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 Tuesday 15 January 2019 with attendance as noted below. Note the Assurance Report and agreed actions resulting from the review of the specific topics detailed below.
Present:
Ann Pascoe, Board Non-Executive Director - In the Chair James Brander, Board Non-Executive Director Ann Clark, Board Non-Executive Director David Garden, Interim Director of Finance Deirdre MacKay, Board Non-Exec Director David Park, Chief Officer, The Highland Partnership Kate Patience-Quate, Lead Nurse Dr Boyd Peters, Associate Medical Director (Medical Lead) Cllr Nicola Sinclair, The Highland Council (Videoconference)
In Attendance:
Sally Amor, Public Health Specialist (from 1.00pm) James Bain, Transaction and Income Manager Gaye Boyd, Deputy Director of Human Resources Cllr R Bremner, The Highland Council (Videoconference)(Observing) Val Gale, Third Sector Interface Dr Ann Galloway, Area Clinical Forum Representative Gillian Grant, Commissioning, Contracts and Compliance Manager (from 12.55pm) Eric Green, Head of Estates (Item 2.12) Tracy Ligema, Deputy Director of Operations, (North and West Division) Brian Mitchell, Board Committee Administrator Gaener Rodger, Board Non-Executive Director Michael Simpson, Public/Patient Representative Elisabeth Smart, Public Health Consultant Kenny Steele, Highland Hospice Katherine Sutton, Head of Acute Services Ian Thomson, Lead Social Work Officer (North and West) Dr Neil Wright, Lead Doctor (Deputy)(Videoconference)
Apologies:
Shirley Christie, Staffside Representative Dr Ian Kennedy, Lead Doctor Margaret MacRae, Staffside Representative Adam Palmer, Employee Director Julie Petch, Associate Lead Nurse (North) Sara Sears, Associate Lead Nurse (North) Simon Steer, Head of Strategic Commissioning AGENDA ITEMS
Assurance Report from 8 November 2018 Implementation of the Carers (Scotland) Act 2016 Clinical Governance Update Sub Committee and External Groups Reports Chief Officer’s Report NHS Highland Recovery Plan Director of Public Health and Policy Annual Report Unscheduled Care Forensic Medical Services Adult Social Care – Day Care Charging and Modelling Proposals Third Sector Alignment, Sustainability and Collaborative Commissioning Plan 2018/2021 Bed Reconfiguration for Patients with Low Acuity Caithness Service Redesign Report on Public Consultation Modernisation of Hospital and Community Services
DATE OF NEXT MEETING
The next meeting will be held on Friday 8 March 2019, in the Board Room, Assynt House, Inverness. 1 WELCOME AND DECLARATIONS OF INTEREST
There were no Declarations of Interest.
At the commencement of the meeting, the Chair read a Statement from Melanie Newdick, former Committee Chair advising as to her reason for having resigned from the position of Chair due to a potential Conflict of Interest and taking the opportunity to thank members and administrative staff for their support during her tenure. As Interim Chair, A Pascoe paid tribute to the Chairmanship of M Newdick and thanked her for her commitment to the role. It was advised a new Chair was to be appointed by the NHS Board at their meeting on 29 January 2019.
D Park took the opportunity to further advise Dr G Smith was currently operating in the role of Interim Chief Executive for NHS Highland, with Mr I Stewart to formally take up the substantive role from the end January/start February 2019.
The Committee so Noted.
2 PERFORMANCE AND SERVICE DELIVERY
2.1 Assurance Report from Meeting held on 8 November 2018
There had been circulated draft Assurance Report from the meeting of the Committee held on 8 November 2018. Members were advised the dates of future meetings would be reconsidered so as to avoid potential clashes that may reduce attendance. Members were also encouraged to continue to consider and submit suggestions for future agenda items.
The Committee otherwise Approved the circulated draft Assurance Report.
2.2 Matters Arising
2.2.1 Implementation of the Carers (Scotland) Act 2016
I Thomson spoke to the circulated report providing an update as to the situation in respect of implementation of the Act, which introduced new rights for unpaid carers and new duties for local Councils and the NHS to provide support to carers. Of the eight new duties placed upon statutory providers, 6 were of direct relevance to NHS Adult Health and Social Care. The report went on to indicate activity to date, and outstanding in relation to Adult Carer Support Plans (ACSPs); eligibility criteria; provision of support to carers; involving carers in carer services, including hospital discharge; completion of a Local Carers Strategy; and provision of information and advice services for carers. I Thomson advised, working with Connecting Carers, there had yet to be produced a completed Implementation Plan with an outline of associated costs, thereby delaying the progress of the partnership in respect of meeting duties to carers. The circulated report went on to detail there had been a renewal of the collaborative approach to developing a shared Implementation Plan, the draft of which set out a number of high level actions to be progressed. In terms of ensuring focused monitoring and appropriate oversight arrangements, the Carers Improvement Group had been established. In terms of coordinating the work involved, it was suggested there should be recruitment of a Carers Services Development Coordinator, as outlined in the report.
During discussion, members welcomed the detail of the circulated report and sought clarification as to activity relating to Young Carers. It was advised this would be raised with the Carers Improvement Group. On the points raised by A Clark in relation to providing support to carers, it was advised that the waiving of charges would apply to all four Options and that there is no facility to carry over unspent resource in to 2019/20. D Park emphasised resource remained available for use in 2018/19. On the issue of support for carers in remote areas, it was advised Connecting Carers helped with identification of individuals after which support was offered as appropriate. The Carers Services Development Coordinator would play a key role in that regard moving forward.
ACTION: Agreed the Implementation Action Plan include relevant timescales – S Steer ACTION: Agreed regular progress updates be provided to future meetings – S Steer
After discussion, the Committee:
Noted the current position on implementation and areas where action still required. Approved the use of the Carers Support Plan templates. Approved the use of the national eligibility Criteria/Framework. Approved the draft Implementation Action Plan. Agreed to Approve the recruitment of a Carers Services Development Coordinator.
2.3 Sub Committee and External Group Reports
Clinical Governance Update
G Rodger advised further consideration was being given to the relevant Clinical Governance Framework reporting requirements and arrangements for North Highland. Discussion continued with the Chief Officer and Board Nurse Director in this regard. D Park advised the aim was to ensure appropriate reporting to this Committee whilst avoiding duplication of activity with the overarching corporate Clinical Governance Committee.
Finance and Performance Sub Committee
There had been circulated abridged Notes of Meetings held on 18 September and 17 October 2018 providing updates on the matters considered in detail at the meetings, and associated action points. A Clark advised the Sub Committee received appropriate, detailed information and data to enable strong discussion and the subsequent provision of relevant assurance to this Committee. The Sub Committee was considered to be working effectively.
ACTION: Agreed Notes of recent Meetings be circulated to members – B Mitchell
North Highland Local Partnership Forum
There had been circulated Note of Meeting held on 14 November 2018. A Clark sought an update on the reference to information flow within Raigmore Hospital. D Park advised a further meeting, Chaired by the Board Medical Director, had been held with clinicians along with a series of associated management meetings. Whilst the John Sturrock Review was ongoing, activity was being taken forward to ensure improved communications. Staff members were being encouraged to raise any issues or concerns with management at an early stage. K Sutton confirmed a common approach was being developed at that time.
After discussion, the Committee:
Noted the position in relation to the Clinical Governance Sub Committee. Noted the Notes of meetings of the Finance and Performance Sub Committee. Noted the Note of Meeting of the North Highland Local Partnership Forum. 2.4 Chief Officer’s Report
D Park spoke to the circulated report which provided an outline of Operational activity across the three North Highland Divisions, highlighting areas of focus for improvement as well as areas of development and further opportunity. Updates were provided in relation to People (Recruitment and Selection, Staff Experience, Sickness Absence, Service Redesign), Quality and Safety (Improvement Activity, Waiting Times, Infection Prevention and Control, Patient Safety), Care (Service and Delivery, Adult Social Care, Mental Health & Learning Disabilities and Drug & Alcohol Recovery, Out of Hours, Primary Care Services, Midwifery, Highland Sexual Health, Technology Enabled Care and Prison/Custody Services). Specific updates were provided in relation to ongoing recruitment concerns, the range of expansive redesign activity underway, and strong recent Emergency Department performance.
During discussion, G Rodger referred to the range of redesign activity underway in North and West Highland and sought feedback on how this was managed in terms of existing staff capacity. T Ligema advised limited additional resource had been allocated overall although dedicated capacity had been agreed in relation to activity relating to Skye. She stated strong team working was in evidence across the wider Divisional Unit. A Clark referenced recent comments from Internal Audit relating to ensuring the sharing of key skills and knowledge across redesign projects and D Park confirmed the points made had been recognised.
D MacKay raised the matter of sickness absence levels within Adult Social Care and was advised relevant absence levels had declined since Health and Social care integration was introduced. Recruitment to specific key posts had assisted in this regard. D MacKay further requested an update in relation to previous reference to development of a Care Academy.
ACTION: Agreed a progress report on development of a Care Academy be submitted to a future meeting – S Steer/I Thomson
After discussion, the Committee otherwise Noted the detail of the Chief Officer’s Report.
2.5 NHS Highland Recovery Plan
D Garden advised NHS Highland had, at the end of November 2018 entered Level 4 of the Scottish Government’s Five Level scale of Escalation. This had arisen in light of the overall NHS Highland financial position and sought to provide support in development of a balanced, sustainable Financial Recovery Plan and associated governance framework. A Programme Management Office had been established to oversee progress in relation to savings plans. D Park advised that this welcome level of support was made available to all NHS Boards in Scotland requiring the same, with four organisations currently being assisted in this way. He confirmed this Committee would remain sighted on elements relating to North Highland, with overall financial balance and control the key aim.
ACTION: Agreed a formal update be provided to the next meeting – D Garden/D Park
The Committee otherwise Noted the current position.
2.6 Director of Public Health and Policy Annual Report
S Amor gave a presentation to members in relation to a Public Health approach to understanding and responding to adversity (adverse childhood experiences, resilience and trauma informed care). A series of key messages were outlined including that risk factors associated with increased likelihood of experiencing adversity through abuse, trauma and stress in childhood are extremely varied. Other key messages related to resilience; toxic stress; impact; environmental, community and individual adversity; supporting staff and developing services; the Public Health perspective; trauma informed systems and services; cultural shift; routine enquiry; resilient and compassionate communities; and the Getting it Right for Every Child Practice Model. The next steps and future direction were also outlined, on the basis of an upstream approach to prevention while recognising the need to work with the impact of adversity in the most affected and vulnerable groups. S Amor went on to advise this activity would have clear links to that of the Human Resources Service and that she would be seeking to meet with relevant managers and staff to look to build in a preventative, public health aspect.
Dr Galloway emphasised the importance of developing appropriate screening for individuals, considering the question set to be utilised, and developing relevant responses. S Amor advised work in this area was at a very early stage and that assistance was to be provided to the NHS Board with regard to future developments. D Park welcomed the offer of assistance to develop services and functions, on a targeted approach and in the context of limited resources. He stated a clearly defined Action Plan would be required. He further emphasised the important role played by Highland Council in relation to children’s services and on that point G Rodger advised the new Council Chief Executive had indicated her aim to provide leadership in that area. The Committee Chair would link to relevant future activity.
ACTION: Agreed the weblink to an associated animation (Window of Tolerance) be circulated to members – B Mitchell ACTION: Agreed any Action plan be developed on the basis of inclusion of a framework of next steps – S Amor
The Committee otherwise Noted the presentation content.
S Amor left the meeting at 2.05pm.
2.7 Six Essential Actions Delivery and Winter Planning 2018/19
K Sutton gave a presentation to members in relation to the governance approach being adopted in relation to a refresh of Six Essential Actions activity, involving a series of locally owned and chaired Groups and a NHSH 6EA Delivery Oversight Group, the membership of and aims of which were outlined. It was noted the Oversight Group would review actions on current plans, consider progress, and agree with local groups their priorities for action to ensure patient safety. K Sutton went on to provide an overview of the 6EA Project Plan Refresh including activity to establish local priorities for action prior to winter 2018/19, consideration of how/what and where capacity would be enhanced from December 2018 to March 2019 and ensuring local ownership by delivery through local operations teams. The work of Local delivery Groups was referenced and it was stated that relevant issues were to be escalated as required to Senior Management for support. The detail of In-hospital and community Local Delivery Plans was provided, in relation to which the associated staffing and resource requirements were also outlined. Recent data on Emergency Department performance was provided to members. In terms of the winter planning goals for 2018/19 it was stated these would be for each acute hospital and affiliated community locality to be able to understand and manage its own demand, maintain and improve on the four hour Emergency Department access target, and minimise the number of occasions that whole system escalation is required. To this end the five priority workstreams were indicated. Members were then shown the results of a Raigmore Hospital Day of Care Survey which gave detail of the reasons for non-discharge of patients along with the relevant Raigmore specific initiatives that had emerged from consideration of those results. A Highland Daily Status Report had been developed. The NHS Highland Winter Plan 2018/19 had been made available online. Members welcomed the presentation detail, acknowledged the improvements being introduced and took the opportunity to record thanks to all staff had contributed. Advising that regular updates on activity would be provided to the Finance and Performance Sub Committee, K Sutton also extended an open invitation to members to raise matters of interest with her directly.
ACTION: Agreed presentation be circulated to Committee members – B Mitchell
The Committee otherwise Noted the presentation content.
2.8 Custody Healthcare and Forensic Medical Services
G Gunn gave a presentation to members in relation to NHS Highland activity relating to new Scottish Government, Police and Health Improvement Scotland Standards issued in December 2017 for NHS response to rape and sexual assault cases. This represented a high prominence national level Workstream, was subject to reporting by the Chief Medical Officer to the Scottish Parliament, and in relation to which implementation was expected in 2019. G Gunn confirmed she was Project Lead for Highland at that time. She went on to advise there remained a number of issues to be addressed including appropriate staffing resource, finance, facilities and development of relevant organisational strategy. It was stated facilities in Wick and Inverness were no longer fit for purpose, with services to be relocated to Caithness General and Raigmore Hospitals. In terms of developing an appropriate strategy, there would be a need to reflect on and strategically assess the legacy arrangements inherited from Police Scotland. Further, the development of a Chaperone Nursing Service, as promoted by the Chief Medical Officer, would be a challenge for NHS Highland in terms of both resource and training.
Dr Peters advised most patient contact took place Out of Hours, with overall numbers relatively low in the Highland area. The key risks associated with this activity were recognised and strong partnership working arrangements were in place. He emphasised that the geography of NHS Highland meant any suggestion of a move towards provision of a centralised facility would be extremely challenging. It was emphasised that these services applied to children as well as adults. He went on to add that the development of services would benefit from a local hero approach and emphasised the staff development opportunities that would accrue for those with a flexible, appropriate skillset base. D Park took the opportunity to advise activity remained at an early stage and whilst the number of individuals requiring this service would be relatively low it was important to ensure these were of a level that was fair to all concerned. This would bring an associated financial challenge for NHS Highland.
During discussion, it was acknowledged that the actual level of service demand was an unknown quantity, with NHS Boards also being required to take and store relevant samples from individuals self-reporting to any of their respective services or clinics. The overall level of reporting was steadily increasing at this time. On the point raised as to the potential to utilise existing Sexual Health facilities in Highland, Dr Peters confirmed this would require to be included as part of the detailed discussion moving forward. Any future Implementation Plan would require to be initially agreed by the Senior Management Team, with further updates to be provided to this Committee in due course.
The Committee otherwise Noted the reported position.
G Rodger left the meeting at 2.45pm. 2.9 Adult Social Care – Day Care Charging and Modelling Proposals
At their meeting held on 8 November 2018 the Committee had agreed that an impact assessment report be submitted to this meeting in relation to a flat rate charge Option.
J Bain spoke to the circulated report, which in addition to outlining the four charging Options previously considered, provided the requested wider impact assessment of an increased flat rate charge with no financial assessment, subject to a maximum weekly charge of £15 per person. This proposal would retain the existing charge of £7.50 for those who only attend for one day, £10 for two days and £15 for three days or more. There would be no further uplift applied for two years.
After discussion, M Simpson, Seconded by A Clark, Moved that the Committee Approve the implementation of an increased flat rate daily charge, with no financial assessment, from 1 April 2019 capped at a maximum service charge of £15 per person per week. There being no counter proposal, the Motion was therefore Carried.
The Committee otherwise Approved the implementation of the recommended flat rate charge Option.
2.10 Third Sector Alignment, Sustainability and Collaborative Commissioning Plan 2018/2021
G Grant spoke to the circulated report providing an update on progress in relation to the Third Sector Alignment Plan presented to the Committee at their meeting held on 8 November 2018. It was noted, in recognition of the scale and complex nature of this area of activity and to allow sufficient time to undertake further engagement with the Sector, there had been agreement to extend current providers’ contracts until 30 June 2019. Updates were provided in relation to the work of the Advocacy Sub Project Team on undertaking a tender exercise for the future purchase of Independent Advocacy Services beyond 30 June. It was reported the overarching Project Team continued to meet on a weekly basis to determine what future services are to be purchased from the Third Sector and how these services would be purchased. The circulated report also included a series of supporting documents including a driver diagram highlighting the relationship between the overall project aim and proposed key drivers; criteria capturing the proposed types of services to be commissioned, outcomes to be achieved and types of characteristics to be sought for in Third sector organisations; and an outline number of a number options for how future services could be purchased from the Third Sector. It was reported the Highland Third sector Interface had met with current and potential providers to seek feedback in relation to the commissioning process, the detail of which feedback was also provided. Feedback was subsequently further obtained from North Highland Senior Leadership Teams, the result of which was that Option 5 (Tiered Funding System) had emerged as the preferred future purchasing route for NHSH operational areas. The Project Board had welcomed this approach as providing the ability to allocate funding locally through a participatory budget approach. Members were also advised an Equality Impact Assessment would be undertaken by the Project Team and submitted to a future meeting of the Committee.
