1 There Will Be a Virtual Meeting of Forth Valley NHS Board On

There will be a virtual meeting of Forth Valley NHS Board on Tuesday, 28 July 2020 at 10.30am

Janie McCusker Chair

AGENDA

1. Apologies for Absence

2. Declaration (s) of Interest (s)

3. Minute of Forth Valley NHS Board meeting held on 30 June 2020 For Approval

4. Matters Arising from the Minute

5. BETTER HEALTH

5.1 Pandemic COVID-19 Update Seek Assurance (Paper presented by Dr Graham Foster, Director of Public Health 15 minutes & Strategic Planning)

6. BETTER CARE

6.1 Healthcare Associated Infection Report Seek Assurance (Paper presented by Prof Angela Wallace, Executive Nurse Director) 15 minutes

6.2 Primary Care Improvement Plan Seek Assurance (Paper presented by Mrs Cathie Cowan, Chief Executive) 10 Minutes

7. BETTER VALUE

7.1 Finance Update Seek Assurance (Paper presented by Mr Scott Urquhart, Director of Finance) 15 minutes

7.2 Elective Care Development Programme For Approval (Paper presented by Ms Gillian Morton, Programme Director) 15 minutes

8. BETTER STAFF WELLBEING

8.1 Communications Update Report Seek Assurance (Paper presented by Mrs Elsbeth Campbell, Head of 10 minutes Communications)

1 9. BETTER GOVERNANCE

9.1 Blueprint for Good Governance Seek Assurance (Paper presented by Mrs Cathie Cowan, Chief Executive) 10 minutes

9.2 Change to Board Operating Arrangements Seek Assurance (Paper presented by Mrs Cathie Cowan, Chief Executive) 10 minutes

9.3 Committee Chairs Minutes 5 minutes

9.3.1 Committee Chairs Meeting: 23 June 2020 (Minute presented by Ms Janie McCusker, Chair)

10. ANY OTHER COMPETENT BUSINESS

10.1 Emerging Topics

FORTH VALLEY NHS BOARD TUESDAY 28 JULY 2020

For Approval

Item 3 – Draft Minute of the Forth Valley NHS Board Meeting held on Tuesday 30 June 2020 at 10.30am via teleconference

Present: Ms Janie McCusker (Chair) Cllr Allyson Black Stephen McAllister Mr Robert Clark Ms Michele McClung Mrs Cathie Cowan Mr Andrew Murray Mr John Ford Mr Allan Rennie Dr Graham Foster Mrs Julia Swan Mr Gordon Johnston Ms Angela Wallace Dr James King

In Attendance: Mrs Elsbeth Campbell, Head of Communications Ms Linda Davidson, Associate Director of Human Resources Ms Kerry Mackenzie, Head of Performance Ms Jackie McEwan (minute

1. Apologies for Absence

Apologies for absence were noted on behalf of Linda Donaldson, Susan McGill, Allyson Black and Scott Urquhart.

2. Declaration (s) of Interest (s)

Robert Clark declared an interest in Item 5.2, however it was agreed he would remain present for this item.

3. Minute of Forth Valley NHS Board meeting held on 26 May 2020

The minutes of the last meeting were approved subject to the following amendments:

Item 5.1, paragraph 5, amendments to read:

“Mr Allan Rennie sought clarity on the software in response to Scottish Government media coverage.”

“Dr Foster assured Board members that there was a system in place that was not reliant on national software.”

4. Matters Arising from the Minute

There were no matters arising from the minute.

5. BETTER HEALTH

5.1 Pandemic Update

The NHS Board considered a paper “Pandemic Update” presented by Graham Foster, Director of Public Health.

Dr Foster provided an update in respect of the overall public health strategy to address the COVID-19 pandemic, focussing on progress with the Test and Protect service.

It was noted that the levels of COVID-19 disease were consistently falling across Scotland. National deaths data were continuing downward trend for the eighth successive week. There was still a small number of recovering patients in FVRH but few new cases and no cases in ITU at time of writing.

National modelling suggested that the R number remained between 0.6 and 0.8 however it was noted that this became a less significant measure as overall case numbers were low.

It was noted that Test and Protect had been in place in Forth Valley since 28 May 2020. All cases notified to NHS Forth Valley had been contacted and compliance appears to be good. The National elements of Test and Protect were in place and would extend to supporting NHS Forth Valley staff from 8 July 2020. The local health protection teams would continue to handle contact tracing for more complex incidents and enquiries for example should outbreaks in schools, care settings or workplaces present.

Workforce challenges were outlined, noting an ongoing focus to maintain additional support to Public Health through temporary and redeployed staff. Liaison was underway with HR to strengthen the Health Protection Team and a dedicated manager had been appointed to assist in this area.

Following an enquiry from Mrs Swan, Dr Foster advised the Chief Medical Officer had written to Boards to confirm that blood tests for antibodies were not reliable enough to be utilised for any clinical purpose.

The Board acknowledged the collaboration and work undertaken by all staff throughout the Pandemic.

The NHS Board: • Noted the public health update describing overall progress with responding to the pandemic and the Test and Protect programme that is now underway in Forth Valley

5.2 Non Clinical Space Policy

The NHS Board considered a paper “Non Clinical Space Policy” sponsored by Mrs Cathie Cowan, Chief Executive.

Mrs Cowan introduced the paper and acknowledged the work by those people listed in paper then invited Ms Linda Davidson to present the paper.

Ms Davidson highlighted that NHS Forth Valley has a responsibility to ensure all staff have a safe work environment. The COVID-19 Non-Clinical Spaces Policy for Staff and Managers provides information to help managers and staff understand how to work safely alongside this virus. The policy sets the minimum standards for all NHS Forth Valley staff to follow during this COVID-19 pandemic. The policy in particular relates to Health & Safety and Wellbeing of all staff and the key responsibilities and actions to meet and support statutory requirements at individual, management and organisational levels.

It was highlighted that risk assessments must be completed by the manager/assessor for each department or team and reflect the specific hazards and risks within each of the operating environments.

NHS Board members noted that the policy will be subject to ongoing updates in response to the Scottish Government’s – COVID-19: Scotland’s route map through and out of the crisis. The policy focused on the current 2 metre physical distancing requirement within non-clinical areas. It was confirmed that any change would require discussion with Staff Side representatives.

The NHS Board expressed support for the policy and highlighted that this provided reassurance in respect of Governance processes outlined. A presentation to Staff Governance was proposed and cognisance was taken of the inclusive consultation undertaken.

The NHS Board: • Noted the COVID-19 Non-Clinical Spaces Policy for Staff and Managers • Noted the ongoing nature of the work with the Policy being updated to reflect changes in ‘lockdown measures’

6. BETTER CARE

6.1 NHS Response to Re-mobilise, Recover and Re-design: The Framework for NHS Scotland

The NHS Board considered a paper “NHS Response to Re-mobilise, Recover and Re-design: The Framework for NHS Scotland” presented by Mrs Cathie Cowan, Chief Executive.

Mrs Cowan introduced the NHS Board’s ‘Our System-Wide Remobilisation Plan. NHS Board members noted that the Plan sets out how NHS Forth Valley will safely and incrementally start to resume services over the next 100 days whilst being vigilant and able to continue to respond to ongoing challenges of COVID-19. There was a focus on ensuring the provision of urgent care which was being informed by clinical prioritisation. The Plan also took cognisance of the need to prepare for winter with the importance of implementing a flu vaccination programme that reached out to the population. The response would be local, but if required regional partners would work together to maximise capacity which would include support from the Golden Jubilee and Louisa Jordan.

The potential for a second wave of Covid-19 was highlighted, with ongoing work around retention of ITU capacity and ring fencing of COVID-19 beds.

The transformation work undertaken at pace was acknowledged along with plans to maintain and develop the new innovations and disinvest where appropriate. Mrs

Cowan detailed the proposal to establish a Renewal and Recovery Mobilisation Programme Board and that this was due to be presented to the System Leadership Team. It was also noted that NHS Boards were anticipating correspondence from the Scottish Government commissioning the next phase of recovery to the end of March 2021. Mrs Cowan agreed to update Board members on work underway to continue to resume services from August to March 2021.

The limited patient and public involvement was noted however the emergency footing in place and the required pace of response was acknowledged. The high level of patient and public involvement in NHS Forth Valley through its strong partner network was noted. A letter received from the Cabinet Secretary in regard to informing and involving people would be shared with Board members. Action: Cathie Cowan

Professor Wallace noted that there was work required however agreed to bring a paper to a future NHS Board meeting in relation to the opportunities for the inclusion of patient and public networks in remobilisation. Action: Angela Wallace

The challenges around access to equipment for Near Me were highlighted, along with public access to technology particularly within deprived areas. Mr Jonathan Procter, Director of Facilities & Infrastructure and eHealth Lead was working closely with GPs around facilitation and reimbursement for costs such as webcams. Mrs Cowan advised that a paper would be brought back to a future NHS Board detailing the position and how this related to IT and infrastructure and supporting service delivery within this Pandemic. Action: Cathie Cowan

The duty of the Health Board to implement the new GMS contract was noted with positive changes around recruitment and additions to Multi Disciplinary Teams.

Mental Health remained a key area of challenge with a significant increase in demand. Reassurance was provided that services had not been stood down and urgent cases were being seen. It was noted that an update in respect of CAMHS and Mental Health in relation to remobilisation was being presented to the Performance & Resources Committee on 14 July 2020.

In her absence, the Chair highlighted points from Cllr Allyson Black and it was confirmed these had been covered during the discussions.

The NHS Board: • Noted the proposal discussed at SLT to engage staff in the development of a single strategic transformational plan • Noted Our System-Wide Remobilisation Plan - 2020

7. BETTER GOVERNANCE

7.1 Finance Report

The NHS Board considered the Finance Report presented by Simon Dryburgh, Deputy Director of Finance.

The paper provided the position for NHS Forth Valley to 31 May 2020 and reported a revenue overspend of £0.196m for month 2 financial position. This comprises of an

4 underspend on Health and Social Care Partnership (H&SCP) services of £0.052m, and an overspend on Clinical Directorates including set aside services and Estates/Corporate areas of £0.248m

The additional costs arising from mobilisation response to COVID-19 identified and reported to Scottish Government, with a funding allocation anticipated at a value equivalent to costs incurred to date; £2.5m for health services across NHS Forth Valley for April and May. Until funding allocations are confirmed there is a significant risk around affordability.

It was noted that there has been a reduction in costs related to non urgent elective care services which have been temporarily postponed, including theatre consumables and hospital drugs, albeit costs are expected to pick up again as clinical services are reintroduced on a phased basis. Financial arrangements supporting Cross Boundary Flow costs and activity also require to be reviewed.

Initial savings requirement was noted as £20.6m. There was identification of new opportunities following the response to COVID-19 with progression of this work supported by the Corporate Programme Management.

It was noted that the Capital Resource Limit (CRL) would be met and the expectation was for completion of capital works related to improving access to elective care within this financial year. It was confirmed dialogue was ongoing with Scottish Government.

An area of challenge was highlighted around Forensic Mental Health inpatients with increased costs. NHS Forth Valley currently had patients within NHS Lothian, NHS Tayside and within The State Hospital. Work was ongoing to review processes.

The Annual accounts process was ongoing for 2019/20 and subject to audit, all financial targets had been achieved. Risk share arrangements have been finalised, noting an improved social care outturn which increased the NHS Board reported under spend.

The NHS Board noted: • A revenue overspend of £0.196m to 31st May 2020, (Month 2 of 2020/21 financial year) with a projected year end outturn of break even, subject to key risks outlined in the report • Funding is anticipated to meet COVID-19 health costs incurred to date, with allocations being confirmed following quarter 1 • A balanced capital position to 31st May 2020 based on expected phasing and a projected break even position on capital at financial year end • A full review of financial position and associated risks will be undertaken in July based on the Quarter 1 position • Financial risks and issues associated with COVID-19

7.2 Governance Review

The NHS Board received a paper “Governance Review” led by Ms Janie McCusker, Chair.

Ms McCusker highlighted a paper setting out interim governance changes during the COVID-19 pandemic that was presented to the NHS Board on 31 March 2020. The paper noted a further review of these arrangements in 3 months time.

It was noted that the NHS in Scotland continued on an emergency footing however as the Board of NHS Forth Valley resumed services there is a need to re-establish its Assurance Committees. It was proposed that all the Assurance Committees will be re-established virtually and the frequency of meetings will be revised to enable the Chief Executive to focus on resuming services gradually and safely with her System Leadership Team.

Detail in respect of Audit Committee, Staff Governance and Remuneration Committee, Clinical Governance Committee and Performance & Resources Committee was noted.

Full Committee structure would not be resumed at this time however engagement would take place as required. Due to NHS Forth Valley remaining on an emergency footing, the Cabinet Secretary would require to be informed of these changes.

The NHS Board: • Noted the key issues as set out • Approved and endorsed the revised changes to the corporate governance arrangements

7.3 Board Assurance Committee Membership

The NHS Board received a paper “Board Assurance Committee Membership” presented by Mrs Cathie Cowan, Chief Executive.

Mrs Cowan advised that the paper outlined changes to the Integration Authorities membership, made by the NHS Board Chair in discussions with Non Executive Members.

Specifically, it was proposed Mr Gordon Johnston, Non Executive Member would become a voting member of the Clackmannanshire/Stirling IJB from May 2020; this is an interim appointment whilst the Integration Scheme membership from all Parties is reviewed. Mr Johnston has also agreed to take on the role of Chair of the Falkirk IJB Audit Committee, this was approved at a recent meeting (19 June 2020) of the Falkirk IJB.

Mr Stephen McAllister had agreed to take on the role of Vice Chair of the Falkirk IJB Care and Clinical Governance Committee, this was approved at a recent meeting (19 June 2020) of the Falkirk IJB.

Dr Graham Foster restated that he and Mrs Cathie Cowan would remain as voting members on the Clackmannanshire and Stirling Integration Joint Board. This was an administrative arrangement and could only change if the other parties, Clackmannanshire and Stirling respectively, reduced their number of voting members. This would be kept under review.

A summary of NHS Forth Valley voting membership on Falkirk IJB and Clackmannanshire & Stirling IJB was detailed. Mr John Ford advised he was not the Vice Chair of the Clackmannanshire and Stirling Integration Joint Board and that this

6 role was undertaken by Mr Scott Farmer. It was agreed the paper would be amended to reflect this.

Subject to this amendment, the NHS Board: • Approved the change in membership to the Clackmannanshire/Stirling Integration Joint Board (IJB) • Endorsed the appointments to the Falkirk Integration Joint Board (IJB) Committees

7.4 Best Value

The NHS Board considered a paper “Best Value” presented by Mrs Cowan. Mrs Cowan acknowledged the work of Kerry Mackenzie in the drafting of this paper.

Mrs Cowan advised that the paper had been presented to the Audit Committee on 16 June 2020 and positive feedback was received from Internal and External Auditors. It was requested the paper be presented to the NHS Board to ensure public circulation.

The Chair noted the two cross cutting themes of Sustainability and Equality and proposed reference be made to the Scottish Government Performance Framework. It was agreed this would be augment the linkages and demonstrate the work being undertaken. Mrs Cowan confirmed she would liaise with Kerry Mackenzie the author of the paper to ensure this was referenced prior to publication on the website. Action: Kerry Mackenzie The NHS Board: • Noted the detail within the Best Value Framework Summary

7.5 Board “In Attendance” Membership

The NHS Board considered a paper “Board ‘In Attendance’ membership” presented by Mrs Cowan.

Mrs Cowan confirmed a paper was taken to the Senior Leadership Team (SLT) that proposed extending the NHS Board ‘In Attendance’ membership. It was noted that the recent appointment of the new Chair created an opportunity to reposition how SLT engaged with the Board. Ms McCusker was supportive of this change noting positive inclusion as part of overarching engagement with partners, stakeholders and team within the Board.

The NHS Board: • Approved the proposal to extend the Board ‘in attendance’ membership to include all SLT members

7.6 Review of Integration Scheme

The NHS Board considered a paper “Review of Integration Scheme” presented by Mrs Cowan.

It was highlighted that the Public Bodies (Joint Working) (Scotland) Act 2014 sets the framework for integrating adult health and social care, to ensure a consistent

provision of quality, sustainable care services for the increasing numbers of people in Scotland who need joined-up support and care, particularly people with multiple, complex, long-term conditions. The Integration Scheme is a legally binding agreement between Councils and Health Boards.

Mrs Cowan acknowledged the contribution of Lesley Fulford, Programme Manager, Clackmannanshire & Stirling Health and Social Care Partnership in preparing the paper, the purpose of which was to ensure that NHS Board members were up to date with the work underway to review the Integration Scheme for Stirling and Clackmannanshire. Similar work was underway in Falkirk.

It was noted that the initial review of the Integration Scheme included an agreement to have a session (mid April 2020) with wider representation (including IJB Voting Members and others) to inform our work and how to proceed. However due to the COVID-19 response this session was put on hold and will be rescheduled. The existing Integration Scheme remains in place.

A number of key actions were detailed highlighting the requirement to reschedule the planned session and ensure agreement reached; develop an action plan and ensure relevant leads are tasked with writing any required amendments to the Integration Scheme sections; and, Chief Executives present the Integration Scheme (with any amendments if there are any) for approval to their Constituent Authority.

The NHS Board: • Noted the requirement to review the Integration Scheme • Noted the progress of the review • Noted the actions proposed in June 2020, if the emergency response to COVID-19 pandemic changes

7.7 Committee Chairs Minutes

7.7.1 Committee Chairs Meeting: 12 May 2020

The NHS Board noted the minute as presented.

7.7.2 Committee Chairs Meeting: 9 June 2020

The NHS Board noted the minute as presented.

8. ANY OTHER COMPETENT BUSINESS

8.1 Emerging Topics

There being no other competent business, the Chair closed the meeting.

FORTH VALLEY NHS BOARD TUESDAY 28 JULY 2020

Item 5.1 Pandemic Covid-19 Update For Assurance

Executive Sponsor: Cathie Cowan, Chief Executive

Author: Graham Foster, Director of Public Health and Strategic Planning

Executive Summary

This paper summarises progress with the overall public health strategy to address the Covid-19 pandemic and describes our local response. The Scottish Government strategy of elimination (driving the virus down to the lowest possible level) continues. With very low virus levels, active surveillance and rapid intensive response by our health protection team are now the highest priority in controlling and responding to any local outbreaks or clusters. The Scottish Government publication Covid-19 Surveillance and Response describes this approach in detail and is attached as an appendix to this report.

Background and progress of Public Health Strategy as at 23 July 2020 Levels of Covid-19 disease are continuing to fall steadily and Scotland moved to Phase 3 of the route map for coming out of lockdown on 10 July. National deaths data has now confirmed a continuing downward trend for the twelfth successive week. The seven-day rolling average deaths per day has effectively reached zero with only one death recorded in the 15 days 08-22 July, having been as high as 50 deaths every day in early May and 13 deaths per day at start of June. Daily test confirmed case numbers now average just below 20 for all Scotland (rolling seven day average is now about 12 cases). This includes asymptomatic test positives identified through widespread screening of health and social care staff and patients.

There are currently no Covid-19 positive patients in FVRH and only 2 ITU cases in Scotland (at time of writing – 23 July).

National testing rates have increased to average over 10,000 per day but there is still substantial additional capacity if required. The number of people with symptoms who require tests is very low which a positive sign is. Only 0.4% of those tested are found to have the Covid-19 virus

National modelling suggests the R number remains between 0.6 and 0.8 although this becomes a less significant measure as overall case numbers are low. Estimates suggest that at 17 June there were approximately 400 active cases in Scotland and less than 40 new cases per day.

Physical distancing and hygiene measures will need to continue as long as the virus is prevalent in the population to help prevent potential community transmission.

On 31 July 2020 the First Minister will decide if elimination efforts have been sufficient to allow all schools to return full time from August 11th 2020 . The First Minister continues to set the challenge of achieving and sustaining as close as possible to the elimination of Covid-19 in Scotland.

Test and Protect The key to driving down and then maintaining low virus levels continues to be the combination of effective public health measures observed by the whole population backed up by effective contact tracing and control measures undertaken by specialist health protection teams whenever positive

1 cases or outbreaks occur. Contact tracing works most effectively to reduce the ongoing transmission of infection when the number of new infections in the community is low, and stays low. Specialists in health protection maintain constant surveillance for signs of possible hot spots or outbreaks and work with the community to identify and reduce risk.

Since the last report there have been local outbreaks in Dumfries and Galloway (originating at Cumbria Royal Infirmary) and Lanarkshire (originating in an open plan call centre). Both have been controlled by a rapid NHS response.

Test and Protect has been in place in Forth Valley since 28 May. All cases notified to NHS Forth Valley have been contacted and compliance appears to be good. Currently the service deals with around one or two suspected cases requiring their contacts to be traced each day however it has the capacity to respond to any increase in demand, if required.

The National elements of Test and Protect are now in place support the local NHS Forth Valley response. The local health protection teams continue to handle contact tracing for more complex incidents and enquiries linked to schools, care settings or workplaces. A new nationally funded Contact Management System has been adopted this week which should help address any data handling issues. As many of the first cohorts of staff have returned to previous roles a number of new staff have undergone training in the systems and call handling processes and an experienced manager is in place. In Forth Valley the test and protect team works seamlessly with the health protection team as one service.

The service is overseen by a local Contact Tracing Implementation Group with input from Public Health, Human Resources, Facilities & Infrastructure, IT, Information Management, Finance and Planning. The service model is largely resourced by staff from Public Health supported by other local staff redeployed from their substantive roles.

Workforce Work continues to maintain enhanced support for public health as temporary and redeployed staff return to their normal duties/roles. Physical distancing remains vital for staff safety and therefore office space is limited. Two newly recruited health protection nurses are now in place and two additional nurses will join shortly to replace two who have returned to the immunisation team that will deliver the seasonal flu campaign. The local health protection team will continue to need to be resourced to mount an extended response over the coming months.

Care Homes Care Homes continue to be an area of intensive multi disciplinary and cross agency focus. A daily care home meeting overseen by a weekly governance group continue to ensure the safety of local homes.

. In the last week NHS Forth Valley oversaw the delivery and reporting of screening tests to over 2000 staff exceeding the government’s target for screening coverage.

The majority of care homes in Forth Valley operate in the independent sector and were not under NHS management or oversight prior to the pandemic starting. In Scotland, the Care Inspectorate regulates and inspects care services to make sure that they meet the set standards. The outcome of inspections and visits, along with any recommendations, is now summarised in a report which is published by Care Inspectorate every fortnight.

Care Homes are now open for outdoors visits. This required the production of 66 individual risk assessments by Care Homes which were checked and approved by the Director of Public Health team. This requires administrative and professional input. We will continue to support Care Homes with our partners for as long as is necessary.

Winter Planning National planning is now beginning to look at the likely changes in Covid-19 infections and transmission when colder weather drives more indoor contact. Concerns also exist around the 2 combined effect of Covid-19 alongside seasonal influenza. NHS winter planning teams will assess and work to counter these potential risks. A number of national groups have been formed to begin this important preparatory work. NHS Forth Valley is working to develop its response our winter plan, Pandemic Influenza Plan, System-wide Remobilisation Plan and Covid-19 Pandemic Framework to ensure we are prepared for winter.

Testing Testing remains a key element in tracking and elimination Covid-19. The current service involves a range of routes and venues to access testing and a mixture of NHS, private, academic and military elements. Mobile military testing arrangements will shortly be passed to the Scottish Ambulance Service. A national Care Home Portal service has been set up to support the extensive screening in care homes. Locally planned and carefully co-ordinated use of testing is vital to help eliminate potential local hot spots. A business case is under consideration to continue staffing of the local NHS testing drive through centres and mobile testing teams.

Recommendation

The Forth Valley NHS Board is asked to: -

• consider this public health update describing overall progress with responding to the pandemic and the latest updates for Forth Valley.

Key Issues to be Considered

The key issues considered in this paper were:

• There are very positive signs at this time that virus levels are at a very low level in the population and we continue the carefully phased approach, now at phase 3 of the route map. • The local Test and Protect Service is working well and seamlessly linked to health protection who manage the more complex cases. • Due to the continued success of the overall public health strategy there has been only a limited requirement for contact tracing to date and an average of about one close contact requiring isolation for each test positive case. • The local model is highly flexible and stands ready to scale up should there be a need to do so. • Outbreaks and potential clusters require to be spotted early (active surveillance) and responded to quickly and assertively. • The public health, infection control and health protection teams will require additional support for some time to come. • The national test and protect hub has supported Forth Valley cases from 07 July 2020. • The support to local care homes will continue. • The specialist health protection team has a vital role in ongoing pandemic response. • Planning attention is now turning to winter pressures and the combined impact of influenza, winter weather and Covid-19.

Financial Implications

Financial implications are difficult to accurately assess. Some elements of the test and protect response are also nationally funded. Cost will increase should there be any significant resurgence in Covid-19 activity in the population.

Workforce Implications

The initial staffing model to provide the test and protect service allowed the model to be flexed in response to demand allowing the training and deployment of additional teams of 5 (1 team leader and 4 Contact Tracers) as demand required.

