Assynt House Beechwood Park Inverness, IV2 3BW Telephone: 01463 717123 Fax: 01463 235189 Textphone users can contact us via Date of Issue: Typetalk: Tel 0800 959598 25 May 2012 www.nhshighland.scot.nhs.uk HIGHLAND NHS BOARD

MEETING OF BOARD

Tuesday 5 June 2012 at 8.30 am Board Room, Assynt House, Beechwood Park, Inverness

AGENDA

1 Apologies

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

2 Minutes of Board Meetings: (a) 21 March 2012 (attached) (b) 3 April 2012 (attached) (c) 3 April 2012 – Board in Committee (attached) (d) Board Rolling Action Plan (attached) (PP 1 – 30) The Board is asked to approve the Minutes.

2.1 Matters Arising

3 PART 1 – REPORTS BY GOVERNANCE COMMITTEES

3.1 Argyll & Bute CHP Committee – Draft Minute of Meeting held on 25 April 2012 (attached) (PP 31 – 42) 3.2 Mid Highland CHP Committee – Draft Minute of Meeting held on 20 April 2012 (attached) (PP 43 – 52) 3.3 North Highland CHP Committee – Draft Minute of Meeting held on 17 April 2012 (attached) (PP 53 – 60) 3.4 Raigmore Hospital Committee – Draft Minute of Meeting held on 16 April 2012 (attached) (PP 61 – 74) 3.5 South East Highland CHP Committee – Draft Minute of Meeting held on 29 March 2012 (attached) (PP 75 – 84) 3.6 Audit Committee – Draft Minute of Meeting held on 15 May 2012 (attached) (PP 85 – 96) 3.7 Clinical Governance Committee Assurance Report of 8 May 2012 (attached) (PP 97 – 114) 3.8 Improvement Committee Assurance Report of 30 April 2012 and Balanced Scorecard (attached) (PP 115 – 128) 3.9 Area Clinical Forum – Draft Minute of Meeting of 29 March 2012 (attached (PP 129 – 136) 3.10 Pharmacy Practices Committee – Minute of Meeting of 10 April 2012 (attached) (PP 137 – 164) 3.11 Governance Committee Annual Reports Report by Kenny Oliver, Board Secretary on behalf of Elaine Mead, Chief Executive (attached)

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

 Appendix 1 – Audit Committee  Appendix 2 – Staff Governance Committee  Appendix 3 – Remuneration Sub-Committee  Appendix 4 – Clinical Governance Committee  Appendix 5 – Improvement Committee  Appendix 6 – Risk Management Steering Group  Appendix 7 – Endowment Funds Committee  Appendix 8 – Argyll & Bute CHP Committee  Appendix 9 – Mid Highland CHP Committee  Appendix 10 – North Highland CHP Committee  Appendix 11 – South East Highland CHP Committee  Appendix 12 – Raigmore Committee  Appendix 13 – Spiritual Care Committee  Appendix 14 – Control of Infection Committee  Appendix 15 – Health & Safety Committee  Appendix 16 – Pharmacy Practices Committee (PP 165 – 236) The Board is asked to: (a)  Note the Minutes. (b)  Note the Clinical Governance Committee met on 8 May 2012.  Note the Assurance Report and agreed actions resulting from the consideration of the specific items detailed.  Note that the next meeting of the Clinical Governance Committee will be held on 7 August 2012.

(c)  Note that the Improvement Committee met on 30 April 2012.  Note the Assurance Report and agreed actions resulting from the review of the specific topics detailed and the Balanced Scorecard.  Note that the next meeting of the Improvement Committee will be held on 2 July 2012. (d)  Note the views of the Audit Committee on the attached Annual Reports of the Governance Committees.

2 Council/Highland NHS Board Joint Committees

3.12 Highland Council Partnership – Joint Committee on Children and Young People – Minute of Meeting of 16 March 2012 (attached) (PP 237 – 246) The Board is asked to:

 Note the Minute.

4 PART 2 – CORPORATE GOVERNANCE / ASSURANCE

4.1 Membership of Committees Report by Garry Coutts, Chair, NHS Highland (attached) (PP 247 – 250) The Board is asked to:

 Review the current membership and in so doing to consider forthcoming vacancies and appointments.  Agree that Sarah Wedgwood be appointed as Vice-Chair until 30/06/14.  Agree to the proposed membership for Highland Health and Social Care Community Health Partnerships and that the Chair should be appointed until 30/06/14.  Agree to the proposed membership for Argyll and Bute Community Health Partnership and that the Chair should be appointed until 30/06/14  Agree to the proposed appointment of Chairs for the main Governance Committees to 30/06/14.

4.2 Establishment of Highland Health & Social Care Partnership Report by Garry Coutts, Chair (attached)

The Board will recall that the decision was made at the December 2012 Board meeting to establish a single operational unit covering the whole of Northern Highland, co-terminus with Highland Council. This report updates on progress with the establishment of the Highland Health & Social Care Partnership. (PP 251 - 274) The Board is asked to:

 Note the ongoing work to establish Highland Health and Social Care Partnership and in particular the setting up of Highland Health and Social Care Partnership Governance Committee

4.3 Integrating Care in the Highlands – Forward Plan Report by Jan Baird, Transitions Director on behalf of Elaine Mead, Chief Executive (attached)

As Planning for Integration reaches conclusion and integrating services in the Highlands becomes a priority, a number of actions are carried forward to ensure the development of longer term sustainable processes and procedures. This report updates on the Forward Plan for Integrating Care in the Highlands. (PP 275 – 306)

3 The Board is asked to:

 Note the forward plan moving on from Planning for Integration.  Note the proposed approach to ensure long term and sustainable arrangements are put in place to support the Integrated front-line services.  Note the development of Programme scope for Central/Corporate services and the appointment of a Programme Manager.

4.4 Integration of Adult Health and Social Care in Scotland – Consultation on Proposals Report by Jan Baird, Transitions Director on behalf of Elaine Mead, Chief Executive (attached)

The Scottish Government has launched it’s consultation on Integration which will run until 31 July. The Highland Partnership have of course implemented integration of adult and children’s’ services under existing legislation namely the Community Care and Health (Scotland) Act 2002. The consultation document outlines the impact on current legislation and configuration of Community Health Partnerships, detailing two options for partnerships to consider across Scotland. A Lead Agency model is one of the options. (PP 307 – 320) The Board is asked to:

 Note the consultation proposals.  Note the consultation response drafted on behalf of NHS Highland.  Agree further circulation of this draft to gather views across leadership and management forums in NHS Highland.

4.5 NHS Highland Financial Report

(a) Interim Financial Position as at 31 March 2012 Report by Nick Kenton, Director of Finance (attached) (PP 321 – 328) (b) Approach to Benefits Realisation Report by Nick Kenton, Director of Finance (attached) (PP 329 – 332) The Board is asked to: (a)  Note the financial out-turn of a £85,000 underspend.  Note this is subject to audit review.  Note the non-recurrent savings carried into 2012 – 2013. (b)  Note the approach to benefits realisation.

4.6 Hospital Scorecard Report by Lesley Anne Smith, Head of Quality on behalf of Elaine Mead, Chief Executive (attached)

NHS Board Chief Executives agreed in November 2011 that it was important to establish a core set of measures which could be used to track a number of key areas of healthcare quality across Scotland. As a result, colleagues across Scotland have explored a range of potential measures, and considered the role of this national ‘scorecard’ alongside the local systems which individual NHS Boards have developed or are developing. The result of this work is the attached ‘Hospital Scorecard’. (PP 333 – 336)

4 The Board is asked to:

 Note the publication of the Hospital Scorecards for June 2011 and September 2011 together with the management and assurance actions being taken in response to the data.

4.7 Infection Control Report Report by Liz McClurg, Infection Control Manager and Dr Emma Watson, Infection Control Doctor on behalf of Heidi May, Board Nurse Director & Executive Lead for Infection Control (attached) (PP 337 – 386) The Board is asked to:

 Note the contents of the Infection Control Report.

4.8 Raigmore Hospital Quality Approach to Improvement in 2012/2013, 2013/14 and 2014/15 Report by Chris Lyons, Director of Operations, Raigmore Hospital on behalf of Elaine Mead, Chief Executive (attached)

This report to the Board sets out to summarise the approach to quality improvement adopted by the Raigmore Management Team. The approach adopted is in line with the Highland Quality Approach and the Highland Quality and Efficiency Plan. (PP 387 – 422) The Board is asked to:

 Note the approach to quality improvement in 2012/2013 by Raigmore Hospital Management Team.  Note the details of the quality improvement initiatives and the expected benefits of the improvements planned and underway.  Note the initial work to identify quality improvement in 2013/14 and 2014/15.

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

This month’s report incorporates updates on:  DALLAS – Delivering Assisted Living Lifestyles At Scale  Diabetes Care across the northern NHS Highland area  Fire Safety - County Hospital, Invergordon  Highland Eating Disorder Out Patient Service and the Eden Unit Specialist In-Patient Facilities  Investigation into the Management Culture in NHS Lothian  Magnetic Resonance Imaging (MRI) Scanner Replacement – Raigmore Hospital  Reform of Police and Fire Services  Regional Planning – North of Scotland Planning Group and West of Scotland Planning Group  Rise in cases of Whooping Cough (Pertussis) (PP 423 – 436) The Board is asked to:  Note the Emerging Issues and Updates Report.

5 5 PART 3 – STRATEGY AND POLICY

5.1 NHS Highland Strategic Framework 2011/12

(a) Developing a Quality Approach to Engagement and Communications: Setting up for Success – Next Steps 2012/13 Report by Maimie Thompson, Head of Public Relations and Engagement on behalf of Elaine Mead, Chief Executive (attached) (PP 437 – 446) (b) Highland Quality Approach to Staff Health and Well Being Report by Cathy Steer, Head of Health Improvement, Pamela Cremin, Workforce Planning & Development Manager, Linda Rawlinson, Occupational Health Strategy and Development Manager and Bob Summers, Head of Health and Safety; on behalf of Anne Gent, Director of Human Resources and Dr Margaret Somerville, Director of Public Health (attached) (PP 447 – 454) (c) Highland Quality Approach to Strategic Commissioning Report by Linda Kirkland, Business Transformation Manager and Simon Steer, Head of Community Care on behalf of Elaine Mead, Chief Executive (attached) (PP 455 – 460)

The Board is asked to: (a)  Note the ongoing work to develop more robust strategic communications and engagement to support delivery of NHS Highland’s aims and objectives.  Discuss and Agree the framework including considering the identified assumptions and risks.  Discuss and Agree the outline forward plan.  Provide direction in terms of what is expected from the Board to provide assurance that progress is being made and how this will be measured. (b)  Note the position in developing a quality approach to staff health and wellbeing.  Endorse the approach and support the ‘next steps’ section of the report.

(c)  Discuss and Agree the definition of a Highland Quality Approach to Strategic Commissioning as described  Agree that work is undertaken to develop awareness, understanding, capability and capacity to progress the Highland Quality Approach to Strategic Commissioning across all sectors.

5.2 Highland Quality Approach to Older Adult Mental Health Services: Update on Implementation of National Standards across Highland Health & Social Care Partnership Area Report by Nigel Small & Gill McVicar, Directors of Operations on behalf of Dr Ken Proctor, Associate Medical Director and Heidi May, Board Nurse Director (attached)

The Scottish Government published the National Dementia Care Strategy and Dementia Care Standards in 2011. NHS Highland has to meet these national standards, and accommodate the expected increase in dementia sufferers, within a set budget and at the same time deliver services in the most cost effective way. The Northern Highland Older Adult Mental Health Services Redesign Steering Group has been assessing NHS Highland’s compliance with the delivery of the standards. As the Argyll and Bute CHP review has been reported previously, this paper focuses on services in the Highland Council area. (PP 461 - 466)

6 The Board is asked to:

 Note the range of initiatives to improve care in Older Adult Mental Health Community Services.  Note the proposals to re-design in-patient care for dementia patients in the Highland Health and Social Care Partnership area.  Note that Directors of Operations are developing action plans to implement the recommendations around appropriate requirements for hospital beds.  Note the requirements for re-investment into community and specialist acute services.  Note the introduction of the patient care system “The Butterfly Scheme” for patients with dementia in acute hospitals in NHS Highland.  Note the work already carried out and future proposal to support communications and engagement.

5.3 Joint Health Protection Plan 2012 – 2014 Report by Ken Oates, Consultant in Public Health on behalf of Margaret Somerville, Director of Public Health (attached)

The report updates on the Joint Health Protection Plan for 2012-14. This has been produced by NHS Highland with Highland Council and Argyll & Bute Council. (PP 467 – 496) The Board is asked to:

 Discuss and Agree the content of the Joint Health Protection Plan for 2012-14.  Note the Joint Health Protection Plan has already been approved by the relevant committees of Highland Council and Argyll & Bute Council.  Once all agencies have signed it off, Agree to it being placed on the NHS Highland website.

5.4 Procurement Strategy Report by Malcolm Iredale, Head of Procurement on behalf of Nick Kenton, Director of Finance (attached)

A Draft Procurement Strategy for NHS Highland is attached, and this identifies the Procurement Principles, and a process for meeting them. (PP 497 - 510) The Board is asked to:

 Note the role of Procurement within overall Board activities.  Agree the procurement principles detailed in section 3 of the Procurement Strategy.  Approve the Procurement Strategy.  Note that a Procurement Workplan will be agreed by the Senior Management Team.

5.5 Property and Asset Management

(a) Asset Management Group – Terms of Reference Report by Nick Kenton, Director of Finance (attached) (PP 511 – 516)

7 (b) Property and Asset Management Strategy Report by Eric Green, Head of Estates on behalf of Nick Kenton, Director of Finance (attached)

CEL(2010)35 required all Boards to provide a Property Asset Management Strategy to Scottish Government and provided guidance as to how this was to be achieved.