During discussion, D Park emphasised the need to be able to ensure any new process is compliant to the procurement legislation, transparent and fair to all Third Sector providers. There was acknowledgement that the new process may result in some organisations losing respective funding, and it was noted the Third Sector Interface had been engaged at all stages and were actively involved in considering relevant, potential mitigating actions. The Committee:
Noted progress on the review and development of the third sector Alignment, Sustainability and Collaborative Commissioning Plan. Noted the future submission of the Equality Impact assessment relating to the project. Agreed to Endorse and Support the redesign process, the types of services and associated outcomes the NHS wishes to purchase, and the proposed adoption of Option 5 for the future purchasing of services from the Third Sector.
2.11 Bed Reconfiguration for Patient with Low Acuity
Members Agreed reporting on this matter should be to the Finance and Performance Sub Committee.
2.12 Caithness Service Redesign Report on Public Consultation
M Johnstone gave a presentation to members and spoke to a circulated report relating to feedback arising from the public consultation on service redesign in Caithness, this process being one of the most extensive and comprehensive ever carried out by NHS Highland, and possibly by any NHS or public sector organisation in Scotland. The presentation provided detail of the consultation process to date, in the context of previous redesign/improvement activity and the local/political unrest that existed in the area around health service provision. The challenge of reaching an agreed way forward for future service provision in Caithness was outlined, the consultation exercise for which ran from 20 August to 23 November 2018.
The consultation exercise sought an independent endorsement of the process, to establish if the case for change has been made, if there was support for overall proposals, support for re-locating GP Practices, support for an agreed location of the Wick Hub, and provide a sound rationale for the final recommendation. It was noted that some 2,017 responses had been received during the process, representing a positive adult response rate of 9.4%, and this followed a series of Public Launch Events and adoption of a responsive process approach. There had been undertaken a Royal Mail drop to all homes in Caithness as well as 105 associated public meetings and a further 28 meetings with staff members. The Scottish Health Council Independent Assurance Report was awaited. It was reported 70% of respondents supported proposals for change and as such the move to implement Care Hubs in Wick and Thurso, and invest in Caithness General Hospital, as part of wider redesign activity would be recommended to the NHS Board as the preferred way forward. Referring to the preferred location of the Care Hub in Wick, the Project Team considered that no firm consensus had been reached as yet and it was noted an alternative site had emerged during the consultation process that was considered worthy of further consideration. It had not been possible to arrive at a decision in relation to inclusion of existing Salaried GP Practices as part of the proposed Care Hubs. M Johnstone went on to state the consultation exercise had also highlighted issues relating to patients travelling for appointments, with clinicians recognising the need to do more to consider options to reduce travel. In conclusion, after a successful consultation exercise, it was recommended the Committee endorse the proposals and model of care, agree to progress to submission of an Initial Agreement to the NHS Board in July 2019, agree further evaluation work on the sites in Wick and to determine the exact specification for Care Hubs, and the eventual submission of an Outline Business Case.
During discussion, Cllr Sinclair advised the Caithness public were appreciative of the level of engagement employed during the consultation process that had been undertaken and were increasingly acknowledging the case for change. She stated there were two clear challenges being faced in light of the proposed way forward, relating to the management of services during any transition period and the importance of ensuring future service provision was appropriate in terms of such aspects as bed numbers and associated staffing levels etc. She indicated her support for the two site evaluation approach that had been adopted and thanked all who had been involved to date. She highlighted the importance of being able to work together in such a positive manner and the need to ensure continued effective communication that sought to listen to the views of residents. The Committee unanimously endorsed this point, noting the Project Team would continue to be at the centre of activity.
In conclusion, D Park stated there had been considerable effort afforded to taking this matter forward in the positive manner evidenced to date and acknowledged during discussion. He took the opportunity to thank all involved to date and praised the innovative approach that had been applied by all, in addition to the positive attitude in which this had been conducted. The next stage would be to develop the appropriate Business Case for submission later in 2019, recognising the Revenue implications of arising from the eventual agreed proposal.
After discussion, the Committee:
Endorsed the comprehensive nature of the consultation process. Agreed that the findings confirm broad support for the case for change and new models of service being proposed. Endorsed the recommendation on the preferred way forward and next steps.
G Boyd left the meeting at 3.30pm.
2.13 Modernisation of Hospital and Community Services
Members Agreed to Defer consideration of this Item to a future meeting.
3 COMMITTEE FUNCTION AND ADMINISTRATION
There were no matters discussed in relation to this Item.
4 FOR INFORMATION
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 Friday 8 March 2019 in the Board Room, Assynt House, Inverness.
The Meeting closed at 3.40pm Highland Health & Social Care Committee Report
Community Divisions including Hosted Services
8 March 2019
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.
2. PEOPLE 2.1 Recruitment and Selection
North & West Division:
North Area: • Staffing remains fragile in the north area. Ongoing efforts are being made to address the challenges. There has been successful recruitment into a one year secondment position for Senior Charge Nurse at Bignold Ward, in Caithness General Hospital. • Laboratory Services Caithness General Hospital – staffing pressures remain, with the service currently being covered by 3 locum biomedical scientists. Vacancies are currently being re- advertised.
West Area: • Consultant staffing in Belford Hospital remains challenging with consultant posts being covered by locums. Physician and anaesthetic positions are currently being advertised, and interviews are planned for the surgeon posts. • Vacancies remain within Telford Centre, Fort Augustus, however recruitment has improved.
South & Mid Division:
There continue to be significant challenges around recruitment and retention of Community Midwives with almost half the workforce aged 50-59 in NHS Highland. In response to this, the Shortened Midwifery Programme commenced in NHS Highland on 7 January 2019, and it is hoped that this return to training Midwives in NHS Highland will help alleviate the workforce pressure going forward.
Access to adequate numbers of nurse Bank staff remain an issue with all community hospitals reporting difficulties. This is particularly affecting service delivery in Royal Northern Infirmary (RNI).
Recruitment is underway for a Senior Drug & Alcohol Practitioner in Badenoch & Strathspey.
A new model of working has been developed to support in-patient and community detoxification services with interviews for an Advanced Nurse Practitioner scheduled early March 2019. This will improve the experience, ensure consistency and support the development of standard work and processes against the emerging national strategies.
Additional resource has been achieved via the Highland Alcohol and Drug Partnership for the next 2 years. Posts will include pharmacy resource, psychology resource, learning disability & autism
1 resource and support workers in NHS provision. Further to that, a number of key partnership service models with housing and Scottish Prison Service are in development.
2.2 Staff Experience 2.2.1 Learning and Development
The iMatter preparation stage has begun in readiness for this year’s team questionnaires and action plan. Hierarchies and team structures are currently being reviewed.
Figures as at 26 February 2019: iMatter North & West South & Mid Division Division
Response Rate 2018 43% 54%
Team Reports Achieved 2018 38% 46%
Action Plans Created 63% 74%
Turas Appraisal
Posts 4495 2711
Signed in 34% 38%
Complete Appraisals 3.7% 6.5%
2.3 Sickness Absence
By month Nov 2018 % Dec 2018 % Cumulative Total at 31 December 2018 % South & Mid 6.09% 5.79% 5.61% Division
North & West 5.02% 4.74% 4.98% Division
South & Mid Division: Protracted absences continue to be well managed. However there is still an overall sickness absence of 5%+ in the Division.
In relation to the Occupational Health Department one of the recommendations from the referral process Rapid Process Improvement Workshop (RPIW) three years ago was that they would continue with the telephone triage and consultation process. This is standard practice for most commercial providers and is similar to NHS Near Me. Staff will experience a quicker triage response than they would with a traditional face to face meeting which is costly, time consuming and resource intensive. The Department is trialling NHS Near me now and both Occupational Health consultants have the equipment installed.
2 3. QUALITY & SAFETY 3.1 Improvement Activity
North & West Division:
Pharmacotherapy Service
This is one of the workstreams of the new GP contract. There had been a Highland HSCP-wide recruitment campaign (for up to 10 wte pharmacists) and a number of excellent candidates have been identified and appointed. At this time, establishing a geographical coverage across the whole are is challenging. Plans are being developed to use remote working to provide an equitable level of service and also to develop the skill mix by using pharmacy technicians and assistants. Protocols to support the service are at an advance stage of development and an IT-based medication review template is being tested in practices.
South & Mid Division:
Dental National Oral Health Improvement Plan (2018)
The Scottish Government is adopting a phased approach to the implementation of the 41 Actions included within the Improvement Plan.
Initial Phase Director of Dentistry (Primary and Secondary Care) to be in place in each Health Board. John Lyon Clinical Dental Director is the NHS Highland Interim Director of Dentistry.
Occupational Health Services are available to all General Dental Practitioners and their practice staff. This in place within NHS Highland.
Domiciliary care services for Care Homes to be provided through accredited independent contractor General Dental Practitioners. There has been no interest from NHS Highland General Dental Practitioners to take this forward at present. Feedback suggests that this is due to short notice of training and lack of contractual information. These services are currently provided by the Public Dental Service.
Next Steps Focus on the development of the Oral Health Risk Assessment and the Preventative Care Pathway of adults.
3.2 Waiting Times 3.2.1 Psychology
South & Mid Division:
The Lead Psychologist and General Manager Mental Health and Drug & Alcohol Recovery Services presented the recommendations from the review of Psychological Services to North Highland Senior Management Team and received their support. North and West Senior Management Team are to receive the presentation to allow discussion with their staff to take place.
The Head of Adult Psychology post was successfully recruited to commencing in April 2019. The post holder will lead on the implementation of the review once approved.
3 A trial of Near Me in delivering therapy has been successful and will be expanded.
Waiting list initiative work continues with a reduction in longest waits in Adult psychology:
August 2018 938 days November 2018 688 days
Recruitment of 2 Clinical Associates in Applied Psychology has increased capacity and is assisting in reducing waiting times.
3.3 Infection Prevention & Control
North & West Division:
Clostridium Difficile Cases (C Diff)
North and West currently have 15 CDIFF cases reported. These have been all investigated and reviewed at the CDiff/SAB meeting and there has been no identified links with any of the cases.
Staphylococcus aureus bacteraemia (SAB) Incidence:
Since the start of April 2018, there have been 12 cases, which is an increase on last year. A root cause analysis has been undertaken for each case to determine where improvements can be made and learning identified.
4 Tissue Viability
Community: There have been 2 grade 3 pressure ulcers reported since the last report. Both these pressure ulcers are currently being investigated and a root cause analysis completed and any learning from this will be shared through the tissue viability leadership group and clinical governance.
Table 1: Incidence of pressure ulcers arising in the community excluding Grade 1 to December 2018.
Hospitals: In the last 2 years there have been no hospital acquired grade 3 or 4 pressure ulcers. There has been a decrease overall in reported pressure ulcers in North and West hospitals.
Table 1, below, Incident of pressure ulcers arising in hospital excluding Grade 1 to December 2018.
5 South & Mid Division:
The current incidence for Clostridium difficile infection (CDI) from April 2018 to date is 15. All cases continue to be reviewed and to date there have been no links to any cases or significant learning from these reviews.
There have no cases of staph aureus bacteraemia attributed to South & Mid Division from April 2018 to date.
Monthly audits of compliance with standard infection control precautions remain above 95% and the latest quarterly compliance monitoring for domestic services also remains above 95%.
Tissue viability
Community acquired pressure ulcers Two previous community acquired cases have been reviewed as possible Duty of Candour cases. One case had been downgraded to a case review following initial review and the second case progressed to a Significant Adverse Event Review. The findings of this review resulted in additional purchase of pressure relieving equipment in the community equipment store and a review of the system for communicating decisions re availability of equipment between the store and ordering professionals.
3.4 Patient Safety 3.4.1 Scottish Patient Safety Programme
North & West Division:
Table 4: All Patient Falls – North & West Division remains on target.
6 4. CARE
Service and Delivery
4.1 Adult Social Care 4.1.1 Delayed Hospital Discharge
Figures as at 20 February 2019:
7 North & West Division: The chart below shows the overall trend in total numbers of Delayed Discharges in the North & West Division as at 5 February 2019.
Current areas of concern resulting in delays are the availability of residential and nursing home placements and the slow progress of guardianship process in the North Area.
South & Mid Division:
There is focused work in hand to improve our understanding of the business systems that support patient flow through our hospitals and to make improvements to facilitate timely discharge of patients. A senior manager from the South and Mid Division has been assigned to this and weekly senior management meetings have been established to monitor and support the work.
4.1.2 Care at Home (including commissioning)
Work continues with independent sector care at home providers to reach an agreement for a new pricing structure from April 2019. The formal proposal will be reviewed through our governance process with a final decision on the pricing model for care at home from April 2019 to be made in late February 2019.
Both divisions expect that a new pricing model will assist to resolve some of the service delivery challenges which have been encountered in recent months. There has been difficulty with provision of care packages for clients in some areas of South and Mid and delivery concerns in the North which are currently being addressed at an escalated level.
Some additional independent sector capacity will shortly be available when Birchwood Highland commences delivery of care at home services. Some additional independent sector capacity will shortly be available the provider commences delivery of care at home services during quarter 1. Work is ongoing to plan transitionary arrangements for this additional capacity coming on stream.
Inverness Overnight Care Service has commenced extended hours of operation to assist with Winter pressures.
8 4.1.3 Care Homes
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 meetings on 27 March 2018 and 29 May 2018. Previous updates advised that the NHS Board on 29 May 2018 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. In progressing this confirmed vision, a Strategic Implementation Plan has been discussed between officers from the Highland Council and NHS Highland. There is broad agreement on direction, with the discussion currently focussing on financial issues.
Sector discussions continue within “Business Stream” activity; this being regular dialogue meetings between NHSH staff and nominated care home sector representatives. The previous meeting took place in December 2018 with progress on a number of issues, which will enable a forward focus on an agreed work plan for 2019-2020.
As previously advised, the new care home Lynemore Care Home in Grantown which is operated by Parklands Ltd, opened on 17 September 2018. This is a 40 bed care home delivering residential and nursing care. The 4 weekly “stop point” meetings are continuing until full capacity is reached.
Two of the three previously reported suspensions of admissions at three care homes, are currently still in place. NHSH is actively monitoring all of these care homes and supporting as appropriate, to ensure the required issues are addressed.
The additional care home bed capacity coming on stream over 2019 and 2020 is currently under consideration and NHSH is looking at any potential opportunities this might afford.
As previously advised, a new work stream has been initiated to consider and improve discharge from hospital to care homes. The work stream will focus on when, where and who makes the decision that a care home placement is required. A one day design event to map out the discharge from hospital direct to care home process took place on 22 February 2019, and invitees include user and carer representation. Further work will be undertaken.
Confirmation on the applicable National Care Home Contract fee rates for 2019-2020 is awaited from Cosla / Scotland Excel. This is not expected to be received until March 2019.
4.1.4 Self Directed Support
North and West Division:
As of 6 January 2019 the number of people accessing a Direct Payment across North and West Division are distributed as follows:
The current 4 weekly payments at district level are as follows:
Numbe Total 4 r Weekly Area District Active Payment North Caithness 31 43,170 North Sutherland 19 21,861 West Skye & Lochalsh 52 50,926
9 West Wester Ross 17 9,632 West Lochaber 29 52,218 Total 148 177,808
The following one-off payments have been made during 2018/19:
Numb One Off Area District er Total North Caithness 8 19,926 North Sutherland 2 2,527 West Skye & Lochalsh 7 7,122 West Lochaber 8 7,102 Total 25 36,678 There are currently 148 active direct payments with a total 4-weekly payment of £177,808.
South & Mid Division:
As of 6 January 2019 the number of people accessing a Direct Payment across South and Mid Division with the current 4 weekly payments at district level are as follows:
Number Total 4 Weekly Area District Active Payment Mid Easter Ross 38 55,286 Badenoch and Mid Strathspey 14 16,748 Mid Mid Ross 42 59,491 South East Inverness 56 96,022 Nairn and South Ardersier 24 25,309 South West Inverness 31 43,472 Total 205 296,331
The following one-off payments have been made during 2018/19:
Area District Number One Off Total Mid Mid Ross 9 15,737 South East Inverness 11 13,075 Nairn and South Ardersier 6 9,791 South West Inverness 3 5,821 Total 44,424
There are currently 205 active direct payments with a total 4-weekly payment of £296,331.
10 4.2 Mental Health & Learning Disabilities and Drug & Alcohol Recovery
4.2.1 New Craigs hospital
Nursing and medical staffing pressures remain. The hospital has 22 registered nurse vacancies. Skill mix changes and temporary recruitment to Band 3 non registered posts to provide cover is underway and the General Manager and Lead nurse are developing a workforce plan. Locum medical staff are in place in General Adult and Older Adult posts. Attempts to recruit to substantive positions are ongoing. Further loss of consultant hours from the end of March 2019 will add to pressures.
There is to be a review of the management structure of Mental Health services over the next few months. Consultation with staff commenced in February 2019.
4.2.2 Community Mental Health Services
North & West Division: An Associate Lead Nurse, Mental Health, for the North & West Division has been appointed.
West Area:
Community Mental Health Team:
At the end of March 2019 there will be a full time band 6 vacancy for Severe and Enduring MH. There is a plan to redesign the team to build capacity.
Learning Disability: In Lochaber, the Self Directed Support cost of this service is still a pressure, however, a service redesign in conjunction with the Montrose centre is planned which could reduce cost for both services whilst providing leaner and more cost effective care.
Psychology: Lochaber - the Cognitive Behaviour Therapy 0.5 WTE post ends in August this year, this will create significant pressure on the Community Mental Health Team, as psychology input to the area is limited. We are continuing to explore with psychology about the possibility of making this post permanent.
Psychiatry: Integrated working continues to develop between the local service and Inverness based services. This will be strengthened by the new Associate Lead Nurse role.
North Area:
In the Sutherland area there are a number of band 6 vacancies coming up which could further destabilise an already challenging picture in terms of psychological support across Sutherland; we are actively proceeding with recruitment to these posts.
Psychology: the lack of Psychology services will mean that there will be waiting lists for all the services, there will be more contact with GP services and consequently repeated referrals to the Community Health Team, with the expectation that current CPNs will take these specialist clients on to support them until they are seen by the Psychology service.
South & Mid Division:
Action 15 funds have been allocated to North and West Division to recruit Band 7 staff to provide urgent practitioner services to the Belford, Skye and Caithness General hospitals.
11 4.2.3 Learning Disabilities and Autism
North & West Division:
The Advanced Practitioner covering the Sutherland area retired at end of October 2018, the post is currently out to advert, with interviews planned for end of February, 2019. Support for this service is presently being provided from the Caithness team; however there is a limit for accepting and assessing new clients.