This model will continue to be in place as a contingency but the core service will be provided by a combination of health protection nurses, consultants and the contact tracing staff. Sufficient trained staff are available to allow a core team of up to 25 contact tracers to be deployed within a matter of hours should this be required but will require recruitment and training of new staff.. Sufficient administrative support staff is required to record and report activity for a number of systems.

Additional specialist health protection and infection control nursing staff are likely to be required for the remainder of the pandemic.

Risk Assessment

A risk assessment has been produced and mitigation steps are summarised in this paper. A summary of risks identified include:

• A second wave remains possible and so public health measures will be lifted slowly and in a phased manner. • Staffing challenges and rapid changes can be managed with flexible model. • Recruitment and retention of staff over an extended period as the recovery process is implemented requiring deployed staff to be repatriated to substantive posts. • Unknowns around how the pandemic will evolve and impacts of new treatments and development of an appropriate vaccine.

Relevance to Strategic Priorities

This is relevant to the continued delivery of NHS Forth Valley’s Strategic objectives and the Public Health Scotland Act 2008.

Equality Declaration

The author can confirm that due regard has been given to the Equality Act 2010 and compliance with the three aims of the Equality Duty as part of the decision making process.

Further to an evaluation it is noted that:

• Paper is not relevant to Equality and Diversity

Consultation Process

NHS Scotland remains on an emergency footing. The approach is overseen by the System Leadership Team, the Contact Tracing Implementation Group and the Care Homes Oversight Group.

Coronavirus (COVID-19): Analysis

Coronavirus (COVID-19): modelling the epidemic in Scotland (Issue No. 10)

Background This is a report on the Scottish Government modelling of the spread and level of Covid-19. This updates the previous publication on modelling of Covid-19 in Scotland published on the 16 July 2020. The estimates in this document help the Scottish Government, the health service and the wider public sector plan and put in place what is needed to keep us safe and treat people who have the virus, e.g. to decide how many Intensive Care Beds (ICU) we need available for Covid patients.

This edition of the research findings also looks back over the period of the epidemic from February 2020 to the present time.

Key Points  Modelling by the Scottish Government estimates that on 17 July there were around 40 new infections and 500 people in Scotland who could be infectious with Covid-19. Both of these numbers have fallen significantly in the last week, with daily new infections reducing by 99.8% since the peak of the epidemic.  The modelling forecasts that the number of infectious people, the number of cases, hospital and ICU use and deaths are all likely to continue to fall over the next two weeks.  We currently use the value of R to talk about Covid-19 in Scotland. On 22 July, R in Scotland was estimated to be between 0.6 & 0.9.  These forecasts were based on estimates of moving in to phase 2 guidance, implemented from 18 June. Changes associated with the move to phase 3 will not be fully seen until early August. The longer term forecasts will be closely monitored against actual cases over the next few weeks as the situation changes.  Since the first modelled cases in February the epidemic has lasted 22 weeks during which an estimated total of 414,000 people have been infected with Covid in Scotland – 7.6% of the population.  Modelling shows the peak week for the spread of Covid-19 was 16-22 March with an estimated number of 99,000 people becoming infected.  The peak in hospital occupancy occurred on 19 April, and ICU occupancy on 12 April1.

Overview of Scottish Government Modelling

Epidemiology is the study of how diseases spread within populations. One way we do this is to use our best understanding of the way the infection is passed on and how it affects people who catch it to create a mathematical simulation. Because people who catch Covid-19 have a the relatively long period in which they can pass it on to others before they begin to have symptoms, and that the majority of people infected with the virus will experience mild symptoms, this “epidemiological modelling” provides insights into the epidemic that cannot easily be measured through testing e.g. of those with symptoms, as it estimates the total number of new daily infections and infectious people including those who are asymptomatic or have mild symptoms.

Modelling also allows us to make short-term forecasts of what may happen with a degree of uncertainty. These can be used in health care planning.

Modelling, based on deaths, suggests that the first infections in Scotland took place around 16 February, and by the time that the first confirmed case was positively identified on 1 March, 890 (400 – 1,650) people had already been infected in Scotland.

Since the first modelled infections in February the epidemic has lasted 22 weeks, during which an estimated total of 414,000 (329,500 – 518,500) people have been infected with Covid in Scotland – 7.6% (6.0 – 9.5%) of the population. This modelling derived estimate forms part of the picture on the number of people who have had Covid in Scotland2.

1 https://www.gov.scot/publications/coronavirus-covid-19-trends-in-daily-data/ 2 A report on a seroprevalence pilot study published by Public Health Scotland is also available. See https://beta.isdscotland.org/find-publications-and-data/population- health/covid-19/enhanced-surveillance-of-covid-19-in-scotland/

The estimated peak week for the spread of the infection was 16-22 March with 99,000 (79,000 – 123,000) people becoming infected. The peak in hospital occupancy occurred on 19 April, and ICU occupancy on 12 April.

Our modelling suggests weekly deaths peaking in the week of 13-19 April, with a simulated 690 (610 – 785) Covid-related deaths occurring during this period. This corresponds closely to the peak seen in the actual data, which occurs in the same week, at 6253. The forecast deaths from the model closely followed the trends seen in real data (Figure 1) providing confidence that the model has accurately reflected the progression of the epidemic.

Figure 1. Results from the model over four weeks, showing estimated deaths (blue) forecast deaths (pink) closely followed what was seen in the actual data (dots).

3 https://www.nrscotland.gov.uk/covid19stats

The current period of modelling shows we are seeing a low level of infections in Scotland, not seen since late-February. Based on modelling, an estimated 5 million people in Scotland have not yet been infected with Coronavirus - the majority of the population. This is why measures such as physical distances as laid out in “Coronavirus (Covid- 19): Scotland’s route map through and out of the crisis” are so critical to maintain, particularly as we move towards autumn and winter, when people are likely to be inside more, and light levels and temperature are lower. It is also why continuing to modelling the epidemic, and continually improve how we do this, is a crucial part of how we monitor our progress and what might happen next.

What the modelling tells us Figure 2 shows how Rt has changed since February. Before the “stay at home” restrictions were put in place Rt was above 1, and most likely to have been between 4 and 6 before any interventions were put in place.

Figure 2: Trends in Rt for Scotland, 2020

Source: Scottish Government modelled estimates using Imperial College model code; actual data from https://www.nrscotland.gov.uk/statistics-and-data/statistics/statistics-by-theme/vital- events/general-publications/weekly-and-monthly-data-on-births-and-deaths/deaths-involving- coronavirus-covid-19-in-scotland

The Rt value estimated by the Scottish Government falls within the range of values estimated by other modelling groups and considered by SPI-M and SAGE (Figure 3). SAGE’s consensus view, as of 22 July, was that the value of Rt in Scotland was between 0.6 and 0.9.

Figure 3. Estimates of Rt for Scotland, as of 22 July, including 90% confidence intervals, produced by SAGE. The estimate produced by the Scottish Government is the 6th from left (yellow), while the SAGE consensus range is the right-most (red).

Source: Scientific Advisory Group for Emergencies (SAGE).

The Scottish Government’s epidemiological model estimates that on 17 July there were around 40 new cases of Covid-19 in Scotland (see Table 1), while the number of people in Scotland who could be infectious on this date was around 500 (see Table 2). Our estimates indicate this number is declining by around 25% each week, and will continue to decline at a similar rate over the next two weeks.

Table 1: Estimated daily number of new Covid-19 cases in Scotland. Estimated new daily infections Date Mid Lower Upper 15 May 800 650 1,000 22 May 560 440 700 29 May 400 310 500 05 June 280 210 360 12 June 200 150 260 19 June 140 100 200 26 June 100 70 150 03 July 70 50 110 10 July 60 40 80 17 July 40 30 60 24 July 30 20 50 31 July 20 10 40

Table 2: Estimated number of people in Scotland who could be infectious. Estimated Infectious Pool Percentage Date Mid Lower Upper Weekly Change 15 May 10,400 8,400 12,800 - 22 May 7,200 5,700 8,900 -31% 29 May 5,000 3,900 6,300 -31% 05 June 3,500 2,700 4,500 -29% 12 June 2,500 1,900 3,500 -29% 19 June 1,800 1,300 2,400 -29% 26 June 1,300 900 1,800 -28% 03 July 900 600 1,300 -28% 10 July 700 400 1,000 -28% 17 July 500 300 800 -25% 24 July 400 200 600 -25% 31 July 300 200 400 -25%

Figure 4 shows the epidemiological model forecasts of daily deaths produced by the Scottish Government, given the present set of interventions. This measure of the epidemic has declined to a very low level.

Figure 4: Scottish Government short-term forecast of the number of deaths from Covid-19 in Scotland, based on actual data (17 July).

The short-term forecast of hospital beds required by Covid 19 patients in Scotland over the next two weeks is not included this week, as the numbers have fallen to a low level. Should these numbers begin to rise significantly this forecast will be reintroduced.

The medium term forecasts presented here will continue for the time being, and are fitted to trends in the historical data. Because it takes time for infected people to develop symptoms, require hospitalisation, and either die or recover, we will not fully see the effect of moving into phase 3 in our modelling until early August.

The medium-term forecasts produced by the Scottish Government (Figure 5 and 6) using the logistics model show a steady decline in the number of people requiring hospitalisation from Covid-19. The logistical model also provides us with a medium term forecast of the number of ICU beds which may be required (Figures 7 and 8).

The three scenarios presented in Figures 5 and 6 for hospital demand and Figure 7 and 8 for ICU demand are for different levels of daily infections. In each case, we translate these into logistical forecasts which are used for planning purposes.

The Worse and Better scenarios should not be considered an upper and lower bound respectively. It is important to note, in particular, that for planning reasons many of the assumptions used are deliberately precautionary, and so it is reassuring that actual case data are lower than the modelled estimate in the past, as is the case with the ICU admissions demand forecast in figures 6 and 8.

The number of hospital beds in use (Figure 5) is tracking above the worse scenario. This is likely to be due to Covid patients remaining in hospital for longer than expected.

Figure 5: Logistical model medium term forecast of the total number of people requiring a hospital bed from Covid-19 in Scotland, 17 July. Capacity is around 4,000.

Source: Scottish Government modelled estimates using outputs from the Imperial College model code, Source: Actual data from https://www.gov.scot/publications/coronavirus-covid-19-trends-in-daily-data/

Figure 6: Logistical model medium term forecast of admissions of people requiring a hospital bed from Covid-19 in Scotland, 17 July.

Figure 7: Logistical model medium term forecast of total number of people requiring an intensive care bed from Covid-19 in Scotland, 17 July. Capacity is around 700.

Figure 8: Logistical model medium term forecast of admissions of people requiring an intensive care bed from Covid-19 in Scotland, 17 July.

What next? The modelled estimates of the numbers of new cases and infectious people, along with how this relates to hospital and ICU requirements will be published each week. Where appropriate, Rt will also be provided. Further information can be found at https://www.gov.scot/coronavirus- covid-19

© Crown copyright 2020 You may re-use this information (excluding logos and images) free of charge in any format or medium, under the terms of the Open Government Licence. To view this licence, visit http://www.nationalarchives.gov.uk/doc/open- government-licence/ or e-mail: [email protected]. Where we have identified any third party copyright information you will need to obtain permission from the copyright holders concerned.

The views expressed in this report are those of the researcher and do not necessarily represent those of the Scottish Government or Scottish Ministers.

This document is also available from our website at www.gov.scot. ISBN: 978-1-83960-926-8

The Scottish Government St Andrew’s House Edinburgh EH1 3DG

Produced for the Scottish Government by APS Group Scotland PPDAS750606 (07/20) Published by the Scottish Government, July 2020

ISBN 978-1-83960-926-8

Web Publication

PPDAS750606 (07/20)

FORTH VALLEY NHS BOARD TUESDAY 28 JULY 2020

6.1 Healthcare Associated Infection Reporting Template For Assurance

Executive Sponsor: Prof Angela Wallace, HAI Executive Lead

Author: Mr Jonathan Horwood, Area Infection Control Manager

Executive Summary

The Healthcare Associated Infection Reporting Template (HAIRT) is mandatory reporting tool for the Board to have oversight of the HAI targets (Staph aureus bacteraemias (SABs), Clostridioides difficile infections (CDIs), device associated bacteraemias (DABs), incidents and outbreaks and all HAI other activities across NHS Forth Valley.

Recommendation

The NHS Board is asked to: • consider the HAIRT report • consider the performance in respect of the AOP Standards for SABs, DABs, CDIs & ECBs • note the detailed activity in support of the prevention and control of Health Associated Infection

Key Issues to be Considered

• CoVID-19 confirmed inpatients numbers have steadily decreased over the month. • SABS remain within normal control limits. There was one hospital acquired SAB in June. • DABs remain within control limits. There were no hospital acquired DABs in June. • CDIs remain within normal control limits. There were no hospital acquired CDIs in June. • ECBs remain within normal control limits There were no hospital acquired ECBs in June. • There have been no deaths with MRSA or C.difficile reported on death certificates. • There were no surgical site infections in June.

Financial Implications

None

Workforce Implications

None

Risk Assessment

Work is ongoing to continually reduce all reducible SABs, DABs, ECBs and CDI numbers across NHS Forth Valley.

Relevance to Strategic Priorities

AOP Standards in respect of SABs, ECBs, DABs & CDIs

• Staph aureus bacteraemia (SABs) There were 4 SABs this month. To date, trajectory for achieving the AOP target is being met. • Clostridioides difficile infection (CDIs) There was one CDI this month. To date, trajectory for achieving the AOP target is being met. • Escherichia coli bacteraemias (ECBs) There were 6 ECBs this month. To date, trajectory for achieving the AOP target is being met. • Device associated bacteraemias (DABs) There was one DAB this month. Hospital and healthcare DABs remain within control limits.

Equality Declaration

The author can confirm that due regard has been given to the Equality Act 2010 and compliance with the three aims of the Equality Duty as part of the decision making process.

Further to an evaluation it is noted that: • Paper is not relevant to Equality and Diversity

Consultation Process

Infection Prevention and Control Team

Healthcare Associated Infection Reporting Template (HAIRT) Page 2

Healthcare Associated Infection Reporting

Template (HAIRT)

June 2020

Healthcare Associated Infection Reporting Template (HAIRT) Page 3

HAI Summary

The HAIRT Report is the national mandatory reporting tool and is presented bi-monthly to the NHS Board. This is a requirement by the Scottish Government HAI task Force and informs NHS Forth Valley (NHSFV) of activity and performance against Healthcare Associated Infection Standards and performance measures.

This section of the report focuses on NHSFV Board wide prevention and control activity and actions.

SUMMARY FOR THIS MONTH • Over the last month there has been a further decrease in CoVID-19 inpatient numbers to less than five inpatients per day. Newly diagnosed inpatients on admission are less than one patient per day. • There have been no instances this month where CoVID-19 has been transmitted from one patient to another across hospital sites in FV. Figures released from Health Protection Scotland suggest NHS Forth Valley’s hospital acquired COVID-19 infections is 2.2% compared to the national average of 5.8%. • Health Protection Scotland has published Quarter 1 (Jan-Mar 20) SAB, CDI and ECB surveillance report and a summary is contained in this report • Escherichia coli bacteraemia infections exceeded control limits in May 2020 but have returned to normal expected levels this month. • Ward visit programme reporting has resumed and results are contained in this report. • Graphs printed off in the wards will now show SABs, DABs and ECBs as ward acquired bacteraemias. • HEI Inspections were suspended as a result of the pandemic, however communication in June from the Inspectorate stated unannounced inspections will resume in July with a focus on community hospitals. Performance at a glance No of Cases Month RAG RAG status toward AOP target (based on status trajectory to March 2022) Staphylococcus aureus bacteraemia (SABs) 4 ↓ Clostridioides difficile infection (CDIs) 1 ↓ Escherichia coli Bacteraemia (ECB) 6 ↓ Device associated bacteraemia (DABs) 6 Hand Hygiene (SPSP) 99% National Cleaning compliance (Board wide) 96% National Estates compliance (Board wide) 94% Surgical Site Infection Surveillance (SSIS) 0 Key infection control challenges (relating to performance)

Staph aureus bacteraemia • There was one hospital acquired SABs this month associated with pre-existing skin lesions. • There were three healthcare acquired SABs attributed to discitis, unknown cause and wound related.

Device associated bacteraemia • There were no hospital acquired DABs this month. • There was one healthcare acquired DABs this month attributed to a permacatheter.

E coli bacteraemia • There were no hospital acquired ECBs this month. • There were 6 healthcare acquired ECBs this month attributed to urinary tract infections (2),biliary tract (2), an unknown source and an intra-abdominal infection.

Clostridioides difficile infection • There were no hospital acquired CDIs this month. • There was healthcare acquired CDI and attributed antimicrobial therapy.

Surgical site infection surveillance • There were no surgical site infections this month.

Key HAI related activities • There were no MRSA or C difficile recorded deaths were reported this month.

Healthcare Associated Infection Reporting Template (HAIRT) Page 4

Glossary of abbreviations

Following feedback from stakeholders below is a list of abbreviations used within this report: HAI - Healthcare Acquired Infection SAB – Staphylococcus aureus bacteraemia DAB – Device Associated Bacteraemia CDI – Clostridioides Infection AOP – Annual Operational Plan NES – National Education for Scotland IPCT – Infection Prevention & Control Team HEI – Healthcare Environment Inspectorate SSI – Surgical Site Infection SICPs – Standard Infection Control Precautions PVC - Peripheral Vascular Catheter

Definitions used for Staph aureus, device associated and E coli bacteraemias

Definition of a bacteraemia Bacteraemia is the presence of bacteria in the blood. Blood is normally a sterile environment, so the detection of bacteria in the blood (most commonly accomplished by blood cultures) is always abnormal. It is distinct from sepsis, which is the host response to the bacteria. Bacteria can enter the bloodstream as a severe complication of infection (like pneumonia, meningitis, urinary tract infections etc), during surgery, or due to invasive devices such as PVCs, Hickman lines, urinary catheters etc. Transient bacteraemias can result after dental procedures or even brushing of teeth although this poses little or no threat to the person in normal situations.

Bacteraemia can have several important health consequences. The immune response to the bacteria can cause sepsis and septic shock, which has a high mortality rate. Bacteria can also spread via the blood to other parts of the body (haematogenous spread), causing infections away from the original site of infection, such as endocarditis (infection of the heart valves) or osteomyelitis (infection of the bones). Treatment for bacteraemia is with antibiotics for many weeks in some circumstances, however cases such as Staph aureus bacteraemia usually 14 days of antibiotic therapy is required.

Cause definitions for Staph aureus and device associated bacteraemia Hospital acquired • Hospital acquired is defined when a positive blood culture is taken >48 hours after admission ie the sepsis is not associated with the cause of admission. An example would a patient with sepsis associated from an infected peripheral vascular catheter. Healthcare acquired • Healthcare acquired is defined when a positive blood culture is taken <48 hours after admission but has in the last three month had healthcare intervention such as previous hospital admission, attending Clinics, GP, dentist etc. Note this does not necessarily mean that the sepsis is associated with the previous healthcare intervention. Nursing home acquired • Nursing home acquired is defined when a positive blood is taken <48 hours after admission and when symptoms associated with sepsis developed at the nursing home

Healthcare Associated Infection Reporting Template (HAIRT) Page 5

Key challenges this month

CoVID-19

The IPCT has been monitoring and reporting on a daily basis current inpatient numbers of confirmed and those investigated for CoVID-19. Over the last month we have seen a further decrease in inpatient numbers to less than five inpatients per day with less than one newly diagnosed inpatient per day. See graphs below.

Graph of inpatients with confirmed and those investigated for SPC chart of newly confirmed inpatient cases of CoVID-19 CoVID-19

Inpatient CoVID-19 Confirmed and investigated for CoVID-19 SPC Chart for newly diagnosed inpatients 1st April - Date 80 16 70 14 60 12 50 10 40 No. of newly confirmed cases in hospital 30 CoVID Confirmed 8 Mean 6 2sd 20 CoVID Investigated of Cases No No of of inpatients No 10 4 0 2 0

Hospital onset COVID-19

On a weekly basis Health Protection Scotland publish infection figures based on electronic data submitted to them on the rate of COVID-19 infection that has been acquired during the patients hospital stay. This is calculated solely based on the time the patient was admitted to the hospital and the incubation period of COVID-19 (14 days). For example, if a patient stay has exceeded 14 days and became COVID-19 positive after day 14 then it is determined to be hospital acquired. Based on purely on admission times does not necessary mean hospital acquired, however, these are the limitations of the data and the report.

The table below is an extract from the report detailing COVID-19 infections and where they were acquired. NHSFV current hospital infection is 2.2% compared to the national percentage infections of 5.8%. There has been no hospital acquired COVID-19 reported this month.

Healthcare Associated Infection Reporting Template (HAIRT) Page 6

HAI Surveillance

NHS FV has systems in place to monitor key targets and areas for delivery. Our surveillance and HAI systems and ways of working allow early detection and indication of areas of concern or deteriorating performance. The Infection Prevention & Control Team undertakes over 180 formal ward audits per month in addition to regular weekly ward visits by the Infection Control Nurse; infection investigation is also a significant function within the team as part of our AOP target reporting. This activity provides robust intelligence of how infection prevention is maintained across all areas in Forth Valley and is reported on a monthly basis to all appropriate stakeholders.

Staph aureus bacteraemias (SABs)

All blood cultures that grow bacteria are reported nationally and it was found that Staph aureus became the most common bacteria isolated from blood culture. As Staph aureus is an organism that is found commonly on skin it was assumed (nationally) the bacteraemias occurred via a device such as a peripheral vascular catheter (PVC) and as such a national reduction strategy was initiated and became part of the then HEAT targets in 2006. The target was a national reduction rather than a board specific reduction, however the latest target set for 2019-2022 are board specific, based on our current infection rates.

NHS Forth Valley’s approach to SAB prevention and reduction

All Staph aureus bacteraemia are monitored and reported by the IPCT. Investigations to the cause of infection consist of examining the patients notes, microbiology, biochemistry and haematology reports to identify potential causes of the infection; from this, in most cases, a provisional cause is identified, however this is discussed further with the clinical team responsible for the management of the patient to assist further with the investigation. Any issues identified during the investigations, such as incomplete bundle completion etc is highlighted at this time and where appropriate an IR1 is reported. Once a conclusion has been agreed, the investigations are presented to the Infection Control Doctor/Microbiologist for approval. The investigation is concluded with the IPCT reporting their findings to the clinical team and management.

This data is entered into the IPCT database collated, analysed and reported on a monthly basis. The analysis of the data enables the IPCT to identify trends in particular sources of infections, such as Hickman line infections etc and identifying areas requiring further support. The data also influences the direction of the HAI annual workplan.

SPC chart monthly SAB totals June 2020 April 2014 - Date 16 14

Monthly Total 4 10

SAB Nos Hospital 1 8 SAB Mean SAB Nos SAB 2 Std Dev Healthcare 3 6 2 Std Dev Nursing Home 0 4 2

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May May May May May May RAG Status - Green denotes monthly case numbers are less than the mean May monthly SAB totals. Amber denotes when monthly case numbers are above the mean monthly SAB totals but less than two standard deviations from the mean. Red denotes monthly case numbers are above two Comments: standard deviations from the monthly mean. Case numbers remain within control limits, no concerns to raise. Staph aureus bacteraemia total - June 20 to date – 14

Healthcare Associated Infection Reporting Template (HAIRT) Page 7

Hospital SABs Healthcare SABs April 2014 - Date April 2014 to date 12 10

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There were 518 blood cultures taken this month, of June Breakdown those there were in total 4 blood cultures that grew Staph aueus. This accounts for 0.8% of all blood Source No of Cases cultures taken this month. Hospital acquired SABs Healthcare 3 account for 0.2% of all blood cultures taken. Discitis 1 Unknown 1 There was one hospital acquired SABs this month. Wound 1 This was associated with pre existing skin lesions prior Hospital 1 to admission. Ulcer 1 No attributed ward 1 Directorate reports and graphs can be accessed using Grand Total 4 the following link: http://staffnet.fv.scot.nhs.uk/index.php/a-z/infection- control/monthly-ward-reports/

National Context All SABs are reported nationally and reported on a quarterly basis. This provides our board an overview and national context of our national position compared to other boards. Due to the national reporting, unfortunately the data publish is 3 months in arrears compared to the local data presented. The funnel plots below are based on the new national AOP targets ie hospital and healthcare are represented as healthcare and provides an indication of FVs position nationally. Below is an extract from the HPS Quarter 1 report (Jan – Mar 20) highlighting Forth Valley’s position compared to all other boards in Scotland.

Figure 5: Funnel plot of SAB incidence rates (per 100,000 TOBD) in healthcare associated infection cases for all NHS boards in Scotland in Q1 2020.1,2

1. Source of data is Electronic Communication of Surveillance in Scotland (ECOSS) & Total occupied bed days: Information Services Division ISD(S)1. 2. NHS Ayrshire & Arran and NHS Tayside overlap.