Please note that due to the size of the Property and Asset Management Strategy this has not been circulated. A link to the full document will be e-mailed to Board members once Board papers are on the NHS Highland website, one week before the meeting.

A copy of the full report is available from the Board Secretary’s office and will be available at the Board meeting. (PP 517 – 520) The Board is asked to: (a)  Approve the Terms of Reference for the NHS Highland Asset Management Group. (b)  Approve the Property Asset Management Strategy.  Note the progress on improving performance.  Note the issues around backlog maintenance and the plans to tackle this problem.

6 FOR INFORMATION

6.1 Date of next meeting

The next meeting of the Board will be held on 14 August 2012 in the Board Room, Assynt House, Inverness.

6.2 Any Other Competent Business

7 Close of Meeting

8 Highland NHS Board 5 June 2012 Item 2(a) Assynt House Beechwood Park Inverness IV2 3BW Tel: 01463 717123 Fax: 01463 235189 HIGHLAND NHS BOARD Textphone users can contact us via Typetalk: Tel 0800 959598 www.nhshighland.scot.nhs.uk/

DRAFT MINUTE of MEETING of the BOARD 21 March 2012 – 10 30 am Board Room, Assynt House, Beechwood Park, Inverness

Present Mr Garry Coutts, Chair Mr Robin Creelman (by videoconference from Dunoon) Cllr Margaret Davidson (until 11.55 am) Mr Mike Evans Mrs Gillian McCreath Mr Okain McLennan Cllr Elaine Robertson (by video conference from Oban) Dr Vivian Shelley (by video conference from Rothesay) Mr Ray Stewart Ms Sarah Wedgwood Ms Elaine Mead, Chief Executive Mrs Anne Gent, Director of Human Resources Mr Nick Kenton, Director of Finance Ms Heidi May, Board Nurse Director Dr Margaret Somerville, Director of Public Health & Health Policy

Also present Mrs Jan Baird, Transitions Director Mrs Linda Kirkland, Head of Business Transformation Mr Kenny Oliver, Board Performance Manager Mr Stephen Phillips, Burness (until 11.55 am) Mrs Lorraine Power, Board Services Assistant Mr Simon Steer, Head of Integrated Community Care Ms Maimie Thompson, Head of Public Relations & Engagement

Apologies – Apologies were received from Mr Bill Brackenridge, Ms Pam Courcha, Mr Ian Gibson, Dr Iain Kennedy, Mr Colin Punler and Dr Ian Bashford.

210 Declarations of Interest

Board members declared the following interests:  Garry Coutts – Scottish Social Services Council (SSSC), ex officio of SSSC on the Care Inspectorate, University of the Highlands and Islands.  Ray Stewart – Member of Unite and Staffside Chair.  Gillian McCreath – husband works for Highland Council, contract with New Start Highland.

The Board a Noted the Declarations of Interest.

127 CORPORATE GOVERNANCE / ASSURANCE

211 Planning for Integration – Partnership Agreement Report by Jan Baird, Transitions Director on behalf of Elaine Mead, Chief Executive, NHS Highland

The Chair referred to the early discussions with the Highland Council regarding Planning for Integration some 18 months ago and the incredible amount of work that had been done since then to reach the stage when the Board was now considering the Partnership Agreement. Mr Coutts formally recorded his appreciation to all staff who had worked on this piece of work, with particular thanks to the Transitions Director and the Planning for Integration team. Prior to the presentation and discussion, the Chair highlighted 3 types of issues, which members might raise during discussion or needed to be aware of:

 Any issues that might affect a decision to move towards integration.  There was still a fair amount of technical work to be resolved relating to areas such as systems, IT, human resources etc. While these had not yet been resolved they had all been identified and work was in progress.  Should the Board agree to the proposals today then this was only the start of the next chapter of redesigning services and working towards more fully integrated services.

The Chief Executive highlighted the commitment of the Highland Partnership to achieving the best possible outcomes for our population and service users. It had been agreed to progress a Lead Agency Model where NHS Highland would be the Lead Agency for Adult Services and Highland Council the Lead Agency for Children’s Services. Ms Mead also wished to record her thanks to colleagues in achieving a very ambitious timeframe. She asked Board members to ensure they had confidence in being able to sign the agreement and clarity around the governance arrangements.

Jan Baird, Transitions Director presented the report to the Board, which outlined progress with the Programme Approach, Implementation, the Partnership Agreement, Performance Monitoring and Governance Arrangements. It was envisaged that the Partnership Agreement would continue to be populated up until 31 March, as some of the final detail would not be available until then and this would enable the most accurate position to be included. However the detail contained in the circulated version was considered to be sufficient to allow the Council and Health Board to agree the content and be assured that liabilities and risks were appropriately managed. In recognition of this, the Programme Board agreed that the Council and Health Board delegate responsibility for further amendments up to 1 April to the Chief Executives in consultation with the Council Convener and Leader, Chairs of the Housing and Social Work and Education Committees, Leader of the Opposition, NHS Highland Chair and Vice Chair.

Considerable work had progressed in determining financial processes and budgets. Section 9 set out indicative budgets for both organisations with, in respect of adult services, the financial contribution payable by Highland Council to NHS Highland for the first financial year as £88,296,000. In respect of Children’s services, the financial contribution payable by NHS Highland to Highland Council for the first financial year would be £8,100,000. These figures are subject to finalisation of the detailed service delivery mechanisms for both Health and Social Care and Central Support Services. It was acknowledged that these budgets would continue to be refined and referred to the Chief Executives for finalisation. It was noted that in relation to property there was agreement that there should be a “Licence to Occupy” for one year, which was a temporary solution that would allow both organisations to look at the asset requirements prior to agreeing a more permanent way forward. There would also be more time for the services and the organisations to consider areas such as central support services.

Mrs Baird asked that Board members consider the content of the document and approve it as the strategic agreement between the Health Board and Highland Council, so the project could progress to the next phase of “Integrating Care in the Highlands”.

128 There followed a detailed discussion on the Partnership Agreement and a number of issues were raised.

 The Chair raised a query on behalf of the Vice-Chair, Ian Gibson who was unable to attend the meeting, regarding risks. NHS Highland had a system in place regarding the risk register, which was reviewed regularly through the Audit Committee, and assurance was sought regarding the robustness of systems and the need to ensure there was a register of risks transferring from Highland Council to NHS Highland. The Chief Executive confirmed that she had spoken with Social Work colleagues and the system in operation in Highland Council was different from NHS Highland. Ms Mead confirmed that she would ask Mr Brian Robertson, the newly appointed Head of Adult Social Care to work with Lesley Anne Smith, Head of Quality to incorporate any risks in relation to Adult Social Care into the NHS Highland Risk Register. Anne Gent, Director of Human Resources confirmed that a report would be submitted to the April Board on the Strategic Risk Register and she would ensure that this issue was highlighted in the report as one that needed to be progressed. The Chair also highlighted the need for NHS Highland to engage with Internal Audit on this issue. The Chief Executive gave assurance that the relevant teams were aware of the risks relating to Adult Social Care and it was simply a matter of ensuring these were incorporated in the NHS Highland Risk Register.

 Mike Evans asked if the Board would get a report on the Project Plan for the next 12 months in relation to implementing integrated care in the Highlands. The Chair confirmed that there would be further clarity around what work was being done and the related timescales and this would be submitted to the June Board meeting. Elaine Mead highlighted the need for the Project Plan to link with related operational plans and the Property Plan. Sarah Wedgwood emphasised the need for a media protocol to be completed at the outset. There was some discussion around how the various workstreams would be managed and it was agreed that the report to the Board should identify the project workstreams and how they would be effectively managed. It was recognised that much of the service redesign across health and adult care would be delivered via the operational units. Social care would need to be mainstreamed into health services. The Chair also sought assurance that there was the capacity and capability within NHS Highland to deliver the necessary redesign of services. The Chief Executive referred to the Directors of Operations, the Head of Adult Social Care and the Chief Operating Officer posts and the expectation that the management structures within the operational units would enable the operational managers to have a more strategic role. There would also be additional capacity within the teams of staff transferring from Highland Council.

 Dr Shelley referred to schedules 4c and 4d and the detail on clinical governance arrangements which she felt were predominantly NHS processes and procedures and asked whether there was anything similar for Highland Council. Mrs Baird acknowledged that Children’s Services staff would be transferring to Highland Council and that there would be clear links to clinical governance via the Head of Health and leaders in nursing and AHPs. The Board Nurse Director confirmed that she would retain clinical accountability and that NHS structures would be used initially, although this may change over time. The Chief Executive confirmed that NHS Highland would still be responsible for the safe delivery of Children’s Services, although Highland Council would undertake this on our behalf. Dr Shelley referred to the staff transferring from Highland Council to NHS Highland who may be unfamiliar with NHS systems. The Chair suggested that this related to the culture of the organisations, and training and support available for transferring staff. This was one of the areas that would be addressed during the first year. It was recognised that as well as issues of clinical governance, there would be governance issues in relation to social work and social care and it may be that the terminology would change to “practice governance” to incorporate all disciplines.

 A question was raised regarding the future of the Planning for Integration Programme Board.

129 The group was currently responsible for the various workstreams in the interim, however this would not continue and it was likely that there would be a group responsible for Integrating Care in the Highlands during the implementation phase with ultimate responsibility falling to the new Highland Health and Social Care Partnership governance committee.

 In relation to staff issues, Ray Stewart, Employee Director, welcomed section 22D in relation to staff governance and partnership working. It was recognised that there would be issues around culture for staff. It was noted that terms and conditions for staff were quite similar and further consideration would be given to harmonising these over time. The Director of Human Resources acknowledged the added value of Staffside involvement in the process to date and the need to ensure the best outcomes for staff.

 Regarding Finance, there had been early concerns regarding VAT conditions and the Director of Finance advised that the main issue had been that Highland Council had a more beneficial scheme than NHS Highland. However, it was noted that the proposals agreed by Deloitte should be VAT neutral. This had still to be agreed by HMRC and it was noted that the potential risk had been quantified as approximately £200k per annum.

 In relation to the Adult Social Care budget transferring from Highland Council to NHS Highland of approximately £88m, there was a savings programme of around £3m – 4m. It was noted that the budgets would continue to be refined and referred to the Chief Executives for finalisation.

 There was a query in relation to capital expenditure and asset management and the Director of Finance confirmed that there would be a future Board paper on finance and capital related to integrating services.

 Mr Stewart expressed some concern regarding future commissioning and the potential for commissioning private contractors and suggested that commissioning should be within the public sector only. The Chair advised that this was not in line with the clause regarding strategic commissioning, which would also involve engagement with the voluntary and independent sector. The Chief Executive confirmed that both Chief Executives, as accountable officers, were required to deliver services for best value.

 Sarah Wedgwood referred to quality and clinical indicators and the need to maintain performance in relation to 80% of complaints being responded to in 20 days and also the zero tolerance policy on tissue viability. It was recognised that these were which were already monitored, but could be included more explicitly in the agreement.

 Reference was made to paragraph 16.6.2 on page 39 regarding monitoring and scrutiny and it was suggested that the wording “the Audit Committees” be amended to read “including for example the Audit Committees” so that other governance committees such as Clinical Governance could be included.

Following the detailed discussion, the Board agreed the proposals set out in the Partnership agreements and the proposals to take forward the integration work post April 2012.

The Board a Agreed the proposals set out in the Partnership Agreement. b Agreed the proposals to take forward the Integration work post April 2012. c Continued to support the programme of implementation.

130 d Agreed that the Health Board delegate responsibility for further amendments up to 1 April to the Chief Executive in consultation with the Council Convener and Leader, Chairs of the Housing and Social Work and Education Committees, Leader of the opposition, NHS Highland Chair and Vice Chair.

In agreeing the above the Board also recommended the following areas of work be progressed: a Issues raised regarding the NHS Highland Risk Register, including revising the report to the April Board and incorporating any risks in relation to Adult Social Care into the NHS Highland Risk Register. b The preparation of a more detailed Project Plan for Integrating Care in the Highlands, to be submitted to the June meeting of the Board. c A future report would be submitted to the Board on finance and capital relating to integrated services. d That more explicit reference be made to quality and clinical indicators in the document. e That the amendment suggested to paragraph 16.6.2 on page 39 be incorporated in the document.

Cllr Davidson and Mr Philips left the meeting.

The Board adjourned at 11.55 am and resumed at 12.10 pm.

212 Highland Health and Social Care Partnership – Governance Committee Membership Report by Elaine Mead, Chief Executive

The report built on the discussions held at the NHS Highland Board Meeting on 7 February regarding the proposed membership of the Highland Health and Social Care Partnership Governance Committee. The Board asked for further clarity on the role descriptions of the proposed additional members of the Governance Committee. It was noted that NHS Highland was required to use existing Community Health Partnership (CHP) legislation as the basis for the new Highland Health and Social Care Partnership. This legislation specifies certain posts that must be members of the Committee. The report proposed additional members and outlined the rationale behind the inclusion of these additional members of the Highland Health and Social Care Partnership Governance Committee.

The Board discussed the various options and agreed the following additional members:

 Head of Adult Social Care  Public / Patient Member Representatives x 3 (2 Patient/Public representatives and 1 Voluntary Sector representative)  Chair of the Professional Executive Committee  Non Executive Directors of the Board x 2 (1 to be Vice-Chair of the Committee)  Elected Members x 3 (2 additional over and above the statutory requirement of 1 Elected Member)  Director of Operations – North & West  Director of Operations – Mid & South  Director of Operations – Raigmore  Head of Financial Planning  Lead Midwife

131 In Attendance:  Head of Personnel  Head of Health & Safety

It was noted that members of the committee had a governance role and this should be clear to members. The Chair confirmed that this would be set out clearly in letters of appointment and also in relation to training and development of committee members. It was agreed that the Chair would write to the Area Clinical Forum who had requested additional representation on the Committee in relation to an additional GP member, additional patient and public representation, a Lead Midwife and a Salaried Dentist, advising that the Board had not agreed to an additional GP member or a Salaried Dentist as there was already GP and dental representation on the Committee.

