on some of the theatre walls as a result of the ongoing refurbishment of the theatres.

Through excellent team work from our own staff, across Theatres, Estates and Domestic Services and the Contractors, urgent work to rectify the problem was completed last week. Theatres were then deep cleaned and with air sampling tests completed and passed,

25 emergency cases started in main theatre on Friday 16th Feb, and the normal service was resumed on the 19th. Daily monitoring of the theatre environment has been continued and all of the steps taken to date have ensured that no further issues have been identified, this monitoring will continue throughout the refurbishment programme

During the shutdown, emergency services were maintained in our peripheral theatres – Vanguard, The Eye Care Unit and the Maternity Theatre. With support from colleagues across NHS Highland we also managed to run extra lists in theatres in Caithness General and Belford Hospital, and set up a temporary theatre for local anaesthetic cases in the Common Admissions Lounge in Raigmore. Work is continuing to try and utilise any spare capacity we have in both Caithness and Belford and other sites in the area.

The priority over the next 2 weeks is to ensure that all of our urgent cases have been dealt with and this is on track to be achieved. Starting from weekend 24th/25th February we are also providing 2 extra weekend operating lists per day to try and catch up with the backlog of patients

2.2 Waiting Times

2.2.1 Out-patients

As at month ending 31 January 2018, there were 2,876 outpatients waiting over 12 weeks for a first appointment with NHS Highland. The target was to deliver a maximum number of 3,170 beaching outpatients by 31 January 2018. NHS Highland were ahead of forecast by 294. Significant progress continues to be made with outpatient transformation work and waiting list validation. Alongside this, there has been some additional activity provided in order to address the backlog. This was agreed with the Access Support Team at the Scottish Government who have funded additional capacity and we are working very closely with the service in order to reduce the waiting times where possible. 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, Ophthalmology and Paediatric Medicine.

Every effort has been made to reduce the longest waiting patients who have waited longer than 26 weeks for a first appointment; there will be a continued focus to further reduce this cohort of patients. At the end of January 2018, there were 555 patients waiting over 26 weeks, this was 129 ahead of forecast.

2.2.2 Treatment Time Guarantee

As at month ending 31 December 2017, there were 1,485 TTG patients waiting over 12 weeks for treatment with NHS Highland. The target was to deliver a maximum of 1,265 breaching TTG patients by 31 December 2017. 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, Ophthalmology, and General Surgery.

There are now plans in place to treat cataract breaching patients in Quarter 4 using external providers on site at Raigmore. Other operating specialties are now working on a plan to continue activity throughout the Theatre Upgrade Project. This has been shared with Scottish Government Access Support team.

26 2.2.3 Key Diagnostic Tests

As at month ending 31 December 2017, there were 176 Scope patients and 624 Radiology patients waiting over six weeks under NHS Highland.

Endoscopy have been running additional clinics to reduce the breaching number, specifically targeting upper endoscopy patients. Of particular note is that there is an external provider, funded via Scottish Access Support team, to provide MRI scanning capacity on site at Raigmore. This will continue in Quarter 4 due to the replacement of a scanner in-house.

Radiology Report

Performance

Reporting performance within the department continues to improve.

Data as of 12/02/18:

Wait to report

 64 CT exams awaiting report (225 Oct 2017)  88 MRI exams awaiting report (268 Oct 2017)  925 Plain Film Exams awaiting report (7393 Oct 2017)

Improvement Plan

Wait to scan time in CT has increased, additional capacity is being sought in Belford to assist in improving wait times.

Ultrasound has shown an increase in work to scan time. Maternity leave and sick leave within the department are influences in this increase. Additional sessions are being held throughout February, March and April to reduce the wait time with money provided by the Scottish Government.

In terms of reporting there are now 3 consultant vacancies. There are 14 Consultant Radiologists in post across NHSH. A 12 month fixed term locum joined the department in February 2018, along with a specialist registrar in January 2018.

The loss of a reporting radiographer is still impacting on reporting performance. ED films have improved slightly, awaiting further information from ED to continue with improvement work.