Healthcare Associated Infection Reporting Template (HAIRT) Page 8

Device Associated Bacteraemias (DABs)

In addition to the nationally set targets, infections from an invasive device caused by Staph aureus would be investigated fully and reported, any other organism causing the same infection was not mandated to report nationally or to be investigated. As a result of this, in 2014, the IPCT started reporting all bacteraemias attributed to an invasive device regardless of the bacterium causing the infection. Due to the importance and significance of this surveillance, it is now part of our local AOP.

NHS Forth Valley’s approach to DAB prevention and reduction

Continual monitoring and analysis of local surveillance data enables the IPCT and managers to identify and work towards ways to reduce infections associated with devices. All DABs are reviewed and investigated fully and highlighted to the patients’ clinicians, nursing staff and management. Where appropriate an IR1 is generated to enable infections that require learning is shared and discussed at local clinical governance meetings.

In addition, on a weekly basis the IPCT assess bundle compliance of three invasive devices (PVCs, urinary catheters, CVCs etc) as part of their ward visit programme and this is reported in the monthly Directorate Reports.

June 2020 SPC Chart monthly DAB totals Apr 14 - Date Monthly Total 1 16 Hospital 0 14 Healthcare 1 12 10 Nursing Home 0 DAB Nos 8 DAB Mean

DAB NosDAB 2 Std Dev 6 2 Std Dev 4

RAG Status - Green denotes monthly case numbers are less than the mean 0 monthly CDI totals. Amber denotes when monthly case numbers are above the monthly mean but less than two standard deviations from the monthly mean. Comments: Red denotes monthly case numbers are above two standard deviations from the monthly mean. Case numbers remain within control limits, no concerns to raise. Device associated bacteraemia total - June 20 to date - 13

Hospital DABs Healthcare DABs April 14 - Date April 14 - Date 10 8

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DAB Mean SAB Mean Case Nos Case No of cases of No 4 2 Std Dev 3 2 Std Dev 3 2 2

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May May May Comments: Comments: Case numbers remain within control limits, no concerns to raise. Case numbers exceed control limits, see narrative below.

Healthcare Associated Infection Reporting Template (HAIRT) Page 9

June Breakdown

Source No of Cases Healthcare 1 Permacath 1

Grand Total 1

Action Taken

There were 518 blood cultures taken this month, of those there were in total 1 blood cultures that were positive and attributed to a device. This accounts for 0.2% of all blood cultures taken this month.

Hospital DABs • There were no hospital acquired DABs reported this month

Healthcare DABs • Permacatheter infection – Following investigation, the patient had a history of removing the dressing from the catheter which is suspected the cause of the infection.

Directorate reports and graphs can be accessed using the following link: http://staffnet.fv.scot.nhs.uk/index.php/a-z/infection-control/monthly-ward-reports/

The graphs above provide an overview of the number of device associated bacteraemias, however, it doesn’t provide sufficient detail of the individual device and whether the number of infections have exceeded control limits. Below are graphs relevant to the identified devices for this month.

Healthcare – Permacatheter Permacatheter infections Healthcare Permacatheter DABs April 17 - Date 3 The SPC chart above shows a consistent number of infections over the last several months. The IPCT

2 will liaise with the Renal Department to assess

DAB Nos these infections to understand and identify any

Axis Title Axis DAB Mean 1 2 Std Dev potential opportunities to reduce infection incidence.

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Comments: Case numbers remain within control limits, no concerns to raise.

Healthcare Associated Infection Reporting Template (HAIRT) Page 10

Escherichia coli Bacteraemia (ECB)

NHS Forth Valley’s approach to ECB prevention and reduction E coli is one of the most predominant organism of the gut flora and for the last several years the incidence of Ecoli isolated from blood cultures ie causing sepsis, has increase so much that it is the most frequently isolated organism in the UK. As a result of this, the HAI Policy Unit has now included E coli as part of the AOP targets. The most common cause of E coli bacteraemia (ECB) is from complications arising from urinary tract infections (UTIs), hepato-biliary infections (gall bladder infections) and urinary catheters infections.

In NHS FV, device associated bacteraemias (DABs) surveillance has been ongoing since 2014 and have seen a reduction in urinary catheter bacteraemias over the years including Ecoli associated infections and will hope to continue to reduce so to achieve our target for 2022.

June 2020 Total No of ECBs 18 16 Monthly Total 6 14 12 ECB Nos Hospital 0 10 ECB Mean 8

Healthcare 6 2 Std Dev No of CasesNo 6 2 Std Dev 4 2 0 E coli bacteraemia infection total – June 20 to date - 27 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Apr-20 May-20 Jun-20 Comments: case numbers remain within control limits, no concerns to raise.

Total No of Hospital acquired ECBs Total No of Healthcare acquired ECBs 9 14

8 12 7 10 6 8 ECB Nos 5 ECB Nos ECB Mean ECB Mean

4 6 2 Std Dev No of of cases No

No of of cases No 2 Std Dev 3 2 Std Dev 4 2 2 1 0 0 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Apr-20 May-20 Jun-20 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Apr-20 May-20 Jun-20 Comments: case numbers remain within control limits, no Comments: case numbers remain within control limits, no concerns to raise. concerns to raise. June Breakdown Action Taken There were 518 blood cultures taken this month, of those Source No of Cases there were in total 16 blood cultures that grew E. coli. This Healthcare 6 accounts for 1.2% of all blood cultures taken this month.

Biliary tract 2 Hospital ECBs Intra abdominal 1 There were no Hospital ECBs reported this month. Unknown 1

UTI 2 Healthcare ECBs – May 2020 data excedance Grand Total 6 In May 2020 healthcare ECBs exceeded control limits and the number of cases was the highest since reporting started. The predominant increases were urinary/urinary catheter sourced and unknown causes. Investigations did not identify common or related causes for these infections. Directorate reports and graphs can be accessed using As these infections developed in the community it could be the following link: speculated that given the current Covid-19 pandemic, http://staffnet.fv.scot.nhs.uk/index.php/a-z/infection- patient apprehensions to seek early medical attention might have been the reason for this increase. Fortunately control/monthly-ward-reports/ this month, case numbers have return to normal and within expected control limits.

Healthcare Associated Infection Reporting Template (HAIRT) Page 11

National Context

All ECBs are reported nationally and reported on a quarterly basis. This provides our board an overview and national context of our national position compared to other boards. Due to the national reporting, unfortunately the data publish is 3 months in arrears compared to the local data presented. The funnel plots below are based on the new national AOP targets ie hospital and healthcare are represented as healthcare and provides an indication of FVs position nationally. Below is an extract from the HPS Quarter 1 report (Jan – Mar 20) highlighting Forth Valley’s position compared to all other boards in Scotland.

Figure 3: Funnel plot of ECB incidence rates (per 100,000 TOBD) in healthcare associated infection cases for all NHS boards in Scotland in Q1 2020.1,2

1. Source of data is Electronic Communication of Surveillance in Scotland (ECOSS) & Total occupied bed days: Information Services Division ISD(S)1. 2. NHS Orkney and NHS Western Isles overlap.

Healthcare Associated Infection Reporting Template (HAIRT) Page 12

Clostridioides difficile infection (CDIs)

Following the Vale of Leven outbreak in 2007 where 131 patients were infected with C. difficle resulting in 34 deaths, it became mandatory for all health boards to monitor, investigate and report all infections associated with C. difficle. NHSFV has met its targets over the years and has maintained a low rate of infection. Similar to the SAB target, the new target set for 2019-2022 is based on Forth Valley’s rate rather than an overall national rate.

C. difficile can be part of the normal gut flora and can occur when patients receive broad spectrum antibiotics which eliminate other gut flora allowing C. difficile to proliferate and cause infection. This is the predominant source of infection in Forth Valley. C. difficile in the environment can form resilient spores which enable the organism to survive in the environment for many months and poor environmental cleaning or poor hand hygiene can lead to the organism transferring to other patients leading to infection (as what happened in the Vale of Leven hospital). Another route of infection is when patient receive treatment to regulate stomach acid which affects the overall pH of the gut allowing the organism to proliferate and cause infection.

Cause definitions for Clostridioides difficile infections

Hospital acquired • Hospital acquired is defined when symptoms develop and confirmed by the laboratory >48 hours after admission which were not associated with the initial cause of admission. Healthcare acquired • Healthcare acquired is defined as having symptoms that develop and confirmed by the laboratory prior to or within 48 hours of admission and has in the last three months had healthcare interventions such as previous hospital admission, attending Clinics, GP, dentist etc Nursing home acquired • Nursing home acquired is defined as having symptoms that develop and confirmed by the laboratory that developed at the nursing home prior to admission

NHS Forth Valley’s approach to CDI prevention and reduction Similar to our SABs and DABs investigation, patient history is gathered including any antibiotics prescribed over the last few months. Discussion with the clinical teams and microbiologists assist in the determination and conclusion of the significance of the organism, as sometimes the organism isolated can be an incidental finding and not the cause of infection. Data is shared with the antimicrobial pharmacist and cases are discussed at the Antimicrobial Management Group to identify inappropriate antimicrobial prescribing.

SPC Chart Monthly CDI totals June Breakdown April 14 - Date

Monthly Total 1 10 9 Hospital 0 8 7 Healthcare 1 6 CDI Nos 5 CDI Mean Nursing Home 0 nos CDI 4 2 Std Dev 3 2 1

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Aug Aug RAG Status - Green denotes monthly case numbers are less than the mean Aug monthly CDI totals. Amber denotes when monthly case numbers are above the monthly mean but less than two standard deviations from the monthly mean. Red denotes monthly case numbers are above two standard deviations from the monthly mean. Comments: Case numbers remain within control limits, no concerns Clostridioides difficile infection total - June 20 to date - 6 to raise.

Healthcare Associated Infection Reporting Template (HAIRT) Page 13

Healthcare acquired CDIs Hospital acquired CDIs April 2014 - Date April 14 - Date 9 4.5 8

4 7 3.5 6 3 2.5 5 Hospital CDI Nos HealthcareCDI Nos 2 Nos CDI 4 CDI Mean CDI Mean No of of Cases No 2 Std Dev 1.5 2 Std Dev 3 1 2 0.5

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Apr Apr Apr Comments: Comments: Case numbers remain within control limits, no concerns to Case numbers remain within control limits, no concerns raise. to raise. June Breakdown Action Taken There was no hospital CDIs reported this month. Source No of Cases The healthcare CDI was attributed to Healthcare 1 antimicrobial therapy. Directorate reports and graphs can be accessed Grand Total 1 using the following link:

http://staffnet.fv.scot.nhs.uk/index.php/a- z/infection-control/monthly-ward-reports/

National Context

All CDIs are reported nationally and reported on a quarterly basis. This provides our board an overview and national context of our national position compared to other boards. Due to the national reporting, unfortunately the data publish is 3 months in arrears compared to the local data presented. The funnel plots below are based on the new national AOP targets ie hospital and healthcare are represented as healthcare and provides an indication of FVs position nationally. Below is an extract from the HPS Quarter 1 report (Jan – Mar 20) highlighting Forth Valley’s position compared to all other boards in Scotland.

Figure 1: Funnel plot of CDI incidence rates (per 100,000 TOBD) in healthcare associated infection cases for all NHS boards in Scotland in Q1 2020.1,2

1. Source of data is Electronic Communication of Surveillance in Scotland (ECOSS) & Total occupied bed days: Information Services Division ISD(S)1. 2. NHS Orkney and NHS Shetland overlap.

Healthcare Associated Infection Reporting Template (HAIRT) Page 14

AOP TARGETS

New HAI AOP targets for 2019-2022 On the 10th October 2019, a letter was sent to all Health Board Chief Executives highlighting our new HAI targets. These targets are based on our (Forth Valley) current rates of infection and a percentage reduction has been set to be achieved by March 2022. This target is different from our previous targets and includes the reduction in hospital and healthcare acquired infections and does not include community acquired. (note, community acquired infections are included in this report. The data will be adjusted in next and subsequent reports). Hospital and healthcare acquired infections are now classified as healthcare infections as it is perceived nationally that all hospital and healthcare infections are all reducible. For continuity, we will continue to report separately hospital and healthcare infections to maintain our quality and transparency in our data, however, the total number of infections will reflect on what we are reported nationally and in line with our set targets. In addition to SABs and CDIs targets, Escherichia coli bacteraemia (ECB) is now included in our targets.

The data is currently being reformatted to address these targets and will be included in future reports. Please see table below for our new targets:

2018/19 Rate (base No of cases Target line) per 100,000 (per Date for Target rate per 100,000 cases per total bed days annum) Reduction % reduction total bed days annum

ECB 40.8 135 25 2022 30.6 101 SAB 16.6 55 10 2022 14.9 50 CDI 11.4 38 10 2022 10.3 34

AOP target progress to date

AOP Target AOP Target E coli Bacteraemia rate per 100,000 Occupied bed days SAB bacteraemia rate per 100,000 total occupied bed days June 19 - Date June 19 - Date 35 80 30 70 Rate 60 25 Rate 50 Expected 20 Tragectory to Expected Tragectory to

40 Target Rate 15 Target Rate 30 10 20 5 10

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Rate CDI ↓ Rate 10.00 Expected Tragectory Comments to Target 5.00 Last month saw a sharp increase in healthcare

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Mar Mar Mar May May infection rates have now return to normal expected levels. Comments: Reduction is on trajectory. No concerns to raise.

Healthcare Associated Infection Reporting Template (HAIRT) Page 15

Surgical Site Infection Surveillance (SSIS)

Surgical site infection surveillance is the monitoring and detection of infections associated with a surgical procedure. In Forth Valley, the procedures include, hip arthroplasty, Caesarean section, abdominal hysterectomy, major vascular surgery, large bowel, knee arthroplasty and breast surgeries. We monitor patients for 30 days post surgery including any microbiological investigations from the ward/GP for potential infections and also hospital readmissions relating to their surgery. Any infection associated with a surgical procedure is reported nationally to enable board to board comparison. NHS Forth Valley infection rates are comparable to national infection rates.

NHS Forth Valley’s approach to SSI prevention and reduction Surgical site infection criteria is determined using the European Centre for Disease Control (ECDC) definitions. Any infection identified is investigated fully and information gathered including the patients weight, duration of surgery, grade of surgeon, antibiotics given, theatre room, elective or emergency etc can provide additional intelligence in reduction strategies. The IPCT monitor closely infection rates and any increases of SSIs are reported to management and clinical teams to enable collaborative working to reduce infection rates.

June Breakdown Caesarean Section Procedure Confirmed SSI Caesarean Section Total Numbers including SSIs April 2020 - March 2021 90 Abdominal Hysterectomy (v) 0 80

70 Breast Surgery (v) 0 60 No of C-sections 50 Caesarean Section (m) 0 No of C-section SSI 40 Infections 30

Knee Arthroplasty (v) 0 20

Hip Arthroplasty (m) 0 0

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Large Bowel Surgery (m) 0

Comments: case numbers remain within control limits, no concerns to raise. Abdominal Hysterectomy Hip Arthroplasty

Abdominal Hysterectomy Total Numbers including SSIs Hip Arthroplasty Total Numbers including SSIs April 2020 - March 2021 April 2020 - March 2021 7 8

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Knee Arthroplasty Total Numbers including SSIs Breast Surgery Total Numbers including SSIs April 2020 - March 2021 April 2020 - March 2021 4 35

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Healthcare Associated Infection Reporting Template (HAIRT) Page 16

concerns to raise. concerns to raise. Large Bowel Surgery Recent publications from Health Protection Scotland Large Bowel Surgery Total Numbers including SSIs highlight NHSFV SSI rates for C-Section and hip April 2020 - March 2021 arthroplasties are below national infection rates. 5 Large bowel surgery national comparison will be 4 available later this year.

No of Large Bowel Surgeries 2 No national comparison can be made for breast, No Large Bowel SSI Infections knee arthroplasty and abdominal hysterectomy as 1 these are voluntary reported surveillance.

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Meticillin resistant Staphylococcus aureus (MRSA) & Clostridioides difficile recorded deaths

The National Records of Scotland monitor and report on a variety of deaths recorded on the death certificate. Two organisms are monitored and reported, MRSA and C. difficile. Please click on the link below for further information:

https://www.nrscotland.gov.uk/statistics-and-data/statistics/statistics-by-theme/vital-events/deaths

This month, there were no deaths where Clostridioides difficile or MRSA was recorded on the death certificate.

SPSP Hand Hygiene Monitoring Compliance (%) Board wide

Data taken from TCAB (self reported by ward staff) July Aug Sept Oct Nov Dec Jan Feb Mar Apr May June 2019 2019 2019 2019 2019 2019 2020 2020 2020 2020 2020 2020 Board 99 99 98 98 98 98 95 99 99 99 99 99 Total

HEI Inspection Preparation

As a result of the COVID-19 pandemic, in April, the HEI Inspectorate decided to suspend all unannounced inspections across Scotland. As case numbers decline and Scotland is now in phase 3, the Inspectorate announced that inspections will resume in July with a predominant focus on Community Hospitals. Stakeholders are aware and assurance checks are being performed in all areas to ensure all sites are HEI inspection ready.

Healthcare Associated Infection Reporting Template (HAIRT) Page 17

Estate and Cleaning Compliance (per hospital)

The data is collected through audit by the Domestic Services team using the Domestic Monitoring National Tool and areas chosen within each hospital is randomly selected by the audit tool. Any issues such as inadequate cleaning is scored appropriately and if the score is less than 80% then a re-audit is scheduled. Estates compliance is assessed whether the environment can be effectively cleaned; this can be a combination of minor non-compliances such as missing screwcaps, damaged sanitary sealant, scratches to woodwork etc. The results of these findings are shared with Serco/Estates for repair. Similar to the cleaning audit, scores below 80% triggers a re-audit.

Estates & Cleaning Scores April – June 2020

FCH FCH 97% 87%

SCV Bo'ness SCV Bo'ness 97% 94% 95% 91% Board Board Total Total 97% 97% CCHC Bellsdyke CCHC Bellsdyke 93% 99% 93% 87%

FVRH FVRH 97% 98%

Cleaning Compliance Estates Compliance

Bellsdyke Hospital & Falkirk Community Hospital Estate Scores

This quarter the estate score from Bellsdyke Hospital and Falkirk Community Hospitals were 87% and 87% respectively, compared to the previous quarter of 83% and 88% respectively. Both sites have similar issues highlighted including damage to fittings, flooring and paintwork. These issues are reported to Estates and monitored through the Facilities & Infrastructure Compliance Group. See below for details.

Facilities & Infrastructure Compliance Group

The Facilities & Infrastructure Compliance Group was set up in January 2020 by Morag Farquhar, Associate Director of Facilities & Infrastructure. The group aims to meet bi-monthly and any estates issues will be raised at this meeting. Minutes of this meeting will be sent to various stakeholders including the Area Prevention and Control of Infection Committee. The estates scores in some of the community hospitals are amber as detailed above will be raised through this group. The next meeting will be held July 2020.

Healthcare Associated Infection Reporting Template (HAIRT) Page 18

Ward Visit Programme

Below are table and graphs detailing the non-compliances identified during the ward visits.

Managing Safe Patient Hand Patient Care Control of the Safe Management Disposal of Placement Hygiene PPE Equipment Environment of Linen Waste Totals Acute Services 0 0 3 36 19 12 18 88 Primary Care & Mental Health Services 0 2 5 13 29 2 2 53 WC&SH Directorate 0 0 1 2 1 0 1 5 Totals 0 2 8 49 48 14 20 146

All non-compliances are fed back to the nurse in charge immediately following the ward visit. A follow-up email is also sent to the ward and service manager. Details of each non-compliance are reported in the monthly HAI Service Reports.

Rolling totals for each service will be available in the next HAIRT report.

Acute Services

Managing patient care equipment remain the most predominant non-compliance with missing labels to identify when the equipment is cleaned most common. Primary Care & Mental Health Services

Control of the environment was the most predominant non- compliance this month. This includes storage and the fabric of the buildings

Healthcare Associated Infection Reporting Template (HAIRT) Page 19

Women, Children & Sexual Health Services Total no. of non compliances by SICP Breakdown of total no. of non compliances by ward June 2020 June 2020 3 4

WC&SHS Total

1 1

WARD 7 WARD WARD 8 WARD Personal Protective Equipment Managing Patient Care Equipment Control of the Environment Safe Disposal of Waste 6 WARD Non-compliances remain very low. No concerns identified this month

Incidence/Outbreaks

Incidence and outbreaks across NHSFV are identified primarily through ICNet, microbiology or from the ward. ICNet is the IPCT data management system that automatically identifies clusters of infections and specific organisms such as MRSA, admission of patients with known infections etc to enable timely patient management to prevent any possible spread of infection. The identification of outbreaks is determined following discussion with the Microbiologist. In the event of a declared outbreak a Problem Assessment Group or Incident Management Team meeting is held with staff from the area concerned and actions are implemented to control further infection and transmission.

There have been no outbreaks notified to Health Protection Scotland and Scottish Government (see below for further details).

Healthcare Acquired Infection Incident Reporting Template (HAIIRT)

The HAIIT is a tool used by boards to assess the impact of an incident or outbreak. The tool is a risk assessment and allows boards to rate the incident/outbreak as a red, amber, or green. The tool also directs boards whether to inform Health Protection Scotland/SGHD of the incident (if amber or red), release a media statement etc.

HAIIT Green – None reported this month

HAIIT Amber – None reported this month

HAIIT Red – None reported this month

IPCT Support to Care Homes

Scottish Government informed health boards across Scotland of enhanced professional clinical and care oversight of care homes and instructs each board to provide expert clinical support to care in particular focusing on infection prevention and control. As a result of this, the IPCT are working closely with public health, HSCP and Care Commission staff to provide such guidance and support to care homes.

In conclusion the NHS Board is asked to:

• Note the HAIRT report • Note the performance in respect of the AOP Standards for SABs, DABs, ECBs & CDIs • Note the detailed activity in support of the prevention and control of Health Associated Infection

Healthcare Associated Infection Reporting Template (HAIRT) Page 20

FORTH VALLEY NHS BOARD TUESDAY 28 JULY 2020

6.2 Forth Valley Primary Care Improvement Plan For Assurance

Executive Sponsor: Mrs Cathie Cowan, Chief Executive

Author: Dr Stuart Cumming, Primary Care Improvement Plan and GP Clinical Lead; Kathy O’Neill, General Manager

Executive Summary

The early and significant momentum gained in Forth Valley in the first two years of Primary Care Improvement Plan remains central to maintaining the conditions currently in place. Iteration 3 of the plan includes an introductory tripartite statement and details the local requirements to deliver the Memorandum of Understanding to implement the 2018 GMS Contract.

Recommendation

The Forth Valley NHS Board is asked to:

• endorse iteration 3 of the Forth Valley Primary Care Improvement Plan

Key Issues to be Considered

Delivery of the new GMS contract by April 2021, is an ambitious programme of change, however, Forth Valley is on a clear trajectory, subject to funding availability, to successfully deliver the Primary Care Improvement Plan and achieve practical implementation of the Memorandum of Understanding priorities by or very soon after April 2021.

Iteration 3, submitted to the Scottish Government on 20 July, outlines the significant positive incremental progress and scale of the work carried out across all priority workstreams. All stakeholders across Forth Valley endorse this as being crucial to the sustainability of general practice and wider community services.

Despite the challenging situation due to COVID-19 all work streams of the Primary Care Improvement Plan are actively moving forward with recruitment and service development continuing.

It is anticipated that the Tripartite Statement, within the introduction of the plan, enables Forth Valley tripartite partners to:

• maintain their collective representation to Scottish Government that they are united in the view that the priorities and revised service specifications described in Iteration 3 of Forth Valleys Primary Care Improvement Plan • continue to set out what is believed to be essential to deliver the commitments of the Memorandum of Understanding by (or soon after) April 2021

However, partners also agree that the cost of fully delivering the requirements of the new GMS contract continues to exceed the indicative revenue funding allocation provided by the Scottish Government, and without further national funding is not fully deliverable.

It should be noted that Falkirk IJB, Clackmannanshire and Stirling IJB and the GP sub-committee have approved the Primary Care Improvement Plan Iteration 3 within the context of the tripartite statement. The System Leadership Team also considered the Plan and recommend the NHS Board endorse iteration 3 of the Forth Valley Primary Care Improvement Plan.

Financial Implications

Primary Care Improvement Plan iteration 3 reflects a continual focus on cost effectiveness and best value. The finance plan indicates that the year 3 (20/21) funding gap has reduced to a more balanced picture for 2020/21. The recurrent projected overspend beyond 2021 remains. A summary of the financial position is set out within the financial plan at Appendix 2

Workforce Implications

Workforce issues are detailed within the plan.

Risk Assessment

There are detailed risk assessments in place to support the Primary Care Improvement Plan Programme of Change with a risk register and mitigation plan maintained for the programme. Non delivery of the contract brings with it significant risk in terms of general practice sustainability and significant challenge to sustaining the strong collaborative relationships between stakeholders. This risk is notable and high on both IJB and NHS Board risk registers.

IT and Premises are also included in the NHS Board’s Risk Register.