South & Mid Division:
Following consultation last year work is underway to finalise a Project Initiation Document in relation to the significant redesign of Learning Disability Day Care Services. Project teams for each work stream will also be created.
It is anticipated that the refresh to the Keys to Life, Unlocking Futures for People with Learning Disabilities Implementation framework and priorities 2019-2021 will be released very shortly. We will ensure the recommendations and priorities in this document are reflected in the Highland Learning Disability Strategy.
The Inverness Waking Night responder service started in November 2018 and is now supporting people overnight. This work is a strand of the Redesign of Overnight Support across Highland. NHS Highland are liaising with colleagues across Scotland to ensure that people’s needs are met overnight within the new models and maximising the use of technology and telecare.
The Head of Service Learning Disabilities and Autism continues to meet with groups of people with autism to hear more about their experiences in accessing NHS Highland Health and Social Care Services.
4.2.4 Support for People with Dementia and their Families
North & West Division:
The lead nurse, associate lead nurse and senior charge nurses met in January 2019 to review development of the successful pilot of Delirium prevention work that has been undertaken by ward 1 in Belford Hospital, and work undertaken in Royal Northern Infirmary in South and Mid. This is a collaborative piece of work and both areas are currently undertaking test of change Plan Do Study Act cycles to review at the next meeting in March 2019.
4.2.5 Drug and Alcohol Recovery
Work continues to embed our improvement work across all teams, initially in the South & Mid Division, with standard work in place. The achievements against the HEAT A11 standard are being maintained within Osprey House despite recent staffing challenges. The service is currently facing unprecedented demand with vacancies in the Highland Alcohol & Drug Advice & Support Service (drop in – Inverness). Wider service staff are providing cover to ensure that the service remains open. The number of clients is increasing with demand increasing for the Image & Performance Enhancing (IPED) service.
4.3 Out of Hours
Work is ongoing for North coast redesign. The first Advanced Nurse Practitioner will be available to start covering Monday to Thursday evening and overnight from 25 February. Appropriate support from GP colleagues both in the area and in Wick is being finalised. The OOH contracts for Fort William and
12 Wick are being renegotiated to incorporate remote support for ANPs and detention under Mental Health Act. There is potential cost pressure as overall OOH rates in NHSH remain lower than central belt.
Work continues in workstreams for Raasay and Glenelg for Ritchie report for north Skye. Training continues for ANPs on Skye with a view to taking over full Minor Injury Unit service from May/June 2019. Recruitment also taking place for further Rural Practitioners to support the model.
Dr Chris Mair is retiring from his role within OOH consortium in East Sutherland. The remaining members are reorganising the administration but are planning to continue.
There is interest from a number of Health Board areas and from University of Edinburgh in learning about the Palliative Care Direct access line and the impact it has had on care and patient experience. This is following on from our poster at National Out of Hours event in November 2018.
A plan to introduce an Advanced Nurse Practitioner to support the Out of Hours GP team in Lochaber has progressed with the appointment of a new trainee Advanced Nurse Practitioner to the Rural Support Team.
4.4 Primary Care Services
GP Quality Clusters The six quality clusters continue to make progress in their quality-driven areas. They met again on 14 December 2018 and delivered further updates. The workstreams data is being updated following the meeting and will be available shortly.
Any additional funding from the Primary Care Transformation Fund underspend will no longer be available from April 2019 to allow implementation of any other new projects.
Recruitment & retention There are no GP recruitment and retention issues within the South & Mid Division.
Primary Care Modernisation Plan (PCIP) As we come to the end of Year 1 of the three year improvement plan we are in the process of refreshing the plan going forward.
The three workstreams that were prioritised for Year 1 are progressing well with the Pharmacotherapy service successfully appointing to posts.
The role of the First Contact Practitioner (FCP) is being introduced in to GP practices. 1:5 GP Consultations are musculoskeletal (MSK). The majority of a GPs MSK caseload can be seen safely and effectively by a physiotherapist without a GP referral. Physiotherapists have a high safety record and are trained to diagnose serious pathologies and take appropriate action. Under the plans, physiotherapists will work in GP practices, as part of a multidisciplinary team tasked with performing some of the duties currently carried out by GPs.
In North Highland this will be 1 physiotherapist to 13,000 practice population. Work is underway to progress the redesign of the MSK Physiotherapy Service as this will lead to significant change with patients diagnosed, assessed and treated more locally. The two lead posts for North Highland have been appointed. Some tests of change have been undertaken already and feedback has been excellent from GPs.
The next steps are to:
13 1. Work collaboratively with GP practices to discuss what the changes mean to their practice. 2. Identify which practices can accommodate Physiotherapy and develop options for those practices where space is a challenge. 3. Start working with GP practice reception staff. 4. Recruit to new FCP posts and support staff through the redesign of current MSK departments.
In relation to the Additional Professional Roles for Mental Health a business case is in the final stages of preparation for consideration by the Project Team.
The three remaining workstreams (Urgent Care, Community Treatment and Care and Community Link Worker) are continuing to develop their models.
Enhanced Services Negotiations with the Highland Local Medical Committee (LMC) (the negotiating body for GP practices) for enhanced services from the period from 1 April 2019 are ongoing. All enhanced services (which are voluntary and do not form part or core GMS Services), apart from those defined by Scottish Government, are within scope of these negotiations. The negotiations seek to further align as far as possible the differing contractual arrangements in place in South & Mid and North & West Divisions.
An SBAR on the position from 1 April 2019 was presented to the North Highland Senior Management Team on 14 February 2019. The SBAR highlights the risk associated around service delivery within the current enhanced service budgets.
4.5 Midwifery - Community Midwifery Units
Midwifery staffing remains an issue in Skye and Lochalsh; however the team are still providing a local birth service out of hours.
Midwifery staffing in Caithness is less fragile that it has been in the past. The Community Midwifery Unit continues with out of hours on call provision for unscheduled care and home births.
The midwifery teams are achieving 100% named midwife allocation at booking, in line with Best Start.
Caithness General Hospital will shortly be equipped with a new obstetric scanning machine. This new piece of equipment will standardise service delivery and care provision in the area in line with Raigmore.
4.6 Highland Sexual Health
North & West Division:
Dr Fiona Gibson has been appointed to provide clinical leadership to the Gender Identity team.
Waiting times for long-acting reversible contraception (LARC) continue to grow with many women reporting delays or lack of access within primary care.
Demand for pre-exposure prophylaxis for HIV (PrEP) continues, with all Scottish Sexual Health services describing increasing demands on time and clinic appointments.
Work is underway to introduce online appointment booking for some patient groups.
4.7 Technology Enabled Care
With over 100 new patients enrolled on Florence every month during 2018, the total number of
14 patients to have benefited from Home Health Monitoring using Florence has now reached 3172.
Key Florence protocols
The most rapidly growing Florence protocol continues to be for BP monitoring, while a number of other protocols show a steady rate of take-up over the months
26 GP practices have been trained to use Florence (39% of the total), 20 of whom are currently enrolling patients, predominantly for diagnosis of hypertension.
GP practices are continuing to show a keen interest in using Florence to monitor patients on their hypertension register on an ongoing basis.
There is still plenty of scope for further engagement work with GP practices, to encourage uptake of Florence, and to build up use amongst those who are less active.
Florence Steering Group
On 16 January 2019 NHSH Senior Management Team approved, ongoing funding for the fixed costs and overheads of providing a Florence service – including staffing costs and the licence fee. The use of Florence to be available to all services and teams within NHS Highland, with individual teams encouraged to use Florence to enable pathway redesign rather than as an addition to current patient pathways. The use of Florence for COPD and Asthma patients to be funded centrally during a whole service transformation exercise, with future costs to be covered by the Respiratory Service itself, out of savings made.
Approval for an application to be made for funding from the Scottish Government National Scale-Up Blood Pressure Management Programme using Florence. The closing date for bids is 15 February 2019.
15 4.8 Dental
Treatment Time Guarantee (TTG)
Paediatric Dental General Anaesthetics Based on the current theatre sessions allocated it is anticipated that 72 children will have breached their TTG as at 31 March 2019.
A review of allocated theatre sessions for Paediatric Dental General Anaesthetics list is pending by the Children’s Surgical Services group.
4.9 Prison & Custody Services
The Forensic Medical Examiner (FME) and Custody Suite strategy development has continued and we are beginning to move into a clearer operational implementation phase of the work. For custody services nurse staffing is in place and we continue to work to develop aspects such as chaperoning. Staff are being trained as required in non-medical prescribing and we are looking longer term at the development of the role to include triage of FME calls along with establishing the model of custody healthcare provision across Highland. Challenges remain given the geographical issues, the prevalence of need and availability of staff. Nationally there are discussions around the role of non- medical staff in provision of evidence that may well impact on the future role.
For the FME part of the service, the future model is being decided upon, with variation across Highland likely to continue for the same aspects as with the custody service. We are still seeking to refine the service in terms of governance, availability of FMEs, working in partnership with paediatricians and with the police, and establishing a Highland FME lead.
5 SERVICE REDESIGN
North & West Division: North (Sutherland) Coast Redesign
Care Hub: Progress continues to be made on the design of the building. (The building itself is being designed by Highland Council with NHS Highland having “submitted” a design brief and accommodation schedule). It is expected that initial drawings will have been costed by a Quantity Surveyor and will be available to the Steering Group at its next meeting at the end of February.
Day Care: As noted previously Day Care will continue to be provided in the Melvich area. It will follow a similar format to that which exists in Brora, Lochinver and Tongue. A meeting took place at the end of February with the relevant community councils in late February. It was a very well attended meeting with the representatives of the community councils. They were introduced to the concept of the Health & Wellbeing Hubs elsewhere in Sutherland and Caithness. Attendees included North Coast Connections (Kyle Centre in Tongue) and Dementia Friendly Communities (Helmsdale Hub) who talked about the model they work to and how they support people in the community using a model which is different to that traditional model of registered day care. It was agreed that NHS Highland would pull together information on all the community health and wellbeing hubs locally and help there we will have representatives from housing including Albyn and Prof Angus Watson and will be taking about how Fit Housing could potentially build into the model.
16 Modernising Health & Social Care Services in Caithness
The formal three month period of consultation closed towards the end of November 2018. During December analysis of the responses from the public and statutory partners was undertaken. This work was supported by a Senior Epidemiologist within NHS Highland’s Public Health Department. The consultation process was subject to an Independent Assurance by the Scottish Health Council. In their report of 18 January 2019 they stated that “Based on the evidence outlined in this report, the Scottish Health Council’s view is that NHS Highland has met the national guidance outlined by the Scottish Government.”
A draft report on the consultation was taken to Highland Health & Social Care Committee on 15 January 2019 and the full report was taken to the Board of NHS Highland on 29 January 2019. Both fully endorsed the consultation process and recommendations. The Cabinet Secretary for Health who has the final decision has been formally written to.
In expectation of approval to move to the next stage (Initial Agreement) by the Cabinet Secretary the project team is working with services and staff to develop the proposed model.
The Caithness redesign has also been selected to participate in a pathfinder programme on shifting the balance of care to community care, sponsored by the Scottish Futures Trust on behalf of the Scottish Government. There are three projects covering Scotland. Caithness, one in Fife and one in North Ayrshire. The intention is to produce three projects that deliver a paradigm shift in the provision care from hospital based care to community based care so that patients are treated as close to home as possible. NHS Highland will be supported by the Scottish Futures Trust and Carnall Farrar (specialist health care planners) to achieve this.
Lochaber
The final internal governance stage for the Strategic Assessment was not discussed at the November Board meeting; and postponed until the January 2019 meeting. This has now been approved and the next stage, formally notifying the Scottish Government, is now progressing.
The majority of services have fed into the draft Clinical Model. Work to-date on the Clinical model was the main discussion at the February 2019 Steering Group.
The next stage of the Capital process for a new facility began early February. This is the Initial Agreement (IA). With this stage being reached there will need to be discussion as to the commencement of the formal Programme Board and the future role and responsibilities of the Steering Group.
Skye
Design work is being concluded for the hospital Hub in Broadford and work packages are currently out to the market to inform the costs for hub North Scotland’s stage 2 submission in March. Collaborative work is ongoing with consultants within the project to review the technical aspects of the design and ensure all compliance regulations are adhered to. In January the design team, including the architect, principal contractor and M&E specialist met with the community to assess the quality of the design as part of the NHS Scotland Design Assessment Process. The local community and Skye Lochalsh and South West Ross Steering Group continue to be engaged in the process, inputting into the internal and external design.
In February 2019, there were a Public Information Events held in the Lighthouse Centre, Kyle (6 February) and in Portree Chambers (7 February). These events will give the community of Skye, Lochalsh and South West Ross an opportunity to meet the design team and discuss any queries they
17 may have. There will also be visual displays to view elevations of Broadford Hub and the internal layout. NHSH Communications team have worked with NHSH Estates team to ensure this has been publicised broadly to ensure maximum attendance on the day.
After a series of meetings with lead stakeholders for Portree Spoke, a design concept has been agreed and is currently being costed to include in the Full Business Case. This work was progressed as per information submitted in the Outline Business Case with the knowledge that it may be subject to change dependent on the outcome of the Sir Lewis Ritchie recommendations work.
An early draft of the Full Business Case (FBC), joint with the Badenoch & Strathspey redesign, is on schedule to be shared with Capital Investment Group in February for initial comments in an attempt to mitigate delay further down the line. The FBC will be formally submitted to the NHSH Board and Scottish Government in April 2019. Financial close of the hub contract will follow in May once the FBC is approved, allowing construction work on the new hospitals to start.
Sir Lewis Ritchie recommendations
Work continues in all workstreams of the Sir Lewis Ritchie report recommendations and whilst challenges remain it is acknowledged that progress being seen in all areas. A Project Manager for the community and an NHS Project Manager both commenced in post in early February and attended the February Steering Group meeting.
South & Mid Division:
Modernising Community and Hospital Services in Badenoch and Strathspey:
The major service change in the area continues with the Full Business Case for the redesign of community services and closure of two community hospitals in Grantown on Spey and Kingussie with re-provision in Aviemore due for submission to the Scottish Government Capital Investment Group in May 2019. The site purchase has now concluded and our planning application was considered and agreed at the end of February 2019.
18 Raigmore & Rural General Hospitals
2. PEOPLE
2.1 Staff Experience 2.1.1 Learning and Development
Statutory and mandatory training compliance is now being overseen through the Raigmore Strategy Deployment approach. With an A3 in development to help identify the root causes for non-compliance with standards within Raigmore and with specific associated actions to address the non-compliance. iMatter Raigmore
Response Rate 2018 51%
Team Reports 49% Achieved 2018
Action Plans Created 59%
Turas Appraisal
Posts 2891
Signed in 46%
Complete Appraisals 12%
2.2 Sickness Absence
Sickness absence in Raigmore remains below the NHS Highland average overall at 3.99% compared to 4.74% NHS Highland average.
By month November December Cumulative Total at 2018% 2018% 31 December 2018% Raigmore 4.15% 3.99% 4.64%
3. QUALITY & SAFETY 3.1 Improvement Activity
Raigmore: Value Management (VM) • 19 teams undertaking VM. HQA Report outs on Friday’s now include VM teams and their work. Intensive coaching on Post Acute Ward (PAW) in the last few weeks to establish baseline metrics to improve on. List of all teams report out times are in the management corridor meeting room under the Quality Improvement section.
HLVS – Hospital, Ambulatory, Post Acute, Home • (Post Acute & Home) Hospital to Care Home Workstream – A workshop took place 22 February in the CfHS around the decision making process. Looking at the decision to discharge someone to long term care. Audit of individual cases to understand the patient journey better is being done currently with help from the Discharge Support Team.
19 Training • Intermediate training available, next Raigmore cohort began training 6 & 27 February. • All staff are to complete. 196 staff in Raigmore have completed so far. Advanced HQA training available every month during 2019. • No active Kaizen events or RPIWs planned in Raigmore at present.
Daily Management • The Director of Transformation & Quality Improvement met with QI leads on 20 February.
Professional Development Course • Presented to the Endowments Committee in Jan and highlighted the need for the rest of the team to have time away from their substantive roles in order to progress the work. Readmissions being looked at and surgical flow as part of the Raigmore strategy deployment and the Boston learning.
Other Work • Ortho rehab pathway • Digital ward project • Wardview consolidation sub group • A3 training with various teams • Post Acute tracking • Support for all programmes on the strategy deployment and support for wall reporting
3.2 Waiting Times 3.2.1 Key Diagnostic Tests
Raigmore:
As at month ending 31 December 2018, there are currently 419 Scope patients and 600 Radiology patients waiting over six weeks in NHS Highland.
Endoscopy funding was agreed on 17 September therefore plans are later in being initiated. Additional clinics have now been set up with support from in-house team. Cystoscopy patients are being seen by external provider, via National Contract. There has been a considerable increase in referrals from Bowel Screening Programme which has impacted on the unit’s capacity. Fit testing for symptomatic patients will be in place from 1 November and it is expected there will be data available around this in February 2019. There has also been funding to appoint nursing staff to undertake clinical validation of waiting lists for surveillance patients in line with the Scottish Access Collaborative and discussions are underway to introduce this.
In Radiology the second MRI scanner is now operational which completes the upgrade work. A mobile MRI van has been booked to provide additional capacity and this will continue intermittently up to end of financial year. Plans are underway to convert the CT cannulation room and this will ensure demand and capacity is in balance. Ultrasound team lead has appointed a trainee sonographer which will provide sustainability for the team in the future.
North & West Division:
North (Caithness General Hospital)
• Endoscopy Caithness General Hospital currently have 2 patients unbooked for USC. Waiting time is 2-3 weeks
20 • Urgent - 8 patient un-booked with a 3-4 week wait time • Routine endoscopy - 7 patients currently unbooked with a 4-6 week waiting time • Return Endoscopy patients - 10 patients on return waiting list.
• Radiology – CT Some delays in contacting duty Radiologist at Raigmore for urgent/same day/Accident & Emergency referrals as there are an increasing number of sessions not covered. Short term options being considered however this continues to be high risk for patients due to delay in investigations. • Radiology reporting – ongoing delays across NHS Highland in line with shortage of Radiologists – some imaging is out sourced at financial cost.