The department continue to work on the action plan devised following a visit from Margaret Sherwood from Scottish Government. A Short Life Working Group has commenced led by Rod Harvey with an improvement plan to be presented to the board in March. In addition the following actions are in progress:

 Interventional Radiology additional support through planned sessions in place. Dr Harvey leading clinical discussion and planning for a regional/NoS approach to Interventional Radiology services  NHS Highland is fully involved in Regional and National Radiology Improvement Programmes particular focus on a national data mart and IT connectivity.

27  An Enhanced Recruitment Short Life Working Group has been established. NHSH are fully part of the current NHS Scotland International Radiology Recruitment campaign  Local software has been upgraded in preparation for a Scotland wide solution to Reporting infrastructure being led by the national programme and National Services Scotland  Work has commenced on the installation of the first replacement MRI machine. The second being installed in the next financial year.  Measurements in scanning machines capacity are being undertaken in order to identify any additional capacity  Review of booking processes within the department are being undertaken to complement the work being carried out locally and nationally.

2.2.4 ED 4hr Compliance

December saw a dramatic increase in the numbers of people attending the ED with flu like respiratory symptoms and together with the increase in admissions this contributed to a difficult period. The ED performance remained consistently above the national average until early January when the increased demand really started to make a significant impact.

120 4 hour ED performance by Board in December 2017

NHS 100 Highland

80

60

40

20

The numbers attending ED continue to increase as can be seen in the table below. The cumulative year to month totals attendances have increased by over 5000/year since 2008. (source ISD AE activity waiting times MME)

Date Total year to date attendances December 2017 34 884 December 2016 33987 December 2015 32447 December 2014 32103 December 2013 30949 December 2012 31014 December 2011 31579 December 2010 30412

28 December 2009 30122 December 2008 29731

The exceptional pressures were acknowledged by the Scottish Government who had adjusted the reporting procedures during the difficult period.

By far the biggest reason for ‘breaching’ the 4 hour target was waiting for a bed. This was due to the large numbers of people admitted with flu like symptoms and the need for single room accommodation and ‘cohorting’ of both infected people and contacts. This was further compounded by the loss of access to community capacity where Community Hospitals were closed to admissions due to flu outbreaks during this period. Additional capacity was created by reopening some beds previously forced into closure by staffing shortages and the re designation of 5 beds in the Highland Rheumatology Unit for low acuity patients to increase the throughput from Raigmore.

2.2.5 Cancer Access & Treatment Times

See appendix 7.

3. Care Service and Delivery

3.1 Delayed Discharge

The number of delayed discharges remained high up to the end of December increasing from earlier in the year numbers.

4. Finance

This winter season has been particularly testing for Raigmore with Theatre closures along with flu issues. Some of this has helped financially as we have not been spending on Theatre consumables to the level that had been anticipated – however, this is more than offset by the cost of keeping at least 10 beds open in Surgical.

For the final two months, the greatest risks for Raigmore continue to be around the management of the existing and emerging pressures across all of the Divisions alongside the necessity to deliver the balance of the £10.66m of savings.

For the whole of this year, drugs costs have been significantly variable especially around the home delivery areas – this has made forecasting even more difficult. The risk for the next two months is that the forecast for February and March is considerably less than the average for April-January. Work will continue and will be presented at future weekly finance huddles.

Locum costs have been lower for the last three months when compared to the start of the year although there are now several alternatives in place around managing vacancies – we have recruited Clinical Development Fellows, International Medical Fellows, Specialty Doctors and are looking towards Physician Assistants also The analysis to prove that these are better value for money is still to be developed..