Relevance to Strategic Priorities

Investing in Primary Care, delivering the new GMS contract and supporting sustainability of GP Services is a key Scottish Government, NHS Forth Valley and Integration Joint Board priority. Commitment to implementing PCIP in full is part of the Health Board’s Annual Operating Plan and a priority for both HSCP strategic plans.

Equality Declaration

The author can confirm that due regard has been given to the Equality Act 2010 and compliance with the three aims of the Equality Duty as part of the decision making process.

Further to an evaluation it is noted that:

• Paper is not relevant to Equality and Diversity

Consultation Process

• Primary Care Improvement Plan Steering Group which included representation from the Tripartite Partners. • Primary Care Programme Board • GP Sub Committee of Forth Valleys Local Medical Committee • Integration Authorities

Forth Valley Primary Care Improvement Plan

2018 to 2021

Iteration 3 June 2020

DRAFT

Iteration 3 DRAFT V3.7_ 2020

Contents Page Tripartite Statement 3 PCIP Iteration 3 Overview 5

1. Background 6 2. Implementation of 6 MoU Priorities 10 3. Evaluation 23 4. User Engagement 27 5. Administration and Change Management 28 6. Primary Care Premises 29 7. Digital 30 8. Risks / Issues 31 9. Finance 32

DRAFT

Tripartite Statement Forth Valley’s Primary Care Improvement Plan (Iteration 3) is submitted to Scottish Government on behalf of our tripartite partnership of Clackmannanshire and Stirling, and Falkirk Health and Social Care Partnerships, NHS Forth Valley Health Board and the Forth Valley Local Medical Committee. All partners recognise and commend the significant achievement in delivering all of the commitments of PCIP Iteration 2 to date. This level of progress has been achieved through highly effective local collaboration and with significant additional, but non-recurrent, investment support from Health Board funding and primary care partnership reserves.

The tripartite partners unanimously agree that the priorities and revised service specifications described in Iteration 3 of Forth Valley’s PCIP continue to set out what we believe is essential to enable delivery of the commitments of the MoU beyond April 2021. Our partners agree that Iteration 3 continues to reflect the revenue costs associated with our assessment of what is required to adequately deliver commitments of both the GMS Contract and the supporting MoU.

We have consistently highlighted a significant recurring shortfall (£1.3m) in the funding provided and are extremely disappointed that our detailed business case seeking additional funding was rejected with no explanation or feedback. In the absence of additional funding for 2020/21, we have implemented a number of non-

recurring measures to enable us to progressDRAFT some elements of the plan and ensure we do not lose GP engagement. This includes focussing on priorities identified through an LMC MoU prioritisation exercise and GP survey and phasing of the planned recruitment programme (Table 1, page 5). Also securing additional non- recurring funding through NHS Forth Valley. These actions do not address the underlying funding gap and it is clear that we will not be able to fully implement the contract by 31 March 2021.

While the focus of work in recent months has centred on our response to the Covid- 19 situation our tripartite group is strongly aware of the importance of maintaining the momentum and progress of our PCIP work. We are therefore having a renewed focus on the priorities being taken forward by our three key PCIP working groups.

This is considered essential as we recognise that the new models of care supported by the PCIP have been integral to supporting a level of sustainability in primary care that has allowed our rapid mobilisation response to the Covid-19 situation. Practices have been enabled to work collaboratively to engage with and support our Community Assessment Centres, Triage Hub, Care Home Response Team and Enhanced Community Team. This level of support during the pandemic would not have been practical without our PCIP workforce being in place. They will also play a vital role in practices being able to deliver on their recovery plans as we move forward.

Looking to the near future we will also have additional challenges due to Covid-19 including the delivery of the influenza immunisation programme in the context of pandemic restrictions through alignment with the VTP with the flu programme. There remains a position across Forth Valley that the primary care flu programme will be the responsibility of the practices this year in line with the DES requirements but that the programme for this year, due to the impact that COVID 19 will have on our ability to deliver the usual approach to mass vaccination clinics will require a collaborative approach between the Board and the practices. There is no available funding in our plan that can support this in 2020/21

This plan does not commit IJB or NHS Board funds beyond that set out in the finance plan and so without additional recurring Scottish Government funding, sustainable delivery of the plan by April 2021 is not feasible. This presents significant risks to service resilience, ongoing sustainability of primary care and losing the high level of collaborative engagement between services, partners and primary care. Clarity on the funding position is required as a matter of urgency.

Clackmannanshire and Stirling Integrated Joint Board Falkirk Integrated Joint Board NHS Forth Valley Board DRAFT Forth Valley Local Medical Committe

Table 1: (Tripartite Statement). Resource requirements and risks to programme delivery.

The table below provides a high level PCIP summary or required workforce and delivery timelines. It also highlights the MoU commitments by GP priority, as defined with GPs and other stakeholders through a workshop and practice survey. This enabled targeting of available resources to priorities which were valued as having most impact for general practice. Delivery of the PCIP relies, however, on funding beyond the current allocation and so the table also highlights the likliehood of delivery in current financial envelope: Confirmed funding (GREEN), no confirmed funding (RED), MoU priorities for residual funding (Amber) prio MoU Priorities Wte @ Iteration 3 Plan to March 2021 20/21 April 21 –March 22 Finall rity 03/19 + WTE WTE 1 Pharmacotherap 38.5 Full service already in place to 4 clusters / 23 practices, 13 Full Pharmacotherapy 60 (+ y In 20/21 an agreed partial level of Pharmacotherapy to all 54 GP practices in all 54 GP practices 3.75 ps) 1 Urgent Care / 47.8 Full allocation of additional roles in 31 practices and MH role in additional 9 (Circa 1wte 73 Additional Roles practices is in place. In 20/21 at least one additional role for NW Stirling, 14 equivalent role(s) in Falkirk, Stenhousemuir, Denny and Bonnybridge. place per 5000 A level of resource for care home support is in place (3.6). practice (+12wte) 3 CTAC / CDM 14.6 Phlebotomy service to 4 clusters 20/54 practices in place to be scaled up to Phlebotomy with base 29 Phlebotomy phlebotomy service to all GP practices (some assumption of secondary 8 level CDM (+6.4wte) care support to complete area wide bloods model this year) 3 CTAC Treat 0 Treatment Room service in place delivering services to existing guideline Treatment room 3 Room extended to include V B12 injection provision 2 service in place 3 Children’s /mat 13.8 Conclude Childhood immunisations increase from 19 practices to all 1 Complete As 20/21 18.9 Vacs in 19/54 practices (aside from rural). Maternity vaccines by midwife in place. practices Under 5 years Flu service to x clusters (temp B5 workforce) 60wks 6 Link workers 0 4 link workers are funded by Falkirk partnership 0 (4) Link worker to 15 4 8 Link workers in place supporting approximately 15 practices 4 practices embedded 4 6 Chron Disease 0 CDM level limited to bloods, BP, weight, pulse and urinanalysis (included in 0 Broader CDM model 3 Monitoring phlebotomy provision above) No further increase to service in year (e.g. spirometry) 8 Travel and other 0 A yet to be defined travel vaccination service tested at HB level. Tbc 2 Travel and all adult tbc3.6 Vacs Ad hoc/ shingles and pneumococcal vaccinations immunisations 8 Flu Vacs - nil 0 options for delivery of flu are under consideration – delivery planned 2021 Flu Solution tbc place Tbc Tot Incl GPN/PM 125 Additional workforce 2020/21 45 Further 25-30 posts 195-205

1 PCIP Iteration 3: Background

The early and significant momentum gained in Forth Valley in the first two years of PCIP remains central to maintaining the conditions currently in place. We are on a clear trajectory, subject to funding availability, to successfully implement Forth Valleys four year Primary Care Improvement Plan. These include:

 excellent collaboration and engagement with GPs at LMC, GP sub, cluster and practice level in the development and implementation of the plan  significant collaboration, commitment and dedicated leadership at an early stage for all new services and supports  hugely supportive and engaged practice teams, particularly practice managers preparing the foundations for change at practice level.  successful early and broad ranging recruitment to posts which have been generated and promoted as modern, well supported, innovative and fulfilling roles. Growing our own workforce has been key with many training posts.  significant additional in year funding contribution from NHS Board and Partnership Primary Care related reserves

In addition, we are making significant progress in developing a capital case to support and develop a primary care premises programme/management case in line with SCIM requirements.

1.1 Progress to Date

At January 2019, 126 of 119 planned posts are in place with a further 3 currently under appointment (mainly health care support workers). All practices (54) are now receiving additional “in practice” additional services:

 23 practices with full pharmacotherapy resource (a further 9 practices with partial service initiated)  31 practices with additional professional roles (up to 3 additional roles per practice: Advanced Nurse, Paramedic, Advanced Physiotherapy, Mental Health Practitioners)  9 practices with both pharmacotherapy and additional professional role (mental health practitioner).

Additionally  All practices have access to an agreed range of treatment room services already in place at 2018  17 practices are being supported through phlebotomy service provision  20 practices have childhood immunisation service re-provided  Approximately half of GP practices have a level of care home workload supported by Care Home Liaison Nurses

1.2 Iteration 3 Review

In planning Iteration 3 of our PCIP we continue to commit to fulfilling delivery of each of the priority work streams largely as outlined in Iteration 2. In order to re-confirm timescales and phasing, particularly with the prospect of insufficient funds, we sought, through the survey, an understanding of what is most important to practices in the next 12-18 months. 44 of 54 practices responded and the table below outlines our findings.

10 9 8 7 6 5 4 3 2 Avg 1 0 Median

Summary Graph: “How Important PCIP Services are To Practices”: 0 of no Importance, 10 of utmost importance

In order to maintain momentum whilst uncertain about any additional funding, a workshop with LMC representatives was held in Dec 2019 to ascertain the priorities for available funding in 20/21. Whilst being clear that all deliverables are necessary, it was proposed to maintain momentum with Pharmacotherapy and additional professional role services. The summary table of page 3 is informed by this process.

1.3 Workforce and Skill mix Planning Each priority area has been continuously reviewed as we learn from early phases of implementation. From this we have taken significant learning from our first phase across all priorities. This has also informed a reduction in PCIP costs for Iteration 3.

 The pharmacotherapy workload is better understood, a quality improvement approach is now core to service development and the team skill mix has been revised with a plan to increase pharmacy technicians and reduce pharmacists. With low technician availability comes the need to train technicians and the 2 year lead in time to “grow our own technicians”

 Our ANP training pipeline has been very successful. Despite losing some trained ANPs to salaried practice posts, most were retained in Forth Valley. We have learned much with regards to workforce availability and the significant level of training support required to create a capable workforce.

We have an agreement to recruit in excess of the plan in light of anticipated attrition, however also revised and phased our remaining ANP training timeline in line with the capacity to train nurses now over two years rather than one with necessary support from practices and dedicated ANP trainers.

 We have successfully implemented childhood vaccinations with an effective and increasingly efficient workforce. There is significant concern regarding the feasibility of re-providing adult flu services and further work is ongoing around this.

 We already have a staffed community treatment room and all additional posts have been band 2 HCSWs to date

 Additional professional roles are a mix of band 6 and band 7. At this early stage of service development we see no further opportunity to skill mix.

1.4 Population health needs

The MoU sets out an agreed understanding that the nature of implementation and related service redesign is required to reflect local circumstances. While the contract offer1 and the MoU set out six key priorities for service redesign, the MoU states:

“Plans must determine the priorities based on population healthcare needs, taking account of existing service delivery, available workforce and available resources”.

Implementing Forth Valleys PCIP is a priority in both HSCP partnership strategic plans which highlight the significant interdependencies between strategic priorities and local population health and care needs. These priorities are informed by strategic needs assessment and include; enabling communities, focusing on early intervention, prevention and harm reduction, supporting carers and a particular focus on mental health in Clackmannanshire and Stirling.

Significant engagement and planning at cluster level has helped to tailor PCIP provision to local needs. For example the balance of provision of additional supporting roles and urgent care models have been delivered in line with cluster and practice needs. Some informed by caseload study to help determine the right balance of support for practice populations.

The specific needs of maintaining locally delivered services to rural populations has also been considered and options for CTAC and VTP in particular considered.

Chronic disease prevalence has also been a key driver in both pharmacotherapy model and CTAC with the aim of improving and supporting self care with people who have long term conditions

1 The 2018 General Medical Services Contract in Scotland. https://www.gov.scot/publications/2018-gms- contract-scotland/

2 Implementation of the six key MOU commitments

2.1 Vaccine Transformation

In the period to 2021 change will be delivered in a phased way as part of the Primary Care Improvement Plan to meet a number of nationally determined outcomes including shifting vaccination work to other appropriate professionals and away from GPs. It is expected that this change will be managed, ensuring a safe and sustainable model and delivering the highest levels of immunisation. There may be geographical or other limitations to the extent of any service redesign.

Timeline

At April 2019 Pre-school childhood immunisations (0-5 years) 7/54 practices

By April 2020 Pre-school childhood immunisation (0-5 years) 38/54 practices Maternity Immunisations (Influenza and Pertussis) 54/54 practices

By April 2021 (subject to available funding) Pre-school childhood immunisation (0-5 years) 45/54 practices (Subject to clarification of rural practice arrangements (9 practices)) Travel Immunisations and advice 54/54 practices (Vaccines covered within the NHS routine immunisation schedule) 2-5 years Flu -Pilot in advance of 2021 full implementation 1 Cluster

April 2021 and beyond Adult Programmes (Shingles and Pneumococcal) 45/54 practices 2-5 years Flu Immunisation 45/54 practices Ad Hoc Vaccinations 45/54 practices (Each programme is subject to clarification of rural practice arrangements (9 practices))

Workforce

In place at April 2019 11.0 WTE In place by April 2020 14.8 WTE (13.8 WTE in post, 1.0 WTE to 20/21l), Workforce required to be in place prior to April 2021 service delivery level will depend on resource availability - anticipate 3wte for travel, 3 wte seasonal posts for childrens flu. Additional Administration resource also sought Projections for Flu Programmes will be covered in a separate options appraisal for consideration at PCIP

Learning and Analysis To Date: Patient –Centred : Service user feedback has been positive.:  Patients like the specialised service.

 Patients appreciate appointment flexibility and a choice of where to attend  Patients have not been keen to have to travel further for the service than before  Parking can be challenging in new Hub locations  Request to increase the accessibility of baby changing and feeding facilities within new service sites.  Waiting areas in Hubs are busier than previous due to increase in footfall as an impact of combining practice lists.

Outcome-Focussed: There has been no significant change to uptake rates post transfer of pre-school vaccinations across the Clusters. Patients who have opted out of the programme have been given the opportunity to re-engage with the service at point of transfer. There has been a temporary increase in clinic demand as a result of a recall backlog in a number of clusters. This is expected to reduce in the long term. Flexibility has been built in to the new model to allow for an element of patient choice and improve accessibility helping to maintain pre-school rates.

By age 12 mths By age 24 mths By 5 years By 6 years 2018 uptake 95.7% 95.2% 95.5% 95.6% 2019 uptake 97.1% (+1.4) 95.5% (+0.1) 95.2% (-0.3) 96.3% (+0.7)

Safety: SOP and clinical guidelines to support governance and promote quality improvements have been developed for the pre-school programme. Access to GP patient records (via EMIS) has been essential in supporting delivery of safe clinical care at the point of contact and ensuring GP health records are kept updated.

What is new or altered from Iteration 2 The revised timescales between Iteration 2 and 3, reflect resource available from PICP during 2019/2020. Delivery of VTP is expected to carry into 2021/22. In particular the model for adult flu will not be delivered in 20/21 as per Iteration 2.

Full and final delivery as per the MOU will be dependent on both funding and essential infrastructure being in place to ensure services are safe and sustainable. At January 2020 there remains ambiguity around rural practice arrangements and the extent to which they should be included in any future planning.

Vaccination programmes in scope for 2020/21 have been revised as follows: 1. Childhood Flu 2-5 years (pilot) 2. Routine NHS Travel Vaccinations and Advice 3. Completion of Children’s pre-school (0-5 years) schedule

A feasibility study for the transfer of the Adult Flu Programme from GP to the Board led Service for winter 2021, is being prepared separately. The complexity of challenges that exist in delivering a programme of its size and scale will be explored and options for delivery will be fed back in March 2020. Feedback will be included from the National VTP Programme Board, currently collating learning from a number

of Boards piloting Seasonal Flu this year. This will help inform development of local solutions which are both practical and realistic.

The Travel Immunisation Service in scope for 2020/21 will cover NHS routine immunisations only. Current data does not provide the level of detail necessary to accurately scope the potential demand or workforce. As a baseline for moving forward, a workforce estimate will be based on 2% of population as per feedback from similar sized Boards running pilots.

A number of private companies offering travel immunisations currently exist within Forth Valley and will continue to compete with any local NHS run service however there is an expectation that the Board led service will grow in future years to include Yellow Fever and non- NHS vaccinations and provide a level of income generation.

The proposal for the coming year will require continual review post implementation to determine if the resource allocated is sufficient to deliver a safe and equitable service

Key Performance Measures There is ongoing formal evaluation as each programme transfers to the NHS service.  Service user feedback is sought through patient questionnaire given out in each clinic within the first few weeks of transfer.  Feedback is requested from Practice Managers within the 6 weeks post transfer.  Vaccination uptake rates  Moving into 2020- Supplementary read codes will be added to EMIS Childhood Vaccination Templates to collect data on clinic capacity and DNAs. The data will inform where best to make improvements.

Challenges and Constraints to Implementation of VTP  Maintenance of Cold Chain: There has been significant loss of vaccine and impact on the pharmacy service over the last 12 months.  Pharmacy Infrastructure: It is anticipated that pharmacy support workforce, additional transport vans and additional cold storage facilities will be required.  IT: The absence of a dedicated IT system has slowed and limited the roll out of the VTP. A comprehensive IT system is critical for delivering the VTP.  Accommodation:  Sustainability: Sourcing an appropriately trained workforce to deliver seasonal programmes has highlighted a very limited bank workforce of staff availability.  Administrative Burden: Links with the National VTP forum are highlighting that the true admin and clerical component required to successfully deliver VTP is much greater than originally scoped, posing a risk to developing programmes beyond pilots when not adequately factored in as part of the infrastructure.  Affordability/Value for Money: Taking into account all of above, the value risk around VTP is significant.

2.2 Pharmacotherapy

Extract from Memorandum of Understanding By 2021, phase one will include activities at a general level of pharmacy practice including acute and repeat prescribing and medication management activities.

At April 2020 – All practices in six of nine clusters have a pharmacotherapy service (four with full service and 2 with core service). There are 42.6 WTE Pharmacists and Technicians in post in a range of bands from 5 to 8A.

Workforce in place April 2019 28 WTE staff Workforce by April 2020 (It. 2) 40 WTE staff (skill mix 3:1 Pharmacist: Technician) Actual workforce April 2020 42.6 WTE (38.5 + 2c PCIP ) skill mix ~5:1 Pharmacist: Technician) incl 1 service lead post. Planned Workforce April 2021 51.6 WTE (includes 1WTE 8b Pharmacist) Final Planned workforce 60 WTE PCIP (+ 3.75 WTE from Prescribing 2021 Support) Current Planning Assumption Remains at 1 WTE per 5000 overall ( 6,000 WTE ratio: accounting for cover) However this may vary slightly practice to practice as service need is better understood.

Variance from Iteration 2: In order to enable deliver a level of service to all remaining clusters there is an additional 1.6 wte posts in Iteration 3 for 2020-21. (final workforce remains as it was in Iteration 2)

Pharmacotherapy Implementation

What have we learned from implementation and/or service analysis to date? a) Most practices with pharmacotherapy are experiencing a positive impact from the service and are reporting a measurable reduction in daily GP workload.

“Having pharmacy support from fully trained and experienced pharmacists has made a huge difference to GP workload daily. We are still to establish clinics for the pharmacist but Acute scripts and most Docman medication requests and reconciliation is done daily.” GP Practice Survey, 10/19 b) Most practices initially require a significant amount of resource to streamline their prescribing workload. c) The number of acute requests varies significantly from practice to practice (from 1 per 1000 to 19 per 1000 patients, mean/median = 8). Some of this can addressed by implementing a robust programme of patient reviews which enables a proportion of unscheduled work to be safely transferred to scheduled work, facilitating a manageable workload for pharmacy staff. d) Service leadership across the pharmacotherapy service is critical to driving service forward and evaluating progress.

Any Changes in Iteration 3? a. All GP practices will have at least partial pharmacotherapy service in place by March 2021. An already agreed level service will be provided to the four remaining clusters, the plan, previously, of rolling out cluster by cluster would mean no provision for two clusters until 21/22. The service will then be increased to practices in these four clusters in 2021/22 b. The partial service will be a defined provision and split between Level 1 and Level 2 tasks as detailed in the 2018-21 GMS contract in an attempt to move some of the unscheduled workload such as some acute requests to scheduled care, with assurance that patients will be reviewed. This will make the service more planned and less reactive as is the case at the moment. c. The Pharmacotherapy Collaborative will delve further into prescription processes to determine best practice. Benefits identified from this will be scaled to all. d. The ratio of Pharmacist to Technician for a full Pharmacotherapy Service is being tested at a ratio of 3:1. It is hoped that in time, with more experienced staff, the role of the technician can be further developed with the aim of having a Pharmacist to Technician ratio of 3:2. e. The number of patients who have their medicines managed utilising the Medication, Care and Review service from Community Pharmacy will increase. f. Support for rural practices will be developed including utilising remote access into practice records and systems, and harnessing the skills of the local Community Pharmacist to carry out core Pharmacotherapy functions such as processing hospital discharge letters and recommendations from specialist clinicians.

How will we know if these changes lead to improvement? Key performance indicators will capture a. number of acute requests actioned by Pharmacy Team as a proportion of total acute requests b. Variation in pharmacotherapy workload between practices c. number of patients reviewed by Pharmacy Team  Practice satisfaction survey  Patient satisfaction survey  Cost per patient

Describe any particular issues and constraints which are directly impacting on our ability to deliver service as per PCIP and MOU d. Lack of experienced workforce to deliver a new service, coupled with expectation to deliver full service in a short time frame e. Financial constraints around service.

To date, recruitment of pharmacists has been successful; however technicians remain difficult to recruit. A plan has been submitted to recruit student technicians to train over a 2 year period to increase workforce.

2.3 Community Treatment and Care

AIM: Extract from Memorandum of Understanding By 2021 a safe and sustainable service delivery model, based on appropriate local service design for services including, but not limited to; basic disease data collection and biometrics (such as blood pressure), chronic disease monitoring, the management of minor injuries and dressings, phlebotomy, ear syringing, suture removal, and some types of minor surgery as locally determined as being appropriate. Phlebotomy will be delivered as a priority in the first stage of the HSCP Primary Care Improvement Plan.

Workforce in place 8 WTE (6 HCSW and 2 team leads) initiating phlebotomy in 2 clusters. April 2019 7 non recurring GPPN training posts part funded by NES. Existing NHS funded treatment room in place providing most treatment room services to all practices. Planned Workforce 12.6wte HCSW: Phlebotomy service to 19 practices (4/9 clusters) by April 2020 Chronic disease monitoring to 6/54 practices (2/9 clusters) Treatment Room Core Service 54 / 54 GP practices (Existing Service) Treatment Room Enhanced Service (with B12) - additional x patients see in year - no additional resource Actual Workforce 12.6 HCSW in place (tbc)– 12.6 funded + 2 team lead posts.(14.6) at April 2020 Phlebotomy initiated for 19 practices in 4/9 clusters. 7fixed term GPN trainees. No additional resource for treatment room. Planned Workforce 22 HCSW and 2 additional band5 RN – All practices offered GP By April 2021 Phlebotomy service including CDM bloods, weight, BP and Pulse only to all practices. 2 Band 5 Treatment room nurse to enable capacity for B12 Final Workforce in 29 HCSW and x ?5RNs + 2 team lead (this may be adjusted for preferred 2021 rural option ) extension of CDM to be confirmed

Variance: As per Iteration 2: Phlebotomy delivery now phased to Sept 2021. All practices to be offered phlebotomy service (incl CDM bloods, BP, weight, urinalysis) by March 2021. Subject to Funding.

What have we learned from implementation and/or service analysis to date?

Based on labs and chronic disease prevalence data, is estimated that Forth Valleys phlebotomy service will require to support at least 3000 phlebotomy appointments weekly plus provide capacity for around 65000 annual chronic disease management appointments annually.

 1300 new phlebotomy service appointments are now scheduled weekly across the first three clusters Stirling, non rural NW Stirling, Denny and Bonnybridge with service to Stenhousemuir cluster starting by March 2020. To date, although demand varies between practices, the predicted resource has proved, overall, to be adequate. However, in one or two cases CDM as an indicator of need has not been appropriate e.g. university practice.  The existing community treatment room service also provides over 2700 10 minute appointments weekly across Forth Valley.

Implementation of phlebotomy has been more complex than first imagined. Whilst practices who have not had phlebotomy provision, or have had vacant HCSW posts, have embraced the service as a more accessible option for patients, others have been reluctant to move away from reliable and flexible practice based models.

Both a Hub model and Practice based model have been tested with different issues and interdependences arising. Also different experiences for staff and patients. The Hub model appears to engender better peer support and staff morale and a greater percentage of utilised appointments. Whilst the Practice Model provides closer working relationships with patients and practice staff and less risk in relation to IT systems and accessing patient information.