Mr Stewart referred to Staffside representation on the Committee and advised that the current CHP and Raigmore Committees had 2 Staffside representatives and suggested that the HH&SCP Committee should also have Staffside representation. The Board agreed there should be Staffside representation. A copy of the final membership for the Committee is attached as Appendix 1 to the minute.

The Chair advised that he had written to Non Executive Board members in relation to training and development for Board members and a report on this and the future membership of Board governance committees would be submitted to the June Board meeting.

The Board a Agreed the final membership of the Highland Health & Social Care Partnership Governance Committee. b Noted the proposals relating to training for Committee Members. c Noted the update on training and development and that a further report would be submitted to the June Board.

213 Date of Next Meeting

The next meeting of the Board will be held on Tuesday 3 April 2012 at 8.30 am in the Board Room, Assynt House, Beechwood Park, Inverness.

The meeting concluded at 12.40 pm.

132 APPENDIX 1

HIGHLAND HEALTH AND SOCIAL CARE PARTNERSHIP – GOVERNANCE COMMITTEE MEMBERSHIP

1 Highland Health and Social Care Partnership – Governance Committee Members

The members of the Highland Health and Social Care Partnership Governance Committee are listed below:

Chair Chief Operating Officer Head of Social Care Chair of Professional Executive Committee NHS Board Non Executive Directors X 2 Elected Member X 3 Staff Side Representative X 2 Public/Patient Member Representative X 3 Lead Doctor (GP) Medical Practitioner (not a GP) Director of Operations – North & West Director of Operations – Mid & South Director of Operations – Raigmore Pharmacist Dentist Optometrist Lead AHP Lead Nurse Lead Midwife Head of Financial Planning

In Attendance Head of Personnel Head of Health & Safety

Those marked in bold are statutory members as laid down in the Community Health Partnerships (Scotland) Regulations 2004 and the subsequent amendment in 2010.

2 Additional Members of Highland Health and Social Care Partnership Governance Committee

Outlined below is a brief summary as to the reasons behind the inclusion of these additional members of the Highland Health and Social Care Partnership Governance Committee.

133 Head of Social Care This is a professional advisory post and required under the Social Work (Scotland) Act 1968.

Public/Patient Member Representatives X 3 The number of Public/Patient representatives has been increased from 1 in the current legislation to 3. This reflects the Boards desire to strengthen Public/Patient representation across its Governance Committees in order to ensure that their views are represented at all levels of the Organisation. These members will represent the wide geographical spread of the Highland Health and Social Care Partnership; one member will represent the Voluntary Sector.

Chair of Professional Executive Committee The Professional Executive Committee will bring together the full range of professional staff and primary care contractors to ensure there is a strong professional and clinical voice. This post will be a key link between the Governance Committee and the professions covered in the Partnership.

Non Executive Directors of Board X 2 These will be included to provide a key link between the Partnership Governance Committee and the Board. They will be chosen to reflect the geographical spread of the Partnership. One will be designated as the Vice Chair of the Governance Committee.

Director of Operations X 3 These posts are key posts that will provide the leadership at a local level and reflect key areas of service delivery across the partnership.

Head of Financial Planning With the vast majority of NHS Highland’s budget sitting with the Highland Health and Social Care Partnership, this post will ensure a close link with the overall financial position, co- ordinating financial management for the Highland Health and Social Care Partnership Governance Committee

Lead Midwife The addition of the Lead Midwife will represent this profession on the committee and offer scrutiny and assurance of midwifery services, ensuring there are effective and robust structures in place to identify and manage risk in maternity services.

In Attendance

Head of Personnel The Highland Health and Social Care Partnership will be responsible for the majority of staff within NHS Highland and with the integration agenda and the transfer of a significant number of staff from Highland Council to NHS Highland.

Head of Health and Safety In order to ensure the importance of the Health and Safety agenda is recognised, in particular with the integration of adult social care services and the additional health and safety risks associated.

134 Highland NHS Board 5 June 2012 Item 2(b) Assynt House Beechwood Park Inverness IV2 3BW Tel: 01463 717123 Fax: 01463 235189 HIGHLAND NHS BOARD Textphone users can contact us via Typetalk: Tel 0800 959598 www.nhshighland.scot.nhs.uk/

DRAFT MINUTE of MEETING of the BOARD 3 April 2012 – 8 30 am Board Room, Assynt House, Beechwood Park, Inverness

Present Mr Garry Coutts, Chair Mr Bill Brackenridge Mr Robin Creelman Cllr Margaret Davidson (from 9.15 am) Mrs Myra Duncan Mr Mike Evans Mr Ian Gibson Dr Iain Kennedy Mrs Gillian McCreath Mr Okain McLennan Mr Colin Punler Cllr Elaine Robertson Dr Vivian Shelley Mr Ray Stewart Ms Sarah Wedgwood Ms Elaine Mead, Chief Executive Dr Ian Bashford, Board Medical Director Mrs Anne Gent, Director of Human Resources Mr Nick Kenton, Director of Finance Ms Heidi May, Board Nurse Director Dr Margaret Somerville, Director of Public Health & Health Policy (from 10.30 am)

Also present Mrs Jan Baird, Transitions Director (Item 22) Dr Paul Davidson, Clinical Director, North & West Mrs Linda Kirkland, Head of Business Transformation Mr Alasdair Lawton, Non Executive Board member designate Mr Kenneth Mitchell, Programme Manager – Acute & Workforce, North of Scotland Planning Group (by videoconference – Item 24) Mr Kenny Oliver, Board Performance Manager Mrs Lorraine Power, Board Services Assistant Dr Lesley Anne Smith, Head of Quality (Item 21) Ms Maimie Thompson, Head of Public Relations & Engagement Ms Caroline Tolan, Policy Development Manager (Item 29) Ms Pat Tyrrell, Lead Nurse, Argyll & Bute CHP (by videoconference – Item 22)

Apologies – An apology was received from Dr Margaret Somerville, Director of Public Health and Health Policy and Mrs Jan Baird, Transition Director, who would join the meeting late, due to adverse weather conditions.

1 Welcome – The Chair welcomed Mrs Myra Duncan and Mr Alasdair Lawton to the Board meeting. Mrs Duncan and Mr Lawton had recently been appointed as Non Executive Board members for NHS Highland from 1 April 2012 and 1 June 2012 respectively, both for a period of 4 years. The Chair also welcomed Mr Brian Robertson, Head of Adult Social Care and Dr Paul Davidson, Clinical Director, North & West who had been appointed as part of the review of Senior Operational Management arrangements, which came into effect from 1 April 2012, to lead the new Highland Health and Social Care Partnership. It was noted that Mr Robertson would be a regular attendee at the Board, although he was unable to stay for today’s meeting. The Chair referred to the recent decision by the Board to agree the Partnership Agreement with the Highland Council in relation to integrated services for health and social care with NHS Highland now being responsible for Adult Social Care and the Highland Council for Children’s Services. He highlighted the need to work with the public and patients to focus on outcomes for the population of the Highlands.

1 Declarations of Interest

Board members declared the following interests:  Garry Coutts – Scottish Social Services Council (SSSC), ex officio of SSSC on the Care Inspectorate, University of the Highlands and Islands.  Myra Duncan – Member of Scottish Government Joint Improvement Team Action Group on Reshaping Care.  Colin Punler – Member of Pentland Housing Association Board.  Ray Stewart – Member of Unite and Staffside Chair.

The Board a Noted the Declarations of Interest.

2 Minute of Meeting of 7 February 2012

The minute of 7 February 2012 was approved.

The Board a Approved the Minute of Meeting held on 7 December 2012. b Noted the Board Rolling Action Plan.

3 Matters Arising

There were none.

REPORTS BY GOVERNANCE COMMITTEES

4 Argyll & Bute CHP Committee – Draft Minute of Meeting held on 7 March 2012

Bill Brackenridge, Chair of Argyll & Bute CHP updated on items discussed at the meeting. He highlighted that the meeting had become inquorate towards the end. There had been a presentation on Pressure Ulcer Prevention by the Lead Nurse, detailed discussion on the financial position within the CHP and a number of ongoing service reviews had been highlighted. It was noted that there had been a significant underspend on the Argyll & Bute Change Fund allocation, however this would be carried forward to 2012/13. The Chair welcomed the ongoing work in relation to pressure ulcers and asked that Nursing Staff and Managers focus on the benefits realisation relating to this area of work. Mr Gibson referred to the Child Protection Business Improvement Plan and asked if there were any lessons which could also relate to adult protection in Argyll & Bute.

2 Mr Brackenridge confirmed that the Head of Adult Protection was also a member of the Review Group on Child Protection to ensure any learning was shared across these areas. The Board Medical Director welcomed the discussions on quality including the Scottish Patient Safety Programme (SPSP)

5 Mid Highland CHP Committee – Draft Minute of Meeting held on 24 February 2012

Mr McLennan, Chair of Mid Highland CHP updated on items discussed at the meeting, including the Critical Incident Review (CIR) at the MacKinnon Memorial Hospital and the development of an action plan and an issue around discharge planning which was being followed up with Raigmore. Mr Creelman asked how learning relating to the CIR would be shared throughout NHS Highland. The Board Medical Director advised that this would be rolled out to other Community Hospitals. It would also be discussed at the local Clinical Governance Groups as well as the Clinical Governance Committee and the Clinical Governance Forum in relation to lessons learned, the development of a template for Community Hospitals and a plan for rolling this out across all operational units. Dr Shelley referred to the item 4.3 on Mortality Statistics in General Practice in relation to the data being misconstrued and difficult to present in a meaningful way. Following discussion, it was agreed that the Board Medical Director should consider the issues around meaningful statistics and report back to the Board.

6 North Highland CHP Committee – Draft Minute of Meeting held on 21 February 2012

Colin Punler, Chair of North Highland CHP, updated on issues discussed by North Highland CHP Committee including a presentation on the Director of Public Health’s Annual Report, the West Caithness Redesign Project and the financial position within the CHP. Mr Punler noted his disappointment that the North CHP had been unable to deliver a balanced budget. The Chair recognised the issues around sustainability in the North and hoped that the new structure arrangements which included a new operational unit for North and West would make a difference.

7 Raigmore Hospital Committee – Draft Minute of Meeting held on 20 February 2012

Mike Evans, Chair of Raigmore Hospital Committee updated on the last meeting of the Raigmore Committee including Children and Adolescent Mental Health (CAMHs), Orthopaedics, Kyle Court and SPSP. He referred also to the recent outbreak of Clostridium difficile and confirmed that an action plan would be submitted to the next meeting of the Committee. In relation to the financial situation at Raigmore it was noted that while NHS Highland would break even at the end of the financial year Raigmore had a forecast overspend of £4.7m. Accordingly there was a request for a detailed report to be submitted to the June Board in relation to Raigmore Savings Plans. The Chair confirmed that there would be a report also to the next meeting of the Improvement Committee. Work was also ongoing in relation to orthopaedics to ensure NHS Highland continues to meet the waiting time target. There was some discussion around accommodation at Kyle Court and the Chair advised that work was ongoing regarding this accommodation and it was likely there would be a future report to the Board.

8 South East Highland CHP Committee – Draft Minute of Meeting held on 26 January 2012

Gillian McCreath, Chair of the South East Highland CHP Committee updated on the last meeting of the Committee. There had been a detailed discussion on mental health services. It was noted that South East Highland CHP had reached the year end with a small underspend.

9 Audit Committee – Draft Minute of Meeting held on 13 March 2012

Mr Iain Gibson, Chair of the Audit Committee updated on issues discussed by the Committee, including Planning for Integration and the Internal Audit Plan. It was noted that Audit Scotland had been invited to the next meeting of the Committee to discuss their national reports and their application to local issues.

3 10 Clinical Governance Committee – Assurance Report of 14 February 2012

Sarah Wedgwood, Chair of the Clinical Governance Committee updated on issues discussed by the Committee, including a discussion on reporting format to the Committee in relation to assurance, consideration of work in relation to integrated services, the contribution of lay representatives on the committee and performance in relation to complaints and the 20 day response rate. The Chair welcomed the discussion in relation to lay representatives on the committee. Regarding meeting the 80% target in relation to complaints he requested that Chairs and Directors of Operations prioritise this target and ensure that the necessary systems are in place.

11 Staff Governance Committee – Assurance Report and Draft Minute of Meeting held on 22 November 2011

Ann Gent, Lead Executive for the Staff Governance Committee update on issues discussed by the Committee, including the proposals for a revised Staff Governance Standard, the Knowledge and Skills Framework and the eKSF target. Mrs Gent confirmed that the NHS Highland response to Scottish Government on the revised Staff Governance Standard would be circulated to Board members in due course. It was noted that the target that 80% of staff should have a Personal Development Plan and Review recorded on eKSF was currently at 63%. The Chair expressed some disappointment in this position and referred to the previous assurances by General Managers regarding this target. He highlighted the need to have a future plan in place to deliver this target from the start of the financial year. It was agreed that the final position in relation to the eKSF target would be circulated to Board members in due course. Mr Stewart referred to a recent academic report on partnership working in Scotland which had highlighted that greater partnership involvement leads to improvement. He confirmed that he would circulate a link to the report to Board members, for information.

12 Improvement Committee Assurance Report of 5 March 2012 and Balanced Scorecard

The Board noted the Improvement Committee Assurance Report of 5 March 2012 and Balanced Scorecard. Ian Gibson, Vice-Chair updated on the meeting which had considered the financial situation at Raigmore, eKSF, the benefits of patient focus booking and the Scottish Patient Safety Programme (SPSP). The Chair advised that in the vast majority of targets NHS Highland was performing very well. He confirmed that NHS Highland was the only Board in Scotland which monitored and reported on standards in the way we do. The Chief Executive referred to the recent signing of the Partnership Agreement and confirmed that work was in progress to collate baseline data in relation to social care key performance indicators and targets which would form part of the Balanced Scorecard in future. It was also noted that there was work in progress in relation to targets relating to dementia in Argyll & Bute and relating to endoscopy.