29 APPENDIX 1

NORTH & WEST OPERATIONAL UNIT: ACCESS TARGETS – 12 WEEK OUTPATIENT/TREATMENT TIME GUARANTEE (TTG)/REFERRAL TO TREATMENT (RTT) REPORT

1 CURRENT POSITION.

NORTH:

Inpatients:

 Surgical - 1 patient breaching, 34 patients on waiting list with an average wait of 10 weeks  Chronic Pain – 1 patient breaching, 20 patients on waiting list for Caithness General Hospital. 3 patients breaching, 36 patients on waiting list for Lawson Memorial Hospital with an average wait of 12 weeks  Gynaecology – 2 patients breaching. 19 patients on waiting list with an average wait of 16 weeks.  Cataract – 75 patients on the waiting list, only 6 sessions available at present. 40 patients who will breach with an average wait of 7 months  Dental – 5 patients on waiting list, 4 patients breaching with an average wait of 16 weeks

Out Patient Department:

 Chronic Pain – 0 patient breaching  Medical – 2 patient breaching, 1 waiting for MRI and 1 for King of Hearts, both patients will be seen in February 2018  Surgical – 0 patients breaching  Gynaecology – 0 patients breaching.  Ophthalmology – There is a current backlog of return patients, 180 in total, plus 66 visual fields from August 2017 onwards. WEST

 Inpatients – currently meeting Treatment Time Guarantee (TTG) dates with no foreseen breaches.  Outpatients – local specialties within Referral to Treatment (RTT) dates. Problems with timely X-ray/MRI availability continue to affect some Medical and Surgical referrals.  Visiting Consultant clinics are regularly breaching due to insufficient New Patient appointment slots, but numbers of patients waiting has been improving significantly in recent weeks.

2 ACTION PLANS TO ADDRESS

North:

 Theatre utilisation has been reviewed and Pre Operative Assessment (POA) appointments have been increased with an additional session arranged to reduce waiting times. POA service has been transferred to the Surgical Suite and staff identified for training to improve capacity and efficiency.  Referrals are being triaged by Raigmore and Locum Consultants  Discussions are ongoing with visiting Surgeons who will assist in managing the

30 current position. Visiting Consultants notified of available theatre sessions. The rotational Raigmore consultants have been requested to provide additional theatre sessions when covering their locum week.  Inpatient Treatment Time Guarantee weekly meetings in place to closely monitor position to take necessary action to improve performance.  Additional Chronic Pain session in place to maintain current position  Cataract Surgery – Waiting times increased following the retirement of one of the ophthalmologists. It has been confirmed that a locum ophthalmologist has been recruited to provide monthly cataract sessions from February 2018 which will have a positive impact on the current waiting list. Meetings are ongoing with the Ophthalmology team in Raigmore to review current service provision. An Optical Coherence Tomography (OCT) scanner has been purchased to introduce regular nurse led clinics in Caithness General Hospital to improve local services, reduce the number of people who have to travel to Raigmore and create capacity in Raigmore.  OPD staff trained in visual fields.

WEST

 Inpatients – Treatment Time Guarantee monitored to ensure no patients will breach.  Outpatients – Patients on waiting lists for visiting Consultants offered Raigmore appointments where there is availability but this is very limited due to pressures on Raigmore waiting lists.  Referral to Treatment times monitored to ensure no local specialty breaching.  Breach report provided to Rural General Hospital Manager & Area Manager on a monthly basis.  Change of Consultant in October has resulted in monthly Dermatology clinics in place which has meant a reduction in patients currently waiting for a Dermatology appointment.  There are now two Gynaecology Consultants and this has resulted in a reduction of patients waiting for a new Gynaecology appointment

3 EXPECTED IMPACT OF ACTIONS ON PERFORMANCE

North:

 Cataract Surgery – difficult to predict. Ongoing discussions with Raigmore to review and improve current services.

4 FORECAST OF RETURN TO PLANNED PERFORMANCE (ie Trajectory)

North: Cataract surgery – Cataract waiting times are expected to improve following the appointment of a locum ophthalmologist.

West: Planned performance currently being met, with the exception of patients awaiting MRI/ Magnetic Resonance Cholangiopancreatography (MRCP) scans, and there are plans in place to closely monitor this.

31 Appendix 2

NORTH & WEST OPERATIONAL UNIT: 8 Key Diagnostic Tests – Endoscopy

1 CURRENT POSITION

North:

 Endoscopy Caithness General Hospital currently has 1 patient unbooked for Urgent Suspected Cancer with a 2-3 week wait.  Urgent 2 patients unbooked with a 2 -3 week wait time.  Routine endoscopy 15 patients currently unbooked with a 4-6 week waiting time.