Describe briefly what is new or altered from Iteration 2

Timelines and overall workforce remain the same as Iteration 2. All practices, opting for phlebotomy, will have access a local phlebotomy service by April 2021. The operational approach going forward will include:

 Co-location of phlebotomy workforce at one or two hubs within a cluster, outreaching to practices with sufficient population or geographical need.  The service will work via EMIS and practices will manage patient app’ts into dedicated practice phlebotomy appointments until IT solution improves.  All bloods must be booked onto Ordercomms by practice OR for annual CDM phlebotomy – Practices must note CDM reason in appointment slot note and Phlebotomy service will add agreed group tests to ordercomms (E-health will work with service to create validated “group tests” for CDM on Ordercoms  CDM to include BP, weight, urinalysis and pulse as appropriate to review will be provided to the 21 practices in 3 clusters who have phlebotomy service at April 21. Remaining practices will receive this post phlebotomy implementation in 2021.  CDM reviews are limited to one appointment annually.  CDM will be limited, under current resource, to bloods for all practices.  GP practices can opt to use the service wholly, in part or not at all.  NPT, warfarin, coagucheck will be part of the service  Wider CDM model will be reviewed and Rural practices will conclude options.

By 2021 the CTAC service will deliver all B12 injections, estimated at an additional 22000 B12 injections annually.

How will we know if these changes are leading to improvement?

We are continuing to collate data on a monthly basis to assess capacity and demand and to ensure that we are delivering an equitable service. We are also encouraging feedback in relation to service improvement from patients, staff and GP Practices.

Issues and constraints: Lack of IT interoperability, Recruitment and accommodation.

2.4 Urgent Care (Advanced Nurse and Paramedic Practitioners)

By 2021, there will be a sustainable advance practitioner provision, based on appropriate local service design, available to assess and treat urgent or unscheduled care presentations and home visits within an agreed local model or system of care.

At March 2020 - slightly increased ANP workforce in place. Training ongoing.

Workforce in place Practice ANP 13.2wte (2019 – some loss to IP and other April 2019 boards). 1 x 8a only + 1 vacancy Care Home ANP x 3.6 recruited Planned Workforce Practice ANP /PP 15.2 ANPs in 5 clusters by April 2020 Care Home ANP 4.1 wte Actual Workforce at 16.7wte plus 2 8A trainers and 4.3 care home. 1.8ANPs for 2C April 2020 practices will now need to be recruited. (leaving14.9). Planned Workforce 23.5wte (B-7 ) (3-8a, 1 of which fixed term)) By April 2021 4.1wte care homes (incl 0.5 Clacks ANP) Final Workforce in 33.6wte (cluster adjustment from 32.6) ANPs including care 2021 home and 2 x 8a (29urgent care+ 3.6 Care Home wte) (No change from Balance of resource between practice and care home / home Iteration 2) visits determined by cluster assignment of resource

Variance from Iteration 2: Total workforce remains the same, cluster preferences currently indicate +1wte ANP in lieu of other mdt. Recruitment is now, phased.

What have we learned from implementation and/or service analysis to date?

All ANP resource is in place for the first phase clusters, however, placement to final practices will conclude in May when trainees qualify and move from host training practices. It is likely however, that we see a continued attrition of trained staff to practice employed posts and other boards. An agreed level of over recruitment has helped mitigate this and will continue to be required.

Most ANP recruits require significant education, support and supervision to achieve the required skill set and ANP qualification. Trainees, however, still contribute significantly to managing urgent care workload and evidence grows that ANPs can competently manage a significant proportion of on the day, urgent appointments. Supporting and assuring training continues to be challenging, however we now have part time qualified practitioners in addition to a full time trainer in Falkirk cluster.

Care Home Liaison (CHL) service, although limited in scale, has evidenced significantly reduced GP visits to care homes.

Changes, if any, being made to the planned model of care in Iteration 3? All practices have been offered APP, ANP and PCMHN resource and choice with regards phasing and balance of each. All practices will have at least one of the three

additional supports by mid 2020. The total ANP/ CHL workforce remains the same, however, recruitment is now phased over the next two years in line with our ability to support and train new staff. Our first cohort of trainees on a two-year programme and those subsequently employed on a one-year programme will complete the competency frameworks in May 2020. The remainder of our current workforce will be qualified during 2021 (4.6 WTE), this includes two paramedic practitioners (16.4 WTE in total). It is likely that most of the next two cohorts will require at least 1 year of supported training to complete competency frameworks.

The Care Home team will integrate with the urgent care ANP model and the balance of Urgent care workforce between practice based urgent care and community based support including care home, residential home and house calls will be determined by cluster preferences. It is anticipated that some practices will prioritise urgent care resource to community based support in the next phase. This will influence recruitment towards practitioners with an interest in community based medicine.

A unified urgent care model will allow an equitable and standardised approach to competency training and supervision, creating a resilient and flexible workforce. Flexibility is also being explored with the GP OOH ANP service. ANP resource allocation within the clusters is quite fragmented (small allocations of e.g. 0.2 WTE to a practice). This makes assignment of ANP resource very difficult. Having a flexible workforce would allow ANPs to undertake dual roles such as daytime practice and OOH or CHL. With appropriate management of resource from both services improvements can be made which would benefit the workforce and patients.

Iteration 2 assumed that no additional MDT recruitment would be required for 2C practices as PCIP funding would align to support existing NHS employed MDT at April 2020. Three 2C practices are, however, now returning to 17J status which means that 1.8 additional ANPs require to be recruited and likely trained.

How will we know if these changes are leading to improvement?

Quantitative - measuring appointments undertaken by ANP / APP impact on GP e.g. ANP/GP workload study, 2C Analysis, Week of Care Audit (See Evaluation Section) Comparative Qualitative Data: complaints, compliments, adverse events, experience Measurement of staff experience / service resilience: Recruitment and retention – equitable supervision and educational opportunities.

Describe any particular issues and constraints impacting on implementation.

 Lack of / loss of administration support to management ANPs in PC (2C support)  Fragmented workforce linked to fragmented practice allocation in clusters  Constraints to scaling: sustainable training placements, space and supervision.  Expectations of practices due to the restricted no of qualified ANPs and variation in trainee experience, in particularly if trainee unable to prescribe  Lack of IT flexibility, Room availability, Recruitment and Retention (See Risks)

2.5 Additional Professional Roles; Advanced Practice Physio (APP)

AIM: Extract from Memorandum of Understanding

By 2021 specialist professionals will work within the local MDT to see patients at the first point of contact, as well as assessing, diagnosing and delivering treatment, as agreed with GPs and within an agreed model or system of care.

At April 2020: Delivery of APP continues to 28/54 practices (5/9 clusters) 3.8 additional APPs planned for 2020 to support around half of remaining practices /clusters as part of integrated and phased role out of all professional roles to all practices (14 of final 23 APP, PCMHN, APP roles to be delivered in 2020)

Workforce in place April 2019 9.4wte

Planned Workforce by April 2020 9.4wte

Actual Workforce at April 2020 9.2wte (adjusted to cluster preferences) Planned Workforce By April 2021 13.2WTE (incl 1 8A lead) Final Workforce in 2021 16 (cluster adjustment from 17WTE)

Variance from Iteration 2 :1 Wte final variance due to cluster preferences. (1+ANP)

Advanced Practice Physiotherapy Implementation: Learning to Date: The APP service has now been fully operational in the majority of practices in 5 clusters since May 2019 with a few Practices commencing from July 2019.  APPs now have the capacity to offer approximately 685 MSK appointments per week across 28 practices.  Capacity v fill rate analysis (August 2019) highlighted that in 20 out of 28 Practices, APP clinician appointments are utilised in excess of 80% capacity.  With additional support and education and support for enhanced signposting from reception and other Practice staff, those with lower fill rates have risen to comparable levels.

A 3 month audit by APP clinicians highlighted that:  80.4% of patients seen by an APP were dealt with solely in Primary Care and did not require any onward referral.  8.7% patients were referred to mainstream MSK Physiotherapy services.  1.7% of patients were referred to Orthopaedics.  9.2% patients were referred to other Secondary Care services such as Podiatry and Orthotics or referred to Third sector services.

The main learning from the first phase of implementation has been around the APP skills and educational needs. An initial need for training and support was consistently required which required time out of practice. This has been mostly resolved in the initial 3 months.

 Networks are established to support governance and training in Injection Therapy, Radiology and Non Medical Prescribing.  A further 4 APPs have recently completed Injection Therapy qualification with another 3 clinician’s with completion due in April 2020.  3 APPs are Non Medical Prescribers and commenced prescribing in 3 Practices. Further staff will be supported through this process in the later part of 2020.  All APP staff have now completed NHS Forth Valley Radiology IR(ME)ER training and have the ability to refer for all agreed diagnostic imaging

What is New in Iteration 3? There are no changes from Iteration 2. All practices have been offered APP, ANP and PCMHN resource and choice with regards priority and balance of each. All practices will have at least one of the three additional supports by mid 2020.

The remaining 22 GP Practices are scheduled for APP implementation during 2020 and 2021. It is anticipated that half of the remaining practices will be supported in 2020. The majority of the APP workforce in 2020 will be released from existing 2C Practices which return to 17J status from April. APP resource is allocated to GP Practices equitably (1:20,000) as part of an integrated approach with ANPs and PCMHNs. Phasing of roles will be aligned to Practice preferences where possible.

What are we measuring? Daily data collection of  patients seen and their management and intervention outcome.  daily logs for Radiology requests (as per IR(ME)R 2017 requirements)  Injection Therapy records.

In 2020 a National APP Data Collection template on EMIS/Vision will commence and be automatically reported through SPIRE.

Patient / Service user feedback is being collected at practice / cluster level with a view of understanding awareness and satisfaction of new professional roles.

NHS Forth Valley (Viewfield Practice) has been selected to take part in the APP FRONTIER Study led by Bristol University (2020: 12 months). The study aims to measure: patient satisfaction, analyse cost effectiveness practice staff experience.

Issues and Constraints  IT: Recruitment: Accommodation: See Risks – common issues  Workload variation: Levels of APP appointment fill rate varies and is linked to practice signposting systems but also to variation in need between practice populations.  GP expectations: Not only around the capacity of MSK patients the APP service can accommodate, but also understanding the role as first contact service as opposed to historical models which provided a Practice Physiotherapist.

2.6 Additional Professional Roles; Primary Care Mental Health

At April 2019: In line with PCIP 1, there were 15.7 WTE Mental Health Nurses in post with 1 WTE (2 headcount) acting as Leads and 13.7 in MHN posts. Delivery of MHN support is happening in 40/54 practices (7/9 clusters).

At April 2020: Delivery of APP continues to 40/54 practices (7/9 clusters).

By April 2021: 48/54 practices to have PCMHN resource

Workforce in place April 2019 15.7wte

Planned Workforce by April 2020 15.8wte

Actual Workforce at April 2020 17.2 wte (incl 2 team leads 0.5 clinical)

Planned Workforce By April 2021 20.3 WTE Final Workforce in 2021 23 WTE (circa 1:15,000)

Variance From Iteration 2: Small adjustments in MDT as requested by practices.

What have we learned from implementation to date?

Primary Care Mental Health Nurses now provide service within 40 GP practices with a weekly combined Appointment Capacity of: o Face to Face scheduled weekly capacity = 870 (leave adjusted = (696) o Telephone Call scheduled 348 (Leave adjusted = 278) o Stirling/Clacks Face: to Face: 470 (423) | Telephone Call: 188 (170) o Falkirk: Face to Face: 400 (360) | Telephone Call: 160 (144) o Capacity of 2 posts on maternity leaves in Falkirk not factored in. (110)

Whilst resource is allocated by practice population, practice demand doesn’t always correlate to the practice population size. Health inequalities and practice demographic significantly impacts on the mental health needs of each practice.

There can be some challenges in rural areas – small amounts of time in small practices. In the future this may benefit from a hub format.

Each practice can have different expectations of the PCMHN. This can vary depending on the population; skills of each staff member, pressure on staff etc. The development off of a working agreement between practice and service has been of great benefit in terms of integration, implementation and managing expectations of practice and nursing staff.

What, if anything, has changed from Iteration 2? Iteration 3 plan is not substantively changed. Remaining practices have been consulted on their MDT preferences and it is hoped to place PCHMNs in all remaining practices which opt for the service this year.

Additional action 15 funding has been secured to support this, however, funding will not fully be in place until 21/22.

The practices have been given the choice to adjust allocation of professional groups to incorporate a core practice needs approach, so in some cases more mental health support is desired from the practices, some less.

How will we know if these changes are leading to improvement? The PCMHN’s have been completing audit work with the second large scale audit due to be completed in February 2020. This looks at  capacity,  attendance  objective mental health data which helps us to measure outcomes from consultations and against the aims of this post  Impact on GP mental health workload.  Practice survey for staff feedback.  Patient feedback. feedback regarding the service has been very positive.  PCMHN’s completing I-Matters for team leaders.

Describe any Particular Issues or Constraints  Ability of team leads to support existing and new staff across so many practices

 The recruitment of staff: as the team expands we may have less candidates applying or more impact on other areas of MH provision in Forth Valley.

 Mental health nurses are employed based on a 1wte to 15K population which can mean that staff are spread thinly across 3 sometimes 4 practices. Pressure on the team as there is a high demand for the service so staff can have full clinics with high expectation.

 Lack of flexibility to provide cover during times of prolonged absence is a real challenge: a clear working agreement with practices which sets out expectations around short and long term leave at the outset has helped. The aim by 2021/22 is that there will be a small amount of flexibility to support this (circa 5%).

2.7 Link workers

The PCIP proposes 8 link worker posts to support 15 practices in most deprived communities. Funding for link workers is aligned to 2020/21/22. Falkirk Partnership has provided 2 year funding of four link worker posts who will support:

 Falkirk Cluster: In place extension of FDAMH social prescribing model  Grangemouth practices : Link worker to be employed by the Kersiebank project  Denny / Bonnybridge Cluster : Link worker employed by Strathcarron Hospice. Appointed and in early stages. Stirling Council are also supporting a two year model of welfare support link workers in two Stirling Practices (Fallin/Cowie and Orchard House) and a rural link worker in West Stirling supporting the model of neighbourhood care.

3 Evaluation: Are these changes making a difference?

3.1 GP Workload:

All practices were surveyed in October 2019 as part of our Iteration 3 engagement and planning process. Practices were asked, amongst other things:

“Do you think the support from additional services has had an impact on GP workload to date?”

39 out of 44 practices responded “Yes, we are seeing a positive impact on workload”

Comments from practices include

“The GPs feel that the additional services have made a great impact on the practice and their workload. The MH Nurse and ANP in particular have made a great impact to their workload. They are great additions to our team.”

“Every patient that is seen by the APP or MHN is freeing up valuable time for our GPs. Having these specialists in Practice is excellent”

“Having pharmacy support from fully trained and experienced pharmacists has made a huge difference to GP workload daily. We are still to establish clinics for the pharmacist although we are keen to do so but Acute scripts and most Docman medication requests and reconciliation is done daily.”

GPs also have concerns

“Concerned that there may not be full implementation of the contract by April 2021”

“It is disappointing that this far into the new Contract we are only seeing one new service provided to the Practice.”

3.2 Week of Care Baseline Study

In February 2019 22 GP practices took part in a two week caseload analysis exercise. The aim of this was to understand complexity and nature of clinical workload prior to implementation of additional professional roles. Over 14000 consultations were recorded by practitioners, mainly GPs with a consultation reporting rate of 62-84% on each of 10 days. The indicative balance of consultations by acute/ urgent, routine and Long term care/complex/ undifferentiated is outlined below. This exercise is being repeated in March 2020 to help ascertain whether GP workload is changing.

3.3 Safe and Effective Transfer of Workload: ANP

As part of the plan, Advanced Nurse Practitioners (ANP) will form a key part of the general practice workload with a primary role in managing urgent care; particularly on the day appointments and in some cases house calls and care home visits. As a relatively new role, it is not known whether patients seen by an ANP are more likely to return or return sooner to see a GP for same issue. A retrospective study conducted in Polmont Park medical practice looked at all GP urgent care presentations to the practice in one month (417 patients) and a comparative analysis between GP and ANP care was conducted on outcome of triage and number of follow ups within 7 and 28 days.

The study concluded that although ANPs are more likely to offer an appointment from telephone triage (80% v's 60%), those seen by an ANP for same day assessment were no more likely to return within 7 or 28 days than if they had been seen by a GP.

 ANPs are a safe and effective alternative to GP for face to face consultation of patients who request same day urgent appointments.

 ANPs provide a significant transfer of urgent demand away from the GP allowing them to focus on their new role as an Expert Medical Generalist.

3.4 Physiotherapists as an alternative to GP for musculoskeletal consultations

Advanced practitioner physiotherapists (APP) are now providing around 700 weekly appointments in 30 practices in Forth Valley. Providing a longer consultation time (20 mins) for people with muscle and joint pain or movement problems. APPs have expertise in assessing, diagnosing and managing musculoskeletal issues and are well placed to manage primary care MSK demand. A realistic estimate of msk demand in primary care with potential to be redirected is around 6-10% of GP workload (week of care).

A 2 year cohort study of more than 8000 appointments in two practices in Forth Valley was published in the British Journal of General Practice in 2019. This study highlighted that 64% of people who saw a physiotherapist as alternative to a GP appointment received self care only. 1% required a GP review and 29% had a return appointment within 3 months. Satisfaction rates were very high.

A three month audit of the newly expanded APP service found similar results with 80% of people being managed by APP without need for onward referral or second opinion. 1.9% of people being referred to orthopaedics and 8% to physiotherapy.

3.5 Community Treatment and Care

If successfully implemented the CTAC service will manage most blood tests ordered by GPs which can be identified via the ordercomms service. The chart below shows the variance in uptake of service within one cluster in August 2019 and graph below the increase in use of service from September. 700 weekly bloods appointments are offered in Stirling Cluster.

Total bloods managed by CTAC – Week Snapshot August 2019 200 Total No. Bloods 150 requested

100 Number of bloods managed 50 by CTAC

0 Practice 1 Practice 2 Practice 3 Practice 4 Practice 5 Practice 6 Practice 7 Practice 8

% of Total Appointments used per Day in Stirling CTAC Service

100%

90% 80% 70% 60% 50% 40% 30% 20% 10%

0% % Capacity used per day in CTAC in perday used Capacity % 1st Aug 8th Aug 15th Aug 22nd Aug 29th Aug 5th Sept 13th Sept 20th Sept 27th Sept 4th Oct 11th Oct 21st Oct 28th Oct

3.6 Pharmacotherapy The pharmacotherapy implementation group are continuosly reviewing the impact of the new pharmacotherapy services. This includes analysing the impact on GP and pharmacy team workload, measuring quality outcomes for patients and efficiency and effectiveness of pharmacotherapy processes. An example of success has been demonstrated by a pharmacy technician model, applying practice based improvement methodology to analyse practice prescribing systems and processes and evidencing added value to the repeat prescribing process as highlighted in the graph below.

Number Total Number of Precription Reauthorisations 100

40 Goal

Jun Jun Jun Jun 1st

8th 8th 15t 22n 29t 5th 12t 19t 26t

Jul

Jul Jul Jul

3rd 3rd

Au Au Au Au

17t 24t

0 10t

Jul

h h h g g h g h g h

y y y

e e h e h e h

d d

Ten GP practices are currently involved in the national pharmacotherapy collaborative with the aim of developing and utilising similar methodology to optimise and ultimately reduce current level 1 pharmacotherapy processes.

4 PCIP3s should set out how local partners are ensuring that patient engagement is a key part of their plan.

The work of the practice administration collaborative and subsequent scale up across Forth Valley has been key to service user and engagement. Primarily through the significant work supporting and developing models of improved signposting to "Right Care". Communications materials, administration training and user engagement and awareness activities have been central to the change process. Each priority work stream also engaging and taking feedback about service delivery and design.

A user survey including public engagement officer discussions with 478 service users across 14 practices with new professional roles was conducted in November 2019. Findings included:

Public Awareness 60-77% of respondents were aware of the specific new roles in practices, with more people being aware of ANPs (77%) than APPs (64%), PCMHNs (63%) or Clinical pharmacists (60%).

21% reported that they don't feel informed about new services

Public Acceptability 88% of respondents did not mind being asked, by the receptionist, for a summary of their health concern in order to signposted to the most appropriate healthcare professional.

95% of respondents agree that they will be happy to see the most appropriate professional.

Experience of New Services 71% of respondents said that they had experience of contact with new clinical roles 89% of respondents reported positively on all four experience measures, 3-5% responding neutrally and 7% reporting negatively.

When asked "What matters most to you when making an appointment?" People said: Getting seen as soon as possible/speed of appointment/quick 196 response Being seen by the appropriate person 53 Length of time waiting for an appointment 45 Being listened to/treated considerately/finding out the problem 31 Getting the right information/care advice/get better 13 Taken on time/GPs need to be in the practice more 10 Continuity of care/seeing the same GP 10

5 Programme Support

PCIPs should describe what administrative capacity is allocated to developing and implementing plans, any specific administrative challenges to implementation (e.g. HR issues) and what actions are being taken to address these challenges.

PCIPs should describe what change management capacity is in place to facilitate implementation of the contract

The PCIP is supported by a dedicated Improvement Programme manager and Improvement Advisor post who support the development, implementation and reporting of plans. Additional quality improvement support has been received for week of care data support and survey support. The Programme manager and improvement advisor work very closely with the senior LIST analyst in supporting the plan and cluster quality work.

Each work stream area has service leadership resource funded, team leads and service leads play a key role in the implementation and service design, working very closely between work stream delivery group and practical delivery with practice managers and GP clusters to ensure optimal implementation and delivery.

The development of a cluster improvement facilitator role has been supported and funded at one day per month for each cluster. seven of nine clusters have a practice manager identified as taking on this role. These roles play a key consultative and facilitative role in planning and delivery of the plan.

The impact and engagement of practice admin teams through the Practice Administration Collaborative and subsequenet scale up accross Forth Valley has been instrumental in creating the conditions for change within GP practices. Preparation and training for signposting and evidence of reducing the administrative workload for GPs.

All leadership and improvement roles are connected via a Primary Care Improvement Network which, largely virtually, shares information and updates and meets approximately quarterly with a focus on evaluation and service design.

LMC GP Sub Committee representation on all working and governance groups is supported through NHS funding. The GP sub plays a central role in assuring service specifications and supporting the implementation interface between PCIP and general practice.

6 Primary Care Premises Review

A review of primary care services and premises, taking account of the implementation of the new GMS contract and primary care implementation plan and proposed new housing developments was commissioned by NHS Forth Valley in 2019. This review had the objective of identifying investment priorities for primary care estate.

The approach included the following key stages:  Data Gathering - national, local, board level and practice level information  Establishing Trends - demographic, housing, impact of new models of care  Future Capacity Planning - identification of new models of care within PCIP, increased use of information technology and smarter working  Prioritisation of Investments - identifying the investments both short term minor modifications and long term investment required.

The review outlined and prioritised 8 primary care premises with long term major investment need (listed by priority below) and a range of additional immediate, short term and mid term priorities.

1. Cowie 2. Alva 3. Tor (Plean) Kersiebank (Grangemouth) 5. Creation of a Falkirk Primary Care and community services hub 6. Bonnybridge 7. Meadowbank 8. Dollar

Early estimates of the financial implications indicate circa. £30M required to facilitate the long term major investment in new build primary care premises, that includes a Falkirk Hub which will be linked with the development of the Community Hospital.

In the short term, funding of £1.25M has been proposed in the Capital plan for FY 2020/21 to progress the works identified in the Primary Care Services and Premises Review.

There is also a requirement to identify funding for a separate strand of work that focuses on those premises not subject to redevelopment but which require investment to be brought to and maintained at the required quality and compliance standards.

7 PCIPs should outline what specific steps are being taken to improve the digital infrastructure as well as any specific challenges and actions taken to mitigate these.

Digitial & eHealth work streams

Windows 10 Workstations & Operating Systems – all PC’s are being upgraded or replaced to meet the new recommended specification. Approx 25% of all GP based PC’s are being replaced, all gain a new hard drive and 8GB of RAM. Double monitors to all consulting room PC’s are deployed where they are not already in situe. Windows 10 is being implemented and Office 2016 (Excel, PowerPoint & Access) and 2013 (Word) are also included. When the GP System refresh is completed Word will be upgraded as well (this is a current GP System requirement)

Office 365 Office 365 will be rolled out to all users in NHS FV, including GMS & Community services. From a GMS Perpective (office aside), they have already seen the benefit of the Teams rollout, by Sept 2020 all email will have been migrated to the Office 365 platform from NHS Mail. Additional functionality around SharePoint for collaboration and sharing of files and content will be available towards the end of the calandar year.

Directory Services Currently users in Practices access a Practice only domain (i.e. we have 57 separate silos), we are moving to having one GP & Community domain across all GMS & community services. Essentially this will open up access across FV for all users in GMS & Community services. This will allow for the easier sharing of systems, content and ICT Services across Forth Valley.