13 Area Clinical Forum – Draft Minute of Meeting held on 2 February 2012

Dr Iain Kennedy, Chair of the Area Clinical Forum, confirmed that he had updated on the meeting of 2 February 2012 at the February Board meeting and therefore gave a verbal update on the most recent meeting held on 29 March 2012. The main matters discussed were pressure ulcer prevention, CEL(2012)01 regarding a Health Promoting Health Services and integrating services in the Highlands. Dr Kennedy welcomed the recent decision by the Board on the expanding the membership of the Highland Health and Social Care Partnership Committee. He also confirmed that Dr Paul Davidson, Clinical Director, North & West would also be invited to be a member of the Area Clinical Forum.

14 Constitution – NHS Highland Area Healthcare Science Forum

The Board noted the Constitution for the NHS Highland Area Healthcare Science Forum had been agreed by the Area Clinical Forum and approved the Constitution.

4 15 Health & Safety Committee – Draft Minute of Meeting of 9 February 2012

Anne Gent, Joint Chair of the Committee updated on the meeting and advised that Elspeth Caithness had been re-appointed as the Staffside Chair of the Committee. It was noted that significant work was ongoing regarding the Improvement Notice for dermatitis in the ward areas at Raigmore hospital and there would be a further visit by the end of April. The Chief Executive advised that there were 3 improvement notices relating to care homes transferred from Highland Council which were now the responsibility of NHS Highland.

The Board a Noted the Minutes. b Agreed that Nursing Staff and Managers should focus on the benefits realisation from the work around pressure ulcer prevention. c Agreed that the Board Medical Director should consider the issues around meaningful statistics and report back to the Board. d Noted that a detailed report on Raigmore Savings Plans would be submitted to the June meeting of the Board. e Noted:  the Clinical Governance Committee met on 14 February 2012.  the Assurance Report and agreed actions resulting from the consideration of the specific items detailed.  that the next meeting of the Clinical Governance Committee would be held on 8 May 2012. f Agreed that Chairs and Directors of Operations need to prioritise the target in relation to Complaints and ensure that the necessary systems are in place. g Noted:  the Staff Governance Committee met on 21 February 2012  the Assurance Report and agreed actions resulting from the consideration of the specific items detailed.  the next meeting of the Staff Governance Committee will be held on 22 May 2012. h Noted that the final position in relation to the eKSF target would be circulated to Board members in due course. i Agreed that the final NHS Highland response to Scottish Government on the revised Staff Governance Standard would be circulated to Board members. j Noted that the Employee Director would circulate a link to an academic report on partnership working to Board members, for information. k Noted:  that the Improvement Committee met on 5 March 2012.  the Assurance Report and agreed actions resulting from the review of the specific topics detailed and the Balanced Scorecard.  that the next meeting of the Improvement Committee would be held on 30 April 2012. l Approved the Constitution of the Area Healthcare Science Forum.

5 Council/Highland NHS Board Joint Committees

16 Highland Council Partnership – Joint Committee on Children and Young People – Minute of Meeting of 20 January 2012

Mr Ian Gibson updated on the meeting and advised that the last meeting of the Committee had been held on 16 March.

17 Highland Council Partnership – Joint Leadership and Performance Group – Minute of Meeting of 14 February 2012

Mr Coutts updated on the meeting and advised that the main topic on the agenda had been Planning for Integration. It was noted that discussions were still ongoing regarding the Community Volunteering Strategy.

18 Argyll & Bute Health & Social Care Strategic Partnership

Bill Brackenridge advised that the meeting scheduled for 25 January 2012 had been cancelled as it would be inquorate. There had not been a meeting in March, however dates for the rest of the year had now been agreed.

The Board a Noted the minutes.

CORPORATE GOVERNANCE / ASSURANCE

19 Board Governance Committees Report by Kenny Oliver, Board Secretary on behalf of Garry Coutts, Chair (attached)

A new organisational and governance structure had been agreed which will be implemented from April 2012 although there would require to be some overlap with existing committees until the new structure was established. There was a need to recruit members to this as soon as possible. As this would impact more widely on all members it was felt that now would be a good time to review the chairmanship and membership of all our Governance Committees. In order to facilitate the process of appointment to the Vice Chair, Chair of the two CHPs and the Chairs and members of the other Governance Committees of the Board, the Board was asked to approve the following changes, detailed in the report:

a) The remunerated Chairs of the Highland Health and Social Care Partnership, Argyll and Bute CHP and the Vice Chair are all appointed through an interview process involving external panel members b) The current remuneration of the CHP Chairs and Vice Chair be split on an even basis between the 2 new Chairs and the Vice Chair. c) The Chair and Vice Chair (once appointed) will seek to fill the vacancies for the other committee chairs and members

The Chair advised that provisional dates had been set over the next two weeks for interviews for those who had expressed an interest in the various positions. It was noted that the in view of the forthcoming council elections that the local authority representatives on the Board would change and that those representatives would not have an opportunity to apply for these positions. The Chair confirmed that the appointments for Chairs of the Operational Units would be for one year in the first instance, and then be reviewed. Following discussion the Board agreed to approve the proposals.

6 The Board a Approved that the remunerated Chairs of the Highland Health and Social Care Partnership, Argyll and Bute CHP and the Vice Chair are all appointed through an interview process involving external panel members. b Approved the current remuneration of the CHP Chairs and Vice Chair be split on an even basis between the 2 new Chairs and the Vice Chair. c Agreed that the Chair and Vice Chair (once appointed) would seek to fill the vacancies for the other committee chairs and members. d Noted that the appointments of Chairs of the Operational Units would be for one year in the first instance, and then be reviewed.

20 NHS Highland Financial Position as at 29 February 2012 Report by Nick Kenton, Director of Finance

Mr Kenton updated on the financial position to 29 February 2012, which continued to estimate a revenue break-even position for the financial year. The position for February now incorporated sufficient improvements to deliver break-even from an overall NHS Highland perspective. This had been achieved as a result of a positive movement in operational units’ forecasts of £334,000, combined with a final tranche of non-recurrent resources of just over £1m. As highlighted in previous reports, the level of non-recurring resource underpinning the financial position for 2011/12 was unprecedented and results in a considerable carry forward into future years savings targets.

In terms of operating units’ performance, the improvement above had reduced the overall operational overspend to £6.9 million and this was summarised within the report. Whilst its financial deterioration had stabilised, Raigmore continued to account for the majority of the Operational overspend at £4.7m. Small improvements within South East, Argyll & Bute and North CHPs were also reported. Detailed financial positions for each Operational Unit were detailed in section 3 of the report.

The delivery of Efficiency Savings was detailed in Table 3 and highlighted that, of the £19m savings target, plans were in place to deliver £13.6m, with units focusing on further delivery of full year effects to improve the carry forward into next year. At present, the current carry forward into 2012/13 totalled £9m which put additional pressure on the financial position going forward. Table 4 highlighted the capital spend against the Capital Resource Limit (CRL). The forecast position was to meet financial targets with a breakeven position.

There was some discussion around the Raigmore financial position and the Chair confirmed that, as discussed previously, a separate report would be submitted to the next meeting of the Board on the Raigmore Savings Plans. The Chief Executive referred to excellent work undertaken in the past year to reach break-even and highlighted that future years would be equally challenging. It was suggested that a message be issued to all staff regarding the financial position. The Chair highlighted the need for quality to be at the centre of what we do and the need to be more efficient and reduce waste and variation. As well as improving efficiency, this would also help to improve outcomes for patients. The Chief Executive suggested that it would be beneficial to submit a future report to the Board to illustrate where savings had been made and benefits realised. Cllr Davidson emphasised the need to involve patient and public representatives in work to redesign services and the Chair confirmed NHS Highland’s commitment to patient and public involvement.

The Board a Noted the continued forecast of break-even in the current year.

7 b Recommended that a message be issued to all staff regarding the financial position. c Agreed that it would be helpful to have a future report to illustrate where savings had been made and benefits realised.

21 NHS Highland Strategic Risk Register Report by Lesley Anne Smith, Head of Clinical Governance on behalf of Ian Bashford, Board Medical Director

In order to be effective, risk management should be embedded throughout the organisation in such a way as to facilitate the timely identification and mitigation of the risks to the achievement of business objectives. This means that risk registers should be based on NHS Highland’s strategic and operational plans, and in particular those risks that would prevent the achievement of strategic and operational objectives. Dr Smith spoke to the report which updated on the current position in relation to the Strategic Risk Register, Operational Risk Registers and risks relating to Adult Social Care Services. It was noted that the updated Strategic Risk Register, including risks relating to Adult Social Care Services would be presented to the June meeting of the NHS Board.

Sarah Wedgwood, Chair of the Clinical Governance Committee welcomed the report which highlighted the importance of risk management and suggested that the Board have a future discussion on the key priorities for the Board in relation to risk management and the governance of risks.

There was some discussion around the need for more regular reporting to the Board on the Strategic Risk Register. Dr Smith suggested that an update could be submitted to each Board meeting, with a more formal report every six months. Mr McLennan referred to the diagram on page 5 of the report and asked where Control of Infection sat within this. Dr Smith confirmed that further work was ongoing in relation to all the operational committees and that a Risk Management Policy and Strategy was also being drafted. Cllr Robertson referred to the work in progress regarding adult social care services and asked about child care and family services and whether the local authority had a similar risk register. She also highlighted that the one very high risk identified was in relation to failure to effectively engage stakeholders in the way services will be delivered in the future and asked if this issue was reported to one of the governance committees. The Chair confirmed that the risk owner for this was the Chief Executive, however it was also a responsibility for Operational Directors within the CHPs / Raigmore. Cllr Davidson thanked Cllr Robertson for raising the issue relating to children’s’ services. The Chair confirmed that this would be progressed. Mr Gibson highlighted the achievement in the work to date in relation to identifying 18 strategic risks and how this work was fundamental to the internal audit plan.

The Board a Approved the NHS Highland Strategic Risk Register. b Agreed to the process for integrating risks associated with Adult Social Care Services. c Agreed the management and assurance arrangements for NHS Highland’s Strategic Risks. d Noted the ongoing review of the risk management process within NHS Highland and that a further report would be submitted to the next meeting of the Board regarding Adult Social Care Services. e Noted the proposal for a future discussion on the key priorities for the Board in relation to risk management and the governance of risks.

8 f Recommended that the Strategic Risk Register should be a standing item on future Board agendas.

22 Argyll and Bute Child Protection Business Improvement Plan Report by Pat Tyrrell, Lead Nurse, Argyll & Bute CHP on behalf of Jan Baird, Transitions Director, The Highland Partnership

Pat Tyrrell, Lead Nurse, Argyll & Bute CHP linked into the meeting by videoconference for this item. The Care Inspectorate undertook a Joint Inspection of Services to Protect Children and Young People in Argyll and Bute during the month of June 2011. The inspection considered the statutory services provided by social work, education, health, police and the reporter. It also looked at range of services from the voluntary and independent sectors. As a result of the findings the Argyll and Bute Child Protection Business Improvement Plan had been developed and priority actions were being implemented. The inspectors recognised a number of strengths in the interagency approaches to protecting children and young people in Argyll and Bute. These strengths included the following:

 High quality support in schools to help children learn and develop well  Staff persistence in building relationships with families and helping them understand what they need to do to reduce risks for their children  Helping vulnerable children learn how to keep themselves safe

In addition the inspectors commended staff for sharing a common vision for protecting children and for improving their lives. They acknowledged the commitment of the Chief Officers in meeting regularly with staff from across Argyll and Bute. They did however identify significant areas for improvement in the current provision of interagency services. These were detailed in the report as follows:

 Improve the initial response of staff to children in need of protection and the impact of immediate actions to keep children safe.  Continue to develop approaches to self-evaluation, ensuring it is based on robust evidence.  Identify key priorities for improvement and ensure that staff have sufficient direction, support and challenge to take these forward.

The report included a detailed Business Improvement Plan which identified the key actions necessary to address the shortfalls identified by the Care Inspectorate. The plan was divided into tiers to reflect the prioritisation of the improvement actions to ensure that greatest and most immediate attention was given to the most important actions. This was also in line with advice from the Inspectors in their report.

During discussion a number of points were raised, including:

 The need to ensure that “Getting it Right for Every Child” (GIRFEC) is embedded in this work and to utilise peer support and links with Highland Council.  The initial report had been disappointing for NHS Highland, however this had given NHS Highland the opportunity to look more closely at child protection arrangements in Argyll & Bute and put improved measures in place.  The need for improved dialogue between health and local authority colleagues was a vital element to the success.  Jan Baird confirmed that the teams in Highland and Argyll & Bute Council areas had worked together to progress this work.

Mr Brackenridge highlighted the need to think ahead to inspections for Adult Support and Protection from January 2013. The Chief Executive referred to the need to learn from the Child Protection Inspections and reports and to utilise this learning across Highland and Argyll & Bute

9 Council areas. The Chair suggested that the GIRFEC approach could also be considered in relation to Adult Support and Protection services.

The Board a Noted the findings and proposed follow up inspection of Services to Protect Children and Young People in Argyll and Bute by the Care Inspectorate. b Noted and Agreed the contents of the Child Protection Business Improvement Plan. c Recommended that the learning from these reports should be disseminated across NHS Highland.

The Board adjourned at 10.35 am and resumed at 10.50 am.

23 Infection Control Report Report by Liz McClurg, Interim Infection Control Manager on behalf of Heidi May, Board Nurse Director & Executive Lead for Infection Control

Heidi May, Board Nurse Director updated on the Infection Control Report. The Executive Summary, which summarised the key information in the report, is detailed below:

Staphylococcus aureus On course to meet target of 0.26 cases per 1000 acute bacteraemia (SAB) occupied bed days. NHS Highland rate April – February 2012 is 0.179.