 Return Endoscopy patients:

o 6 patients on the return waiting list should have been seen in 2017 o 11 patients on return waiting list should have been seen 2018

Caithness General Hospital have reduced lists in January, February and March 2018 due to Consultant availability.

West:

 There are currently no patients waiting beyond breach date for a new endoscopy appointment.  There are challenges with capacity for all BOSS colonoscopies and referrals from Skye GP’s for endoscopy. Referrals are being sent to Belford Hospital for assessment and booking for capsule endoscopy service.  Only 2 Consultants available to undertake Endoscopy sessions. o Lack of Consultant capacity to undertake endoscopy sessions over the last few months, combined with cancelled lists due to winter pressures earlier in January has had an impact on the booking of return endoscopy patients and we currently have 1 patient from November; 1 patient from December and 10 patients from January awaiting appointment dates.

2 PLANS TO ADDRESS

North:

 Endoscopy sessions – Surgeon (Annual Leave) locum cover for 1 week to utilise the available endoscopy sessions. Colorectal surgeons have increased their Thursday morning sessions from 10 to 12 points.  Ongoing screening of referrals/return patients undertaken.  Review endoscopy equipment with a view to increase the number of gastroscopes from 3 to 4 to maximise the allocated list time.  Day case capacity is limited, funding identified to progress to the next stage of the day case redesign project to increase capacity. Plans currently being drafted.

West:

 Continued assessment and review of waiting list for return patients. Plans to have return

32 patients seen as soon as possible.  Escalation of any potential patients breaching their target date to Consultant/Hospital Manager in order to avoid the breach.  Continued monitoring of waiting lists to ensure patients are seen within target date.

3 EXPECTED IMPACT OF ACTIONS ON PERFORMANCE

Continue with improvement on the current position.

4 FORECAST OF RETURN TO PLANNED PERFORMANCE (ie Trajectory)

North: 2017 repeat scopes expected to be completed by March 2018

West: Continue to ensure no new patients wait beyond breach date and return patients are booked within their recall date month.

33 Appendix 3

NORTH & WEST OPERATIONAL UNIT: 8 Key Diagnostic Tests: Non Obstetric Ultrasound: Caithness General Hospital North Area)

1 CURRENT POSITION

2 ACTION PLANS TO ADDRESS

 There is no capacity to provide additional Ultrasound sessions within the diagnostics team due to the on call commitment. One sonographer is due to commence maternity leave in March 2018. The remaining sonographer on site is required to multi skill in Xray, CT and on-call in addition to AAA screening and management which will further impact on the Ultrasound Sonography waiting list.  Patients’ are offered sonography appointments at Lawson Memorial Hospital in Golspie if deemed urgent and if no capacity at Caithness General Hospital.  The Sonographer at Lawson Memorial Hospital Golspie, can occasionally be deployed to Caithness General Hospital for annual leave cover, with reverse back-fill to Lawson Memorial Hospital necessary on occasion to cover radiography based clinics.  Liaison with Raigmore Hospital to discuss maternity cover support to ensure there is minimal impact on Ultrasound waiting list.  All scan referrals are vetted by a Sonographer to approve justification of scan, and to ensure that destinations of referrals are appropriate.  Regular liaison with GP Practices in the area to ensure that they are aware of the capacity issues within the service, and to ensure that clinical information contained within the referral is categorised appropriately at point of referral.  Staff development in Ultrasound Sonography remains a priority but this will be challenging to progress with one Sonographer on maternity leave for a year. A second radiographer is also due to commence maternity leave June 2018 for up to one year. Locum maternity leave cover will be required to ensure minimal cover for the service.  Focused Ultrasound training in Abdominal Aortic Aneurysm screening to reduce blocked sessions for sonographers in Caithness General Hospital and Lawson Memorial Hospital is under review along with the development of a Band 4 Ultrasound Screener post will release band 7 and 8 staff.

3 EXPECTED IMPACT OF ACTIONS ON PERFORMANCE

 Ultrasound Sonography waiting lists are expected to increase with sonographer maternity leave and competing demands on remaining sonographer.