• Non Obstetric Ultrasound - There are 169 routine Out Patient referrals with a 15 week wait • 15 patients are protocol led as soon and will be seen within 6 weeks • 79 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 although some have breached to 3 weeks due to lack of ultrasound capacity
Action plans in place to address the above include:
• Endoscopy – Colorectal surgeons have increased their Tuesday and Thursday morning sessions from 10 to 12 points. • Ongoing screening of referrals/return patients undertaken. • Endoscopy equipment has been reviewed and a bid has been submitted for funding for a 7 day drying cabinet which will create an additional 34 sessions. The purchase of a 4th endoscope will increase the number of sessions available and provide increased flexibility to accommodate the visiting consultants • Day case capacity is limited, funding identified to progress to the next stage of the day case redesign project to increase capacity.
Radiology
• Waiting time initiative funding has been secured to provide additional sessions, 127 appointments have been booked before 31 March 2019. • Bid has been submitted for a second ultrasound scanner and room to create an additional 75 Ultra Sound Scan sessions, which will significantly improve the waiting times and efficiency of the department • Staff development in Ultra Sound Scanning is currently being progressed. • Two Abdominal Aortic Aneurysm screening training posts have been approved and training has commenced
• The X-ray unit at the Lawson Memorial Hospital Golspie is no longer fit for general x-rays due to poor image quality, therefore radiography duties have been deployed to the County Community Hospital in Invergordon. • 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.
West (Belford Hospital): Endoscopy
• There are currently no patients waiting beyond breach date for a new endoscopy appointment.
21 • Problems with capacity for all BOSS colonoscopies. Since October 2018 Belford has received 58 referrals. • Limited number of consultants available to undertake endoscopies within Belford has an impact on number of sessions available. • Return endoscopy patients waiting: 1 patient from June, 3 patients from July, 3 patients from August, 7 from September, 7 from October, 7 from November, 6 from December and 10 from January 2019 not yet booked.
Action plans in place to address the above include:
• Continued assessment and review of waiting list for return patients. Plans to have return patients seen as soon as possible, but this is impacted by number of new referrals. • 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. • Discussion at weekly Theatre and Waiting List meeting.
3.2.2 ED 4hr Compliance
Raigmore:
North & West Division:
Both Caithness General Hospital and Belford Hospital continue to maintain or exceed the target
Belford Hospital is currently achieving 95.3%, compliance as at 10 February 2019.
22 Challenges with junior doctor cover during the last week of January, along with waits to transfer patient to a major centre, has had an impact on the ED performance in Belford Hospital.
Caithness General Hospital is currently achieving 96.2% compliance as at 10 February 2019.
In Caithness General Hospital staff continue to maintain an increased focus on patient flow throughout the hospital, using the breach alert system, medical handovers and board rounds. Weekend receptionist cover for the Emergency Department has been introduced due to the increase in ED attendances. There is ongoing liaison with Scottish Ambulance Service to review any transfer related delays. A visual board has been introduced to the laboratory department to monitor Emergency Department samples and improve results reporting.
23 3.3 Infection Prevention & Control
Raigmore: Tissue viability:
Hospital acquired pressure ulcers
4. CARE 4.1 Older People in Acute Hospitals (OPAH)
North & West Division
There have been no recent OPAH inspections within North and West Division. Inspections and learning from other areas is being shared. Work is in progress in reviewing OPAH walk round audits to align with the national improved change in inspections. Work is being undertaken to introduce open visiting across all Highland hospitals and the current plan is to launch this in April, some hospital areas in north and west have already introduced this. This is being lead by the Lead Nurses.
4.2 Technology Enabled Care
NHS Near Me update
The clinic infrastructure continues to be developed. Staffed Near Me clinics are now open in Wick, Golspie, Portree and Fort William.
Near Me at home (video consultations with patient in their own home) is now being provided by a small number of clinical services. Unstaffed clinic rooms with Near Me equipment as an alternative if patients cannot connect from home are now open in 8 locations, with a further 7 locations to go.
18 clinical services are now providing NHS Near Me consultations. These are mainly to patients in Caithness (starting location for Near Me) so now needs to be spread across Highland. In Caithness in January, 9% of outpatient appointments were provided by Near Me. This shows the potential for Near Me but wider service engagement is still needed. An all staff email was sent in January, and a public awareness campaign began in February.
24 Highland Health and Social Care Committee 8 March 2019 Item ?
Monitoring the Delivery of Adult Social Care Contracted Services
Report by Gillian Grant, Commissioning, Contracts and Compliance Manager, on behalf of Deborah Jones, Director of Strategic Commissioning, Planning and Performance.
The Committee is asked to:
Note the outcomes of the 2018-2019 third quarter reviews and progress made in resolving issues highlighted in previous reviews.
1. Background
1.1. On 10 January 2013, the Health and Social Care Committee agreed a contract monitoring framework to provide information on adult social care contracts.
1.2. This report details the outcomes of the monitoring process for Quarter 3 (October to December 2018).
2. Reviews Undertaken
2.1. Financial Year 2018-19 (1 April 2018 to 31 March 2019) Plans are in place to monitor over 135 contracts for NHS Highland during the period 1 April 2018 to 31 March 2019, through a contract monitoring visit or a desk-top exercise, depending on the level of agreed risk. A total of 70 dedicated contract monitoring visits have been undertaken in this financial year so far, between 1 April 2018 and 31 December 2018. Please note that the number of contracts planned for monitoring in this financial year has decreased slightly due to a reduction in staffing resources. Outstanding contracts were re-prioritised in December 2018 to focus on priority areas for monitoring for the remainder of 2018-19.
2.2. Quarter 3 (October to December 2018) A total of 17 dedicated contract monitoring visits were undertaken in Quarter 3, monitoring a total of 24 contracts for NHS Highland during this period. For information, a further 6 monitoring visits were undertaken for The Highland Council, under agreed shared service arrangements.
2.3. A summary of those monitored in Quarter 3 for NHS Highland is provided at Annex 1. It should be noted that some providers have multiple contracts and it is normal to monitor these in one visit and produce one report.
2.4. In addition to the dedicated contract monitoring visits, monitoring is also undertaken through operational meetings with providers, as well desk-top monitoring (primarily for low value and/or low risk contracts).
2.5. Following the Scottish Government’s new Living Wage requirements from 1 May 2018, monitoring of the payment of the Living Wage (£8.75 per hour) for care staff remains a priority.
2.6. For 2018-19, priority monitoring themes have focused on new legislative requirements, in particular the General Data Protection Regulation (GDPR) and Duty of Candour. 3. Progress in Resolving Issues
3.1. Contract monitoring regularly highlights issues and concerns, which involve further follow up action and review. In Quarter 3 (October to December 2018), 10 main issues/concerns were identified, which are currently being acted upon. These include service delivery and quality concerns; management/staffing issues; a number of potential or actual ASPs/LSIs; breach of contract; and non-payment of living wage.
3.2. There has also been progress and ongoing follow-up with a number of providers regarding service delivery concerns, as identified in previous quarters. This has led to, for instance, the standing down of LSIs, the backdating of Living Wage payments to care staff, and the on-going review of provider Service Improvement Plans. The Contracts Team is implementing a new system for escalating and de-escalating risks to service delivery.
4. Conclusion
4.1. Routine contract monitoring continues to identify and resolve issues in relation to adult social care contracted services and the intention remains to focus effort on priority areas.
Gillian Grant Commissioning, Contracts and Compliance Manager 25 February 2019
2 Annex 1
Contract Monitoring Visits Undertaken in Quarter 3 (October to December 2018)
Area Service Type Issues Identified / Concerns / Comments
Housing Support Service / Support No issues highlighted. Services (3 contracts, 1 provider) Pan Highland Support Services (2 contracts, 1 No issues highlighted. provider)
Care Home Service x 2 No issues highlighted. North and Day Care Service No issues highlighted. West Division Third Sector Service No issues highlighted.
Care Home Service x 6 No issues highlighted in 4 of the services.
No Duty of Candour policy in place in one of the services; provider currently addressing this matter.
In one of the services, staff had not yet had training on new GDPR and Duty of Candour policies, although provider is aware and was rolling out training; no information asset register or Data Protection Officer – provider made aware of legislative requirements. New brochure and introductory pack being developed.
Care Home Service / Day Care Staff had not yet had training on new GDPR and Duty of Service / Care at Home Service (3 Candour policies, although provider is aware and was contracts, 1 provider) rolling out training; no information asset register or Data Protection Officer – provider made aware of legislative requirements. New brochure and introductory pack being developed.
Care Home Service / Day Care No issues highlighted. South and Service (2 contracts, 1 provider) Mid Division Day Care Service All care staff not receiving Living Wage; provider aware and had engaged an HR firm for assistance (this issue was subsequently resolved outwith the reporting period). No Duty of Candour policy and associated requirements in place, and no Information Asset Register, privacy notice and associated GDPR requirements in place; provider made aware and looking to address, and this will be reviewed in next contract monitoring visit.
Housing Support Service / Third No issues highlighted. Sector Service (2 contracts, 1 provider)
Support Service (non-registered) No quality assurance system in place; policies in place, however, they are outdated and need to be reviewed and updated, if required; no information asset register in place; and no Duty of Candour policy or associated requirements. These elements are to be reviewed at the next contract monitoring visit. Provider noted sustainability issues with current service levels (minimal).
3
Care Inspectorate Summary: 1 April 2018 - 31 December 2018
Care Homes in Highland Care Inspectorate NHS Highland
NHS Service Name Service Town SubtypeIn-House or Number of Last Inspection Grades Quality Inspection Framework Evaluations (used as of July Complaints Enforcements Requirements Action Plan Action Plan Received Highland Independent Registered Date 2018 for care homes for older people only) 2018/19 2018/19 2018/19* Requested by NHSH by NHSH (as of 31 Dec Operational Sector Places (Upheld or (as of 31 Dec 2018) 2018) Quality of Quality of Quality of Quality of How well How good How good How good How wel is Unit Partial) Care and Environment Staffing Mgmt & do we is our is our staff? is our care and Support Leadership support Leadership setting? supoprt people's ? planned? wellbeing?
West Abbeyfield Ballachulish (Care Home) Ballachulish Older People Independent 30 28/08/2018 6 6 6 6 6 6 No South Ach-an-Eas (Care Home) Inverness Older People NHS Highland 24 05/11/2018 * 5 5 4 4 5 5 5 No North Achvarasdal (Care Home) Thurso Older People Independent 28 01/02/2018 3 3 4 4 N/A Ceased operation in June 2018 South Aden House (Care Home) Inverness Older People Independent 24 10/10/2018 4 2 3 2 4 3 3 3 4 No West An Acarsaid (Care Home) Isle of Skye Older People NHS Highland 10 13/11/2018 5 4 5 5 5 4 No South Ballifeary House Inverness Older People Independent 24 13/04/2018 6 6 6 6 1 No North Bayview House (Care Home) Thurso Older People NHS Highland 23 22/08/2018 4 4 4 4 No South Beechwood House Inverness Alcohol & Drug Misuse Independent 15 14/12/2018 * 5 5 4 5 No South Birchwood Highland Recovery Centre Inverness Mental Health Independent 23 13/11/2017 6 6 6 6 N/A South Bruach House Nairn Older People Independent 22 27/11/2018 * 4 3 5 3 4 4 4 4 4 No West Budhmor House (Care Home) Portree Older People Independent 29 03/05/2018 5 5 5 5 No North Caladh Sona Lairg Older People NHS Highland 6 31/10/2018 * 4 3 4 3 3 3 3 No South Cameron House (Care Home) Inverness Older People Independent 30 18/10/2018 4 4 4 4 2 3 3 3 Yes Ongoing dialogue with provider South Carolton Care Nairn Older People Independent 20 12/12/2018 * 4 4 5 4 3 3 4 N/A Mid Castle Gardens Care Home Invergordon Older People Independent 40 06/11/2017 5 4 5 5 N/A Mid Catalina Care Home Alness Mental Health Independent 28 14/09/2018 5 3 4 5 1 No South Cheshire House (Care Home) Inverness Physical and Sensory Impairment Independent 16 12/10/2018 6 6 6 5 No South Cradlehall Care Home Inverness Older People Independent 50 23/11/2017 5 5 6 6 N/A South Culduthel Care Home Inverness Older People Independent 62 04/07/2018 3 4 3 3 Yes West Dail Mhor (Care Home) Acharacle Older People NHS Highland 6 28/02/2017 4 4 4 4 N/A South Elmgrove Care Home Inverness Older People Independent 27 11/09/2018 3 2 3 3 1 1 2 2 1 1 Yes Ongoing dialogue with provider Mid Fairburn House Muir of Ord Learning Disabilities Independent 40 30/11/2018 * 5 5 5 4 5 4 No South Fairfield Care Home (Inverness) Limited Inverness Older People Independent 35 12/04/2018 2 3 2 2 1 Yes Ceased operation in September 2018 Mid Fodderty House Dingwall Older People Independent 16 17/12/2018 5 5 6 4 N/A South Fram House Beauly Learning Disabilities Independent 5 21/03/2018 5 5 5 5 N/A South Grandview Nursing Home Grantown-on-Spey Older People Independent 45 01/10/2018 5 5 4 5 5 5 No South Grant House (Care Home) Grantown-on-Spey Older People NHS Highland 20 29/08/2018 3 4 4 4 4 4 4 4 5 No South Hebron House Nursing Home Ltd Nairn Older People Independent 22 16/03/2018 4 4 4 4 N/A South Highview Care Home Inverness Older People Independent 83 27/07/2018 3 4 4 4 2 No South Hillcrest House Nairn Mental Health Independent 23 31/08/2017 5 5 5 5 N/A West Home Farm Care Home Portree Older People Independent 40 06/12/2018 * 4 5 4 4 3 3 3 Yes Mid Innis Mhor Care Home Tain Older People Independent 40 23/08/2018 3 5 4 3 3 3 2 4 2 1 Yes Ongoing dialogue with provider West InvernevisHouse(CareHome) FortWilliam OlderPeople NHSHighland 32 11/06/2018 3 4 3 3 No West Isle View Care Home Achnasheen Older People Independent 25 07/06/2018 5 4 4 4 No South Isobel Fraser Home** Inverness Older People Independent 28 24/07/2018 4 4 4 4 No South Kingsmills Care Home Inverness Older People Independent 60 15/06/2018 * 5 4 5 5 No South Kinmylies Lodge Inverness Mental Health Independent 18 24/04/2018 5 5 4 5 No Mid Kintyre House (Care Home) Invergordon Older People Independent 41 20/03/2018 4 5 5 4 N/A West Lochbroom House (Care Home) Ullapool Older People NHS Highland 11 16/11/2018 * 5 5 5 5 5 5 No South Lynemore*** Grantown-on-Spey Older People Independent 40 New care home opened in Sept 2018, contracted with NHSH as of Sept 2018 West Mackintosh Centre (Care Home) Mallaig Older People NHS Highland 8 28/05/2018 4 4 4 4 No South Main's House Newtonmore Older People Independent 31 20/07/2017 4 4 4 4 N/A South Maple Ridge (Care Home) Inverness Learning Disabilities Independent 18 04/12/2017 5 5 6 6 N/A South Mayfield Lodge Inverness Learning Disabilities Independent 12 07/02/2018 5 5 5 5 N/A South Meallmore Lodge Inverness Older People Independent 94 04/06/2018 3 4 3 4 No North Melvich Community Care Unit (Care Home) Thurso Older People NHS Highland 6 21/12/2018 5 4 5 4 N/A West Mo Dhachaidh Care Home Ullapool Older People Independent 21 26/03/2018 5 4 5 5 N/A West Moss Park Nursing Home Fort William Older People Independent 40 26/07/2018 3 3 3 3 No Mid Mull Hall (Care Home) Invergordon Older People Independent 42 20/10/2017 5 5 4 5 N/A North Oversteps (Care Home) Dornoch Older People Independent 24 04/06/2018 3 4 3 3 Yes North Pentland View - Highland Thurso Older People Independent 50 30/03/2018 5 4 5 5 N/A North Pulteney House (Care Home) Wick Older People NHS Highland 18 29/03/2018 5 5 5 5 N/A Mid Redwoods (Care Home) Alness Older People Independent 42 29/03/2018 5 5 5 5 N/A North Riverside House Care Home Wick Older People Independent 44 30/11/2018 * 5 4 4 5 4 4 No North Seaforth House (Care Home) Golspie Older People NHS Highland 15 27/03/2018 5 5 5 5 N/A Mid Seaforth House Ltd (Care Home) Dingwall Learning Disabilities Independent 22 22/08/2018 3 3 3 2 Yes Ongoing dialogue with provider North Seaview House Nursing Home Wick Older People Independent 42 05/09/2018 5 4 5 4 5 5 No Mid Shoremill (Care Home) Cromarty Older People Independent 13 13/04/2018 3 4 4 3 1 No South Southside Care Home Inverness Older People Independent 33 28/08/2018 2 3 3 2 3 3 3 3 2 1 No Ongoing dialogue with provider South St. Olaf - Cawdor Road Nairn Older People Independent 44 13/02/2018 4 5 5 5 N/A Mid Strathallan House (Care Home) Strathpeffer Older People Independent 32 26/10/2018 4 3 3 3 4 3 4 4 3 No West Strathburn (Care Home) Gairloch Older People NHS Highland 14 28/03/2018 5 4 5 5 N/A West Telford Centre (Care Home) Fort Augustus Older People NHS Highland 10 30/07/2018 4 4 3 5 No South The Manor Care Centre Nairn Physical and Sensory Impairment Independent 43 16/03/2018 4 5 5 5 N/A North The Meadows (Care Home) Dornoch Older People Independent 40 13/12/2018 * 5 4 4 5 5 5 No Mid Tigh-na-Cloich Muir of Ord Learning Disabilities Independent 4 21/03/2018 5 5 5 5 N/A Mid Urray House Muir of Ord Older People Independent 40 15/09/2017 4 5 4 4 2 N/A Ongoing dialogue with provider South Wade Centre (Care Home) Kingussie Older People NHS Highland 11 17/10/2018 5 5 4 4 5 5 No South Whinnieknowe (Care Home) Nairn Older People Independent 24 04/05/2018 5 4 5 4 No Mid Wyvis House Care Home Dingwall Older People Independent 50 22/03/2018 4 5 5 5 N/A
Grading Details Service Details
Quality Inspection Framework Evaluations is the new grading system based on the 2017 Health and Social Care Standards ,which currently only applies to Care Homes for Older People. The Care * For services with N/A, please note that there was no inspection (to date) in 2018-19. Inspectorate began rolling out the new framework as of July 2018 and as such not all Care Homes for Older People have been inspected and graded using the new framework. For accuracy gradings from **Isobel Fraser has re-registered as a SCIO (26/03/2018) and all grade history has been erased - grades for last inspection the previous inspection methodology and new inspection methdoloy have been included within the report. included Source of data: 31 Dec 2018 Data taken from the Care Inspectorate Datastore, publicly available here: http://www.careinspectorate.com/index.php/statistics-and-analysis/data-and-analysis ***Lynemore - new care home which opened in September 2018; to date, this care home has not been inspected.