Clostridium difficile On course to meet target of 0.39 per 1000 total occupied bed days. NHS Highland rate April – February 2012 is 0.25. Reasons for the Raigmore outbreak are being investigated.

Hand Hygiene Compliance with hand hygiene 97% in January and February 2012. It is felt more can be done to achieve compliance and work will begin with staff side to explore options.

Cleaning and the Healthcare Cleaning Compliance 94% in January and February 2012. Environment Estates Monitoring Compliance 94% in January and 96% in February 2012.

Significant HAI incidents / Clostridium difficile infection outbreak in Raigmore Hospital outbreaks, emerging threats January 2012. An incident debrief has been held, actions agreed, including the setting up of an HAI Task Force in Raigmore and an in depth review of cause is nearing completion.

Antimicrobial Prescribing Continuing compliance above 95% with antibiotic choice and duration of prophylaxis.

Surgical site infections Orthopaedic and caesarean section surgical site infections rates remain low, and within anticipated levels. We are continuing to work with the colorectal surgeons to reduce the SSI rate in elective patients.

10 There would be a Health Environment Inspectorate (HEI) visit to Lorn & Islands Hospital on 18 April and there would be a future visit to Caithness General Hospital. It was noted that an update had been requested some time ago on catheter associated urinary tract infection, however, the current NHS Highland laboratory IT management system did not have the capability to allow the Infection Prevention and Control team to develop an effective surveillance system required to effect a reduction in catheter associated urinary tract infection (CAUTI). Work was under way to resolve this. Regarding the recent Clostridium difficile outbreak at Raigmore Hospital, there would be a further more detailed report submitted to the next meeting of the Board. Ms May highlighted a potential risk for NHS Highland in relation to Microbiology. Following an advert for a Microbiology Consultant, NHS Highland was unable to recruit to this post. Locum Microbiology Consultants were in place, however this situation was not ideal and recruitment to the post was a priority for the organisation.

Mr Punler referred to Planning for Integration and Care Homes and asked if these premises were subject to the same inspection process as hospitals. The Board Nurse Director advised that the Care Commission was responsible for inspecting care homes. NHS Highland would need to become more familiar with the inspection process for care homes and to ensure similar standards and the required reporting to the Board was in place.

Dr Shelley referred to the update on the Clostridium difficile outbreak at Raigmore Hospital in relation to ward monitoring highlighting that not all wards were monitored and how could NHS Highland be confident in the data. The Board Nurse Director confirmed that the sample had always been taken from the same areas and consideration might need to be given to extending this in future.

The Board a Noted the contents of the Report. b Noted that a more detailed report on the recent Clostridium difficile outbreak at Raigmore Hospital would be submitted to the June Board meeting.

24 North of Scotland Planning Group – Annual Report Report by Mr Kenneth Mitchell, Programme Manager – Acute & Workforce, North of Scotland Planning Group

The Chair welcomed Mr Kenneth Mitchell to the meeting by videoconference link. The Annual Report of the North of Scotland Planning Group for 2011/12 was submitted together with the Report from the Annual Planning Event, held in Nairn, in September 2011. The Workplan for 2012/13 was also enclosed, although it was recognised that it might require to change in year. Mr Mitchell spoke to the reports, highlighting some of the key themes for the North of Scotland Planning Group. The emphasis of the regional workplan during 2011/12 had continued to focus on children’s services, mental health services and acute services, together with those overarching groups that provide support across disciplines. Reference was also made to national projects including the Remote and Rural Implementation Group, the Scottish Neonatal Transport Service and Nursing and Midwifery Workforce Planning. There followed a detailed discussion on the reports and a number of issues were raised:

 Regarding Children’s Services which were now the responsibility of Highland Council, a question was raised as to whether the Highland Council would now be part of the North of Scotland Planning Group. The Chair remitted to the Chief Executive in consultation with the Director of Health and Social Care at the Highland Council to take this forward.  It was noted that there was some slippage in relation to Children’s Services and it was confirmed that this funding would be carried forward to the next year and prioritised.  It was recognised that IT system integration was a challenging area and work was in progress.

11  Mention was made of the West of Scotland Planning Group and the Chair advised that their Annual Report should be submitted to the Board in due course.  A question was raised regarding the planned evaluation of the Eden Unit and the Chair requested an update on this be included in the next Chief Executive’s report to the Board.

The Chair welcomed the reports and assured Mr Mitchell that NHS Highland would continue to play an important role in regional planning.

The Board a Noted the Annual Report for 2011/12. b Noted the Report from the Annual Planning Event held in September 2011. c Approved the Workplan for 2012/13. d Agreed that Highland Council should be linked in with the North of Scotland Planning Group, as appropriate and remitted to the Chief Executive to progress this. e Noted that there was a planned evaluation of the Eden Unit and that an update on this should be included in the next Chief Executive’s report to the Board.

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

This month’s report incorporated updates on:

 Annual Accounts 2010/11  Clinical Advisory Group – Annual Report  Older People in Acute Care/Dementia Standards  Patient Rights (Scotland) Act 2011  Regional Planning – North of Scotland Planning Group  Waiting Lists – Use of Unavailability Codes

The Chief Executive referred to the item on Waiting Lists and confirmed that NHS Highland could reassure the Board that we have always enforced a strict policy on the use of “unavailability” codes for patients and monitor the position on a weekly basis. We were well below the Scottish average with one of the lowest rates of the Scottish Boards. It was also noted that NHS Highland had requested a specific code for rurality issues and travel times. It was confirmed that a report on Waiting List management and the use of “unavailability” codes would be submitted to the next meeting of the Improvement Committee.

The first Annual Report of NHS Highland’s Clinical Advisory Group (CAG) was circulated as Supplementary Paper 1 to the Chief Executive’s Report. CAG’s Annual Report described the rationale, role and remit of the Group; highlighted CAG’s activities and achievements to date; and proposed a future work programme relevant to the core business of NHS Highland. The Board was asked to approve the Annual Report for 2011/2012 and endorse the Future Work Programme.

The Board a Noted the emerging issues and updates report. b Noted that a report on Waiting List management and the use of “unavailability” codes would be submitted to the next meeting of the Improvement Committee.

12 c Approved the Clinical Advisory Group Annual Report for 2011/2012. d Endorsed the Future Work Programme for the Clinical Advisory Group.

STRATEGY AND POLICY

26 NHS Highland Local Delivery Plan 2012/13 Report by Kenny Oliver, Board Performance Manager on behalf of Elaine Mead, Chief Executive

The Local Delivery Plan 2012/13 had been prepared in accordance with national guidance and timescales. The initial draft was submitted to the Scottish Government Health Department (SGHD) on 17 February 2012. All comments received from within NHS Highland and additional information requested in feedback from the SGHD leads has been reflected in this final version, which was submitted by the required deadline of 16 March 2012, subject to ratification from NHS Highland Board.

The format of the LDP has a slightly revised format from previous years and consists of the following 6 sections.

 The Quality Ambitions and wider outcomes-based approach  NHS Boards contributions to Single Outcome Agreements  LDP HEAT Risk Management Plans  LDP HEAT Delivery Trajectories  LDP Financial Plans and Efficiency Savings  Summary of main workforce issues facing the NHS Board

Appendix 1 detailed the Draft Partnership Service Agreement with NHS Western Isles.

Kenny Oliver spoke to the report and advised that there were 3 new HEAT targets relating to the Detecting Cancer Early programme, Children and Adolescent Mental Health Services (CAMHs) and Psychology and Delayed Discharges.

Dr Shelley referred to Surgical Services Redesign in relation to Caithness General Hospital and Belford Hospital. Dr Bashford advised that work was ongoing in relation to capacity and demand across NHS Highland with the aim of changing referral patterns to encourage referral Rural General Hospitals to free capacity in Raigmore Hospital. Reference was also made to Detect Cancer Early and it was noted that there would be a future discussion on this topic at the Improvement Committee.

The Board a Ratified the Local Delivery Plan 2012/13 for NHS Highland.

27 NHS Highland Revenue Budget 2012/13 Report by Nick Kenton, Director of Finance

NHS Highland receives funding for revenue expenditure in the form of its’ Revenue Resource Limit (RRL). It is a statutory requirement that the Board operates within this resource limit, and a Financial Plan to support this is submitted as part of the Local Delivery Plan (LDP). Mr Kenton spoke to the 2012/13 Budget report. With regards to the NHS Highland uplift for 2012/13, the headline uplift was noted as 2.5%, however, this included a number of adjustments for funding which were not part of a baseline uplift such as:

 The prison healthcare transfer

13  Access resources previously provided as supplementary allocations  The Change Fund

The actual baseline uplift in resources for 2012/13 was 1% which represented an increase of just under £5m on the Board’s baseline allocation; this excluded a wide range of other allocations such as primary care funding which are allocated separately. Indicative allocations for future years had been provided and these were 2.8% for 2013/14 and 2.5% thereafter, although it was not clear whether this would be reduced by adjustments such as those highlighted above. All NHS Boards are required, under the Efficient Government agenda, to deliver Efficiency Savings which are locally retained by NHS Boards, to maintain and develop local services including addressing cost pressures, inflationary uplifts, and any service / volume changes, as well as the significant impact of demographic change with an increasing number of elderly people. For 2012/13, the NHS Highland financial plan will also incorporate the financial impact of the Integration agendas around Adult Social Care and Children’s Services resulting in approximately £90m (net) of resources transferring into NHS Highland and approximately £8.5m transferring out. This had been well documented in various recent reports to the Board.

The Financial Plan indicated a breakeven budget over the 5 year period however, this would be extremely challenging to achieve within the context of the pressures highlighted above, and therefore carries a significant risk which must be very carefully managed by the Board. The required level of savings would only be delivered through whole system joined up plans which embrace the Quality agenda to reduce waste, harm and variation and to improve efficiency and productivity.

Following discussion, the Board agreed the 2012/13 Revenue Budget as part of the Board’s Financial Plan. The Board also endorsed the approach being taken with regard to efficiency savings and noted that of just over £23.8m of savings was required during the year. This would demand significant commitment, ownership and input throughout NHS Highland and would be closely monitored in Financial Reports throughout the year.

The Board a Agreed the 2012/13 Revenue Budget as part of the Board’s Financial Plan. b Endorsed the approach being taken with regard to Efficiency Savings

28 NHS Highland Capital Plan 2012/13 Report by Nick Kenton, Director of Finance

The Board’s Capital Plan was last discussed at the February 2012 Board when an update on the 2011/12 plan was noted. This report provided details of the capital resource available to the Board for 2012/13 and indicative funding for subsequent years. It also recommended a detailed expenditure programme for 2012/13 and provided an indicative programme for future years.

The Board has been notified of its allocations from Scottish Government for 2012/13 and indicative allocations for the following two years which were detailed in Appendix 1. Specific Government allocations had been made for the legally committed schemes of Mull & Iona PCC and Oban Dental Clinic, these schemes were currently underway and would complete in 2012/13. A specific allocation had been received as part of the national radiotherapy programme in 2012/13 and continuing into subsequent years. In future years there was also funding to complete the upgrading of Dingwall Health Centre and to build a new health centre in Drumnadrochit.

As notified to the Board previously, the demands on the capital formula allocation far outweigh the funding available and it is therefore necessary to prioritise the competing bids and a system is in place to do this. It is essential that the Board’s Capital Plan links to its Property Asset Management Strategy and there is a clear plan to reduce high risk backlog maintenance to no

14 more than 10% of total backlog maintenance. The proposed Capital Plan reflected this in the allocations for Estates Backlog Maintenance over the next five years. Allocations had also been made to rolling programmes for Medical Equipment, eHealth and Radiology replacement. However, the requirement to focus on Estates Backlog Maintenance has resulted in the rolling programmes relating to equipment having to be reduced in comparison to the proposed programme. This results in an increased risk of equipment failure during the period of the Plan.

It was noted that the terms of reference for the Asset Management Group were being revised and would be submitted to the next meeting of the Board. Mr Kenton advised that he would welcome Non-Executive membership on that Group.

During discussion Cllr Davidson expressed concern that the Drumnadrochit health centre project had been put back a year and asked that this be re-considered. The Director of Finance advised that representatives from each of the operational units had been involved in the discussions at the Asset Management Group and this had also been agreed with the Head of Estates and Scottish Government. The Chief Executive advised that the reason that work on Dingwall Health Centre was progressing ahead of Drumnadrochit related to the fact that work had already commenced on the Dingwall site. The Chair invited Mrs Davidson to move an amendment, suggesting what projects should be deferred to allow the Drumnadrochit project to progress, but this offer was declined. Cllr Davidson sought assurance that if there was any possibility that the Drumnadrochit project could be progressed more quickly that this would be considered. She also asked the Chief Executive to provide an explanation for the delay that she could relay to constituents.

The Board a Noted the capital resources of £9.882m for 2012/13 and indicative funding for future years. b Agreed the proposed Capital Plan for 2012/13 and indicative plan for future years. c Noted that the terms of reference for the Asset Management Group were being revised and would be submitted to the next meeting of the Board.

29 Gaelic Language Plan Report by Moira Paton, Head of Community & Health Improvement Planning on behalf of Elaine Mead, Chief Executive

NHS Highland Board approved a draft Gaelic Language Plan on 1 December 2009 for submission to Bòrd na Gàidhlig. This draft was considered by Bòrd na Gàidhlig and they subsequently made suggestions for changes to our plan. Several of these suggestions needed further negotiation to ensure that they would be acceptable to both organisations. These negotiations had now taken place and the revised draft was the result.

Dr Shelley noted the timeframe in relation to Gaelic content on the NHS Highland website detailed in the action plan as February 2016. It was noted that work was in progress regarding the NHS Highland website generally and if the opportunity arose to update this more quickly then this would be progressed.