4 FORECAST OF RETURN TO PLANNED PERFORMANCE (ie Trajectory)

 Difficult to forecast a planned return to trajectory.

34 APPENDIX 4

NORTH & WEST OPERATIONAL UNIT: EMERGENCY DEPARTMENT REPORT – 95% OF ALL EMERGENCY DEPARTMENT PATIENTS SHOULD BE ADMITTED, DISCHARGED OR TRANSFERRED WITHIN 4 HOURS OF ARRIVAL AT AN EMERGENCY DEPARTMENT.

1. CURRENT POSITION

As at 18th February Belford Hospital were achieving 92.8% performance against the target.

As at 18th February Caithness General Hospital were achieving 97% performance against the target.

35 2. ACTION PLANS TO ADDRESS

West:

 Continued improvements in Belford Hospital include the potential introduction of a Nurse Practitioner post at weekends to provide cover and support in wards to free up doctor hours along with a trial of rota changes to provide 2 doctors in Accident & Emergency at weekends.

 Development of breach alert/escalation system in A&E

North:

 To continue to maintain an increased focus on patient flow throughout the hospital through the breach alert system, medical handovers and board rounds.

 Escalation alert system is in place within the Emergency Department.

 Liaison with SAS to review transfer related delays.

 Breach cross updated daily resulting in increased staff awareness of delays within the Department.

3 EXPECTED IMPACT OF ACTIONS ON PERFORMANCE

 Improved performance against the 4 hour target across both the North and West Rural General Hospitals.

 Within the North area, the measures introduced are expected to continue to improve the number of patients breaching the 4 hour target.

4 FORECAST OF RETURN TO PLANNED PERFORMANCE (ie Trajectory)

 To continue to closely monitor performance.

36 APPENDIX 5

NORTH & WEST OPERATIONAL UNIT: Musculoskeletal Waiting Times Report.

CURRENT POSITION

Latest Figures January 2017 – Dec 2017

NORTH AND WEST OPERATIONAL UNIT OVERALL COMPLIANCE

MONTH % COMPLIANCE WITH NHSH %

4 WEEK TARGET COMPLIANCE JANUARY 44 46 FEBRUARY 63 58 MARCH 64 59 APRIL 68 63 MAY 73 55 JUNE 68 61 JULY 69 60 AUGUST 66 58 SEPTEMBER 73 57 OCTOBER 75 62 NOVEMBER 74 61 DECEMBER 78 67

N&W mean compliance was 68% against NHS Highland’s overall 59% compliance. East Sutherland is the only district which has repeatedly reached above 90%.

Introduction of a First Contact Practitioner (advanced Physiotherapy Practitioner) within Caithness will offer greater support to transition of GP services, enabling all MSK conditions to be directly managed by physiotherapy from first contact with the practice to discharge, thus reducing the GP caseload. This will be monitored with the aim of further such developments elsewhere in N&W as we learn from this change in practice.

Interestingly First Contact Practitioner referrals are exempt from reports to the Scottish Government, but this will change once they have evolved beyond early testing across Scotland. We are liaising with the national Primary Care Lead AHP to agree metrics for evaluation of the current role.

The first role of this kind in N&W will cover Riverview, Riverbank and Lybsyter Practices as well as linking with the mainstream physiotherapy service in Caithness.

37 Details of compliance per District is tabled below.

Waits in all Districts Jan – Dec 2017 MONTH DISTRICTS CAITHNESS E N&W LOCHABER SLWR SUTHERLAND SUTHERLAND JANUARY 48 60 65 24 44 FEBRUARY 63 93 87 35 58 MARCH 74 90 77 48 47 APRIL 72 90 72 61 44 MAY 78 87 74 70 56 JUNE 83 84 60 76 57 JULY 68 78 69 75 49 AUGUST 65 80 75 78 26 SEPTEMBER 64 92 77 83 49 OCTOBER 63 98 86 83 46 NOVEMBER 64 97 61 88 54 DECEMBER 60 96 78 90 69 MEAN % 67 87 73 68 50 COMPLIANCE

All Districts are applying appropriate waiting list management processes including standard triage into urgent and routine categories. The main apparent differences between districts’ waits relates to changes in staffing levels, reflected recently in both Caithness and Skye (the latter is ongoing) where small changes within small teams have significant impact on waits.