Quality Inspection Framework Evaluation: http://www.careinspectorate.com/index.php/inspections/new-inspections For all services with a "*" after the inspection date, grades for these services were taken from the Care Inspectorate website as at 20 February 2019. 2017 Health and Social Care Standards: http://www.newcarestandards.scot/ Care Inspectorate Summary: 1 April 2018 - 31 December 2018
Care at Home in Highland Care Inspectorate NHS Highland NHS Highland Grades Complaints Enforcements Requirements Action Plan Action Plan Received Operational Quality of Quality of Quality of Quality of 2018/19 2018/19 2018/19* Requested by NHSH by NHSH (as of 31 Dec Unit (Upheld or (as of 31 Dec 2018) 2018) In-House or Last Inspection Care and Environment Staffing Mgmt & Service Name Partial) Independent Sector Date Support Leadership
West Buddies Care Service Independent 25/07/2018 5 5 5 0 0 No North Carr Gomm North Independent 24/05/2018 3 5 3 0 0 No Pan-Highland Castle Care (Scotland) Ltd Independent 18/06/2018 5 4 4 1 0 No South/Mid Contrast Care Limited Independent 16/04/2018 5 4 4 0 0 No West Crossroads Care - Skye & Lochalsh Independent 16/10/2018 4 4 5 0 0 No West Crossroads Caring Scotland - Lochaber Independent 15/11/2018* 4 4 4 0 0 No Pan-Highland Crossroads Caring Scotland - NWS/ES/Caithness Independent 29/03/2018 4 4 3 0 0 N/A Ongoing dialogue with provider Pan-Highland Eildon Limited Support Service - Care at Home Independent 10/08/2018 5 4 4 0 0 No South/Mid Fraser Home Care Independent 09/03/2018 5 4 4 0 0 N/A Pan-Highland Highland Home Carers Ltd Support Service - Care at Home Independent 19/09/2018 4 4 4 0 0 No Pan-Highland Gateway (Highland Homeless Trust) Independent 19/03/2018 5 4 5 0 0 N/A West Home Farm Support Service Independent 06/12/2018* 4 4 4 0 0 No North Homelink Caithness / Pulteneytown Peoples Project Independent 13/02/2018 4 5 5 0 0 N/A West Lochaber Day and Night Owl Service Ltd Independent 29/11/2018* 4 4 4 0 0 No West Lucerne (Scotland) Limited Independent 06/07/2018 5 3 4 0 0 Yes Contract with NHSH ceased July 2018 Mid Mears Nurseplus North Independent 20/11/2017 4 4 3 0 0 N/A NHS Scotland contract in place South/Mid Strathallan House (Support Service) Independent 03/11/2017 4 4 4 0 0 N/A North North Highland Care @ Home Service NHS Highland 21/12/2018* 5 4 5 0 0 No South/Mid British Red Cross- Support at Home Independent 09/11/2018 4 6 4 0 0 No South/Mid South and Mid Highland Care at Home Service NHS Highland 29/03/2018 4 4 4 0 0 N/A West Strathcarron Project Support Services Independent 13/12/2018* 6 6 6 0 0 No South Glenurquhart Centre (Support Service) Independent 15/01/2016 5 4 4 0 0 N/A Contract with NHSH ceased Spring 2018 South The Richmond Fellowship Scotland - Highland - Care at Home Independent 17/08/2017 4 4 5 0 0 N/A West West Highland Care at Home Service NHS Highland 08/11/2017 4 4 4 0 0 N/A
Grading Details
Source of data: 31 December 2018 Data taken from the Care Inspectorate Datastore, publicly available here;: http://www.careinspectorate.com/index.php/statistics-and-analysis/data-and-analysis
For all services with a "*" after the inspection date, grades for these services were taken from the Care Inspectorate website as at 20 February 2019.
For services with N/A, please note that there was no inspection (to date) in 2018-19. Highland Health and Social Care Committee 8 March 2019 Item 2.7
NHS Highland Highland Health and Social Care Committee Annual Report
To: NHS Highland Audit Committee
From: Ann Clark Chair, Highland Health and Social Care Committee
Subject: Highland Health and Social Care Committee Report 2018/19
1 Background
In line with sound governance principles, an Annual Report is submitted from the Highland 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 April 2018 to March 2019
The Highland Health and Social Care Committee meet 6 times per year. In the reporting period the Committee met on 3rd of May 2018, 5th of July 2018, 6th of September, 8th of November 2018 and 15th of January 2019 and the 8th of March 2019. The minutes from each meeting have been submitted to the appropriate Board meeting. Membership and attendance are set out in the table below.
Membership from 1 April 2018 – 31 March 2019:
Mrs Melanie Newdick, Chair (to end November 2019) Mrs Ann Pascoe, Non-Exec (Chair, January 2019 Meeting) Mrs Deirdre MacKay, Non-Exec Mr James Brander, Non-Exec Mr Adam Palmer, Employee Director and Non-Exec Ms Ann Clark, Non-Exec Mr David Park, Chief Officer (Highland Partnership) Director of Adult Social Care (previously J Macdonald) Mr David Garden, Interim Director Finance and Finance Lead Dr Boyd Peters, Medical Lead Nurse Lead (to be confirmed) Cllr Kate Stephen, Elected Member (to end October 2018) Cllr Nicola Sinclair, Elected Member Cllr Ronald MacDonald, Elected Member Ms Shirley Christie, Staffside Representative Mrs Margaret MacRae, Staffside Representative Donna Mitchell, Patient Representative (to end October 2018) Mr Michael Simpson, Patient Representative Norman Houston, Carer Representative Ms Mhairi Wylie, Third Sector Representative Dr Iain Kennedy, Lead Doctor (GP) Mr Quentin Cox, Area Clinical Forum Representative Mrs Alison Hudson, Area Clinical Forum Representative (to end October 2018) Dr Ann Galloway, Area Clinical Forum Representative (from January 2019) Area Clinical Forum Representative (Vacant) K Rodgers, Interim Head of Financial Planning
Attendance from 1 April 2018 – 31 March 2019 (From Terms of Reference): Member 3/5/2018 5/7/2018 6/9/2018 8/11/2018 15/1/2019 8/3/2019 Melanie Newdick, A n/a Chair Ann Pascoe A (Chair) Deidre Mackay AA (LA Rep) James Brander Adam Palmer A A Ann Clark Sub David Park, Chief Officer, Highland P’ship Director of Adult Social Care (JMacd) (SSteer) (JMacd) (SSteer) (Sub) David Garden, Interim AAAA Director of Finance Dr Boyd Peters, AA A Medical Lead Nurse Lead A A A (KP-Q) (KPQ) Cllr N Sinclair AA Cllr R MacDonald A A A A A Cllr Kate Stephen A A n/a n/a n/a
In Attendance Ms S Christie (S’side) A A A A A Mrs M MacRae (S’side) A A Donna Mitchell A A n/a n/a n/a (Public/Patient) Michael Simpson A (Public/Patient) Norman Houston AAAAA (Carer) Ms M Wylie (3rd Sector) Sub Sub A A Sub Dr I Kennedy n/a n/a n/a n/a Lead Doctor (GP) (N Wright) (Medical Practitioner) A A A A A A Hudson (ACF) A A n/a n/a n/a D A Galloway AAAA Area Clinical Forum K Rodgers, Head of AA Financial Planning Head of Personnel A A A A G Boyd Bob Summers, Head of AAAAA Occupational Health and Safety
During the period covered by this report the Committee Chair was, for four meetings, Melanie Newdick, who resigned from the Committee towards the end of 2018 as a result of advice received from NHS Highland regarding a conflict of interest. The Committee would like to record its thanks to Melanie and to note that most of its achievements during this period owe a great deal to her commitment and leadership of the Committee. Ann Pascoe, Vice-Chair of the Committee took over for the January meeting and the Board recently appointed Ann Clark as Interim Chair. This Interim appointment is to allow the Board to take into account appointments to two Non-Executive Director vacancies on the Board and any changes to our organisational structure which might be proposed by our new Chief Executive Officer.
2.1 Service Redesign The Committee considered and progressed during the year a number of significant matters related to the modernisation and redesign of services including: A comprehensive consultation process leading to proposals for redesign of health and care services in Caithness Redesign of day services for people with a learning disability Development and approval of the Primary Care Improvement Plan
2.2 Service Planning and Commissioning The Committee scrutinised and received assurance on various aspects of the planning, commissioning and co-ordination of services across North Highland including: planning for winter pressures within the system, implementation of revised standards for forensic medical services, dental services and the Investment Plan of the Highland Alcohol and Drugs Partnership. A key role of the Committee is to provide to the Board assurance of compliance with the Public Bodies (Joint Working) (Scotland) Act 2014. In this regard the Committee approved a revised role and remit for a Strategic Planning group for adult primary and community health and social care services. A new approach to the commissioning of services from the Third Sector was developed and approved during the year. Following identification of a significant failure in timely implementation of the Carers (Scotland) Act 2016, revised plans and assurance reports were requested and regular updates are being provided on progress.
2.3 Scrutiny of Performance 2.3.1 Service Delivery At each meeting the Committee receives a comprehensive assurance and exception report from the Chief Officer which allows the Committee to scrutinise performance under the Highland Quality Approach objectives of people, quality and care. Issues scrutinised and addressed at the Committee arising from these reports included recruitment to vacancies, progress with redesign initiatives in Out of Hours and on Skye, implementation of the Carers Act, Caithness maternity services as well as progress with new technology initiatives such as Florence and Near Me. Contract monitoring reports on the quality of care homes and care at home services, including information on external inspections were received and assurance given on improvement actions required. The Committee noted that overall, external grading of care home services was improving. See also below under Finance and Performance Sub Committee 2.3.2 Finance See below
3 Sub Groups
3.1 Finance and Performance Sub Committee The sub-committee receives detailed reports at each meeting on the financial position of the operating unit and its three divisions. Separate reports are also received on progress against savings and cost containment in the areas where the unit experiences the greatest cost pressures: locums/supplementary staffing, adult social care and prescribing. Cross cutting issues of concern are escalated to the main Committee and/or Board level. Examples this year included cost containment in prescribing and variance levels in pay budgets. Matters progressed at the Sub Committee also include the setting of fees and charges and changes to charges for day care were a significant piece of work this year.
Each meeting also receives reports on different aspects of performance against targets agreed with Scottish Government in the Local Delivery Plan or set nationally such as the 6 Essential Actions and the Health and Wellbeing Outcome Indicators. Consideration at the sub-committee allows for in-depth discussion of trends and mitigating action proposed where performance is below target. Overview reports are also considered at either the main Committee or the Board. The sub-committee also receives assurance reports from the Highland Council on commissioned children’s services.
3.2 North Highland Partnership Forum The purpose of this forum is for Staff side/Trade Unions/ professional bodies, HR and management to work together to ensure that staff and their representatives are consulted as early as possible and involved throughout the process of any changes/service developments that may impact on staff. Following a review of the Staff Governance framework a revised Local Partnership Forum for the Highland Health and Social Care Committee was established and this year has met 5 times. Reports from the forum are submitted to Highland Partnership Forum as well as this Committee. Standing agenda items at each meeting were as follows: Terms of reference, local network meetings, finance, bullying allegations, statutory and mandatory training, iMatter and Health and Safety. Other matters/issues that were discussed included service redesign in all areas within the HHSCP, the transition of Adult Social Care Staff to Agenda for Change terms and conditions, Workforce planning, Radiology, paid as if at work, primary care modernisation and clinical waste.
3.3 Clinical Governance Sub Committee During the year discussions were held between the Chairs of Highland Health and Social Care Committee and Clinical Governance Committee with a view to establishing the Clinical Governance Sub-Committee approved in the review of the Committee’s Terms of Reference in May 2018. This matter is still under consideration, pending possible structural changes in 2019/20. In the meantime, a variety of clinical governance issues are reported to the Committee within the operational report from the Chief Officer and the two Committees have considerable cross attendance. In addition it has been agreed that the minutes of the Board Clinical Governance Committee will be submitted for information to the Highland Health and Social Care Committee.
3.4 Health and Safety The establishment of a Health and Safety Sub Group was approved at the Nov 18 Board. The group’s purpose is to oversee and monitor the Health and Safety performance of the operational unit of North Highland. This will include scrutiny over: operational health and safety plans, health and safety related adverse events, lessons to be learnt, projects with health and safety implications, review of audit reports, review of regulatory interventions etc. The working details of the group will be forthcoming in early Mar 19, and a fuller report will be made available by the Chairs of the new Group in 2020 once established and functioning.
4 External Reviews A number of Internal Audit reports of relevance to the work of the North Highland operational unit were carried out during the year including on delayed discharges; use of locums and supplementary staffing and our approach to engagement around major service redesign. Management actions are agreed in relation to these reports and progress is monitored by the Audit Committee. External reports on matters such as infection control, care of older people in our hospitals etc. are covered in the Chief Officers report by exception or where substantive reports are not being presented to other governance committees of the Board.
Two significant external reports on integration of health and social care services will be dealt with at the March meeting of the Committee and along with the need to renegotiate the Partnership Agreement with the Highland Council during 2019/20, will set the context for a programme of self-assessment and improvement actions in the year ahead.
5 Any relevant Key Performance Indicators In addition to the work carried out at the Finance and Performance Sub-Committee, performance is monitored through the provision of a Health & Wellbeing scorecard which has 9 outcomes, each evidenced by a number of performance indicators. The full year results are not yet available and will be reported in the Annual Performance Report later in 2019. The current position for each outcome is summarised in Appendix A.
6 Emerging issues for 2019/20 Renegotiation of the Partnership Agreement for integration of health and social care services between the Board and the Highland Council will have to proceed at pace during 2019/20. Ensuring alignment between the work of the Committee and that of the financial recovery Programme Management Office will be essential as the Board aims to move back into financial balance over the next three to five years. As the Board’s strategy for financial recovery develops over the course of 2019/20 the Committee will need to ensure its business enables necessary actions. Development of a Three Year Strategic Plan for Adult Social Care; progressing the Place of Care strategy; improving timely access to acute services through an improvement plan for waiting times and improving co-ordination and assurance of children’s services will be some of the matters to be dealt with in the year ahead.
7 Conclusion Ann Clark, as Chair of the Highland Health and Social Care Committee has concluded that the systems of control within the respective areas within the remit of the Committee are considered to be operating adequately and effectively.
Ann Clark, Chair Highland Health and Social Care Committee 28th February 2019 APPENDIX A HEALTH AND WELLBEING SCORECARD Outcome 1 – People are able to look after and improve their own health & wellbeing and live in good health for long. Performance in this area is generally stable with enablement interventions (the percentage of people receiving enablement interventions that do not require ongoing care after the initial 6 weeks) the only area showing a relative decline.
Outcome 2 - People, including those with disabilities or long term conditions or who are frail are able to live, as far as reasonably practicable, independently and at home or in a homely setting in their community. This outcome is supported by a large number of indicators most of which are showing improving or stable performance. Rates of readmission to hospital within 28 days have increased. However, clients/patients are reporting (via survey) that they are being supported to live independently and have a say in how their help, care or support was provided (an improving trend over 2 years).
Outcome 3 - People who use health and social care services have positive experiences of those services, and have their dignity respected. Most indicators are showing improving or stable performance. The percentage of adults supported at home who agree that their health and care serves seems to be well coordinated has grown from 73% to 76% (the national figure is 74%). Satisfaction with care provided by GP practices has dropped from 89% to 87%.
Outcome 4 - Health and social care services are centered on helping to maintain or improve the quality of life of people who use those services. All areas of performance are showing improvement.
Outcome 5 - Health and social care services contribute to reducing health inequalities. All areas of performance are showing improvement, though some targets (waiting time for psychological therapies and drug or alcohol treatment services) have not yet been met, but show year-on-year improvement.
Outcome 6 - People who provide unpaid care are supported to look after their own health and wellbeing, including to reduce any negative impact of their caring role on their own health and wellbeing. Performance information in this area is sparse. The percentage of carers who feel supported to continue in their caring role in Highland is 38%. The national figure is 37%.
Outcome 7 - People using health and social care services are safe from harm. This provides a mixed picture of performance with good survey results (percentage of adults who feel safe - Highland 84%, Scotland 83%), but poorer performance regarding Adult Support & Protection and review of Guardianships. Adult Support & Protection (ASP) processes were reviewed following a recent external inspection and an expanded range of performance indicators for operational and management purposes is now issued to the relevant Managers, Teams and members of the ASP Committee each month.
Outcome 8 - People who work in health and social care services feel engaged with the work they do and are supported to continuously improve the information, support, care and treatment they provide. Generally stable performance, though sickness absence is currently increasing.