Mr Brackenridge referred to priorities for Gaelic provision in relation to the islands of Jura, Islay, Mull, Colonsay, Coll and Tiree and asked on what evidence this had been based as he was only aware of the need to focus on Coll and Tiree. Ms Tolan advised that the information had been taken from the last census and had related to small numbers. The Chair felt that it was important to ensure that the areas that needed information in Gaelic were provided with it and this should be in the spirit of the plan. A number of Board members highlighted the benefit to patients of being able to receive information in their native language.

15 The Board a Approved the revised draft NHS Highland Gaelic Language Plan. b Approved the updated timescale for implementation as 2012-2017. c Approved the Implementation Guidance, as included in annex A, for use across NHS Highland.

30 Any Other Competent Business

Dr Vivian Shelley – The Chair noted that this would be the last Board meeting to be attended by Dr Shelley as her term of office was due to come to an end on 31 May 2012. The Board recorded its appreciation of the work Dr Shelley had contributed to the Board over the last 6 years and wished her well for the future.

Intellectual Property (IP) and the Rewards to Inventors (RtI) Scheme in NHS Highland – It was recommended that this item should be considered in Committee as Appendix 1 to the report contained information provided by other parties which could be considered commercial and confidential. Mr Stewart highlighted his view that this information should be in the public domain. Following discussion the Board agreed that it was not for the Board to make public information, which was considered confidential by other organisations and agreed to consider the item in private session. However, the Chair confirmed that the decision of the Board in relation to the proposed scheme would be made public.

31 Date of Next Meeting

The next meeting of the Board will be held on Tuesday 5 June 2012 at 8.30 am in the Board Room, Assynt House, Beechwood Park, Inverness.

The meeting concluded at 12.30 pm.

16 Highland NHS Board 5 June 2012 Item 2(c) Assynt House Beechwood Park Inverness IV2 3BW Tel: 01463 717123 Fax: 01463 235189 HIGHLAND NHS BOARD Textphone users can contact us via Typetalk: Tel 0800 959598 www.nhshighland.scot.nhs.uk/

DRAFT MINUTE of MEETING of the BOARD IN COMMITTEE 3 April 2012 – 12 30 pm Board Room, Assynt House, Beechwood Park, Inverness

Present Mr Garry Coutts, Chair Mr Bill Brackenridge Mr Robin Creelman Cllr Margaret Davidson Mrs Myra Duncan Mr Mike Evans Mr Ian Gibson Dr Iain Kennedy Mrs Gillian McCreath Mr Okain McLennan Mr Colin Punler Cllr Elaine Robertson Dr Vivian Shelley Mr Ray Stewart Ms Sarah Wedgwood Ms Elaine Mead, Chief Executive Dr Ian Bashford, Board Medical Director Mrs Anne Gent, Director of Human Resources Mr Nick Kenton, Director of Finance Ms Heidi May, Board Nurse Director Dr Margaret Somerville, Director of Public Health & Health Policy

Also present Mrs Jan Baird, Transitions Director Mrs Linda Kirkland, Head of Business Transformation Mr Alasdair Lawton, Non Executive Board member designate Mr Kenny Oliver, Board Performance Manager Mrs Lorraine Power, Board Services Assistant Ms Maimie Thompson, Head of Public Relations & Engagement

Apologies – There were none.

32 Intellectual Property (IP) and the Rewards to Inventors (RtI) Scheme in NHS Highland Report by Prof. Angus Watson and Frances Hines, Research and Development Department on behalf of Ian Bashford, Board Medical Director

At the last Board meeting held on 7 February 2012, the Board agreed in principle with the proposed Intellectual Property policy and Rewards to Inventors Scheme, subject to a further discussion at the next meeting of the Board regarding the proposed split of residual income. It was agreed at the open Board meeting on 3 April 2012 that this item should be considered in Committee as Appendix 1 to the report contained information provided by other parties, which could be considered commercial and confidential.

17 The report offered evidence for a Rewards to Investors Scheme for Intellectual Property in Scotland and the UK as a whole. It was noted that NHS Highland was the only regional Board without a policy. Details were given within the report of the ratios used in different Board areas. The report suggested a proposed split of 40:20:40 (40% to the inventor : 20% to NHS Highland (department or Board) : 40% to Research and Development)of any residual income from products developed by NHS Highland staff once costs had been met for any licensing, marketing or other commercialisation activity.

The Chair welcomed the policy as a way to reward creative staff within the organisation and highlighted that any projects, which were commercially successful could only benefit NHS Highland. Mr Stewart advised that while he was not against innovation or research and development, that he did not agree with the ethos of individuals benefiting from residual income. He suggested that any residual income from ideas or projects should go to the Board or to the team / department. The Board Medical Director did not agree with this as it would make NHS Highland an outlier in relation to other IP Policies throughout Scotland and the Board should be in line with other Scottish Boards. The Director of Public Health agreed with the view of the Board Medical Director and suggested that it was possible to have a team or department as the “innovator” rather than an individual. During discussion it was suggested that the split should be equal thirds (33⅓ to inventor / team : 33⅓ to NHS Highland: 33⅓ to Research and Development). The Chair asked the Board to accept this approach, which would benefit patients, staff and the Board as a whole. All Board members were in favour of this proposal with the exception of Mr Stewart, who voted against and Dr Kennedy who abstained. Accordingly the Board approved the proposal.

Mr Punler proposed that the report and minute should be made public following the meeting and suggested that paragraph 2 of the report could be redacted to allow this to be in the public domain. The Chair agreed that the report could be put in a suitable format and published on the NHS Highland website.

The Board a Agreed that the proposed Intellectual Property policy and Rewards to Inventors Scheme with a 33⅓ : 33⅓ : 33⅓ : split as detailed above. b Accepted the approach as benefiting patients, staff and the Board as a whole. c Agreed to implement the IP policy and RtI system through NHS Highland’s R&D Department and associated departments and systems (i.e. Pay Unit, Employment Services).

33 Any Other Business

Local Authority Board Members – The Chair recorded the work of the local authority representatives on the Board and noted that their terms of office would come to an end on 30 April 2012.

34 Date of Next Meeting

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

The meeting concluded at 12.55 pm.

18 FOLLOW UP FROM BOARD ACTION PLANS – JUNE 2011 ONWARDS Highland NHS Board Those items shaded grey are due to be removed from the Action Plan as they have been completed, or will be considered at 5 June 2012 the next Board. Item 2(d)

Meeting Item Action / Progress Outcome

Board 07/06/11 Audit Committee Hospital and Community Health payments to GPs in Argyll and Future Board – letter received from SG Bute – to seek clarification on this issue and report back to the 21/10/11 – being progressed Board in due course. Being reviewed by national Primary Care Leads with a view to providing additional guidance. Board Dev. Archie Foundation Update The Chair advised that he felt it was necessary for a protocol to Chair / Chief Executive to progress. 08/08/11 be in place regarding similar style projects to ensure that these were brought to the attention of the Board in a timely fashion. Orthopaedic Services in NHS Agreed to defer consideration of this item to allow further work to Future SMT Western Isles be carried out. Board 04/10/11 Matters Arising Patient / Public Representatives on Committees – an action Work in progress should be added to the Board Rolling Action Plan in relation to appointing patient and public representatives to governance committees. Argyll & Bute CHP Committee To raise the issue relating to learning in relation to violent and Bill Brackenridge to action aggressive incidents and advise Sarah Wedgwood. Governance Committees Chairs of Governance Committees to speak to Lead Executives Governance Committee Chairs to regarding their role in the Committee. action Pharmacy Practices Committee Report to be prepared for Board members on the support Work in progress available to applicants, as the new way of working was very complex. Capital Plan 2011/12 To check the query regarding impact assessment and advise CE to action. Mr Punler. Patient Experience at Governance To consider whether patient experiences should also be Chair to consider Committees considered at the Board as well as governance committees. Board 06/12/11 Internal Evaluation of NHS To bring forward proposals to the Board early in 2012 on the Future Board Highland Newspaper production of two editions of the newspaper in the spring and autumn Board 07/02/12 West Caithness Redesign To ensure the Board receives regular updates on the process. Ongoing proposals Highland Health & Social Care To review the governance arrangements once the structure had Board June 2013 Partnership – Proposed been operational for one year. Governance Arrangements Meeting Item Action / Progress Outcome

Board 07/02/12 Highland Health & Social Care Board Secretary to undertake work on the role description for Ongoing Partnership – Proposed members of the HH&SCP Committee. Governance Arrangements (cont.) Appropriate Board Development sessions to be arranged for Ongoing Board members regarding the HH&CSP. Senior Operational Management A more detailed diagram of the structure to be circulated to Not yet finalised. and Professional Leadership Board members for information. Arrangements NM&AHPs Highland Alcohol & Drugs An annual report would be submitted to a future Board meeting. Board 14/08/12 Partnership Strategy – Highland Council Developing a Quality Approach to Further report to be submitted to the April meeting of the Board. Board 05/06/12 Engagement and Communications Board 03/04/12 Mid Highland CHP Committee Board Medical Director to consider the issues around Board Members / Future Board meaningful statistics and report back to the Board. Raigmore Committee A detailed report on Raigmore Savings Plans would be Board 05/06/12 submitted to the June meeting of the Board.

Staff Governance Committee The final position in relation to the eKSF target to be circulated Board Members to Board members in due course. The final NHS Highland response to Scottish Government on Board Members the revised Staff Governance Standard to be circulated to Board members. Employee Director to circulate a link to the academic report on Board Members partnership working to Board members, for information. Board Governance Committees The remunerated Chairs of the Highland Health and Social Board 05/06/2012 Care Partnership, Argyll and Bute CHP and the Vice Chair are all appointed through an interview process involving external panel members. The Chair and Vice Chair (once appointed) to seek to fill the Board 05/06/2012 vacancies for the other committee chairs and members. NHS Highland Area Finance Report Recommended that a message be issued to all staff regarding All Staff the financial position.

Agreed that it would be helpful to have a future report to illustrate where savings had been made and benefits realised. Board 05/06/12 2 Meeting Item Action / Progress Outcome

Board 03/04/12 NHS Highland Strategic Risk A further report would be submitted to the next meeting of the Board 05/06/12 Register Board regarding the risk register relating to Adult Social Care Services. Chair and Chief Executive to consider suggestion for a future Future Board / Brd Dev. Session discussion on the key priorities for the Board in relation to risk management and the governance of risks.

Recommended that the Strategic Risk Register should be a Future Board meetings – ongoing standing item on the Board agenda. Control of Infection A more detailed report on the recent Clostridium difficile Board 05/06/12 outbreak at Raigmore Hospital to be submitted to the June Board meeting. North of Scotland Planning Group Update on the evaluation of the Eden Unit to be included in the Board 05/06/12 – CEs Report next Chief Executive’s report to the Board.

NHS Highland Capital Plan 2012/13 Report on the terms of reference of the Asset Management Board 05/06/12 Group to be submitted to the next meeting of the Board

3

Highland NHS Board 5 June 2012 Item 3.1

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

The Pavilion, Rothesay 25 April 2012

Present Mr Bill Brackenridge, Chairman, Argyll & Bute CHP Mr Derek Leslie, General Manager, Argyll & Bute CHP Mr Duncan Martin, Chairman, Public Partnership Forum Dr Vivian Shelley, Non Executive Director, NHS Highland Ms Pat Tyrrell, Lead Nurse, Argyll & Bute CHP Ms Elaine Garman, Public Health Rep. Ms Liz McMillan, Argyll & Bute CHP, Staffside Rep

In Attendance Mr David Logue, Head of Human Resources, Argyll & Bute CHP Mr George Morrison, Head of Finance, Argyll & Bute CHP Mr Stephen Whiston, Head of Planning, Contracting & Performance, Argyll & Bute CHP Mr Robin Creelman, Non Executive Director, NHS Highland Mr Alistair McLaren, CVO Rep Mrs Margaret Johnston, PA to CHP Clinical Director/CHP Chairman - Minute Secretary

1 CHAIRMAN’S WELCOME

The Chairman opened the meeting by welcoming everyone to the Pavilion, Rothesay

2 APOLOGIES

Apologies for absence were received from:

Dr Michael Hall, Clinical Director, Argyll & Bute CHP Ms Katy Murray, Deputy Chairperson, Public Partnership Forum Ms Tricia Morrison, CVO Rep Mr Neil Robinson, Area Pharmaceutical Committee Rep Ms Dawn Gillies, Argyll & Bute CHP, Staffside Rep Ms Mary Wilson, AHP Rep, Argyll & Bute CHP Councillor Andrew Nisbet, Argyll & Bute Council Representative Ms Linda Currie, Interim AHP Rep, Argyll & Bute CHP Mr Cleland Sneddon, Argyll & Bute Council Ms Glenn Heritage, CVO Rep Councillor Vivien Dance, Argyll & Bute Council Representative Ms Elizabeth Reilly, Area Dental Committee Representative Councillor Elaine Robertson, Non Executive Director, NHS Highland Mr David Ritchie, Communications Manager, Argyll & Bute CHP

3. CONFLICTS OF INTEREST No conflicts of interest were declared. 4. MINUTE FROM PREVIOUS MEETING HELD ON 7 MARCH 2012

4.1 Minute of Meeting held on 7 March 2012

The minute of the meeting on 7 March 2012 was accepted as a complete and accurate record of the meeting.

The Committee Noted the content of the Minute of the meeting on 7 March 2012.

5. MATTERS ARISING

No matters arising

6. HIGHLAND NHS ORGANISATIONAL ISSUES

6.1a Minute of Highland NHS Board Meeting – 21 March 2012

The minute of Highland NHS Board Meeting 21 March 2012 had been previously distributed and the contents were noted.

The Committee Noted the contents of the draft minute of Highland NHS Board – 21 March 2012.