Physiotherapy staff have worked very hard to implement the PMS system and revised waiting list business processes and should be commended for their ongoing efforts to support cover of services due to staff absences and periods of vacancy. In Skye, in particular long standing under resourcing of the service continues to place sustained pressure on the local physiotherapy team and this is apparent from their average 50% compliance with the MSK HEAT target.

CONTINUING ACTIONS TO ADDRESS WAITING LIST MANAGEMENT

 Implementation of triage based on DCAQ approach  Centrally managed patient focused booking  All MSK referrals managed on PMS with regular reporting of data.  In addition work to improve MATS (Musculoskeletal Assessment and Triage Service (NHS 24) ) continues in liaison with National AHP Lead at NHS 24.  Further actions aimed at improving waiting times:  NHS “Near Me” to be tested in Caithness as digital (video) consultation for patient reviews could save considerable time for staff and patients as well as travel costs. An Orthopaedic Consultant at Raigmore will work remotely with the patient and MSK Physio attending at CGH.

38  Further development and implementation of specific MSK pathways by Physiotherapy and podiatry professionals across N&W to promote standard working. Being progressed via Physiotherapy Professional Forum

39 APPENDIX 6

NORTH & WEST OPERATIONAL UNIT – DELAYED DISCHARGE REPORT 14 FEBRUARY 2018

1 CURRENT POSITION

Individual Position:

HOSPITAL NO OF DELAYED DISCHARGES Portree 3 Mackinnon Memorial 1 Belford 0 Caithness General 4 Lawson Memorial 0 Migdale 3 Dunbar 0 Town & County, Wick 2

The chart below shows the overall reducing trend in total numbers of Delayed Discharges in the North & West Operational Unit as at 9th February 2018.

2 ACTION PLANS TO ADDRESS

Meetings have been arranged to discuss the ongoing issue in relation to Mental Health Officer (MHO) allocation/involvement within Caithness.

Utilisation of Hospital Home Bundle

Exercise 13ZA in relation to Adults with Incapacity where appropriate.

Daily dynamic discharge is now embedded in Caithness General Hospital. Daily Caithness huddle with Caithness General Hospital, Dunbar, Town &County Hospital and the East/West integrated teams is now embedded as business as usual.

40 3 EXPECTED IMPACT OF ACTIONS ON PERFORMANCE

Delayed Discharge numbers will continue to reduce.

4 FORECAST OF RETURN TO PLANNED PERFORMANCE (ie Trajectory)

Integrated Teams & hospital staff continue to work to get people out of hospital as quickly as possible and to keep people out of hospital. The expectation is that delays will reduce with the increase in care at home and care home capacity, and further development of the senior health & social care support worker role and daily dynamic discharge.

41 42 APPENDIX 7

Cancer Access & Treatment Times

1 CURRENT POSITION

31 Day Performance – Quarterly to end December 17

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

Chart 1 - Number of Patients Treated and Breached

400

350 26 15 11 21 18 11 9 12 15 8 14 300 11 11 9 10 12 12 11 10 5 250

200 317 150 300 295 309 305 308 303 302 292 295 294 291 274 267 269 277 258 260 268 276 100

50

0 20132013201320132014201420142014201520152015201520162016201620162017201720172017 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4

Treated Breached

Performance against 95% Standard 99.0 97.0 98.1 96.9 97.3 96.8 95.0 96.0 96.3 96.4 95.9 96.0 96.3 96.1 95.9 96.0 95.1 95.2 95.5 93.0 94.9 94.3 93.1 91.0 91.5 89.0 87.0 85.0 20132013201320132014201420142014201520152015201520162016201620162017201720172017 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4

31 Day Performance against 95% Standard

As can be seen above, the Board continues to meet this Standard on a regular basis. Failures tend to be within Urology in the main.