Outcome 9 - Resources are used effectively and efficiently in the provision of health and social care services. Generally stable performance. These indicators (e.g. home care costs per hour) are influence by a range of local factors, making national comparisons of little value as it is not possible to compare like-with-like. Assynt House Beechwood Park Inverness Minute of Meeting IV2 3BW Finance & Performance Telephone: 01463 717123 Sub-Committee Fax: 01463 235189 www.nhshighland.scot.nhs.uk
Boardroom, 18th January 2019 Assynt House 9.30am – 11.00am
Present: David Park, Chief Officer (Chair) Ann Clark, Non-Executive Director Tracy Ligema, Head of Community Services, N&W Frances Gordon, Head of Finance Services, S&M Kim Corbett, Senior Project Manager Katherine Sutton, Head of Acute Services, Raigmore Ros Philip, Head of Finance, N&W Georgia Haire, Head of Community Services, S&M Simon Steer, Head of Strategic Commissioning David Garden, Head of Financial Planning Ros Philip, Head of Finance, N&W
In attendance: Susan Clifton, Accountant Kirsty Arnott, Committee Administrator
Apologies: Karen Underwood, Head of Finance Services, Raigmore Hospital George McCaig, Performance Manager Ann Pascoe, Non-Executive Director
1. Welcome, Declarations of Interest and Apologies David Park welcomed everyone to the meeting and noted apologies from Ann Pascoe, George McCaig and Karen Underwood.
2. Minutes of Meeting of 18th December 2018 The minute of meeting of the 18th December 2018 which was previously circulated to the Committee was approved as a true reflection.
The Committee agreed the previous minute.
3. Progress on Finance Plans David Garden spoke to the circulated Month 9 forecast report highlighting a projected year end overspend of £16.9M which was held from the month 8 projection of £19M unidentified savings from the start of the year. An adverse movement in tertiary was noted due to increased SLA costs. Savings targets were discussed which highlighted HHSCP total savings target for 2018/19 was £42.5M with £19M unidentified from the beginning of the year, however £23.5M identified savings would be challenging. Adult Social Care, Pharmacy and drug costs were £4.6M short of delivery, with containment offset. It was recognised that the YTD figures and the year end forecast held a £17M savings against a £19M proposed saving which was recognised. It was considered the financial plans were stable and achievable. Discussion took place around unplanned benefits. The Committee acknowledged fund setting for the future should be realistic to help balance the finances. An improvement of £7.8M was noted which was greater than expected.
Underspend by operational units was discussed and balancing savings and overspending clarified. An explanation was given on how funds for initiatives are held centrally until they are required for projects. It was explained an audit trail is available to show how these funds are utilised to deliver result.
The Committee questioned the language used around finance noting there may be a better understanding if savings and underspends were referred to.
The Committee noted the improved YTD figures and the year end forecast which was held to £16.9M, below the £19M reported to the Board and Government in the Annual Operational Plan. The Committee noted the increased focus on achievement of recurrent savings needs to be the priority for the last 3 months of the year to bring the deficit going into 2019-20 back into line.
3.1 Finance Performance – N&W Ros Philip spoke to the circulated N&W financial position for Month 9. A year to date adverse position was highlighted at £290K. Although there was a reduction in medical staff costs in the first quarter of the year, a change to the internal locum rate had led to higher costs. A savings delivery of £100K was noted. Non-recurring savings delivery achieved. Staff costs are in line with budget. Roster management is ongoing. The Highland tariff was rejected initially and is to be discussed at the earliest opportunity. An operational model with incentives was felt a way forward to resolve issues. It was agreed care at home required a more general progress report. A paper on the outcome of the meeting to be made available for the next HH&SCC in March 2019.
The Committee noted: Year to date adverse position of £290K and forecasted full year overspend of £511K. £102K savings yet to be delivered and £73K non-recurring savings to be converted. Red risks of £0.2M
3.2 Finance Performance – S&M Frances Gordon drew the committee’s awareness to the month 8 report shown which had been circulated in error. She therefore updated the committee verbally on the S&M position in month 9.
The main risk highlighted was ASC which was stable, as was prescribing. It was noted the challenges for S&M were different to other sectors with larger care homes to manage and new models of care. A new criteria for ASC along with package size was discussed. A detailed mapping allocation meeting highlighted a cost of £0.25M care package for transition care, which was considered unmanageable. Escalating costs becoming a recurring theme as patients are cared for at home. It was noted an independent review was ongoing into these costs as it was expected these issues would escalate. David Park proposed taking the matter to the Chief Officers meeting to discuss further. It was highlighted this would be useful for future engagement with Highland Council. Discussion took place on whether a cap could be applied to care, and although it was highlighted other authorities did have a cap this was not the case in Highland. Health and ASC managed at home had the most extreme costs. The Committee agreed there was a need to negotiate this further into next year. Engagement with Highland Council as well as cost pressures required further consideration.
The Committee noted: The year to date adverse position of £198K £396K year end forecast - £19k adverse movement from previous month £545K overspend in prescribing ASC and Prescribing containment plans crucial to maintaining 1718 spend
3.3 Finance Performance – Raigmore Susan Clifton spoke to the circulated month 9 report highlighting a £2M year end overspend. Work is ongoing with recurring savings. Drug costs with an overspend of £1.8M as in month 8 was shown with costs coming down. Savings around drugs still proving challenging. Non-recurrent costs shown will become clearer towards the end of the year.
The Committee noted: £1.83M YTD overspend and the main reasons for this alongside the forecasted £2.0M year end overspend projection. The recurrent target of £3.61M issued by the HB for savings initiatives including procurement, housekeeping and transformational projects and the targets issued to the operational units; the plan and delivery of the cost containment for secondary care drugs and also the balance of £1.2M for which there are currently no confirmed or deliverable plans. The removal of vacancy factor and replacement with a reduced pay budget per code (approx. 2.7%) as a trial for one year and the reasons for the re-basing exercise. The ongoing service pressures including drugs, temporary unfunded beds (non-acute patients), vascular locum, vasectomy service, multiple vacancies in Radiology and Haematology. Total amber risk of £879K.
3.4 ASC Summary Report Kim Corbett noted red risks around medicine and prescribing which was due to a shortage of medicine. It was highlighted day care charging had not been agreed, key project deliverables had now been completed and transport policy work is ongoing. LD Day Care project initiation ongoing.
The Committee noted submitted Medicine and Prescribing and Adult Social Care report.
4. Savings Plans for 2018/19 Due to pressures of time this item was not discussed.
5. TTG & Waiting Times Andrew Ward spoke to the current situation within Raigmore Hospital regarding outpatient performance. He noted the outpatient performance being off trajectory as expected. The Committee was advised of the requirement to meet the revised forecast as well as additional funding. North Highland currently has 1400 breaching outpatients. TTG proving difficult due to staff pressures as well as issues with the critical care upgrade. Theatre experienced pressures on services due to ophthalmology surgery demand for cataracts due to direct referrals from optometrists. Endoscopy demand has increased due to screening requirements which has impacted on the gastroenterology workload. Significant work is ongoing to remove breachers from the system by March 2021.
David Garden questioned whether access funding would be spent and targets achieved. David Garden and Andrew Ward will discuss this issue further. Discussions took place around waiting lists, tighter protocols and estimating demand on services. A 2 year plan was discussed including removing all waiting lists as required by Scottish Government and look at additionality, along with tight timescales. Board sign off will be required.
The Committee noted said report.
6. Date of Next Meeting Wednesday 20th February 2019 2.00pm – 4.00pm Centre for Health Science
Future Meetings: Monday 18 March 2019 2.30pm – 4.30pm Anteroom, AH Thursday 18 April 2019 10.30 – 12.30 Boardroom AH Assynt House Beechwood Park Minute of Meeting of the Inverness Finance & Performance IV2 3BW Telephone: 01463 717123 Sub Committee Fax: 01463 235189 www.nhshighland.scot.nhs.uk
Anteroom 18th December 2018 Assynt House 11.30 – 1.30pm
Present: David Park, Chief Officer (Chair) Ann Clark, Non-Executive Director Karen Underwood, Head of Finance, Raigmore Tracy Ligema, Head of Community Services, N&W Frances Gordon, Head of Finance, S&M Kim Corbett, Senior Project Manager George McCaig, Performance Manager Katherine Sutton, Head of Acute Services, Raigmore Ros Philip, Head of Finance, N&W Simon Steer, Head of Strategic Commissioning Georgia Haire, Head of Community Services, S&M
In attendance: Kirsty Arnott, Committee Administrator Susan Clifton, Accountant
1. Welcome, Declarations of Interest and Apologies: David Park welcomed everyone to the meeting and noted no apologies. No declarations of interest were noted.
2. Minute of Meeting of 28th November 2018 The previous minute of 28th November 2018 had been circulated to the group and was approved as a true reflection.
The Committee Agreed the previous minute
3. Progress on Finance Plans Frances Gordon spoke to the overall financial position report of North Highland. Clarity was sought from the group whether the summary provided was adequate to give assurance. David Park commented the report was adequate for the Finance and Performance Sub Committee however a fuller report would still be required for the Board finance meeting. Frances Gordon confirmed this would be available. An improvement of £1M had been identified in slippage. It was explained to the group any underspend could not be carried forward to the new financial year. David Park spoke to a funding statement being required. Ann Clark spoke to the red risk which Frances confirmed £6M was red risk and agreed visibility within the report would be helpful.
The Committee are asked to note that excluding the £19m savings, the operational position had improved in the YTD figures and the year end forecast had reduced to £16.9m which was now below the £19M reported to the Board and Government in the Annual Operational Plan (AOP). 3.1 Finance Performance N&W Ros Philip spoke to the circulated report on the financial position of N&W. The main concerns raised were around Adult Social Care and health however highlighted care at home and internal care home staffing costs although decreasing were still over what was projected. Tracy Ligema spoke to ongoing changes and improvements within the Telford Centre. Discussion took place around a staffing issue which required further discussion. The group were advised care home managers were now on board with the required changes and it was hoped this model could be rolled out to other care homes. Ann Clark sought clarity on the underspend in health. It was reported this was due to recruitment issues within RGH.
Following discussion the Committee noted: year to date adverse position of £138K and forecasted full year overspend of £462K. £102K savings yet to be delivered and £73K non-recurring savings to be converted. £62K internal target yet to be delivered in Health (or alternatives found).
3.2 Finance Performance – S&M Frances Gordon spoke to the report circulated to the committee highlighting the position of S&M. It was noted similarly to N&W, adult social care had overspent, however health had underspent. A reduced risk was noted in prescribing bringing the costs down from £1M to £500K which was previously forecast. Non-recurring savings had been identified to help reduce risk. Georgia Haire commented on containment and the struggle to contain costs. It was reported almost 40% savings had been achieved recurrent and non-recurrently. It was reported Mental Health was proving to be challenging. Ann Clark noted the increase in locums for Mental Health. Georgia Haire spoke to this being unavoidable however the redesign continues with Nurse Practitioners being appointed however this did not help with the issue of recruiting Consultants. Georgia Haire commented on the difficulties in recruiting to the Older Adult Team. It was noted the recruitment process required to be reviewed. Ann Clark questioned whether a piece of concentrated work was required around recruitment. David Park agreed to discuss the recruitment issue with Gaye Boyd. Tracy Ligema spoke to work ongoing in N&W around recruitment and commented on social media being a useful tool for recruitment.
Katherine Sutton left the meeting at 12.15pm
ACTION: David Park to discuss recruitment issues with Gaye Boyd
Following discussion the Committee noted: The year to date adverse position of £153k, a favourable movement of £39K from the previous month. £377K year end forecast – no change from previous month £474K overspend in Prescribing £2.65M of savings to be delivered. ASC and Prescribing containment plans crucial to maintaining 1718 spend.
3.3 Finance Performance – Raigmore Karen Underwood spoke to the financial position for Raigmore noting very little movement since the November meeting. She spoke to the risks not being maintainable and drugs savings being unlikely. She made the group aware of various vacancies available and anticipated this would be higher by the end of the year. David Park questioned the year end forecast given the current trajectory to date. Karen Underwood spoke to some risks coming down which were not reflected in the report. Ann Clark questioned whether the population increase was being recognised, which it was felt was not.
Following discussion the Committee noted: The £1.87M YTD overspend and the main reasons for this alongside the forecasted £2.0M year end overspend projection. The recurrent target of £3.61M issued by the HB for savings initiatives including procurement, housekeeping and transformational projects and the targets issued to the operational units; the plan and delivery of the cost containment for secondary care drugs and also the balance of £1.2M for which there are currently no confirmed or deliverable plans The removal of vacancy factor and replacement with a reduced pay budget per code (approx. 2.7%) as a trial for one year and the reasons for the re- basing exercise. The ongoing service pressures including drugs, temporary unfunded beds (non-acute patients), vascular locum, vasectomy service, multiple vacancies in Radiology and Haematology. Total amber risk of £1.15M
3.4 ASC Summary Report Kim Corbett spoke to reports circulated to the Committee. The primary care prescribing rebate was highlighted as was the reallocation of items. David Park questioned whether the pharmacy costs were reflected in the areas financial report which was confirmed. Oncology was highlighted as an additional red risk.
Simon Steer left the meeting at 12.30pm
4. Premature Mortality Rate George McCaig spoke to the report provided on the premature mortality rate. He noted a decrease in premature mortality in North Highland which was greater than the national average over a 10 year period. An obvious difference in gender death rates was noted showing females generally live longer however overall there was a 4.4% improvement in male figures nationally. The main causes of premature mortality were cancer, circulatory system diseases, respiratory diseases and all other causes of death. Respiratory causes showed an increase towards the national average for the period 2012 to 2016 however dropped back again in 2017. Comment was made to having insufficient data to determine whether this would be an ongoing trend. The source of the provided report was queried and it was noted the statistics are produced by ISD. Highland premature mortality rates are lower than the national average. The group discussed what as a committee could be done with such findings.
The Committee noted said report.
5. Financial Recovery Plan – Update David Park updated the group on the ongoing financial situation. He notified the group that Mark Wylde had been appointed by Scottish Government to implement a transformation plan. He made the committee aware of a small team being established to assist him which included Brian Steven who has been appointed as Interim Finance Director.
The Committee so noted. 6. People with Early Diagnosis of Dementia The Committee questioned the requirement for forward planning due to the increasing number of people being diagnosed with dementia and diabetes and it was agreed forward planning was required. David Park suggested this should be discussed with Public Health with a view to organising a workshop to highlight the additional pressures on services.
George McCaig thereafter presented his report on people with an early diagnosis of dementia and reported this was not a national agreed performance indicator therefore current measurement tools were not readily available. He commented on the limited data available, noting only national data was available covering 2015/16 and therefore could only be used as a broad guide. It was stated in the period 2015/16 42% of people estimated to be newly diagnosed with dementia were referred for post diagnostic support. He advised that what was apparent was the age of first contact in data available was quite high, averaging at 81 years.
ACTION: David Park to discuss with Hugo Van Woerden the increasing statistics over dementia due to aging population.
The Committee noted said report.
7. Psychological Therapies Waiting Times George McCaig spoke to his previously circulated report on psychological therapy waiting times commenting on the Scottish Governments requirement for psychological therapies waiting times to be measured. He reported the Scottish Government standard is for patients waiting no longer than 18 weeks and this target should be delivered for at least 90% of patients. From the data available he noted there had been a gradual increase in the number of people waiting over 18 weeks in NHSH, the data including A&B. NHS Highland performance was generally better than the national average however the number of people waiting for an appointment is gradually increasing. The Committee questioned whether psychological therapy was part of the waiting time initiative within NHSH which Georgia Haire confirmed. Georgia Haire questioned the report speaking to a report completed by the Head of Psychology which recognised historically there had been issues within the department with waiting times however this was now being addressed and improving. This report had been circulated to the SMT and it was agreed this would be circulated to members of the Committee.
ACTION: Paper presented to SMT to be circulated to the F&P Sub Committee
The Committee noted said report.
8. Date of Next Meeting Friday 18th January 2019 9.00am – 11.00am Boardroom, Assynt House
Meeting Concluded 1.20pm NHS Highland Board 29 January 2019 Item 4.1
Financial Positon at 31st December 2018 (Month 9)
Report by David Garden, Interim Director of Finance
The Board is asked to: • Consider the financial position as at December (month 9) which reports a potential overspend of £18m • Acknowledge the financial position as outlined in this report.
Executive Summary
The Board’s two key financial targets are to break-even on revenue and capital resource limits.
For the 9 month period to 31st December 2018 NHS Highland has overspent its budget by £13.7m.
• The forecasted potential position is £18m overspend at year end. • A savings challenge of £50.5m was calculated for 2018/19, with £31.5m of savings identified in the Annual Operational Plan (AOP) leaving a gap of £19m. • An overspend of around £19m- £23m was projected within the final submitted AOP with significant risks and dependencies. • Capital is in balance but remains extremely challenging.
1. Overall Position – Movement month 8 to 9
Table 1 below shows the projected position based on month 9 forecasts against the previous month. The main adverse year to date (YTD) movement is a further month of the £19m deficit budget though other offsets have limited the overall movement to £0.56m. The forecast position has reduced by just under £0.5m with both Argyll & Bute & and Corporate Services improving their forecasted position.
Table 1 year to date and year end projection comparison
2. Month 9 (April – December 2018)
Year to Date
For the 9 months to December 2018, NHS Highland has overspent against budget by £13.7m and, excluding the £19m unidentified savings target, this is an improvement in month of just over £1m. A further month (£1.56m) of the £19m brings the overall movement to a deterioration of £0.56m.
The Highland Health and Social Care Partnership (HHSCP) is reporting a YTD underspend of £1.5m before the effect of the £19m is taken into account, the 3 operational divisions have an overspend of £2.3m, the main cause being unachieved savings, drugs predominately in Raigmore (oncology), Adult Social Care expenditure and continued use of locums.
While in Argyll & Bute the YTD overspend of £1.1m has improved in month due to slippage on specific funding and a general slowdown in expenditure. The main reason for the overspend is the lack of progress in savings delivery with only 23% delivered to month 9.
Table 2 – 2016-17 – 2018-19 Overspend Trends
3. Operational Forecast at month 9
The projected year end position is an overspend of £18m, an improvement of £0.5m from the previous projection at month 8. This is mostly due to Argyll and Bute (A&B) and support services improving on their previous forecast and is a £1m improvement of the £19m deficit budget set at the start of this year.
The three operational divisions within the HHSCP have held their forecasted positions for a further month; with South & Mid (S&M) continuing to show a year end projection of £0.4m, North & West (N&W) £0.5m and Raigmore £2m.
The main pressures in the projected position are; • Adult Social Care, with an overall forecast of £2.2m • Drugs, mostly Oncology, in Raigmore of £2m • The continued use of locums • Unidentified savings in Raigmore of £1.2m.