6.1b Draft Minute of Highland NHS Board Meeting – 3 April 2012

The draft minute of Highland NHS Board Meeting of 3 April 2012 was tabled at the meeting and the contents were noted.

The Committee Noted the contents of the draft minute of Highland NHS Board – 3 April 2012.

7. CLINICAL GOVERNANCE

7.1 Clinical Governance & Risk Management Report

Ms Tyrrell spoke to the previously circulated papers and highlighted a number of areas from the report.

RISK MANAGEMENT

Incidents Ms Tyrrell reported that during Quarter 4 the top three categories of incidents remain as:  Slips trips and falls  Tissue Viability  Disruptive, violent and aggressive behaviour Ms Tyrrell confirmed that two incidents in Quarter 4 were reported to the Health and Safety Executive (HSE) under Reporting of Injuries, Diseases and Dangerous Occurrences (RIDDOR).

2 Pressure Ulcers: Ms Tyrrell advised that three wards in Argyll and Bute CHP hospitals are participating in focussed work which is part of the Zero Tolerance campaign to reduce preventable pressure ulcers across NHS Highland.

Complaints: Ms Tyrrell confirmed that 5 complaints were received by the CHP in February 2012 with 40% compliance within the 20 days response target. She also confirmed that Scottish Public Services Ombudsman Complaints Investigation training was delivered to 16 CHP Senior Managers at the end of March and this will be rolled out to team leaders across the CHP.

QUALITY

External Reviews:

Ms Tyrrell reported that a Health Improvement Scotland (HIS) Pre-Joint Advisory Group (JAG) Assessment Visit took place at Cowal Hospital in February 2012 and an assessment of endoscopy services was carried out. Ms Tyrrell confirmed that the report on the visit has been published and the assessment team considered the endoscopy service to have the following major strengths:

 a robust operational policy  spacious unit  commendable enthusiasm and flexibility of staff, and  motivated staff who are engaged with the GRS and JAG processes

The following recommendations were made:  Implement the GIN competencies for all staff.  Include patient feedback in training to develop staff awareness.  Provide evidence of an equality and diversity policy.  Undertake COSHH risk assessments and store the assessments within the decontamination area for easy access.  Provide evidence of staff exit interviews.  Gather annual feedback from staff on the quality of their work environment.

Audit

The draft audit report on the Admission, Transfer and Discharge Policy has been circulated to the CHP Management Team and actions are being taken forward. A report on this Policy will be brought to the next CHP Committee meeting.

Catering and Nutritional Services Specification Compliance

Ms Tyrrell reported on the results of the December 2011 audit and confirmed a multidisciplinary team from the CHP Food, Fluid and Nutritional Care Group has commenced a programme of visits to all sites to review progress and support local actions. Visits will also incorporate mealtime observational audits to monitor mealtime standards and patient experience.

Clinical Quality Indicators

Implementation of the national Clinical Quality Indicators continues across Argyll and Bute CHP. Each month wards audit a number of case records against the prescribed standards and report their findings as percentage compliance. Local managers are addressing any gaps in data reporting. Ms Garman referred to the nutritional information showing amber in the audit report on Islay Hospital and asked if there is dietician input into meals supplied on Islay. Ms Tyrrell 3 confirmed that work is continuing to improve this service with the team on Islay and although there is no dietician available on the island they do have dietetics input from the Mid Argyll, Kintyre & Islay Team.

The Committee Noted the contents of the Clinical Governance and Risk Management Report.

7.2 Cleanliness, Hygiene and Infection Control Report

Ms Tyrrell spoke to the previously circulated paper and highlighted a number of areas from the report.

Staphylococcus aureus bacteraemia including MRSA: Ms Tyrrell reported that there have been no cases of Staphylococcus Aureus Bacteraemia in Argyll and Bute CHP in 2012.

National Context

Ms Tyrrell reported that in the last year, January 2011 to December 2011, 1609 episodes of Staphylococcus Aureus Bacteraemia were reported to Health Protection Scotland which represents a decrease of 12.3% on the previous year when 1835 episodes were reported. NHS Highland reported the lowest rates of Staphylococcus Aureus Bacteraemia for all mainland health boards with only Shetland being lower.

Clostridium difficile Infection (CDI) Ms Tyrrell advised that from April 2011, all Boards are expected to achieve a rate of 0.39 cases of Clostridium difficile per 1000 total occupied bed days (OCBDs) or lower among patients aged 65 and over by year ending March 2013. For NHS Highland that means no more than 86 cases and are on course to meet this target.

Ms Tyrrell confirmed that figures for hospitals in Argyll & Bute show seven reported cases in 2011/12.

National Context

Ms Tyrrell confirmed that in this quarter (Q4 2011), 344 new cases of CDI were identified inpatients aged ≥65, which corresponds to an overall incidence rate for Scotland of 0.28 cases per 1000 total occupied bed days. In comparison with the previous quarter, the overall incidence rate has decreased by 12%.

Hand Hygiene Compliance with hand hygiene in NHS Highland was 97% in January and February 2012. Local managers are addressing ward areas where audit results are not being submitted on a routine basis. In addition further consideration will be given at the next Infection Control meeting to developing more innovative ways of varying the approach to audit to maintain the high profile of good hand hygiene in delivery of safe patient care.

Cleaning and the Healthcare Environment Compliance with cleaning across NHS Highland was 94% in January and February 2012. Compliance with estates monitoring across NHS Highland was 94% in January and 96% in February 2012.

Outbreaks/Incidents Ms Tyrrell confirmed that there have been no outbreaks of infection in Argyll and Bute since the last report.

4 Healthcare Environment Inspectorate (HEI) Ms Tyrrell confirmed that an announced inspection by the HEI took place in Lorn and Islands Hospital, Oban on 18 April 2012 and reported that the verbal feed back received had been very positive with only a number of smaller issues being highlighted. The final written report should be received by the end of May.

Mr Brackenridge thanked Ms Tyrrell for her report and highlighted the positive feedback from the inspection. Mr Leslie emphasised that this high standard of work is now carried out routinely by staff in the hospital following the previous HEI inspection.

The Committee:

 Noted the contents of the Cleanliness, Hygiene and Infection Control Report.

7.3 Health Improvement

Ms Garman spoke to the previously circulated paper which focused on three areas of health improvement: sexual health, blood borne viruses and breast feeding. Breast feeding has a 36% HEAT target where performance is under scrutiny.

Breast Feeding Ms Garman reported that rates of exclusive breastfeeding across Argyll & Bute CHP area appears to be currently static at around 32% but pointed out that this has increased from the 2006/7 levels of 28%.

Ms Garman advised that Argyll & Bute CHP received UNICEF Stage Two accreditation in 2011 and confirmed that the UNICEF Stage Three assessment will take place during 23 and 24 May 2012.

Training programmes for all professionals and peer support groups are being established in all areas and work is being carried out to increase rates of mothers exclusively breastfeeding to meet the 36% HEAT target.

Sexual Health Ms Garman advised that the rates of unintended pregnancies across the CHP are low although there are health inequalities apparent in some areas. The CHP have now agreed across the Community Planning Partnership to manage performance of SHARE (Sexual Health and Relationship Education) delivery in schools which will help to prepare young people to deal with pressures in this area of life. The CHP are also working on a contract for GPs to provide more specialised sexual and reproductive health care services.

Blood Borne Viruses The CHP are currently awaiting confirmation of the three year allocation from Scottish Government and once this has been received the CHP will make decisions from the priorities below:

 Healthcare support worker for harm reduction in addictions services This would re-establish the service that had been operating prior to the resignation of the member of staff in 2011.

 Specialist nurse for blood borne viruses One of the problems identified is the lack of support for patients receiving most of their treatment in Glasgow. A specialist nurse operating in Argyll and Bute would provide professional expertise and support people on drug regimes.

5  Peer support service In addition to the need for professional support and expertise it is also thought to be beneficial to have peer supporters available to provide encouragement and understanding from a fellow patient’s perspective.

 Drug costs The potential number of patients for the new drugs for 2012/13 is 4 in A&B CHP at a cost of approx £90,000. The estimate cost of a course is about £22,500.

 Harm reduction services Existing needle exchanges in Dunoon, Rothesay and Campbeltown have seen increased activity and this requires to be funded. New clinics in Lochgilphead, Oban and Helensburgh would enable the CHP to provide equity of access across the area.

Mr Brackenridge thanked Ms Garman for her report.

The Committee Noted the contents of the Health Improvement Report.

8. FINANCIAL GOVERNANCE

8.1 Finance Report

Mr Morrison spoke to a previously circulated paper and was happy to report that the year 2011/2012 concluded with a small underspend of £43,000 being recorded against the annual revenue budget of £175.4m. Mr Morrison confirmed that this was an excellent result and that this successful outcome was due to the efforts of managers and staff across the CHP.

Mr Morrison gave a summary of budgetary performance across the CHP in 2011/12 and reported that there were notable areas of overspend in commissioned services and also within three localities due to medical locums, nurse staffing costs and also underachieved savings targets.

Mr Morrison reported that action has, and is, being taken to address all of the issues however confirmed that medical locum costs in these localities are likely to be an ongoing problem due to the nature of medical service provision in a remote and rural area.

The overspend on commissioned services was due to a small number of high cost patients requiring treatment for specific conditions e.g. eating disorders. This is a fluctuating area of expenditure with an ongoing risk that requires careful management.

Mr Morrison reported that a number of budget underspends were achieved which compensated for the overspends, thereby enabling the CHP to achieve a modest year-end net underspend of £43,000. The main areas of budget underspend were in:

 mental health services  prescribing  NHS Greater Glasgow & Clyde patients services SLA (favourable in-year settlement)

Mr Morrison confirmed that through careful stewardship, the CHP’s financial position was managed towards another successful year-end conclusion. He also confirmed that this will be the sixth consecutive year that the CHP has achieved its financial target.

6 CAPITAL PROGRAMME PROGRESS REPORT

Mr Morrison reported that limited capital funding was available in 2011/12. In addition to some minor equipment purchases, only the following four major schemes were progressed in 2011/12.

 Mull & Iona PCC  Fluoroscopy unit, Lorn & Islands Hospital  Upgrading works at Islay Hospital  Oban Dental Access Centre

REVENUE BUDGET

Mr Morrison reported that the revenue budget proposal for Argyll & Bute CHP was approved by the CHP Core Management Team on 24 February 2012 and confirmed by the CHP Committee on 7 March 2012.

The main headlines from the approved budget are;

i) Funding uplift = 1.2% (£1.7m)

ii) Forecast expenditure growth = 4.1% (£5.9m)

iii) In addition to inflationary increases, forecast expenditure growth includes provision for; - increased patient activity in GG&C hospitals - an increase in pharmacy homecare services provided by GG&C - renal dialysis patients receiving services in Fort William - bridging funding to support the redesign of mental health services - increased “Change Fund” expenditure on older peoples services - HEI compliance works in hospitals throughout Argyll & Bute - additional running costs relating to the new Mull PCC

Mr Morrison confirmed that to achieve a balanced budget for 2012/13, it will be necessary to implement a £5m cost improvement programme which will address the in-year funding shortfall of £4.2m and the brought forward recurring deficit of £0.8m. A range of services will be reviewed with a lead officer being assigned to review each service to ascertain how cost savings can be achieved.

Mr Morrison confirmed that the cost improvement programme will be a major challenge for the CHP in 2012/13 and progress towards its achievement will be monitored and reported on a regular basis.

Mr Leslie recorded his thanks to Mr Morrison and the Management Team for the stewardship of their budgets and gave his appreciation and thanks to all staff in the CHP for their support in achieving what has been a very challenging task.

The Committee Noted the contents of the Finance Report.

9. STAFF GOVERNANCE

9.1 Argyll & Bute CHP Partnership Forum Minute - 1 March 2012

The minute of the Argyll & Bute CHP Partnership Forum was previously circulated and the contents noted.

7 The Committee Noted the contents of the Argyll & Bute CHP Partnership Forum Draft Minute of 1 March 2012.

9.2 PDP/R and eKSF Implementation

Mr Logue spoke to the previously distributed papers and confirmed that in March 2011 the Board of NHS Highland set a target that 80% of all staff, including fixed term and bank, on Agenda for Change terms and conditions should have a KSF Development Review and Personal Development Plan completed and recorded on e-KSF by the 31st March 2012. Mr Logue reported that within Argyll & Bute CHP 65.9% of all staff covered by Agenda for Change had a KSF Development Review completed and recorded on e-KSF which fell short of the target of 80%. The total percentage for NHS Highland was 65.61%.

Mr Logue highlighted the challenges faced regarding the inclusion of the significant numbers of bank staff, many of whom with multiple contracts, and confirmed work is continuing with the e-KSF team and managers into this year to ensure that bank staff are engaged with and participate in the review process.

Mr Logue also confirmed the number of reviews undertaken for permanent staff reached a higher percentage of 87.7% this year compared to 83.38% last year. He also advised that 90% of all staff now have a KSF outline specifically allocated to their post.

Actions for 2012/13

Mr Logue advised that the NHS Highland target for 2012//13 has still to be finalised but is likely to include a target of all staff to have KSF Development Review and a target for levels of PDP activity recorded as complete in e-KSF. In order to build on the extensive work done within the CHP in 2011/12 and to ensure a continuing increase in activity with Reviews and PDPs on eKSF actions are proposed as follows:

1. Continue with the current work with bank staff to ensure that all staff know their appropriate reviewing manager, have their KSF post outline, eKSF login and training within the first six months of this year.

2. Set a target within the CHP of achieving 80% of all staff again this year by March 2013. (to be reviewed in the light of an NHS Highland target and trajectory being set).

3. Set a clear trajectory which sets clear monthly targets and evens out the Review and PDP activity month by month across the year (Appendix 2a).

4. Ensure that all managers who are reviewers have clear targets set in their own Review and PDPs to carry out the reviews of their own direct reports.