WiFi Practice WiFi – We have installed WiFi at appropriate sites for clinical access for community staff in line with Morse project requirements. This covers 26 of our 57 GP Practices. As GMS Practices and PC sites are refreshed, as a rule the installation of WiFi should be a priority. Each GMS Practice site requires significant investment to implement WiFi, this is currently averaging £15k per practice. If public WiFi access is required additional revenue investement is required, averaging an additional £3k per site per annum.

Unified Telecommunications With the retiral of traditional telephony systems, VOIP should be emraced as the default technology to deliver voice services. As GMS Practices and PC sites are refreshed, as a rule the installation of VOIP should be the default choice. Introducing this technology allows the convergence of previously separate technologies, namely Data, WiFi and Voice services, moving to unifed communications, this allows NHS FV to leverage the current investement in core communications technology investments already made, which will assist in driving downthe overall cost of moving to this technology.

8 Risks

In preparing the Primary Care Improvement Plan, we have acknowledged that this is both ambitious and aspirational; therefore there are a number of risks associated with implementing the priorities we have set out in the Plan. The highest risks we have identified are:

 Financial Affordability of Delivering MOU commitments.  Timescale – the timescale to deliver this ambitious change and improvement programme is short, and whilst every effort will be made with implementation by 2021, it is anticipate that the service improvement programme will continue through 2021 and beyond. The NHS Board has invested in a Forth Valley wide Primary Care Team working alongside the NHS Board’s Contracts Team to oversee PCIP implementation including primary care premises and IT developments.  Reputational Risk and General Practice Engagement – inability to deliver PCIP commitments will lead to loss of trust and loss of the high level of engagement we have with GPs and their staff. This will further risk the effective delivery of the new service models and the development the multidisciplinary team models.  Workforce – Recruitment and Retention of additional primary care staff in line with timescales and required skill sets. Inability to train professionals in new roles within timescales and subsequently retain them within new primary care services.  Maintaining General Practice Sustainability at scale whilst new models are being developed.  Physical Infrastructure: Premises remains significant constraint and the Primary Care Programme Board whose membership includes our Health and Social Care Partnerships, GP leads and other professional multidisciplinary leads oversee this work. A detailed review of current Primary Care premises has been completed and shared with the Programme Board and is currently being costed. This took into account the condition of existing premises, considering needs of additional workforce and potential options for locality / cluster hubs, as well as the impact of new housing developments. A comprehensive primary care premises plan has been developed outlining our short, mid and long term needs with respect to primary care premises.  Digital Infrastructure: Some of the IT barriers to MDT working are significant. IMT MDT infrastructure group is in place and every effort is being made to develop workable solutions to enable new models of working. Ultimately there is a reliance on GP IT re-provision and digital transformation.  Rural Feasibility: Multiple supports are not only inefficient but not feasible to deliver to small practices in rural locations. A rural view is being taken on priority work streams, particularly VTP and CTAC.

9 Financial Projection

The cost of fully delivering the requirements of the new GMS contract continues to exceed the indicative revenue funding allocation provided by the Scottish Government. Our Primary Care Improvement Plan, originally published in July 2018 and updated in May 2019, has consistently highlighted this issue and reports significant projected shortfalls in financial years 2020-21 and 2021-22.

There are 2 key issues:

1. The profile of the allocation over the 4 year period to 2021-22 is out of sync with the timing of when costs will be incurred due to the necessary pace of the recruitment programme if we are to deliver the contract by the end of the agreed 3 year implementation period.

2. The total value of the overall allocation is inadequate to fully deliver all of the agreed MoU commitments.

Whilst significant work has been undertaken to review the proposed service model in terms of skill mix, the phasing of recruitment and our overall assessment of the total number of staff required to adequately deliver the MOU commitments, iteration 3 continues to reflect the revenue costs associated with our assessment of what is required to adequately deliver the MoU commitments. In addition, iteration 3 now also incorporates the estimated capital costs arising from the necessary eHealth/IT and premises upgrades required to facilitate the successful implementation of the contract.

2019-20 – current financial position

The total number of staff in post or in process to be employed by March 2020 is 125 WTEs (v’s 119 in plan) at a cost of £5.161m for 2019-20 (see appendix 1 for details of current position). Whilst this represents excellent progress, it has only been possible through significant additional non-recurring funding provided in year by the NHS Board and IJBs over and above our 2019-20 Primary Care Improvement Fund (PCIF) allocation.

At this stage in the roll out of the plan, it is recognised that the current profile of expenditure across both IJBs is not precisely in line with Scottish Governments funding allocations for the IJBs largely due to phasing of e.g. transfer of childrens vaccinations from general practice. However, once the plan is fully implemented, it is anticipated that the overall investment at the end of year 4 will be broadly in line the NRAC funding allocations.

2020-21 and 2021-22 financial projections

This year’s PCIF allocation (estimated at £5.962m) requires supplementation of a further £2m additional funding to support the recurring costs of maintaining our plan towards contract delivery in 2020/21. A case, for £1.6m in year and £1.3m recurring, additional funding was submitted to the Scottish Government in December. An email rejection of the case was received at the end of March.

With clarity over our end of year financial position and in light of rejection of our business case, all efforts have been made at tripartite level to maintain and adequately progress PCIP. 2020/21 funding assumptions are outlined in the table below. These unfortunately includes exclusion of lowest priority services (e.g. link workers), detailed revision of costs including individual level pay scales, part year cost alignment with projected start dates, additional support through Action 15 funding, carry forward of under spend and additional board funding. It is clear that without the significant funding in addition to PCIF allocation, further implementation of the plan would not significantly progress during 2020-21 This is a completely unacceptable position to our Local Medical Committee and GP contractors.

NHS FORTH VALLEY 2020-21 2021-22 PCIP FINANCIAL PROJECTION AS AT MAY ESTIMATE ESTIMATE 2020 £m £m

WTE 169.55 207.02 Funding assumptions PCIF allocation £5.962 £8.401 IJB reserves & c/f funds £0.579 £0.150 NES GPPN trainees £0.068 £0.000 Action 15 mental health £0.367 £0.462 Other NHS Board funding £0.699 £0.192 Total £7.675 £9.204

Forecast expenditure Vaccine Transformation £0.587 £1.480 Pharmacotherapy Service £2.663 £3.437 Community Treatment & Care Services £0.909 £1.140 Urgent care - advanced practitioners £1.625 £1.819 Additional professional roles £1.759 £2.238 Other (link workers & programme mgt) £0.133 £0.381 Total £7.675 £10.494

Underspend(Overspend) (£0.000) (£1.290)

All of the costs incurred in 20/21 will be sustainable within the year 4 PCIP allocation (estimated at £8.4m), however a residual recurrent £1.290m gap remains against the plan to deliver all of the required MoU commitments. Of note the board funding includes NHS core funds which the Board have agreed to make available on a non- recurring basis to enable the PCIP to continue to progress at pace during 2020-21 in light that no additional funding has been granted by the Scottish Government. This funding has previously been used to support sustainability in 2C practices on a temporary and gradually reducing basis. This is not part of the General Medical Services funding envelope and is therefore not in scope in term of the IJB delegated budgets. It also includes recurring funding for workforce superannuation uplift. With respect to financial year 2021-22, it is intended that the final recruitment programme will focus on appointing a further 25 WTE posts during this period. This will increase the total number of PCIP staff to 196 WTEs. In addition, £750k is assigned to adult flu vaccinations for 2021/22. The current situation regarding COVID 19 may bring an additional potential risk if the population cohort for flu immunisation is extended.

Total costs by 2021-22 are therefore estimated at £10.650m, which compare to total available funding of £9.360m, resulting in a longer term £1.290m recurring deficit. Note that this projection is subject to change pending confirmation of pay awards (currently estimated at 1.5% for 2021-22) and the impact of incremental drift following changes to the Agenda for Change pay scales.

2019-20 2019-20 2019-20 2019-20 PCIP recruitment summary as at Plan Actual Variance Comments Feb 2020 WTE WTE WTE

Vaccine Transformation Programme Admin Support 3.00 3.00 0.00 Nursing staff 10.80 10.80 0.00 13.80 13.80 0.00

Pharmacotherapy Service Pharmacists 26.98 26.98 0.00 Rotational pharmacists 5.50 5.50 0.00 Technicians 6.00 6.00 0.00 38.48 38.48 0.00

Community Treatment & Care Services Primary Care Lead Nurses 2.00 2.00 0.00 Healthcare Assistants 12.60 7.16 5.44 5.44WTE expected to be in post by 31 Mar Treatment room nurses 0.00 0.00 0.00 GP Practice Nurse trainees 7.00 7.00 0.00 21.60 16.16 5.44

Urgent Care - Advanced Practitioners Advanced Nurse Practitioners 14.20 17.56 (3.36) Out to advert for another 1.64 WTE posts

Additional Professional Roles Care home liaison nurses 4.10 3.65 0.45 0.5WTE expected to be in post by 31 Mar Mental Health Nurses 15.70 17.20 (1.50) Physiotherapists 9.40 9.40 0.00 29.20 30.25 (1.05)

Other Community Link Workers 0.00 0.00 0.00 Programme Management & Support 2.00 1.85 0.15 2.00 1.85 0.15

TOTAL 119.28 118.10 1.18

125.68 Total expected to be in post pending recruitment process

NHS BOARD TUESDAY 28 JULY 2020

7.1 Finance Report Seek Assurance

Executive Sponsor: Cathie Cowan, Chief Executive

Author: Scott Urquhart, Director of Finance

Executive Summary This report provides a summary of the NHS Board financial position for NHS Forth Valley to 30th June 2020. The report also provides an overview of the financial impact of COVID-19 to date and the associated financial risks.

Recommendation:

Board members are asked to:

• Note a revenue overspend of £0.146m to 30th June 2020, (Month 3 of 2020/21 financial year), based on the understanding that costs related to COVID-19 will be funded by Scottish Government. • Note the level of additional Covid-19 costs incurred by the NHS Board in the first three months of the year. • Note that initial Quarter 1 returns with indicative full year financial forecasts will be submitted to Scottish Government on 14th August. • Note that in-year funding allocations from Scottish Governement are expected to be confirmed in mid September 2020 following the quarter 1 review process. • Note a balanced capital position to 30th June 2020 based on expected phasing and ongoing review of spend priorities.

Key Issues to be Considered: Issues are highlighted within the attached Finance Report.

Financial Implications Any relevant financial implication will be discussed within the Finance Report.

Workforce Implications Any workforce implications are highlighted within the Finance Report.

Risk Assessment Key risks are highlighted within the appropriate level of Risk Register.

Relevance to Strategic Priorities There is a statutory requirement for NHS Boards to ensure expenditure is within the Revenue Resource Limit (RRL) and Capital Resource Limit (CRL) set by SGHSCD.

Equality Declaration The author can confirm that due regard has been given to the Equality Act 2010 and compliance with the three aims of the Equality Duty as part of the decision making process. Further to an evaluation it is noted that: • Paper is not relevant to Equality and Diversity

Consultation Process Directorate Management Teams with Finance colleagues.

1.0 EXECUTIVE SUMMARY

1.1 Table 1 sets out the NHS Board financial position to 30th June at £0.146m overspend against budget to date. Further information on the financial position of each service area is provided in Section 2 of this report.

1.2 The reported financial position is based on the understanding that additional costs incurred by the NHS Board related to Covid-19 will be funded by Scottish Government and an anticipated funding allocation has been factored into the NHS Board budget.

Table 1: Revenue Financial Position as at 30th June 2020

Variance at 30 June Budget Area Annual Budget 2020 £m £m NHS Services (incl. Set Aside) Clinical Services Acute Services 166.115 (0.014) Cross Boundary Flow 54.067 (0.054) Primary Care, Mental Health and Prisons 26.915 (0.176) Women and Children 39.735 (0.303) Income (25.774) 0.124 Non Clinical Services Facilities and Infrastructure 97.000 (0.032) Corporate Services 33.242 0.097 Other Ringfenced and Contingency Budgets 31.794 0.000 Partnership Funds - Falkirk 1.044 0.000 Partnership Funds - Clacks Stirling 1.758 0.000 Subtotal 425.897 (0.358)

Health & Social Care Partnerships Falkirk HSCP 143.732 0.056 Clacks/Stirling HSCP 126.773 0.156 Subtotal 270.505 0.212

Total 696.402 (0.146)

1.3 The key financial issues and risks are outlined below. Initial Quarter 1 returns with indicative full year financial forecasts will be submitted to Scottish Government on 14th August, with formal monthly financial reporting to Government following thereafter.

Financial Impact of COVID-19. • COVID-19 costs have been identified and reported to Scottish Government with a funding allocation anticipated at a value equivalent to costs incurred to date. Intial funding is being considered for allocation in the next funding letter (August) based on returns submitted on 17th July detailing costs incurred in the first two months of the financial year. • COVID-19 costs for three months to 30 June total £4.673m including additional capacity, testing, cleaning, equipment, cross boundary flow and temporary staff costs. Beyond that there is a further financial pressure due to the delay in delivering the NHS Board’s planned £20.6m annual savings programme, and an impact on adult social care costs which are reported through IJBs. Expenditure levels remain under ongoing scrutiny and review and resources require to be used to their maximum potential.

• Detailed COVID-19 cost estimates have been prepared and submitted for the remainder of the financial year. Costs aligned to the remobilisation plan and are being prepared and will be submitted to the Board in due course. Planning is contingent on COVID-19 infection levels and remains an iterative process.

Underlying Expenditure Trends • Given the reduced level of patient activity across both non urgent elective care and unscheduled care settings there have been a range of underspends in variable costs including theatre consumables and hospital drugs. These costs are expected to return to previous levels as services are reintroduced on a phased basis. • Cross Boundary Flow costs and patient activity levels are being reviewed to understand potential implications on changes in expenditure and income values. • As previously highlighted, costs in relation to Forensic Mental Health Services are showing a marked increase on previous years trend due to increased activity levels at specialist medium secure facilities. • Temporary workforce costs continue to be closely monitored with costs to date of £4.653m, representing an 4% increase over the same 3 month period last year. The areas of highest use are in COVID-19 services across acute and community services with medical locum spend continuing in Old Age Psychiatry and Day Medicine services. Further details are provided at Appendix 1.

2020/21 Projections • Initial scenario modelling indicates that a balanced position can be delivered contingent on confirmation of funding sources including those required to meet COVID-19 related pressures, development of affordable service plans for the remainder of year and close management of non COVID-19 related underlying cost pressures. • The impact of winter and requirements for flu immunisation continue to represent a risk and additional funding will be required to meet those associated costs. • Planned cost improvement work against the six themes identified as part of the approved financial plan plus identification of new opportunitites from embedding the recent digital and service transformation is being supported by the Corporate Programme Management Office. • A reassessment of financial planning assumptions, including identification of slippage against planned investments which have not progressed or have had to be postponed as a result of COVID-19 is underway.

1.4 Annual Accounts The 2019/20 Annual Accounts will be considered for approval at the next NHS Board meeting following Audit Committee planned for 11th August. The External Audit clearance meeting with Audit Scotland was held on 22nd July in line with revised accounts timescales.

1,5 Capital The capital budget to 30th June 2020 reflects a balanced position with spend to date totalling £1.335m. Expenditure to date on COVID related items totals £0.755m. The impact of COVID-19 on development of capital schemes and the phasing of planned expenditure will continue to be kept under close review with facilities and infrastructure colleagues.

1.6 Scottish Government Funding Allocations The annual budget of £696.402m represents the following funding allocations: • Confirmed allocations (letter dated 8th July 2020) of £562.275m. Allocations recieved in June totalled £1.823m and included Scottish Living Wage uplift £0.579m and Hospice loss of Income £0.990m. • Anticipated allocations of £97.903m. It is expected that funding allocations will be agreed in mid-September following finalisation and review of the Quarter 1 returns to Scottish Government. • An indicative budget for Family Health Services (FHS) of £36.224m

2.0 CLINICAL SERVICES

2.1 Clinical Directorates report an overspend of £0.423m to the end of June 2020.

Annual YTD YTD YTD Budget Budget Spend Variance Directorate £m £m £m £m Acute Services 166.115 41.774 41.788 (0.014) Cross Boundary Flow 54.067 13.506 13.560 (0.054) Primary Care, Mental Health, Prisons 26.915 6.734 6.910 (0.176) Women & Children 39.735 10.180 10.483 (0.303) Income (25.774) (6.619) (6.743) 0.124 Total 261.058 65.575 65.998 (0.423)

Budgets highlighted above reflect those services which are not in scope for Health & Social Care Partnership (H&SCP) integration, plus those services defined as ‘Set Aside’. Directorate services in scope for H&SCP integration are reported between the two partnerships within the H&SCP section of this report.

2.2 Acute Services • Acute services are reporting a small overspend of £0.014m to the end of June 2020. Variable supplies costs for the first quarter of the financial year costs are lower than budget as a result of the reduction in both scheduled and unscheduled care activity, particularly surgical sundries, laboratory supplies and drug spend across many services and wards. The main exception to this is the spend on cancer services drugs which continues to grow and exceed available budget. Reduced patient activity has also resulted in lower than usual outsourcing costs particularly within radiology.

• Staff costs are under budget reflecting a number of high cost consultant vacancy posts which would normally be backfilled with locums to maintain activity levels and lower noncore spend.

• Cost pressures remain in several services, particularly Cancer services and ENT services which are in part this month being offset from activity reductions elsewhere in the Directorate. Spend on Cancer Services drugs continues to remain high in the first quarter of the financial year but has been offset partly by a decrease in ophthalmology and theatre drugs spends due to reduced patient activity.

• Acute Services has delivered savings in the first quarter which total £0.831m and have been allocated to savings targets during the month. Specific additional COVID-19 costs have been identified and mostly relate to additional staff costs.

• Work has commenced on recovery plans which will identify the financial impact of new ways of working which could lead to efficiencies to support achievement of the directorates cost improvement targets.

2.3 Cross Boundary Flow • This budget covers patients travelling outwith NHS Forth Valley for treatment including tertiary services i.e. those which require specific specialist care services such as oncology, neurosurgery, specialist medical health, and cardiac services. There is a year to date pressure of £0.054m

• For Forensic Mental Health inpatients, activity and costs started to increase in the later part of 2019/20 and are significantly higher than previous years. There are currently 9 Inpatients at three external NHS facilities. Costs vary between £0.020m and £0.025m per patient per month plus any special observation charges. The forecast in this area remains unchanged and presents as a significant financial pressure. The General 3

Manager and the Service Manager are looking at the implementation of a new process for monitoring and recording the patients at the various stages of their treatment.

• COVID-19 is currently being assumed to have a nil impact for 2020/21 for Cross Boundary and Cross Border activity however this is being closely monitored. Whilst there will be timing issue due to the differing recharge arrangements and periods for inflow and outflow activity, as a Board with a net outflow of activity, any reduction in income from a reduction in inflow activity is currently being assumed to be offset by a reduction in outflow activity and costs.

2.4 Primary Care, Mental Health and Prison Services • This budget area covers Specialist Mental Health and Prison Services and is reporting an adverse variance of £0.176m

• Prisons and Community Services have pressures in GP locum cover costs, supplementary staffing costs in prison facilities together with unachieved savings targets, partially offset by some a number of underspends across the area.

• Within Specialist Mental Health Services, unachieved savings targets present a significant pressure, together with the additional costs of managing complex patients in the Mental Health in patient facility Unit at Forth Valley Royal Hospital.

2.5 Women and Children’s Services and Sexual Health Services • The Directorate is reporting an overspend at the end of the first quarter of £0.303m. The movement in-month relates to historic savings targets and anticipated reductions in anticipated funding. The underlying costs remains as in previous month namely unachieved savings, challenges within Health Visiting budgets and backfill costs associated with sickness absence and maternity leave.

• Work to review each service and develop individual service financial plans which will identify all financial risks and potential solutions to manage those risks is almost complete.

2.6 Income • This represents income received by the Board for Junior Doctor base salary costs from NES, income for treating patients from other NHS Boards areas, and miscellaneous income sources from other organisations.

3.0 NON CLINICAL SERVICES Non Clinical Services report an underspend of £0.065m to the end of June 2020.

Annual YTD YTD YTD Budget Budget Spend Variance Directorate £m £m £m £m Facilities & Infrastructure 97.000 24.669 24.701 (0.032) Corporate Services Director of Finance 3.364 0.841 0.818 0.023 Area Wide Services 3.732 -0.291 -0.204 (0.087) Medical Director 8.038 1.745 1.733 0.012 Director of Public Health 7.427 5.334 5.341 (0.007) Director of HR 4.018 1.005 0.989 0.016 Director of Nursing 2.733 0.602 0.650 (0.048) Chief Executive 1.817 0.445 0.359 0.086 Portfolio Management Office 0.000 0.000 0.067 (0.067) Immunisation / Other 2.113 0.416 0.247 0.169 Total 130.242 34.766 34.701 0.065

3.1 Facilities and Infrastructure Directorate • This budget covers estates, maintenance, transport and domestic services other than those covered by the Forth Valley Royal Hospital (FVRH) Contract, management of the payments for FVRH, Clackmannanshire Community Healthcare Centre and Stirling Health and Care Village contracts, and Capital Projects. It also covers eHealth/ICT, Information and Procurement services.

• At the end of June the Facilities & Infrastructure Directorate is £0.032m overspent. Some reductions have been seen in ASDU activity and the provision of linen services as a direct impact of COVID-19, and these have been offset by other pressure areas.

• The level of expenditure on private ambulances has reduced due to decrease in activity but continues to be significant, although it is important to recognise that this is led by demand across a range of NHS Forth Valley services.

3.2 Corporate services • These services cover a range of services of functions including Finance, Human Resources and Public Health. There are offsetting over and underspends across these services. Corporate services are now showing a net underspend of £0.097m to the end of June.

3.3 Ring-fenced and contingency budgets • These are a range of budgets that are held centrally, including funds ring-fenced for waiting times / access funding, contingency arrangements, and anticipated allocations yet to be distributed, offset by the year to date impact of area wide savings not yet distributed.

4.0 HEALTH AND SOCIAL CARE PARTNERSHIPS

4.1 NHS services in scope for Health and Social Care Partnerships (H&SCPs) report an underspend of £0.212m to 30th June 2020.

Annual YTD YTD YTD Budget Budget Spend Variance HSCP £m £m £m £m Falkirk Operational Services 63.305 16.516 16.138 0.378 Universal Services 80.427 20.075 20.397 (0.322) Subtotal 143.732 36.591 36.535 0.056 Clackmannanshire and Stirling Operational Services 51.142 13.384 12.843 0.541 Universal Services 75.631 18.995 19.380 (0.385) Subtotal 126.773 32.379 32.223 0.156 TOTAL 270.505 68.970 68.758 0.212

4.1 Health and Social Care Partnership budgets detailed above are Health budgets designated as in scope for HSCP integration, excluding services defined as Set Aside. Financial pressures related to ‘Set Aside’ services are met by NHS Forth Valley and are captured within the Clinical Services section of this report.

4.2 The main financial pressure areas for partnership services continue to be Prescribing, Complex Care and Community Hospital Inpatient Services, partly offset by historic underspends against community services budget areas. The majority of issues affecting the prescribing budget are demand driven and pressures including medicines pricing and increased uptake are being experienced nationally across HSCPs. Plans to deliver cost and quality improvements for prescribing have been developed and are due to commence in August.

5.0 SAVINGS

5.1 At the Board meeting on 31st March the Board approved the 5 Year Financial Plan, which incorporated a savings requirement of £20.6m to break even. As part of the Board’s longer term strategy to meet the savings challenge, the NHS Board has invested in the establishment of a Corporate Portfolio Management Office (CPMO) to facilitate change at pace to drive improved value and efficiency. Initial savings plans were set out against six key themes: • Medicines Efficiencies • Innovation, Corporate and Digital Development • Patient Flow and Demand Management • Integrated Service Opportubities • Workforce including eRostering • Financial Grip and Control

These savings were supplemented with a global 1% savings target which has been applied across services.

5.2 Following the COVID-19 outbreak the majority of actions supporting the above plans required to be paused with staff resources reprioritised to support mobilisation plans. The risk on savings delivery directly resulting from COID-19 delays has been quantified at approximately £10m and this was been included within the COVID-19 cost template submitted to Scottish Government. Work is now however starting to progress on delivery of the above plans and to reprioritise new ways of working to introduce efficiencies and improved value across services as they are reintroduced on a phased basis and further detailed information will be presented to the Performance and Resources Committee on this area.

6.0 FINANCIAL RISKS The following key financial risks were reassessed at July 2020. There is a corporate level finance risk ‘that NHS Forth Valley is unable to maintain financial stability and meet its financial requirements in regard to revenue and capital.’

Risk Rating (R/A/G) There is a risk that COVID-19 mobilisation plan costs are not fully Red funded and that subsequent infection rates will impact on the Boards ability to meet its financial targets.

There is a risk that anticipated Scottish Government funding allocations, Red including those required to meet winter pressures, cannot be met in full. The position is expected to be confirmed in mid September.