Additional savings being realised centrally, adult social care income and forecasted underspends within support services have kept the HHSCP forecast broadly in line with the position reported in month 8.
Argyll & Bute have a projected overspend of £1.4m, an improvement of £0.3m against the month 8 position of £1.7m. Overspend factors being;
• Psychiatric medical services (£0.4m) • Increased patient activity to private sector (£0.3m) • Oncology drugs (£0.3m) • Mull ongoing use of locums (£0.25m) • Use of agency in Lorn and the Isles hospital
Offsetting budget underspends and slippage on specific allocations has resulted in the forecast improvement of £0.35m in month.
Table 3 below shows the position by unit;
Table 3 - Operational forecast
4. Savings
NHS Highland identified a savings challenge of £50.5m was required to deliver a balanced position. Of this total, £31.5 was identified in plans leaving an unidentified amount of £19m that had no plans to deliver and this was discussed with the Scottish Government indicating that the position was not expected to improve and that assistance would be required to bridge that gap.
The approach taken to savings in 2018/19 for specific cost increases in Social Care and Drugs has been around cost containment in those areas, with a target to maintain expenditure to the same level, to all intents and purposes, as in 2017/18. On this basis, the identified challenge was split into cost containment targets of £8.7m and other savings schemes amounting to £22.8m
The tables below show the progress on savings at month 9 and show that £15.5m has been achieved with a further £3.6m forecast to achieve by the end of the year, totalling £19.1m against the £22.8m target.
Cost containment has not delivered as had been expected and achievement to date is £3.3m with a further £0.7m forecast by then end of the year.
The current forecast highlights a shortfall in the delivery on savings plans of £3.7m and an underachievement on cost containment of £4.7m. Whilst this has been offset by benefits in other areas, these are, in the main, unplanned and non-recurrent in nature which, once again, adds to the recurrent carry forward into 2019/20.
Table 4a - Savings
Table 4b – Containment
5. Revenue Summary 2018-19
The NHS Highland projected year-end financial position of an £18m deficit at month 9 is broadly in line with the position reported to the Board and Government in the Annual Operational Plan (AOP), £19- £23m, meeting the aim to deliver a position which is closer to or below £19m.
Delivery of the forecast position is predicated on the achievement of savings and cost containment plans as projected for three key areas of Adult Social Care and Drugs and prescribing, and all savings forecast to deliver by the end of the year.
While the projected year end position is now under the AOP target of £19m continued effort is required to maintain or improve this over the remaining months.
6. Capital Position to 31st December 2018
The 2018-19 Capital plan is expected to spend to the limit of funding of £21.1m. This includes a capital to revenue transfer of £1.2m for the revenue costs of the MRI, Linear Accelerator and other radiology schemes – as originally planned for.
For the 9 months to August 2018 there has been expenditure of £8.6m and a breakeven position is projected for year end.
Table 4 below shows the position to date;
Governance Implications
Accurate and timely financial reporting is essential to maintain financial stability and facilitate the achievement of Financial Targets which underpin the delivery and development of patient care services. In turn, this supports the deliverance of the Governance Standards around Clinical, Staff and wider Public awareness and involvement. The financial position is scrutinised in a wide variety of governance settings in NHS Highland.
Risk Assessment
Risks to the financial position are monitored monthly. There is an over-arching entry in the Strategic Risk Register.
Planning for Fairness
A robust system of financial control is crucial to ensuring a planned approach to savings targets – this allows time for impact assessments of key proposals impacting on services.
Engagement and Communication The majority of the Board’s revenue budgets are devolved to operational units, which report into two governance committees that include staff-side, patient and public forum members in addition to local authority members, voluntary sector representatives and non-executive directors. These meetings are open to the public. The overall financial position is considered at the full Board meeting on a regular basis. All these meetings are also open to the public and are webcast.
David Garden Interim Director of Finance 22nd January 2019
Florence Steering Group Update to Highland Health and Social Care Committee – February 2019
1 Background
1.1 With the end of the TEC Programme funding, a Steering Group was convened to consider the future of Florence within NHS Highland, with a view to moving towards a more strategic approach, and identifying how to get the most benefit from use of Florence, including how to get a return on investment in financial terms.
1.2 The Steering Group held a short series of meetings to discuss the options and produce recommendations for the way forward.
2 Approach
2.1 The strategy recommended by the Steering Group consists of two strands: Identify the Florence protocols with the greatest potential and use Florence, together with other digital technologies, as a catalyst for whole service transformation, thereby enabling significant efficiencies to be realised Require other services and teams which wish to continue to use Florence to finance the cost of the text messages from their own budgets, thereby providing an incentive for services to focus on gaining best value from their use of Florence
2.2 In addition, the Steering Group prepared a separate briefing document specifically about the use of Florence for BP monitoring and management within primary care and how this could be funded.
3 Respiratory Service
3.1 The Respiratory Service has been chosen as the first service to undertake whole service transformation and to become an exemplar for how digital technologies (including Florence) can contribute to service transformation.
3.2 The Respiratory Service has been chosen for the following reasons: The service already makes use of Florence for Asthma, COPD and Pulmonary Rehab Florence, especially the Asthma protocol, has already proved to be of considerable benefit to patients and to have reduced demand on the respiratory service eHealth has developed a report so that readings recorded by asthma patients are integrated into SCIStore Other existing Florence protocols may also be able to play a role, e.g. healthy weight The Respiratory Consultants are enthusiastic about service redesign and eager to use Florence and other digital technologies in every aspect of the service, and to change the respiratory service pathways
Mairi McIvor TEC Service Manager February 2019 The TEC team have made a successful Test of Change funding bid for implementation of MyCOPD, a telehealth system which supports patients with COPD within both secondary and primary care. This will involve redesigning care pathways within both sectors
3.3 The Senior Management Team agreed that the full costs of the Respiratory Service’s use of Florence be covered centrally during the service transformation work (up to a maximum of one year), with future costs being covered by the Respiratory Service itself, out of savings made.
4 Other services
4.1 For all other services, including those which may wish to start using Florence in the future, SMT agreed that: Florence will remain available to all services and teams within NHS Highland (North) Individual services will be charged (on a monthly basis) for their use of text messages. In addition, services will be encouraged to consider how they could make better use of Florence as part of a strategy to transform care pathways, rather than using Florence as an addition to current service delivery The TEC team will be available to help teams to drive this change, however, nurses and AHPs who use Florence will be responsible for liaison with their colleagues and clinical leads, and for redesigning their services
4.2 This approach will enable individual teams to use Florence in line with their own perception of its value to their service.
4.3 If transformational change within the Respiratory Service is successful, we would expect to go on to work with other services to achieve similar changes, from year two onwards.
4.4 SMT agreed this approach.
5 Scottish Government ‘Scale-up BP’ funding opportunity
5.1 The Scottish Government is keen that use of remote BP monitoring, using Florence, should become the standard approach to hypertension management throughout Scotland.
5.2 Information presented at a recent event, organised by the Scottish Government1 provides compelling evidence of the benefits of using Florence for hypertension management. Based on this, the Scottish Government is committed to scaling up its use, with the aim of reaching 20,000 patients and 50% of GP practices across Scotland by 2020.2
5.3 The Scottish Government is now offering funding of up to a total of £150,000 to each Health Board, over a period of two years (April’19 to March’21).
5.4 The aim of the funding is to enable the use of Florence for blood pressure monitoring to be scaled up, with Florence being used for diagnosis of hypertension, titration of hypertension medication and the ongoing monitoring of patients on the hypertension register.
1A Revolution in Blood Pressure Management, Are We Ready? Conference held by the Scottish Government on 29th November 2018. 2Evidence presented by Professor Richard McManus, Oxford University; Professor Brian McKinstry, University of Edinburgh; and Professor Sarah Wild, University of Edinburgh
Mairi McIvor TEC Service Manager February 2019 5.5 The funding can be used to cover the costs of text messages and BP monitors, but not other operational costs.
5.6 The Scottish Government has stated that, to obtain this funding: The health board should have a strong track record of service transformation projects within primary care Plans for use of remote BP monitoring should sit comfortably within the local Primary Care Improvement plan A clinical lead should be identified to lead the funding application Applications must be submitted by 15th February 2019
5.7 SMT gave approval for an application to be made for funding from the Scottish Governments National Scale-Up Blood Pressure Management Programme using Florence. Closing date for bids is 15th February 2019.
5.8 The TEC Service would like to thank all members of the Steering Group, SMT and HHSCC who contributed and supported this approach to the future use of Florence in NHS Highland (North).
Mairi McIvor TEC Service Manager February 2019
Highland Health and Social Care Committee 8 March 2019 Item 4.1
HEALTH AND SOCIAL CARE PARTNERSHIP ARRANGEMENTS
Report by David Park, Chief Officer, Highland Health and Social Care Partnership
Summary This report advises the Health and Social Care Committee of the “Review of Progress Under Integration Authorities”, which was undertaken by a Ministerial Strategic Group, and updates that this review has now concluded its deliberations and produced a set of proposed actions for driving forward health and social care integration.
The proposals arising from the review (attached at Appendix 1) cover a range of key areas in which progress must be made to deliver the ambitions of health and social care integration.
This item presents the Health and Social Care Committee with the final output of the Review, which has been endorsed by COSLA Leaders.
This paper invites the Committee to:
1. Consider the output of the Review of Progress Under Integration Authorities, as provided at Appendix 1;
2. Reflect on their assessment of the Highland position within the context of the Review outputs;
3. Agree that an action plan is now required to define the actions to meet the expectations of the Review; and.
4. Consider any wider implications arising from this Review in the context of the current Partnership Agreement and further, to mandate the Chair of the Committee and Chief Officer to consider the timescales for delivering a revised Partnership Agreement and to revert to Committee with a proposal in this regard.
1.0 Background
1.1 In May 2018, the Cabinet Secretary for Health and Sport made a commitment to Parliament to undertake a Review of Progress Under Integration Authorities, including their governance arrangements. It was confirmed that the review would be taken forward under the oversight of the Ministerial Strategic Group for Health and Community Care, co-chaired by the Cabinet Secretary and the COSLA Spokesperson for Health and Social Care.
1.2 Subsequently, a Review Leadership Group and wider reference group were established to take forward the review and to ensure a joint and collaborative approach.
1.3 Underpinning the approach was a clear understanding that the focus of the review was on delivery progress and not the underlying principles of integration, and that it was to be an exercise in considering how health and social care integration can be improved and delivered at an appropriate pace.
2.0 Review of Progress Under Integration Authorities
2.1 The final output of the review is attached at Appendix 1. 2.2 The review had initially been drafted as a ‘recommendations’ document, however to ensure that the momentum of the Review will be maintained with an immediate move to implementation, the document now outlines a set of proposed actions (‘proposals’).
2.3 Given the timing of this Review of Progress publishing its findings shortly after the Audit Scotland phase two report on integration, the actions are presented under headings of six key areas for improvement highlighted by Audit Scotland i.e. Collaborative leadership and building relationships; Integrated finances and financial planning; Effective strategic planning for improvement; Governance and accountability arrangements; Ability and willingness to share information; and Meaningful and sustained engagement.
2.4 The proposals are provided in full within Appendix 1 and are summarised here:
Table 1
Area Proposal Timescale (i) All leadership development will be 6 months focused on shared and collaborative practice. 1 (ii) Relationships and collaborative 12 months Collaborative working between partners must leadership and improve building relationships (iii) Relationships and partnership 12 months working with the third and independent sectors must improve. (i) Health Boards, Local Authorities and By 1st April 2019 IJBs should have a joint understanding and thereafter each of their respective financial positions as year by end March. 2 they relate to integration. Integrated finances (ii) Delegated budgets for IJBs must be By end March 2019 and financial planning agreed timeously and thereafter each year by end March (iii) Delegated hospital budgets and set 6 months aside requirements must be fully implemented. 3 (i) Statutory partners must ensure that 12 months Effective strategic Chief Officers are effectively supported planning for and empowered to act on behalf of the improvement IJB. Area Proposal Timescale (ii) Improved strategic inspection of 6 months health and social care is developed to better reflect integration. 3. (iii) National improvement bodies 3-6 months must work more collaboratively and deliver the improvement support partnerships require to make integration work. 3. (iv) Improved strategic planning and 12 months commissioning arrangements must be put in place. 3. (v) Improved capacity for strategic 12 months commissioning of delegated hospital services must be in place. 4. (i) The understanding of 6 months accountabilities and responsibilities between statutory partners must improve. (ii) Accountability processes across 12 months statutory partners will be streamlined 4 (iii) IJB chairs must be better supported 12 months Governance and to facilitate well run Boards capable of accountability making effective decisions on a arrangements collective basis (iv) Clear directions must be provided 6 months by IJBs to Health Boards and Local Authorities. (v) Effective, coherent and joined up 6 months clinical and care governance arrangements must be in place. (i) IJB annual performance reports will By publication of be benchmarked by Chief Officers to next round of annual allow them to better understand their reports in July 2019 local performance data. information 5 (ii) Identifying and implementing good 6 - 12 months Ability and practice will be systematically willingness to share undertaken by all partnerships. (iii) A framework for community based 6 months health and social care integrated services will be developed. (i) Effective approaches for community 6 months engagement and participation must be put in place for integration. 6 (ii) Improved understanding of effective 12 months Meaningful and working relationships with carers, sustained people using services and local engagement communities is required. (iii) We will support carers and 6 -12 months representatives of people using services better to enable their full involvement in integration. 2.5 The document sets out that, in support of these recommendations, the Review Leadership Group overseeing the review will continue to meet, and its constituent partners will:
Provide support with implementation; Prepare guidance and involve partners in the preparation of these; Assist with the identification and implementation of good practice; Monitor and evaluate progress in achieving proposals; Continue to provide leadership to making progress with integration.
2.6 The Ministerial Steering Group has been clear that it will be expected that every Health Board, Local Authority and IJB will take action to make progress accordingly using the support on offer. Partnerships will also be expected to initiate or continue the necessary “tough conversations” to make integration work and to be clear about the risks being taken and ensure mitigation of these is in place. National improvement bodies, including Healthcare Improvement Scotland, Care Inspectorate and Improvement Service will work with the key partners to deliver the improvement support required to implement our proposals.
2.7 COSLA Leaders have endorsed the final output of the Review of Progress and agreed to work with Scottish Government, statutory agencies and providers of health and social care to implement the actions proposed and have requested that adequate resources are allocated to the implementation of the Review of Progress.
3.0 Next Steps
3.1 Scottish Government will work with statutory agencies and providers of health and social care to implement the actions proposed.
3.2 As set out in the Appendix, the Review Leadership Group that undertook the Review will continue to exist in some form and be tasked with implementing the proposals within. The Ministerial Strategic Group will be the main vehicle for joint political oversight.
3.3 In view of the above, it is therefore incumbent on the Highland Health and Social Care Partnership to:
a) Review progress against the outputs of the review. To this end, the Committee is invited to reflect on their perception of the Highland position in terms of the review proposals provided in Appendix 1 and summarised at Table 1 above.
b) Agree to the preparation of a draft action plan in response to the Review.
c) Consider any wider implications arising from this review in the context of the current Partnership Agreement.
4.0 Recommendations
4.1 The Health and Social Care Committee is asked to:
1. Consider the output of the “Review of Progress Under Integration Authorities”, attached at Appendix 1;
2. Reflect on their assessment of the Highland position within the context of the Review outputs; 3. Agree that an action plan is now required to define the actions to meet the expectations of the Review; and
4. Consider any wider implications arising from this review in the context of the current Partnership Agreement and further, to mandate the Chair of the Committee and Chief Officer to consider the timescales for delivering a revised Partnership Agreement and to revert to Committee with a proposal in this regard
David Park Chief Officer 28 February 2019 Appendix 1
REVIEW OF PROGRESS WITH INTEGRATION OF HEALTH AND SOCIAL CARE PROPOSALS FROM THE REVIEW LEADERSHIP GROUP
Introduction
Since 2016, work has been underway across Scotland to integrate health and social care services in line with the requirements of the Public Bodies (Joint Working) (Scotland) Act 2014. By integrating the planning and provision of care, partners in the public, third and independent sectors are improving people’s experience or care along with its quality and sustainability. Evidence is emerging of good progress in local systems. Audit Scotland’s1 report on integration that was published on 15 November 2018 highlights a series of challenges that nonetheless need to be addressed, in terms particularly of financial planning, governance and strategic planning arrangements and leadership capacity.
The pace and effectiveness of integration need to increase. At a health debate in the Scottish Parliament on 2 May 2018, the then Cabinet Secretary for Health and Sport undertook that a review of progress by Integration Authorities would be taken forward with the Ministerial Strategic Group for Health and Community Care, and that outputs arising from any further action stemming from such a review would be shared with the Health and Sport Committee of the Scottish Parliament.
Why has Scotland integrated health and social care?
We have integrated health and social care so that we can ensure people have access to the services and support they need, so that their care feels seamless to them, and so that they experience good outcomes and high standards of support. We are also looking to the future: integration requires services to be redesigned and improved, with a strong focus on prevention, quality and sustainability, so that we can continue to maintain our focus on reforming and improving people’s experience of care. In undertaking this review we have built upon Audit Scotland’s observation that integration can work within the current legislative framework, but that Integration Authorities are operating in an extremely challenging environment and there is much more to be done: our focus is on tackling the challenges rather than revisiting the statutory basis for integration.
As part of the review, it is important to acknowledge fully the key importance of staff working across the entirety of health and social care. People working in health and social care services are driving forward many improvements in the experience of care, every day and often in challenging and difficult circumstances. Without the insight, experience and dedication of the health and social care workforce we will simply not be able to deliver on out ambitions for integration. This review does not make recommendations about the health and social care workforce: that work is being undertaken through the National Workforce Plan for health and social care. We nonetheless felt it important to emphasise here the importance of our shared ambitions to develop and support the workforce for integration.