43 62 Day Performance – Quarterly to end December 17

(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

200 23 26 27 16 25 13 18 11 13 7 22 29 9 12 10 21 12 150 13 21

218 100 191 188 185 181 187 178 178 167 175 171 166 165 174 166 169 145 153 156 145 50

0 20132013201320132014201420142014201520152015201520162016201620162017201720172017 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Breached Treated

Chart 4 – Performance Against 95 Per Cent Standard

100.0 62 Day Performance against 95 Per Cent Standard

95.0

90.0

85.0 94.6 96.0 93.8 92.8 93.9 92.7 92.4 91.4 92.2 91.0 89.7 88.0 86.7 80.0 86.2 86.5 86.2 85.5 85.8 85.6 82.8

75.0 20132013201320132014 201420142014201520152015 201520162016201620162017 201720172017 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4

As can be seen above, the performance against the standards, particularly the 62 Day Standard continues to be a significant cause for concern, both locally but also Nationally where the 62 Day Performance in November was 87.0 per cent.

44 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.

31 Day Target

Oct Jan Apr Jul Oct Jan April July Oct to to to To To to to to to Dec Mar Jun Sep Dec Mar June Sept Dec 15 16 16 16 16 17 17 17 17 Other(NonUrology)1 6 4 3 1 3 6 4 6 Prostate 3 1 1 Bladder 2 2 31 Renal 7 6 1 8 5 2 3 7 4 TotalUrology 8 14 5 14 9 5 12 12 11

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.

62 Day Target

Oct to Jan to Apr to Jul Oct Jan to Apr to July to Oct to Dec Mar Jun 16 To To Mar June Sept Dec 15 16 Sep Dec 17 17 17 17 16 16

Other (Non 3 3 14 9 12 10 16 8 13 Urology)

Urology Bladder 1 221 Prostate 10 5 7 11 7 11 8 13 10 Renal 4 3 0 3 2 1 4 7 TotalUrology 17 12 21 24 21 12 16 27 31

For the 62 Day target the problems are within Prostate with delays to TRUS at the beginning of the pathway and also Renal Surgery where there is a dependency upon a single handed specialist. Of the other cases, the majority, are within Colorectal and GI Surgery where delays to scope are being experienced. Both these problem areas are expected to begin to improve during quarter 2 of 2018 – construction on the dedicated TRUS Biopsy area in Outpatients is finally scheduled to start on 19 February and be complete and at the beginning of March. The space freed up in Endoscopy as a result of that move will also provide for additional capacity there. The additional staff member who took up post in the summer is not expected to work independently however until the end of 2018.

The number of patients breached without an agreed treatment date has reduced in recent months but the continued high number of patients waiting to be treated after periods of annual leave indicates even that after the recent Prostate RPIW that there is insufficient capacity within the service to provide for a smooth throughput. There is sufficient capacity for the 42 weeks of the year that the Nurse Specialist is available.

45 Urology Capacity A number of actions have been put in place regarding Urology in particular however a sustained improvement will not be evident for a number of months given the number of patients who have already breached but do not have a treatment date confirmed.

Additional Urology Clinic, Scope and Theatre Capacity continues to be commissioned in order to deal with the immediate backlog of Prostate, Bladder and Upper Tract patients waiting to be treated

2. Colorectal/HPB - Scope Delays There has been a recurring capacity problem here for some time however the number of patients breaching is reducing following the appointment to key vacancies and case by case management of individual cases.

General

Cancer Tracking. Efforts have also re-doubled to improve the monitoring and tracking of patients at risk of breaching. There are now more frequent and separate meetings being held between the Cancer tracking team and Administrators and Service Managers in key specialities to manage patients on a case by case basis. Members of the Senior Management Team will be reviewing progress against this plan on a daily basis.

Cancer activity has also been prioritised, where possible over routine activity

Endoscopy

A proposal to implement FIT (Faecal Immunochemical Testing) to reduce demand for colonoscopy by approximately 15% will be presented to SMT in the spring with a view to implementation during 2018.

A sustained improvement in the position cannot easily be achieved until the National Review of Urology is concluded and the additional Nurse Specialist is appointed and fully trained.

46