There is a risk that the Board’s cost improvement programme will not Amber deliver the required level of recurring savings, increasing the underlying deficit in future years.

There is a risk that additional financial contributions required from Amber partner organisations to meet IJB financial pressures will exceed affordable levels, particularly given the COVID-19 impact on adult social care services.

There is a risk that the Board’s cost improvement programme will not Amber deliver the required level of recurring savings in 2020/21, increasing the risk on financial and service sustainability in future years.

There are uncertainties associated with EU withdrawal arrangements Amber which carry potential financial risk.

There is a risk that areas of specific clinical service sustainability risk Amber will require additional financial resources to maintain safe and effective services for patients.

New Drugs - proportion of spend on hospital drugs has been rising Amber above inflation year on year. Approvals for new high cost drugs have significant impact on spend profile.

There is a risk that capital spend on approved infrastructure and Amber equipment programmes will fall out of alignment with annual budget plans.

7.0 CAPITAL

The year to date capital position is break even. Total capital resources comprising CRL and retained property and land receipts are £17.880m as set out in Appendix 2. Expenditure to date is £1.335m, with £0.225m spend in-month for June. The phasing of capital expenditure is expected to considerably increase towards the mid point of the year.

Total £m Capital Resources General Allocation 17.280 Property Disposals 0.600 Total Capital Resources 17.880

Capital Expenditure Spend to 30th June 2020 1.335 Anticipated Spend July 2020 to March 2021 16.545 Total Planned Capital Expenditure 17.880

Information Management & Technology – to date £0.263m has been spent on Information Technology and eHealth projects. During June expenditure included staff recharges costs, professional adviser fees and hardware costs to the value of £0.143m.

Medical Equipment – as at 30th June 2020 £0.831m has been spent on medical equipment items. £0.755m of this total relates to equipment required to combat the Covid-19 pandemic, and during June a further £0.076m was spent on a Faxitron used to support surgery.

Facilities & Infrastructure – expenditure to date within this category totals £0.241m with a further £0.024m spent during June 2020.

A detailed analysis is attached at Appendix 2.

Appendix 1 – Non-Core Staff Cost Trends

Medical Agency & Bank 2019/20 v 2020/21

1,200 1,000 800 600

£'000s 400 200

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

FY 2019 FY 2020

Nurse Bank & Agency 2019/20 v 2020/21

1,400 1,200 1,000 800 600 400 £'000s 200 0 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

FY 2019 FY 2020

Admin Bank & Agency Staff 2019/20 v 2020/21

1,200

1,000 800 600

£'000 400 200

0 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar FY 2019 FY 2020

Appendix 2 – Capital

Annual YTD YTD YTD Budget Budget Spend Variance CAPITAL RESOURCE LIMIT £000 £000 £000 £000 As at 30th June 2020 CAPITAL RESOURCES SGHD - General Allocation 6,085 580 580 0 SGHD - Improving Access to Elective Care 5,000 0 0 0 SGHD - GP Sustainability Loans 916 0 0 0 SGHD - Covid-19 795 755 755 0 SGHD - Return of Banked Funding 4,484 0 0 0 Total Core Capital Resource Limit 17,280 1,335 1,335 0 Value of Asset Sales Retained 600 0 0 0 Total Capital Resources 17,880 1,335 1,335 0 PLANNED CAPITAL EXPENDITURE Elective Care Elective Care 5,000 0 0 0 Total 5,000 0 0 0 Information Management & Technology Information Management & Technology 3,059 263 263 0 Total 3,059 263 263 0 Medical Equipment Medical Equipment 2,000 76 76 0 Covid-19 Equipment 795 755 755 0 Total 2,795 831 831 0 Facilities & Infrastructure Facilities & Infrastructure 6,110 241 241 0 Total 6,110 241 241 0 Financial Assets GP Sustainability Loans 916 0 0 0 Total 916 0 0 0 Total Capital Expenditure 17,880 1,335 1,335 0 Savings/(Excess) Against Resource Limit 0 0 0 0

Forecast Property Disposals Doune Health Centre 100 0 0 0 Field X, RSNH Site 500 0 0 0 Square to Plan 0 0 0 0 Total Forecast Property Sales 600 0 0 0

FORTH VALLEY NHS BOARD TUESDAY 28 JULY 2020

7.2 Elective Care Development Programme: Elective Care Ward Update Seek Approval

Executive Sponsor: Scott Urquhart, Director of Finance

Authors: Gillian Morton, Programme Director; Janette Fraser, Head of Planning; Moira Straiton, Project Manager - Elective Care Programme; Morag Farquhar, Associate Director of Estates & Infrastructure; Maxine Michie, Senior Finance Manager

Executive Summary

This paper provides an update on the current status of the elective care modular build and car parking requirements. The additional inpatient ward will enable the Elective Care Development Programme to deliver the commitment to provide a further 1500 joint operations annually.

Recommendations

The NHS Board is asked to:

• approve splitting the variation enquiry for the modular ward into 2 phases to allow the design to be progressed, noting the Board liability for the design fees estimated to be between £200K-300K • approve moving the boundary line, within which Forth Health are contracted to operate, to within the Board’s remit and issue a licence to Forth Health to design and build the new spaces • approve engaging with SERCO to undertake the service requirements of the new car park • note the indicative timeline

Key Issues to be considered

• Procurement and Construction

In order to meet the timeframe for delivering the additional inpatient beds required to support the elective care programme, an extension to the hospital to provide a ward, using modular construction methodology, has previously been approved by the NHS Board.

The additional elective inpatient ward will be constructed in the current mental health unit car park. The extension will provide a single storey ward, comprising up to 30 single bed rooms and associated accommodation. It is planned to staff 26 of the beds initially. The additional elective ward will be connected to the hospital by way of a single storey link corridor to the ground floor and a bed lift to the first floor, to provide access to the Theatre Suite. The rooms are all single rooms and would further support the Boards ability to respond to the current and any future pandemics.

Initial testing of the market identified 7 suppliers on the National Framework, who expressed an interest in constructing the ward extension at Forth Valley Royal Hospital. Through a process of clarifications and detailed assessment against key criteria, site visits and due diligence, a preferred supplier was identified. The Framework Exercise provided assurance that a supplier could meet our requirements to construct a modular build ward which met the relevant standards, including the Health Technical Memoranda; could deliver within the timescale required and was able to

1 demonstrate value for money. Procurement will be taken forward by Forth Health using the variation process.

As per previous agreement the procurement of the elective care centre inpatient ward, including the link corridor and lift will be undertaken by Forth Health. Forth Health by way of Variation will act as the Special Purpose Vehicle for Forth Valley Royal Hospital, as set out within the terms of the Project Agreement for the hospital and in line with relevant procurement legislation.

The procurement process to date has been longer than originally anticipated for a number of reasons:

Firstly, it was important to undertake due diligence in relation to the Framework Advert and response. Whilst it had been anticipated that only 1 or 2 providers would respond, initial expressions of interest were submitted by 7 providers. This required an extended period to seek clarifications and undertake detailed assessment, with input from the Board’s Lead Advisor (AECOM) and Health Facilities Scotland (HFS). This assessment and due diligence also necessitated additional site visits by the Programme Team.

Secondly, PFI (Forth Valley Royal Hospital) considerations and as a result, there was a requirement to provide assurance that the Variation Enquiry and subsequent Variation met all of the relevant procurement rules. These are set out within the terms of the Project Agreement for Forth Valley Royal Hospital, which sets out the scope and requirements for any variations to the original contract. The Central Legal Office (CLO) considered that it was essential that any risks associated with construction should be held by Forth Health, as set out within the terms of the Project Agreement, and therefore it would not be appropriate for NHS Forth Valley to advise Forth Health to use a particular provider for the new build. Forth Health, in accepting the Variation Enquiry, will engage SERCO, the site facilities provider, to contract with a suitable provider, using their own tender processes.

Thirdly, new build requirements in line with changes to NHS Scotland new build requirements. Although these changes relate to buildings of a significantly larger scale than the Forth Valley Elective Ward, it was still essential that a full and detailed appraisal was undertaken. This necessitated detailed investigations and discussions involving the CLO and HFS, before a Variation Enquiry could be issued. Progress has also been impacted by the lack of availability of key people over the festive period and then the COVID-19 pandemic.

A Variation Enquiry for the elective ward, link corridor and lift was submitted to Forth Health on 6 February 2020 and a full response was required within 30 days. To date a full response has not been received for the following reasons:

1. Forth Health Procurement strategy

Forth Health’s preferred route is to utilise the incumbent site facilities provider (SERCO) to undertake the procurement, appointment and management of the contractor on their behalf. SERCO have completed a tender process and have provided a redacted tender report to Forth Health/NHSFV. This has not provided enough information to allow Forth Health/NHSFV to undertake due diligence. Furthermore issues were identified in relation to the contractual process between Forth Health and SERCO which has involved Forth Health having to develop a contractual process to engage with SERCO in this way. This process was finalised at the end of June 2020 with SERCO engaged and the process has been issued to NHSFV’s Elective Care Development Programme Leadership Group. This in turn has been circulated to the Board’s appointed legal advisor (Eversheds); the Board’s Lead Advisor (AECOM) and HFS for comment. Responses are currently being compiled for issue to Forth Health.

2. Variation enquiry-design detail

Forth Health has reported it is currently unable to fully respond to the variation enquiry due to lack of detailed design. Without detailed design they are unable to provide firm construction costs, timescales or lifecycle costs. Various options have been explored with Forth Health, HFS and AECOM to address this issue and aid progression.

In order to progress the project the design requires further development before a firm cost/timeline can be provided. The nature of the modular build is that the design solution requires to be developed by the successful contractor. A design cannot be developed in isolation as the final design may not be compatible with the bespoke modular unit configurations of individual companies. In order to get firm costs for the construction, commissioning and servicing of the new facility a contractor needs to be selected and appointed prior to design finalisation.

The possible options are detailed below in Table 1 and have been evaluated on their ability to deliver the aforementioned objectives in conjunction with the lead advisor and HFS:

A- Do nothing (i.e. leave the variation as a single entity)

B- Split the single variation enquiry into 2 phases (Phase 1: Design and Phase 2: Construction/commissioning and servicing)

C- Issue 2 separate variation enquiries (1. Design; 2. Construction/commissioning and servicing)

Table 1

Option Pros Cons

A Follows the normal variation Protracted Forth Health lenders approval process protocols therefore the preferred required with potential for rejection due to the option of the HFS PFI advisor unknown risks from lack of detailed design

Forth Health unable to respond to variation enquiry in present form therefore progress has halted

Abortive design fees * if the firm costs are in excess of available funding and the NHS Board does not proceed with the construction

Potential for claim against the NHS Board for loss of profits if Variation is issued in its current format and the NHS Board decide not to proceed beyond design

Option Pros Cons

B Simplified lender approval process Deviation from the normal process as minimal risk associated with design fees Abortive design fees * if the firm costs are in Forth Health will be able to respond excess of available funding and the NHS Board to phase 1 of the variation enquiry does not proceed with the construction which will in turn allow progress to the next phase

Phasing of the variation will allow firm costs to be identified and provide a pause where the Board can decide not to proceed if the costs are excessive without facing potential claims for loss of profits

Phasing of the variation facilitates an assurance review stage where the Board can decide not to proceed if there are concerns that the proposed design will not comply with relevant guidance (.i.e. SHTM’s/HTM’s) without facing potential claims for loss of profit

C Simplified lender approval process Full schedule of deliverables will be required for as minimal risk to Forth Health each stage; associated with design fees; Risks that full requirements may be overlooked if Forth Health will be able to respond split between 2 variations; to phase 1 of the variation enquiry which will in turn allow progress; Advice from HFS PFI advisor and Lead Advisor is that this is the least preferred option; Phasing of the variation will allow firm costs to be identified and Abortive design fees * if the firm costs are in provide a pause where the Board excess of available funding and the Board does can decide not to proceed if the not proceed with the construction. costs are excessive without facing potential claims for loss of profits;

* Design fees are the NHS Board’s liability regardless if decide to proceed to construction or not and regardless of the option chosen. Forth Health has advised that the estimated design fees are £200K-300K.

Option A has been ruled out as no further progression can take place without developing the design. Forth Health is unable to respond to the variation in its current form. Advice sought from the HFS PFI lead is that Option A would be the preferred option as that follows the normal contractual 4 process but has agreed that Option B is the only viable option if the NHS Board wish to move forward taking the project particulars into account. The Lead Advisor has advised that the only risk foreseen by proceeding with Option B is that the design fees may require to be paid earlier in the process than with Option A as regardless of the Option the NHS Board is liable for design fees. Option C has been ruled out following advice from the Lead Advisor and HFS that this is the least favoured option due to the risks detailed above.

Proceeding with Option B will allow Forth Health to respond with indicative proposals on construction costs, operational and maintenance costs and any modifications required to the existing project agreement such as FM performance standards and payment mechanisms as part of phase 1. This would be accompanied by a plan and cost for developing these indicative proposals into a final detailed set of deliverables (including lifecycle and confirmed performance standards) which the Board can then consider and approve, before the works can be instructed and commenced - Phase 2.

The NHS Board are asked to note the risks associated with the design fees; agree to underwrite the design fees (Approx. £200K-300K) and approve the recommendation to proceed with Option B and phase the variation enquiry. It should be noted that regardless of the option chosen the Board would assume liability for the design fees.

Next Steps:

If the NHS Board approve the recommendation to proceed with Option B the next steps will be to agree commercial and contract arrangements with Forth Health. The Governance around the variation enquiry will sit with the Project Board.

3. Boundary issues

As previously advised Falkirk Council set conditions relating to the planning application for the modular ward in relation to car parking on the site. Falkirk Council planners advised that in order for the elective ward application to be approved, a parallel plan to re-provide the spaces lost before the ward build commences on site is required and a further plan to provide the additional spaces between the build commencing on site and the ward opening.

The car parking proposal is summarised again below for information purposes.

Table 2 – Replacement and Additional Parking Proposal

BB = disabled spaces SS = standard spaces

A Variation Enquiry relating to the car park works was also issued to Forth Health in February 2020 to provide costs for the car park design and site assessments, including topographical surveys.

Topographical surveys have taken place and a proposed layout provided as shown below:

*Black line signifies the boundary line. The small section of the car park to the right of the black line is within Forth Health’s remit.

However, as part of the new car park is located out with the line boundary, within which Forth Health operates in line with the Project Agreement for the site, Forth Health have requested a decision on how NHS Forth Valley wish to proceed. The proposed options are detailed below and have been evaluated on their ability to deliver the aforementioned objectives:

A- Move the red line boundary so land proposed for the new car park is all within Forth Health’s remit and Forth Health procure, design and build

B- Move the red line boundary so land proposed for the new car park is all within NHS Forth Valley’s remit and issue a licence agreement to Forth Health to procure, design and build

C- Move the red line boundary so land proposed for the new car park is within NHSFV’s remit and NHS Forth Valley design and build

D- Re-design the car park so that it is on land within NHS Forth Valley’s remit and NHS Forth Valley then take on responsibility for the design and build

Solution Pro’s Con’s

A Timescales aligned with planning Complications of amending the Project condition requirements and the Agreement and timescales to fulfil the legal construction obligations

Timescale alignment is Forth Health’s Consent process timescales associated with responsibility/risk moving the boundary

Forth Health have already undertaken Terms & Conditions for the Design & Build topography surveys and have indicative (D&B) contract will be more onerous and we will plan in place reducing associated need to address the interfaces with the timescales provision of services which will increase timeframes and hinder progression until these issues are resolved Tender process for car park has already taken place and additional prices are Restricted contractor pool due to more onerous currently being sought to ensure requirements that Forth Health’s lenders would competitive tender returns and reducing require associated timescales Costs liable to be significantly higher as base cost of works will be inflated by any risk pricing for SERCO’s terms and conditions along with management fees; overheads and profit for SERCO/Forth Health

B Timescales aligned with planning Consent process timescales associated with condition requirements and the moving the boundary construction Costs liable to be higher as base cost of works Timescale alignment/programme risk will be inflated by any risk pricing for SERCO’s sits with Forth Health terms and conditions along with management and overheads and profit for SERCO/Forth Terms & Conditions for the Design & Health Build (D&B) contract will be less onerous potentially saving time and Service agreement would need to be agreed money separately

Timescales to implement licence agreement

Solution Pro’s Con’s

B cont Contractor pool likely to be larger due to less onerous Forth Health lender conditions which may lead to more competitive prices;

Forth Health have already undertaken topography surveys and have indicative plan in place reducing associated timescales

Tender process for car park has already taken place and additional prices are currently being sought to ensure competitive tender returns and reducing associated timescales

C Potential for better value for money Consent process timescales associated with moving the boundary Reduced consent process in relation to Options A/B timescales associated with Additional time and resources to re-tender moving the boundary which will potentially delay the project further

Timescale alignment/programme risk sits with NHS Forth Valley

Potential for delay costs from Forth Health if car park timing delays the ward construction given the planning stipulations

Potential for high professional fees that may exceed any margins applied by Forth Health

Potential for additional fees for design/topography

No guarantee of a response

Service agreement would need to be agreed separately

Costs could increase rather than reduce as current market conditions indicate a greater element of risk being built in

Solution Pro’s Con’s

D Potential for better value for money Forth Health has undertaken an initial design assessment and topography survey and has No consent process therefore no indicated the most suitable option. Moving the timescales associated with moving the layout may increase costs associated with boundary locations of access roads and resolving topographical issues

Additional time and resources to re-tender which will potentially delay the project further

Timescale alignment/programme risk sits with NHS Forth Valley

Potential for delay costs from Forth Health if car park timing delays the ward construction given the planning stipulations

Potential for high professional fees that may exceed any margins applied by Forth Health

Potential for additional fees for design/topography

No guarantee of a response

Service agreement would need to be agreed separately

Costs could increase rather than reduce as current market conditions indicate a greater element of risk being built in

In order to maintain the required car parking numbers an engineering solution would be required to address topographical issues that could significantly increase costs and adversely impact on timescales

Upon consideration of the planning stipulations; timescales associated with the tender process and the risk that returned costs may not necessarily be more competitive, the recommended option is Option B- Move the red line boundary so land proposed for the new car park is all within NHS Forth Valley’s remit and issue a licence agreement to Forth Health to procure, design and build. The other options were ruled out based on timescales; risks and the potential for inflated costs due to this.

4. Car park servicing arrangement

The 3 delivery options are detailed below and have been evaluated on their ability to deliver the aforementioned objectives:

A- NHS Forth Valley engage a 3rd party to service the new car park

B- NHS Forth Valley engage with SERCO to service the new car park

C- NHS Forth Valley undertake the service requirements of the new car park

Solution Pro’s Con’s

A May be able to negotiate more Inconsistent service arrangement economical service agreement compared to the other car parks impacting on staff/patient experience

Potential interface issues with having multiple service providers on site

Costs associated with service requirements (i.e. gritting). Costs have the potential to be higher than those that could be negotiated with SERCO due to existing arrangements

B Consistent service arrangement Costs associated with service relative to the other car parks requirements (i.e. gritting) (these costs will be open to negotiation as per the purple car park and there will be a cost regardless Potential for reduced of who is servicing the car park) negotiation/contract requirements as per the purple car park

C May be potential to reduce costs NHS Forth Valley do not currently have the infrastructure to provide the service arrangement required to be consistent with the rest of the site and therefore workforce; recruitment; sub-contractor contract negotiations would be required with associated costs;

Potential inconsistencies with current service agreement leading to reduced staff/patient experience.

Costs associated with service requirements (i.e. gritting)

The recommended option is option B to ensure service continuity and consistency with other on site car parks. SERCO already service the other car parks on site, therefore existing arrangements on site should facilitate reduced timescales to negotiate contracts and a market cost assessment could be completed to ensure the associated costs are economical.

5. Provisional Timeline

A provisional timeline and key stages for the elective ward is provided in Appendix 1. However, a firm timeline will not be available until a provider is appointed by Forth Health, via Serco, to design, manufacture and construct the ward.

Advisory Note: The timeline is dependent on the key milestones identified being met. Any delay to approvals will impact the delivery date.

Financial Implications

Scottish Government are currently carrying a capital allocation of £5 million for the project, however indicative costs suggest actual costs are likely to be significantly in excess of this figure. This has

10 previously been flagged to the SRO and Scottish Government. Progressing to a design will allow us to get firm costs to inform further negotiations with Scottish Government.

Workforce Implications

Recruitment has been aligned, as far as possible, to the phased elective care programme development, however opportunities to recruit specific staff groups at optimum times have been taken.

Risk Assessment

A detailed risk assessment for the Programme has been developed and is reviewed regularly. Delivery of the Programme to timescales may be impacted by:

• The recent addition of the assurance review requirement being implemented on the elective projects by HFS and associated timeframes • Planning and construction delays • Legal/contractual issues • Approvals

Relevance to Strategic Priorities

• Increased capacity to meet demand for elective treatments • Reductions in waiting times for elective treatments – meeting national waiting time standards • Sustainable future model of elective

Equality Declaration

The author can confirm that due regard has been given to the Equality Act 2010 and compliance with the three aims of the Equality Duty as part of the decision making process.

Consultation Process

The Scottish Government announced its investment in a national Elective Care Programme which included NHS Forth Valley. A communication and engagement plan supports this Programme and to date extensive staff engagement has taken place. A further organogram has been drafted that highlights the communication strategy for the construction, design and build process.

Appendix 1: Indicative Timeline:

Appendix1

FORTH VALLEY NHS BOARD TUESDAY 28 JUNE 2020

8.1 Communications Update Report March – June 2020 For Assurance

Executive Sponsor: Cathie Cowan, Chief Executive

Author: Elsbeth Campbell, Head of Communications

Executive Summary

This paper provides an update on the communications work undertaken to support the organisation’s response to the COVID-19 pandemic from March – June 2020. It also provides examples of some of the resources developed and specific initiatives designed to inform, engage and reassure the public, staff and other key stakeholders during this period.

Recommendation

The NHS Board is asked to:

• note the update and ongoing activity to support remobilisation

Key Issues to be Considered

The COVID-19 pandemic has created unprecedented communications challenges as well as opportunities to highlight the work of and contribution made by local health and care staff. It has generated sustained media interest and an ongoing requirement to ensure local staff, public and patients are kept updated in a very fast paced and challenging environment.

Financial Implications

There have been no additional financial costs associated with the pandemic in relation to communications and it has created an opportunity to use and build on existing internal and external communication channels.

Workforce Implications

The Communications Team, like many departments, has faced challenges associated with staff working remotely and shielding requirements however, the Team has worked overcome these and ensure that services have been maintained throughout the pandemic.

Risk Assessment

Accurate, timely and relevant communications, tailored to the needs of specific audiences can help mitigate some of the pressure on local services, reassure the public and ensure staff are well informed.

Relevance to Strategic Priorities

Communications activities have played a vital role throughout the pandemic and supported the organisation’s wider strategic and operational response.

Equality Declaration

The author can confirm that due regard has been given to the Equality Act 2010 and compliance with the three aims of the Equality Duty as part of the decision making process.

Further to an evaluation it is noted that:

• Screening completed - no discrimination noted

Communications Update COMMUNICATIONS COVID-19 REPORT

Christopher Richards

March-June 2020 OVERVIEW

On the 5th March 2020 the Chief Medical Officer for Scotland confirmed an individual from the Forth Valley area, tested positive for Covid-19. On 17th March 2020, the NHS across Scotland was placed on an emergency footing to help free up capacity to respond to the pandemic and on 23rd March the entire country entered lockdown to help prevent the spread of the virus. This was an unprecedented situation which required an immediate and sustained programme of communications to inform, reassure and support staff, patients and members of the public.

Internal communications were vital to ensure staff could quickly access the new guidance, policies and procedures which were being issued on daily basis and were subject to ongoing review and frequent updates. A new Covid-19 section on the staff intranet was set up to help staff access the latest up-to-date local and national information. New patient letter and text templates were developed to ensure any patients whose appointments were postponed received consistent information and advice. This was supported by additional online information on a new Covid-19 section of the NHS Forth Valley website and regular updates via social media. Weekly virtual media briefings were organised with local reporters to share information, reinforce key messages and respond to questions or concerns. These proved very successful and helped ensure a consistent approach as well as generating positive and balanced coverage across all local titles. Targeted work was undertaken with national media to highlight the work of local staff, volunteers and fundraisers over the last few months.

The Communications Team worked with local staff to promote the message “We stay at work for you. You stay at home for us” to encourage people across Forth Valley to heed the national advice to stay at home to help slow the spread of COVID-19. ACTIVITYCompany SNAPSHOT Statisics 19,500 44

FACEBOOK MEDIA RELEASES Followers on Facebook The number of proactive releases issued 13,800 165

TWITTER MEDIA ENQUIRES Followers on Twitter The number of media enquiries received, managed and responded to. 240,300 113,750

HIGHEST REACH AVERAGE WEEKLY REACH Highest performing post on The number of people who have had Facebook content/posts from our Facebook page visible on their screen/newsfeed 27,900 3,500 AVERAGE DAILY REACH INSTAGRAM The number of people who have had Followers on Instagram content/posts from our Facebook page visible on their screen/newsfeed

ANNUAL REPORT 2019 03/03 KEY INITIATIVES

Details of how to access GP services, including the the new local COVID-19 Community Assessment Centres set up for people with symptoms of coronavirus, were widely shared to remind people to seek advice before turning up at their local GP practice. Work was undertaken with dental leads to ensure local residents were aware of new arrangements that were put in place they could continue to have access to urgent dental advice and treatment.