Reviewing progress with integration
1 Health and social care integration: update on progress As we have reviewed our progress to date, our approach has been to focus on the key questions that matter most to people who use services and the systems we have put in place in order to better support those priorities. We have asked ourselves where we are making progress and where the barriers are that may prevent professionals and staff across health and social care from using their considerable skills and resources to best effect. When the Scottish Government first consulted upon plans for integration2, it focussed on four key objectives, which remain central to our aims:
Health and social care services should be firmly integrated around the needs of individuals, their carers and other family members Health and social care services should be characterised by strong and consistent clinical and care professional leadership The providers of services should be held to account jointly and effectively for improved delivery Services should be underpinned by flexible, sustainable financial mechanisms that give priority to the needs of the people they serve, rather than the organisations through which they are delivered
The legislation for integration, the Public Bodies (Joint Working) (Scotland) Act 2014, sets out principles and outcomes, which sit at the centre of our ambitions:
Principles of integration: services should3:
1. Be integrated from the point of view of service-users 2. take account of the particular needs of different service-users 3. Take account of the particular needs of service-users in different parts of the area in which the service is being provided 4. Take account of the particular characteristics and circumstances of different service-users 5. Respect the rights of service-users 6. Take account of the dignity of service-users 7. Take account of the participation by service-users in the community in which service- users live 8. Protect and improve the safety of service-users 9. Improve the quality of the service 10. Be planned and led locally in a way which is engaged with the community (including in particular service-users, those who look after service-users and those who are involved in the provision of health or social care) 11. Best anticipate needs and prevents them arising, and 12. Makes the best use of the available facilities, people and other resources.
National health and wellbeing outcomes4
2 Integration of Adult Health and Social Care in Scotland: Consultation on Proposals (May 2012) 3 http://www.legislation.gov.uk/asp/2014/9/pdfs/asp_20140009_en.pdf 4 http://www.legislation.gov.uk/ssi/2014/343/pdfs/ssi_20140343_en.pdf 1. People are able to look after and improve their own health and wellbeing and live in good health for longer 2. People, including those with disabilities or long term conditions or who are frail are able to live, as far as reasonably practicable, independently and at home or in a homely setting in their community 3. People who use health and social care services have positive experiences of those services, and have their dignity respected 4. Health and social care services are centred on helping to maintain or improve the quality of life of people who use those services 5. Health and social care services contribute to reducing health inequalities 6. People who provide unpaid care are supported to look after their own health and wellbeing, including to reduce any negative impact of their caring role on their own health and wellbeing 7. People using health and social care services are safe from harm 8. People who work in health and social care services feel engaged with the work they do and are supported to continuously improve the information, support, care and treatment they provide 9. Resources are used effectively and efficiently in the provision of health and social care services
The purpose of this review is to help ensure we increase our pace in delivering all of these objectives.
Review process
At its meeting on 20 June 2018, the Ministerial Strategic Group agreed that the review would be taken forward via a small “leadership” group of senior officers chaired by Paul Gray (Director General Health and Social Care and Chief Executive of NHS Scotland) and Sally Loudon (Chief Executive of COSLA). A larger group of senior stakeholders has acted as a “reference” group to the leadership group.
Membership of the review leadership group is as follows:
Paul Gray (co-chair) (Director General for Health and Social Care and Chief Executive of NHSScotland) Sally Loudon (co-chair) (Chief Executive of COSLA) Paul Hawkins (Chief Executive of NHS Fife, representing NHS Chief Executives) Andrew Kerr (Chief Executive of Edinburgh City Council, representing SOLACE) David Williams (Chief Officer of Glasgow City IJB and Chair of the Chief Officers’ network, representing IJB Chief Officers) Annie Gunner Logan (Chief Executive of CCPS, representing the third sector) Donald MacAskill (Chief Executive of Scottish Care, representing the independent sector)
The work of the review leadership group followed this timetable:
Meeting date Topics for discussion 24/09/18 Finance: agreeing, delegating and using integrated budgets 23/10/18 Governance and commissioning arrangements, including clinical and care governance 27/11/18 Delivery and improving outcomes including consideration of the Audit Scotland report on integration (published 15/11/18) 19/12/18 Conclusions and agreement on recommendations, to be reported to the MSG on 23/01/19
This report draws together the group’s proposals for ensuring the success of integration. It builds upon the first output of our review, the joint statement issued on 26 September 2018, which is at Annex A of this report.
Integration Review Leadership Group 4 FEBRUARY 2019 Audit Scotland report
1. The group recognised that the Audit Scotland report on integration that was published in November 2018 provides important evidence for changes that are needed to deliver integration well. The group noted their agreement with Audit Scotland’s recommendations. The group recommends that these recommendations should be acted upon in full by the statutory health and social care partners in Scotland. In addition, the group noted that workforce issues were not considered in any detail in the audit, but recommends that those should be a key focus for statutory and non-statutory partners taking forward integration.
2. Within a broad context of focussing on improving outcomes for people who use services and delivering sustainable, high quality services, the group noted specifically that exhibit 7 from the Audit Scotland report, reproduced below, provides a helpful framework within which to make progress. The group agreed to set out its proposals, in this report, under the headings identified in the exhibit, each of which was considered fully in turn.
3. As a group, we decided to set out “proposals” in this report rather than “recommendations” to underline that the commitments our proposals make are a shared endeavour, which we are each signed up to on a personal level as senior leaders and on behalf of our respective organisations. We have used “we” throughout the proposals set out in this document to further emphasise this.
4. In our review work, we recognised, as the Audit Scotland report does, that there is good practice developing, both in terms of how Integration Joint Boards (IJBs) are operating, and in how services are being planned and delivered to ensure better outcomes. However, this is not yet the case in all areas. We know there are challenges we must address and want to make use of good practice to drive forward change and reform to truly deliver integration for the people of Scotland.
Leadership Group Proposals
Our proposals focus on our joint and mutual responsibility to improve outcomes for people using health and social care services in Scotland. They are a reflection of our shared commitment to making integration work, set out in our joint statement from September 2018. 1. Collaborative leadership and building relationships
Shared and collaborative leadership must underpin and drive forward integration.
We propose that:
1. (i) All leadership development will be focused on shared and collaborative practice. An audit of existing national leadership programmes will be undertaken by the Scottish Government and COSLA to identify gaps and areas of synergy to support integration of health and social care. Further work will be delivered on cross-sectoral leadership development and support. Timescale: 6 months
1. (ii) Relationships and collaborative working between partners must improve. Statutory partners in particular must seek to ensure an improved understanding of pressures, cultures and drivers in different parts of the system in order to promote opportunities for more open, collaborative and partnership working, as required by integration. Timescale: 12 months
1. (iii) Relationships and partnership working with the third and independent sectors must improve. Each partnership will critically evaluate the effectiveness of their working arrangements and relationships with colleagues in the third and independent sectors, and take action to address any issues. Timescale: 12 months
2. Integrated finances and financial planning
Money must be used to maximum benefit across health and social care. Our aim for integration has been to create a system of health and social care in Scotland in which the public pound is always used to best support the individual at the most appropriate point in the system, regardless of whether the support that is required is what we would traditionally have described as a “health” or “social care” service. Our proposals for integrated finances and financial planning focus on the practicalities of ensuring the arrangements for which we have legislated are used fully to achieve that aim, and to support the Scottish Government’s Medium Term Framework for Health and Social Care5.
We propose that:
2. (i) Health Boards, Local Authorities and IJBs should have a joint understanding of their respective financial positions as they relate to integration. In each partnership area the Chief Executive of the Health Board and the Local Authority, and the Chief Officer of the IJB, while considering the service impact of decisions, should together request consolidated advice on the financial position as it applies to their shared interests under integration from, respectively, the NHS Director of Finance, the Local Authority S95 Officer and the IJB S95 Officer. Timescale: By 1st April 2019 and thereafter each year by end March.
2. (ii) Delegated budgets for IJBs must be agreed timeously. The recently published financial framework for health and social care sets out an expectation of moving away from annual budget planning processes towards more medium term arrangements. To support this requirement for planning ahead by Integration Authorities, a requirement should be placed
5 Scottish Government Medium Term Health and Social Care Financial Framework upon statutory partners that all delegated budgets should be agreed by the Health Board, Local Authority and IJB by the end of March each year. Timescale: By end of March 2019 and thereafter each year by end March
2. (iii) Delegated hospital budgets and set aside requirements must be fully implemented. Each Health Board, in partnership with the Local Authority and IJB, must fully implement the delegated hospital budget and set aside budget requirements of the legislation, in line with the statutory guidance published in June 2015. These arrangements must be in place in time for Integration Authorities to plan their use of their budgets in 2019/20. The Scottish Government Medium Term Financial Framework includes an assumption of efficiencies from reduced variation in hospital care coupled with 50% reinvestment in the community to sustain improvement. The set aside arrangements are key to delivering this commitment. Timescale: 6 months
2. (iv) Each IJB must develop a transparent and prudent reserves policy. This policy will ensure that reserves are identified for a purpose and held against planned expenditure, with timescales identified for their use, or held as a general reserve as a contingency to cushion the impact of unexpected events or emergencies Reserves must not be built up unnecessarily. Timescale: 3 months
2. (v) Statutory partners must ensure appropriate support is provided to IJB S95 Officers. This will include Health Boards and Local Authorities providing staff and resources to provide such support. Measures must be in place to ensure conflicts of interest for IJB S95 Officers are avoided – their role is to provide high quality financial support to the IJB. To ensure a consistent approach across the country, the existing statutory guidance should be amended by removing the last line in paragraph 4.3 recommendation 2, leaving the requirement for such support as follows:
It is recommended that the Health Board and Local Authority Directors of Finance and the Integration Joint Board financial officer establish a process of regular in-year reporting and forecasting to provide the Chief Officer with management accounts for both arms of the operational budget and for the Integration Joint Board as a whole. It is also recommended that each partnership area moves to a model where both the strategic and operational finance functions are undertaken by the IJB S95 officer: and that these functions are sufficiently resourced to provide effective financial support to the Chief Officer and the IJB. Timescale: 6 months
2. (vi) IJBs must be empowered to use the totality of resources at their disposal to better meet the needs of their local populations. Local audits of the Health Board and Local Authority must take account of the expectation that money will be spent differently. We should be focused on outcomes, not which public body put in which pound to the pot. It is key that the resources held by IJBs lose their original identity and become a single budget on an ongoing basis. This does not take away from the need for the IJB to be accountable for these resources and their use. Timescale: from 31st March 2019 onwards. 3. Effective strategic planning for improvement
Maximising the benefit of health and social care services, and improving people’s experience of care, depends on good planning across all the services that people access, in communities and hospitals, effective scrutiny, and appropriate support for both activities.
We propose that:
3. (i) Statutory partners must ensure that Chief Officers are effectively supported and empowered to act on behalf of the IJB. This will include Health Boards and Local Authorities providing staff and resources to provide such support. The dual role of the Chief Officer makes it both challenging and complex, with competing demands between statutory delivery partners and the business of the IJB. Chief Officers must be recognised as pivotal in providing the leadership needed to make a success of integration and should be recruited, valued and accorded due status by statutory partners in order that they are able to properly fulfil this “mission critical” role. Consideration must be made of the capacity and capability of Chief Officers and their senior teams to support the partnership’s range of responsibilities. Timescale: 12 months
3. (ii) Improved strategic inspection of health and social care is developed to better reflect integration. As part of this work, the Care Inspectorate and Healthcare Improvement Scotland will ensure that:
As well as scrutinising strategic planning and commissioning processes, strategic inspections are fundamentally focused on what integrated arrangements are achieving in terms of outcomes for people. Joint strategic inspections examine the performance of the whole partnership – the Health Board, Local Authority and IJB, and the contribution of non-statutory partners – to integrated arrangements, individually and as a partnership. There is a more balanced focus across health and social care ensured in strategic inspections. Timescale: 6 months
3. (iii) National improvement bodies must work more collaboratively and deliver the improvement support partnerships require to make integration work. These bodies include Healthcare Improvement Scotland, the Care Inspectorate, the Improvement Service and NHS National Services Scotland. Improvement support will be more streamlined, better targeted and focused on assisting partnerships to implement our proposals. This will include consideration of the models for delivery of improvement support at a national and local level and a requirement to better meet the needs of integration partners. Timescale: 3-6 months
3. (iv) Improved strategic planning and commissioning arrangements must be put in place. Partnerships should critically analyse and evaluate the effectiveness of their strategic planning and commissioning arrangements, including establishing capacity and capability for this. Local Authorities and Health Boards will ensure support is provided for strategic planning and commissioning, including staffing and resourcing for the partnership, recognising this as a key responsibility of Integration Authorities. Timescale: 12 months
3. (v) Improved capacity for strategic commissioning of delegated hospital services must be in place. As implementation of proposal 2 (iii) takes place, a necessary step in achieving full delegation of the delegated hospital budget and set aside arrangements will be the development of strategic commissioning for this purpose. This will focus on planning delegated hospital capacity requirements and will require close working with the acute sector and other partnership areas using the same hospitals. This should evolve from existing capacity and plans for those services. Timescale: 12 months
4. Governance and accountability arrangements
Governance and accountability must be clear and commonly understood for integrated services.
We propose that:
4. (i) The understanding of accountabilities and responsibilities between statutory partners must improve. The responsibility for decisions about the planning and strategic commissioning of all health and social care functions that have been delegated to the IJB sits wholly with the IJB as a statutory public body. Such decisions do not require ratification by the Health Board or the Local Authority, both of which are represented on the IJB. Statutory partners should ensure duplication is avoided and arrangements previously in place for making decisions are reviewed to ensure there is clarity about the decision making responsibilities of the IJB and that decisions are made where responsibility resides. Existing committees and groups should be refocused to share information and support the IJB. Timescale: 6 months
4. (ii) Accountability processes across statutory partners will be streamlined. Current arrangements for each statutory partner should be scoped and opportunities identified for better alignment, with a focus on better supporting integration and transparent public reporting. This will also ensure that different rules are not being applied to different parts of the system particularly in circumstances of shared accountability. Timescale: 12 months
4. (iii) IJB chairs must be better supported to facilitate well run Boards capable of making effective decisions on a collective basis. There are well-functioning IJBs that have adopted an open and inclusive approach to decision making and which have gone beyond statutory requirements in terms of memberships to include representatives of key partners in integration, including the independent and housing sectors. This will assist in improving the effectiveness and inclusivity of decision making and establish IJBs as discrete and distinctive statutory bodies acting decisively to improve outcomes for their populations. Timescale: 12 months
4. (iv) Clear directions must be provided by IJBs to Health Boards and Local Authorities. Revised statutory guidance will be developed on the use of directions in relation to strategic commissioning, emphasising that directions are issued at the end of a process of decision making that has involved partners. Directions must be recognised as a key means of clarifying responsibilities and accountabilities between statutory partners, and for ensuring delivery in line with decisions. Timescale: 6 months
4. (v) Effective, coherent and joined up clinical and care governance arrangements must be in place. Revised statutory guidance will be developed based on wide ranging consultations with local partnerships, identifying good practice and involving all sectors. The key role of clinical and professional leadership in supporting the IJB to make decisions that Are safe and in accordance with required standards and law must be understood, co-ordinated and utilised fully. Timescale: 6 months 5. Ability and willingness to share information
Understanding where progress and problems are arising is key to implementing learning and delivering better care in different settings.
We propose that:
5. (i) IJB annual performance reports will be benchmarked by Chief Officers to allow them to better understand their local performance data. Chief Officers will work together to consider, individually and as a group, whether their IJBs’ annual reports can be further developed to improve consistency in reporting, better reflect progress and challenges in local systems, and ensure that, as a minimum, all statutorily required information is reported upon. Timescale: By publication of next round of annual reports in July 2019
5. (ii) Identifying and implementing good practice will be systematically undertaken by all partnerships. Chief Officers will develop IJBs’ annual reports to enable partnerships to identify, share and use examples of good practice, and lessons learned from things that have not worked. Inspection findings and reports from strategic inspections and service inspections should also provide a clear means of identifying and sharing good practice, based on implementation of the framework outlined below at 5 (iii) and the national health and social care standards. Timescale: 6 - 12 months
5. (iii) A framework for community based health and social care integrated services will be developed. The framework will be key in identifying and promoting best practice in local systems to clearly illustrate what good looks like in community settings, which is firmly focused on improving outcomes for people. This work will be led by Scottish Government and COSLA, involving Chief Officers and other key partnership staff to inform the framework. Timescale: 6 months
6. Meaningful and sustained engagement
Integration is all about people: improving the experience of care for people using services, and the experience of people who provide care. Meaningful and sustained engagement has a central role to play in ensuring that the planning and delivery of services is centred on people.
We propose that:
6. (i) Effective approaches for community engagement and participation must be put in place for integration. This is critically important to our shared responsibility for ensuring services are fit for purpose, fit for the future, and support better outcomes for people using services, carers and local communities. Revised statutory guidance will be developed by the Scottish Government and COSLA on local community engagement and participation based on existing good practice, to apply across health and social care bodies. Meaningful engagement is central to achieving the scale of change and reform required, and is an ongoing process that is not undertaken only when service change is proposed. Timescale: 6 months
6. (ii) Improved understanding of effective working relationships with carers, people using services and local communities is required. Each partnership should critically evaluate the effectiveness of their working arrangements and relationships with people using services, carers and local communities. A focus on continuously improving and learning from best practice will be adopted in order to maximise meaningful and sustained engagement. Timescale: 12 months
6. (iii) We will support carers and representatives of people using services better to enable their full involvement in integration. Carers and representatives of people using health and social care services will be supported by partnerships to enable meaningful engagement with their constituencies. This will support their input to Integration Joint Boards, strategic planning groups and locality arrangements for integration. This would include, for example, receipt of IJB papers with enough time to engage other carers and people using services in responding to issues raised. It would also include paying reasonable expenses for attending meetings. Timescale: 6 -12 months
In support of these proposals we will:
Provide support with implementation; Prepare guidance and involve partners in the preparation of these; Assist with the identification and implementation of good practice; Monitor and evaluate progress in achieving proposals; Make the necessary links to other parts of the system, such as workforce planning; Continue to provide leadership to making progress with integration; Report regularly on progress with implementation to the Ministerial Group for Health and Community care.
In support of these proposals we expect:
Every Health Board, Local Authority and IJB will evaluate their current position in relation to this report and the Audit Scotland report, and take action to make progress using the support on offer.
Partnerships to initiate or continue the necessary “tough conversations” to make integration work and to be clear about the risks being taken, and ensure mitigation of these is in place.
Partnerships to be innovative in progressing integration. ANNEX A