The Communications Team worked with pharmacy leads to issue advice to help reduce pressure on local pharmacies by asking people not to request their repeat prescriptions before they were due and only order what they needed. This would also help avoid potential shortages and ensure there was enough medication for everyone.

New drive through COVID-19 testing facilities for frontline health and social care staff across the area were showcased by national and local media. Three new drive through testing centres increased staff testing capacity from around 40 to up to 200 each day - allowing staff to safely return to work as quickly as possible. The new in-house laboratory testing service at Forth Valley Royal Hospital was also promoted as a key service development which increased testing capacity and enabled results to be processed within 24hrs.

Work was undertaken to promote the thousands of frontline staff and students who joined NHS Forth Valley to help respond to the Covid-19 pandemic. This included 300 staff who joined our local staff bank. The majority were nurses and healthcare support workers however a number of doctors, domestic staff, pharmacy, theatre, administrative staff, drivers and laboratory staff have returned to help maintain services. A further 400 individuals, who responded to the national appeal, indicated they wished to work in NHS Forth Valley. They were joined by hundreds of student nurses from the University of Stirling and a number of medical trainees. KEY INITIATIVES

Work was undertaken with the Research and Clinical Trials team to promote their involvement in the RECOVERY trial, the world’s largest and fastest growing clinical trial, designed to examine potential treatments for COVID-19. The work of staff at Forth Valley Royal Hospital was featured in national and local media and helped contribute to a major breakthrough when the trial discovered that a common steroid can significantly improve outcomes for patients with COVID-19

The Communications Team supported the Public Health Scotland Campaign to encourage people to attend immunisation appointments for children and pregnant women which continued to take place during the pandemic.

Activity was undertaken with partners to highlight the wide range of actions in place to support the safety and wellbeing of care home residents and staff across Forth Valley during the Covid-19 pandemic. This included an initial assessment of all 66 care homes in the area to ensure local staff are aware of infection control procedures and the safe use of PPE. A daily care home meeting, chaired by Consultants in Public Health Medicine, was established to identify and address any emerging issues or concerns along with a multi-agency team to manage to respond to any local outbreaks.

An innovative virtual consultation initiative for patients with eye injuries or problems, which was piloted in NHS Forth Valley, was rolled out across Scotland to help respond to the pandemic. The Communications Team worked closely with colleagues from the University of Stirling and NHS Grampian to promote the success of the local pilot and the ground-breaking work undertaken by some of the local clinical leads involved. KEY INITIATIVES

The achievements of our medical physics department were highlighted to promote the work they had undertaken to quickly adapt existing medical equipment at Forth Valley Royal Hospital. They converted 35 anaesthetic machines to ventilators which increased the hospital’s capacity six-fold. A ultra-pure water supply system was also installed in the Intensive Care Unit to provide renal dialysis for patients with COVID-19.

Occupational Therapist Sarah Dove, who was redeployed to provide support to the Bellfield Centre, came up with an idea to create laminated badges which could be pinned onto PPE to make communication with patients easier and staff appear less scary. This was just one of the many initiatives promoted by the Communications Team to highlight how local staff were working to support patients and their families at this challenging time.

The Communications Team also highlighted how local staff were supporting wider national developments including Scotland's new temporary hospital at the SEC in Glasgow. Louise Boyle, NHS Forth Valley’s Head of Nursing for Emergency and Inpatient Services was appointed as one of two Associate Nurse Directors at the NHS Louisa Jordan and a number of local clinical staff volunteered to work at the hospital if required.

Thousands of patients across Forth Valley have been able to continue to access expert health information and advice during the Covid-19 pandemic thanks to a huge rise in the use of video consultations. The Near Me service has been used by a wide range of health professionals to keep in touch with their patients and enabled more than 6,000 scheduled appointments to go ahead as planned. Work was undertaken with the national Near Me team to highlight the growth in Forth Valley and encourage people to take part in a national survey to inform future developments. KEY INITIATIVES

Raising awareness of the support available was a key priority, particularly for people struggling with mental health issues during the pandemic. This included media and social media to promote online self-help packages for coping with Covid-19, depression and anxiety as well as a new suite of CBT packages. A new Support and Wellbeing site was developed for local staff and work to highlight the wide range of national and local support available.

Visiting restrictions has been one of the biggest challenges for patients and their families and local staff have helped overcome this by finding alternative ways for people to keep in touch. The Communications Team worked with local staff to highlight how ipads, personally-painted Comfort Stones and hand written letters were being used to reduce isolation and help patients feel more connected to the outside world.

As the focus moves from responding to the pandemic to remobilisation, work is now underway to highlight plans to safely restart a number of health services on a phased basis over the coming weeks and months. This includes diagnostic services for patients whose routine or less urgent scans were postponed, day procedures and planned surgery across a number of specialities with patients prioritised by clinical need.

Details of dental and optometry services for people with urgent dental and eye problems have recently been promoted. Work has also been undertaken to highlight the ongoing use of telephone and video consultations at GP practices throughout Forth Valley. Updates on a number of commonly used services have been added online along with details of new arrangements in place for visiting hospital or attending for an appointment. Specific work has also been undertaken to highlight that although services are restarting they are not back to normal and will continue to operate with reduced capacity for some time due to the need for physical distancing and enhanced safety measures designed to reduce the risk of Covid-19. MEDIA ISSUES

Local 'virtual' media briefings have been organised and supported by the Communications Team weekly throughout this period and have taken place via Zoom video calls. The majority of these have been supported by our Medical Director and Director of Public Health who were able to provide advice, answer questions from readers and address any misconceptions or concerns. Interviews have also been organised with a range of front line staff including doctors, nurses and AHPs and a number also recorded audio diaries for BBC Radio Scotland to give an insight into their day-to-day work.

The Communications Department arranged access for BBC Reporting Scotland, The Nine, Radio Scotland and STV during the pandemic to highlight the work of staff working in the two designated Covid-19 wards at Forth Valley Royal Hospital, local drive-through testing centres, our involvement in national Covid-19 clinical trials, work underway to restart services and raise awareness of the new arrangements in place to help keep patients and staff safe.

Features were arranged with a number of local reporters and photographers to showcase the work of our local doctors and nurses during the COVID-19 pandemic. A number of the striking images taken at Forth Valley Royal Hospital for these articles also featured in national media and were used in a Scottish Government video to mark International Nurses Day. MEDIA ISSUES

The Communications Team received, managed and responded to over 165 media enquiries between March and June 2020. The majority related to Covid-19 including testing, confirmed cases, contact tracing, hospital discharges, service changes and impact on staff.

Work was undertaken with local Health & Social Care Partnerships, care home operators and council communication leads to ensure consistent, accurate and timely responses to enquiries on local care homes. Briefings were also prepared for local MSPs, councillors and media to highlight the wide range of actions undertaken to support local care home staff and residents in all 66 care homes across Forth Valley. SOCIAL MEDIA

NHS Forth Valley's social media platforms have been used extensively to provide quick, clear advice and information as well as signpost people to local services and support throughout the COVID-19 pandemic.

Our social media audience continues to grow and NHS Forth Valley now has over 19,500 followers (an increase of 7,000 followers since March 2020) on Facebook and over 13,800 followers on Twitter. A new Instagram account was recently underway and work is underway to grow the audience on this channel.

One of the most engaging posts during the period was a video of staff from Ward B12 at Forth Valley Royal Hospital celebrating the discharge of an 80 year old patient who recovered from Covid-19 and was able to return to his own home after four weeks in hospital. This was also picked up by BBC Scotland, Global Radio and STV News.

Over the last few months the Communications Team has worked closely with colleagues from the Scottish Government, Pubic Health Scotland and NHS 24 to support a number of new campaigns. These include FACTS, #TestandProtect, Stop Smoking, Clear Your Head, national screening programmes, immunisations, domestic abuse, shielding advice and the NHS is open,

A wide range of staff have featured on our social media platforms #teamnhsfv. This has included community nurses, domestic staff, porters and catering teams. Dental Nurse Leanne shared her experience of being one of hundreds of staff who were redeployed to support colleagues in acute services. Hannah and Molly, two of our new FiY1s junior doctors, shared their experiences of joining NHS Forth Valley early in short video clips. These posts have been very popular and generated many lovely comments for staff. SOCIAL MEDIA

Service information and updates were regularly shared across our social media channels during the pandemic. This included visiting arrangements for appointments and essential visits, regular updates on opticians, dental and pharmacies.

The Communications Team worked with the Maternity Unit to encourage pregnant women to continue to count their kicks and remind them that our midwives were still here for them and the Unit remains open for support and advice. These posts reached over 100,000 individuals and many parents posted positive comments on the support they had received from local staff. Following a number of instances where local staff received verbal abused when carrying out duties in the community, work was undertaken to remind people that some staff working in the community also wear uniforms. The public were asked to be kind and respectful and reminded they had nothing to fear from staff providing vital support to people in their own homes. SOCIAL MEDIA

Hundreds of donations have been received for patients and staff and many of these were highlighted on social media which generated fantastic feedback. They also provided a great opportunity to thank and show our appreciation to local individuals, community groups and fundraisers who have supported us throughout the pandemic. These posts also increased interaction with our existing followers and have helped grow our social media audience over the past few months .

The pandemic also provided an opportunity to showcase the work of the laboratory teams at Forth Valley Royal Hospital whose contribution often goes unrecognised. They were awarded an Advancing Healthcare ESTEEM Award for their contribution to the COVID-19 response. This achievement was promoted on social media and generated some lovely comments and messages of support from their healthcare colleagues, families, patients and members of the public.

The Communications Team showcased some of the amazing artwork created by local staff including Barry Shaw, a porter at Forth Valley Royal Hospital. His work generated a fantastic response on social media and was displayed in the atrium and wards at Forth Valley Royal Hospital. Work was also undertaken with Artlink Central to promote portraits created by local Clackmannanshire-based artist Karen Strang of local healthcare heroes. They are currently featured in an exhibition at Forth Valley Royal Hospital which pays tribute to a range of key workers during the pandemic. SOCIAL MEDIA

A number of commemorative days that have taken place over the period were widely promoted on social media including International Nurses Day, Midwifery Day, VE Day, Biomedical Science Day and the minute silence to remember all the NHS staff and frontline worker who sadly passed away during the pandemic.

The Communications Team supported the weekly clap for our NHS, carers and key workers across our social media channels - retweeting and sharing posts at 8pm every Thursday which encouraged local people across Forth Valley to show their support. These posts reached over 280,000 people and attracted more than 10,000 likes, comments and shares. DIGITAL

WWW.NHSFORTHVALLEY.COM

Between March 2020 and June 2020, there were 579,441 views on our website with COVID-19, news, job vacancies among the most popular pages visited.

A dedicated COVID-19 section was created o our website which is updated regularly with the latest service information and advice for the public. www.nhsforthvalley.com/COVID There has been a huge focus on moving to video based consultations using the near me service which has gone from having less than 5 clinics on the website to over 100 listed since the beginning of the pandemic.

EBULLETIN

Around 1,500 people have now signed up to receive a monthly news update direct to their mailbox. A link to the ebulletin is also published on both Facebook and Twitter. INTERNAL COMMUNICATIONS

Work continues to ensure staff were kept up to date during these challenging times. This included regular updates on StaffNet (the staff intranet), Staff Briefs which are emailed out to all staff, updates from the Chief Executive and updates from NHS Forth Valley Board meetings.

Staff News has undergone a major redesign and is now being produced monthly online and highlights are emailed to all staff monthly. The new Staff News can now be easily viewed by all staff anywhere, anytime on a computer or mobile device.

STAFFNEWS.NHSFORTHVALLEY.COM

FORTH VALLEY NHS BOARD TUESDAY 28 JULY 2020

9.1 Blueprint for Good Governance Seek Assurance

Author: Mrs Cathie Cowan, Chief Executive

Executive Summary

Following the publication of DL (2019)02 to NHS Scotland Health Boards and Special Health Boards – Blueprint for Good Governance, a self assessment was undertake by NHS Forth Valley Board members to understand good practice and areas for further development. As required, the Blueprint Self Assessment report and Improvement Plan were submitted to the Cabinet Secretary at the end of April 2019.

An Improvement Plan was approved which set out the areas identified by NHS Board members where there were opportunities for further development in line the five functions of the Governance System; Setting the Direction, Holding to Account, Assessing Risk, Engaging Stakeholders and Influencing Culture.

This paper builds on NHS Forth Valley’s response to Governance and in particular focuses on work to inform our approach to ‘Active Governance’.

Recommendation

The Forth Valley NHS Board is asked to:

• Consider the key issues set out in the paper • Request an update report to a future NHS Board

Key Issues to be considered

• NHS Forth Valley is one of 14 regional Health Boards. Health Boards are responsible for the protection and improvement of their population’s health and the delivery of frontline healthcare services. • The NHS Board is a governing body. The Board’s role in this regard is to provide leadership of the organisation within a framework of prudent and effective controls which allow risks to be assessed and managed. Board members have a collective responsibility for decisions and all Board members have equal status in discussions. The Chair leads the governing body and the Chief Executive leads and manages the organisation. • The Cabinet Secretary for Health & Sport sought assurance that NHS Boards had implemented the Blueprint for Good Governance and to post their responses on their websites. The Blueprint model for Good Governance is set out below at Diagram 1. It refers to the NHS Board’s enablers to inform those functions and the supports to assure the NHS Board of delivery against these functions.

Diagram 1 – Blueprint for Good Governance

• ‘Good governance ensures we do the right things, in the right way, for the right people in a timely, inclusive, open and accountable manner. As a Health Board we strive to fulfil our overall purpose, achieve our intended corporate objectives and outcomes for our patients, staff and our wider stakeholders and partners whilst operating in an efficient, effective and ethical manner.’ • In April 2019, the Chief Executive set a governance model for the NHS Board to adopt; this was approved and is set out in Diagram 2 below.

Diagram 2

• Our system of governance is set out under the three elements of our adopted governance model:

• Fiduciary governance – providing Fiduciary - holding good stewardship of our to account assets/resources

• Strategic governance – formulating Strategic - strategy and setting our future setting direction direction Generative - providing • Generative governance – influencing leadership and culture through leadership and sense influencing culture making role

• The NHS Board in adopting the model was keen for this to be seen as an integrated model which brought good stewardship to how the NHS Board formulated strategy and by doing so the NHS Board would play a key role in influencing culture to ensure transparency and the necessary information to be assured delivery of the NHS Board’s strategic, operational and service/workforce and financial plans. • In using the model set out above it is proposed that our approach to Active Governance will comprise of 2 linked components: the development of a Board

Assurance Framework which will reinforce strategic focus and better management of risk by providing the necessary information (as described above) to assist NHS Boards obtain assurance and a development programme for NHS Board members to ensure that all members can engage with the information and make informed decisions not only in regard to what is happening in our NHS Board but also have a regard to the wider strategic and policy context in which our NHS Board operates within. • The Cabinet Secretary has made it clear that ‘active governance’ and the importance of incorporating this into work to align governance structures and processes is a priority. • This paper is intended to assure the NHS Board that work is underway to fulfil this requirement.

Financial Implications

There are no specific implications in respect of this report.

Workforce Implications

There are no specific implications in respect of this report.

Risk Assessment

The outcome from this work will further improve our governance arrangements at 2 levels – our authorising environment and our operational environment. The Board Assurance Framework will reinforce our strategic focus and better manage risk.

Relevance to Strategic Priorities

Good governance cuts across all three elements (e.g. fiduciary, strategic and generative) that in turn inform and underpin our approved corporate objectives, strategic priorities and the implementation of the NHS Board Strategic, Operational and Service/Workforce and Financial Plans.

Equality Declaration

The authors can confirm that due regard has been given to the Equality Act 2010 and compliance with the three aims of the Equality Duty as part of the decision making process.

Further to an evaluation it is noted that:

• Paper is not relevant to Equality and Diversity

Consultation Process

The paper is being shared with the NHS Board for their input before the Chief Executive begins work to launch our approach to ‘active governance’. The outcome from this work and engagement will be reported back to the NHS Board for its final endorsement.

FORTH VALLEY NHS BOARD TUESDAY 28 JULY 2020

9.2 Change to Board Operating Arrangements For Approval

Executive Sponsor: Janie McCusker, Chair

Author: Cathie Cowan, Chief Executive

Executive Summary

On 25 March 2020, the Scottish Government wrote to NHS Board Chairs regarding COVID-19 and Health Board governance arrangements. The letter highlighted the need for effective governance to continue albeit in a different structure and that structures be established by respective NHS Boards. The change in structure was intended to support an agile and effective response to COVID-19 to support Chief Executives and Executives Teams implement decisions at pace/scale whilst the NHS was in an emergency footing.

A paper setting out interim governance changes during this Pandemic was presented by Ms McCusker, Chair to the Health Board on 31 March 2020; this was unanimously approved. The paper referred to a review of these interim governance arrangements in 3 months – i.e. at the end of June 2020.

On the 30 June 2020, the Board reviewed its interim governance arrangements and agreed to step up a number of its Assurance Committees, notably: the Audit Committee to oversee end year accounts, the Performance & Resources Committee to seek assurance on performance and the Clinical Governance Committee to seek assurance on clinical matters and risks as services resume. No decision has been taken as yet to re-establish regular assurance committees. The Board may wish to give this due consideration at its August 2020 meeting by which time all Assurance Committees will have met. (Staff Governance is yet to meet but a date in August is being agreed).

Recommendation

The NHS Board is asked to: -

• consider the key issues as set out • approve the revised changes to our corporate governance arrangements

Key Issues to be Considered

The Board of NHS Forth Valley sets strategy, oversees implementation and determines the control environment including the assurance it receives. During this Pandemic it is critical that the NHS Board continues to receive assurance.

On the 31 May 2020 the Cabinet Secretary for Health and Sport launched ‘Re-mobilise, Recover, Redesign: the framework for NHS Scotland’i. This publication referred to the NHS in Scotland being on an emergency footing for the past three months and having risen to the challenges posed by the COVID-19 pandemic. The NHS in Scotland continues to be on an emergency footing.

The Framework sets out how the NHS in Scotland will work to ‘cautiously and safely begin to restart as many aspects of our NHS as is possible’.

As we look to restart services it is crucial that our corporate governance arrangements are aligned to provide assurance to the NHS Board.

The NHS Board at its meeting on 30 June 2020 was updated, and approved the Remobilisation Plan to resume services (next 100 days). Further guidance has been received since then and the NHS Board has been asked to set out Plans to further step up services from August 2020 to March 2021. The Board will receive an updated Remobilisation Plan at its August meeting for approval. In this regard, members of the Performance & Resources Committee at its 14 July 2020 meeting were updated by Directorates on work underway to resume services and members were assured.

At the Chair, Vice Chair and Committee Chairs meeting (21 July 2020) it was agreed to stand down these formal meetings. However the members felt the arrangements during COVID-19 and the ability to share cross Committee information had worked well. It was agreed that these fortnightly minuted meetings move to three weekly. The purpose of this meeting would be to inform Board agenda setting. It was agreed that this change to interim governance arrangements be presented to the NHS Board for approval at its July 2020 meeting.

Revised Changes to Corporate Governance Arrangements

At the NHS Board’s meeting on 30 June 2020 the Board of NHS Forth Valley agreed that it will continue to respect a need for physical distancing. Board meetings using MS Teams where possible will continue to be held virtually. The Board will continue to make available its papers publicly via its website. The Board will continue to meet monthly.

At its meeting on 30 June 2020 the Board of NHS Forth Valley agreed to re-establish its Assurance Committees to coincide with end year accounts and services resuming. The frequency of meetings is yet to be agreed.

The Code of Governance and the NHS Board’s Standing Orders will be changed temporarily and approved at the earliest opportunity to reflect the recommendation to the Governance Arrangements. A review of these changes will take place in line with the review of NHS Scotland emergency footing arrangements.

Principles Underpinning the Change to Corporate Governance Arrangements (unchanged from 31 March 2020)

The NHS Board will continue to meet virtually, where possible via MS Teams. The Chair has set up regular contact with Assurance Committee Chairs outwith NHS Board meetings; these will continue informally and will move to three weekly (if approved by the NHS Board). The Chair will continue to be the guardian of etiquette in virtual meetings to ensure virtual participants remain actively involved and present. NHS Forth Valley’s guiding principles to ensure we remain accountable as the Board will continue and include:

• agreement to conduct as much routine business as possible in advance of formal NHS Board meetings • more pre discussion between board members to ensure best use of time spent collectively • greater commitment to preparation by all NHS Board members in advance of NHS Board meetings • higher rigour on synthesising the issues being presented to avoid a ‘reporting in culture’ • collective intention in a virtual space to create an environment that supports shared problem solving

• recording of meetings will remain unchanged with a note produced for approval at the next NHS Board meeting

In summary, whilst acknowledging the above the Board of NHS Forth Valley must continue to operate within an appropriate legal framework and in doing so:

• put the safety of patients and staff at forefront of its efforts • act in the best interests of the population • use resources efficiently and effectively • provide support whilst questioning planning assumptions to ensure the organisation maximises its resilience in response to the challenges it faces

Functions of the Board

The NHS Board will continue to function in accordance with its approved Code of Governance other than the frequency of meetings, quoracy and receipt of papers.

Financial Implications

There are no financial implications within this paper.

Workforce Implications

There are no specific workforce issues within this paper.

Equality Declaration

The author can confirm that due regard has been given to the Equality Act 2010 and compliance with the three aims of the Equality Duty as part of the decision making process.

Further to an evaluation it is noted that:

• Paper is not relevant to Equality and Diversity

Consultation Process

This paper has been informed by discussions with the Chair of the NHS Board.

i https:www.gov.scot/publications/re-mobilise-recover-re-design-framework-nhs-scotland/

FORTH VALLEY NHS BOARD TUESDAY 21 JULY 2020

Minute of Chair, Chief Executive and Chairs/Vice Chairs of Committees Meeting held on Tuesday 23 June 2020, via teleconference

Present: Ms Janie McCusker (Chair) Mrs Cathie Cowan Mr John Ford Ms Michele McClung Cllr Les Sharp Mrs Julia Swan

In Attendance: Ms Jackie McEwan, Corporate Governance Manager (Minute)

1. APOLOGIES FOR ABSENCE

There were no apologies for absence.

2. MINUTE OF FORTH VALLEY NHS BOARD COMMITTEE CHAIRS & CHIEF EXECUTIVE MEETING CLOSED SESSION HELD ON 9 JUNE 2020

The group approved the minute as an accurate record.

3. MATTERS ARISING FROM THE MINUTE

The Chair proposed the standing up of the Clinical Governance and the Performance and Resources Committee and requested approval for a paper to be taken to the next Board meeting. Mrs Cowan also requested that Staff Governance be reconvened to oversee senior manager’s performance reviews and 2020/2021 objective setting process. Support was sought from Ms McClung in her role as Chair of the Remuneration Committee and this was provided.

Mrs Cowan highlighted the need for sign off of the Board’s Corporate Objectives as had been previously approved, this was supported. It was agreed a paper would be prepared for the Board to step up Assurance Committees.

The Committee chairs thereafter approved the following: • A paper to the NHS Board requesting the standing up of key Committees • Presentation of Objectives to the Remuneration Committee

4. Standing up of Staff Governance Committee

This was covered in the previous Agenda item.

5. Outline Communication Plan

The Committee Chairs meeting considered a paper “Outline Communication Plan” presented by Mrs Cathie Cowan.

1 By way of context, Mrs Cowan advised that the paper was being shared with Committee Chairs for feedback prior to presentation at the NHS Board. Non Executive Allan Rennie would also be consulted, due to his expertise.

The Communication Plan had been developed by Elsbeth Campbell, Head of Communication and supported the ongoing renewal work.

The Committee Chairs highlighted an error in date, but also reiterated the need to ensure the building of public confidence by the document running alongside the Scottish Government phases 1-4 and ensuring appropriate reflection around key dates as issued by the 1st Minister.

The re-opening of schools was discussed, along with the need to ensure appropriate information dissemination around the Board’s legal duties in terms of Public Health.

The inclusion of information around staff PPE was suggested, by way of providing reassurance to the public.

Potential utilisation of social media was discussed to enable broader dissemination of key messages.

Challenge was noted around the fast moving landscape and linkage to phasing messages from Scottish Government and thus potential undermining of public confidence. Mrs Cowan acknowledged this challenge and confirmed that Elsbeth Campbell was contributing to the national position through the National Communications Leads meeting.

Mrs Cowan reported on a paper presented to the Strategic Leadership Team which focused on ‘Recover Rebuild and Reset’. The aim was engagement and conversations with wide public partners and staff and enabling a focus on the strategic direction beyond Covid-19.

The Committee Chairs thereafter: - • considered the draft outline communication plan

6. Any Other Competent Business

There being no other competent business, the Chair closed the meeting.