Development Benefits of KSF

As the KSDF/eKSF has become more used and staff become familiar with the systems, many managers are reporting that they can now appreciate the value and benefits of having a mechanism to promote regular interaction and discussions on performance and development between managers and staff.

Mr Creelman advised that he would like to see where CHP figures stand in May and June of this year and suggested that a month-by-month trajectory report be produced.

8 Mr Brackenridge advised that both Argyll & Bute CHP and NHS Highland failed to meet this target despite Mr Leslie being given assurances by Managers that the CHP would meet this. He also stressed that procedures must be put in place to ensure targets are met in future.

Mr Leslie also confirmed that he was disappointed that the CHP failed to meet the 80% target and that the complexities in dealing with bank staff had not been picked up earlier. He highlighted the importance of having more robust systems in place to ensure the delivery of targets for 2012/2013.

The Committee

 Noted that 65.09% of all staff covered by Agenda for Change had a KSF Development Review completed and recorded on e-KSF.  Noted that this fell short of the target of 80% and demonstrated that considerable work remains outstanding in relation to including staff who are on employee “bank”, in the PDP/KSF process  Approved the proposed actions to address this shortfall and engage with bank staff in relation to KSF  Approved the proposed trajectory for 2012/13  Noted that 87.7% of permanent staff had a review completed and recorded on e-KSF. This is a significant improvement on last year’s figure of 83%

10 PARTNERSHIP WORKING

10.1 Argyll & Bute Public Partnership Forum Draft Notes 28 February 2012

Mr Duncan spoke briefly to the draft notes of the meeting on 28 February which had been previously distributed.

Mr Brackenridge intimated his concerns regarding Helensburgh PPF and asked that a meeting be organised to address the apparent lack of support.

Mr Leslie confirmed that this crucial meeting with Helensburgh PPF representatives will be organised by the CHP and suggested that representation from the Lomond Patient Group also be invited to the meeting.

The Committee Noted the contents of the Argyll & Bute Public Partnership Forum Draft Notes of 28 February 2012.

11. PERFORMANCE MANAGEMENT

11.1 Delayed Discharge/Joint Performance Report

Mr Leslie spoke to the previously circulated report which detailed the CHP’s continuing performance against the Scottish Government target and confirmed that as at 15 March 2012 there were 0 delayed discharge breaches against the target of 0 over 6 weeks and 0 for short stays, which do not have an exception code. He confirmed this strong performance is testimony to good joint working between the CHP, Council and Voluntary and Independent Sector.

Ms Tyrrell confirmed that Scottish Government targets will be brought down to four weeks in 2013/14 and a report will be going to the next Strategic Partnership meeting regarding this.

9 The Committee Noted the contents of the Delayed Discharge Report.

11.2 Local Delivery Plan 2012/2013

Mr Whiston confirmed that the Local Delivery Plan (LDP) 2012/13 was approved by NHS Highland Board on 3 April 2012.

Mr Whiston gave a summary of the plan, asked the Committee to note the revised format of this plan and highlighted the following sections.

The Quality Ambitions and wider outcomes-based approach

Mr Whiston advised that this section reiterates NHS Highland Strategic Framework to provide patient-centered services tailored to people’s needs in a systematic and consistent way and to provide quality care to every person every day.

NHS Boards contributions to Single Outcome Agreements

Mr Whiston confirmed that within the LDP Argyll & Bute CHP has identified “Looked After and Accommodated Children” as the critical issue it wishes to focus on with the purpose of improving the outcomes of this patient group.

LDP Heat Risk Management Plans

Identifies the risks associated with each of the 20 HEAT targets and addresses the risk in the key areas of Delivery & Improvement, Workforce, Finance, Improvement and Equalities.

LDP Heat Targets and Delivery Trajectories

Mr Whiston highlighted a number of the Heat Targets and the planned trajectories of performance to deliver the target by the agreed deadline detailed in the report:

 To increase the proportion of people diagnosed and treated in the first stage of breast, colorectal and lung caner by 25%, by 2014/15

 Reduce suicide rate between 2002 and 2013 by 20%

 NHSScotland to deliver universal smoking cessation services to achieve at least 80,000 successful quits (at one month post quit) including 48,000 in the 40% most-deprived within-Board SIMD areas over the three years ending March 2014

 At least 60% of 3 and 4 year old children in each SIMD quintile to receive at least two applications of fluoride varnish (FV) per year by March 2014

 No people will wait more than 28 days to be discharged from hospital into a more appropriate care setting, once treatment is complete from April 2013, followed by a 14 day maximum wait from April 2015

 Further reduce healthcare associated infections so that by 2012/13 NHS Boards’ staphylococcus aureus bacteriamia (including MRSA) cases are 0.26 or less per 1,000 acute occupied bed days; and the rate of Clostridium difficile infections in patients aged 65 and over is 0.39 cases or less per 1,000 total occupied bed days

 To support shifting the balance of care from Acute hospitals into Community Care.

10 LDP Financial Plans and Efficiency Savings

Mr Whiston confirmed that this section contains the detailed Financial Plan, including recurring and non recurring Revenue, Capital and Efficiency savings.

Summary of Main Workforce Issues Facing the NHS Board Mr Whiston highlighted the following key initiatives on workforce challenges for NHS Highland.

 Planning for Integration: integrated health and social care service delivery  Whole System Capacity and Patient Flow  Care Pathways  Surgical Services Redesign  Review of Corporate Services  Administration Review

Quality, Efficiency and Service Improvement Mr Whiston advised that there are a range of quality improvement and service improvement programmes and projects currently in place throughout NHS Highland such as Scottish Patient Safety Programme, Releasing Time to Care, and Leading Better Care which are fundamental to reducing harm, variation and waste and achieving safe and efficient care and practice across the workforce.

Workforce Efficiency and Productivity Mr Whiston advised that the workforce accounts for approximately 70% of Board expenditure and it is vital that the workforce is deployed appropriately and are as efficient and productive as possible

A workforce efficiency plan is currently under development for 2012/13 adopting the following approaches:

 Reduce whole time equivalent  Reduce Workforce Costs and Increase Workforce Productivity  Change the Skill Mix.

Mr Leslie confirmed that this is an important document which highlights the challenges facing the CHP

The Committee:

 Noted that LDP 2012/13 was approved by NHS Highland Board on the 3rd April 2012.  Noted The revised format of the LDP and the key HEAT and SOA targets.

12. MENTAL HEALTH SERVICES ARGYLL & BUTE 2012: EVERYONE’S BUSINESS

12.1 Update Report

Mr Leslie spoke to the previously circulated paper prepared by John Dreghorn, Project Director and confirmed that there had been no further progress on appointing external advisors. He also reported that Donna MacKay, who is currently the Capital Projects Director at Raigmore Hospital, has joined the project team as Capital Project Director. The appointment of a project manager will be considered once the project management requirements have been reviewed.

11 Inpatient Services Ms Leslie advised that there have been no changes in the profile of inpatient services since the last report. The redeployment of inpatient nursing staff is progressing and this process should be completed during April.

New Posts Mr Leslie also gave an update on the appointment of new posts

 Guided Self Help Workers being appointed through the staff redeployment process.  The next new clinical psychology post will be the Older Adult/Neuropsychologist. This post will work across adult mental health and older adult/dementia service.  CBT Practitioners - the MAKI post has been short listed and interviews will take place in April.  Primary Mental Health Workers being appointed to through the staff redeployment process

Finance Mr Leslie advised that the project budget for 2012/13 has now been confirmed The 2012/13 Cost Improvement Plan requirement has been revised and now stands at £580k which will be achieved mainly through the closure of Tigh na Linne later this year.

Resettlement Group The working group continues to make progress in resettling patients into community and specialist placements. NHS Highland’s Asset Management Group has approved the proposal to lease a 4 bed bungalow in Lochgilphead to accommodate 3 patients as an initial step towards longer term independent living. Argyll & Bute Council’s commissioning team have developed a tender for the care package to support these patients.

Mr Leslie advised that a small number of patients with highly complex needs will continue to require specialist inpatient care, which will be beyond the scope of the new inpatient unit. Suitable alternative placements are being identified and costed for these patients.

Mr Leslie confirmed that an outline business case for the project will be produced and will be brought to the Committee in due course.

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

13 AOCB

No other competent business highlighted.

14 DATE, TIME & VENUE FOR NEXT MEETING

Wednesday 27 June 2012 at 1pm, Rooms JO3-7, Mid Argyll Community Hospital and Integrated Care Centre, Lochgilphead.

12 Highland NHS Board 5 June 2012 Item 3.2 Mid Highland Community Health Partnership CHP General Manager’s Office Larachan House Docharty Road DRAFT Dingwall IV15 9UG Telephone: 01349 869221 Fax: 01349 865870 www.nhshighland.scot.nhs.uk

MINUTE of MEETING MID HIGHLAND CHP Friday 20 April 2012 GOVERNANCE COMMITTEE (11.30 am – 1.00 pm) Glenmoriston Millennium Hall Invermoriston

Present: Mr Okain McLennan (Chair) Non Executive Director, Highland NHS Board Mrs Gill McVicar CHP General Manager Mr Tom Slavin CHP Head of Finance Mr Findlay Hickey CHP Lead Pharmacist Mr Colin Shields CHP Health & Safety Manager Mrs Margaret Moss CHP Lead, Allied Health Professions (from 11.45 am) Mrs Tracy Ligema Locality General Manager Lochaber/Out of Hours and Unscheduled Care Development Manager Mrs Alison Hudson CHP Lead Nurse Ms Margaret Ryan CHP Personnel Manager (from 11.45 am) Mr Bren Gormley Local Councillor, Fort William & Ardnamurchan Mr Hamish Fraser Local Councillor, Skye (from 11.45 am) Ms Mandy Sillars Area Partnership Forum Representative

Apologies: Dr Paul Davidson CHP Clinical Director Ms Lyn Wormald Area Partnership Forum Representative Mr Gavin Hogg Patient/Public Representative Mr Rod Richard Area Social Work Manager Mr James Higgins Community Pharmacy Representative Mr Brian Murphy Local Councillor, Lochaber Mrs Margaret Paterson Local Councillor, Dingwall & Seaforth Mr Michael Macmillan Patient/Public Representative Mrs Annie MacLeod Patient/Public Representative Ms Sarah Wedgwood Non Executive Member Highland NHS Board

1 WELCOME AND APOLOGIES

The Chairman welcomed those present to the final meeting of the Mid Highland CHP Governance Committee. Apologies were noted as above. The Chairman also noted that, due to a serious road traffic accident, the meeting had started late and that some members had had to turn back. Attendance was therefore less than anticipated. 2 DECLARATIONS OF INTEREST

It was noted that Local Councillors are in a re-election period.

3 MINUTES

3.1 CHP Governance Committee Meeting – 24 February 2012 The minutes were approved as an accurate record of the meeting.

3.2 CHP Health & Safety and Clinical Governance Meeting – 7 March 2012 The minutes were noted.

3.3 NHS Highland Improvement Committee Assurance Report – 5 March 2012 The contents of the report were noted.

Governance Committee:

. Approved the minutes of the CHP Governance Committee meeting dated 24 February 2012. . Noted the contents of the report from the Mid Highland CHP Health & Safety and Clinical Governance Meeting on 7 March 2012. . Noted the NHS Highland Improvement Committee Assurance Report dated 5 March 2012.

4 MATTERS ARISING

4.1 West Ardnamurchan Unscheduled Care The emergency responder scheme took off rapidly with the recruitment of a qualified ambulance technician living locally and a further three members of the public with healthcare qualifications. With the addition of the new nurse who has moved into the area, a workable rota was achieved. The Scottish Ambulance Service (SAS) recognised the possibility of having a retained ambulance scheme and advertisements for retained personnel brought forth a good response. Interviews have not yet taken place. On a further positive note, some members of the community are expressing the view that the First Responder scheme or Community Response through Fire and Rescue could be viable as part of a wider solution.

There are however concerns in the community about the Nursing service. The nurse who had intended living in West Ardnamurchan had been unable to find suitable accommodation and would be living in Shielfoot, Acharacle for the time being. This had caused upset in the community, although she will stay locally when on call. The Nursing team is doing a very good job despite staffing shortages and a nurse is present in the area every day. Some members of the public are concerned that nurses are not available at the base as they were in the past but due to busy caseloads elsewhere they are not able to remain at the base without work to do. The current workload in West Ardnamurchan is very small. They are running two Practice Nurse clinics per week on behalf of the Acharacle Practice and are carrying out all local visits as assessed and planned. Patients can contact them through the normal numbers so that any other nursing needs can be assessed and dealt with. Additional information on how to access services has been prepared in credit card and leaflet sizes and these will be distributed soon.

The nurses have been experiencing some antagonism and negativity and have been the subject of adverse media attention which is deeply regrettable and worrying. They are being supported by local and CHP management. Councillor Gormley expressed his disappointment that nurses were being treated in this way. He had been discussing the matter locally and urging the community to give the new system a chance to bed in and to continue to work with NHS Highland on safe and sustainable services. He was pleased that the Emergency Responder model appeared to be working well.

2 4.2 Glenelg & Arnisdale A paper was circulated prior to the meeting. Concerns in the local community are around three issues: in-hours provision of primary care services, out of hours provision of primary care services and emergency and immediate care response. The latter is the responsibility of Scottish Ambulance and the NHSH Chief Executive has indicated that further discussion is required with them. A national group is looking at standards for Out of Hours services which will inform any future service design. The results are not expected for some time however and in the meantime the CHP is exploring the sustainability of the in-hours service and the practice, which is isolated and has only one permanent doctor at the moment. Locums are providing support.

4.3 Critical Incident Review – MacKinnon Memorial Hospital (MMH) Action Plan The quality of both the investigation and follow-up were commended by the General Medical Council (GMC) and the Scottish Public Services Ombudsman (SPSO) and a very robust action plan was developed. The retrospective case note audit of 40 MMH patients has been completed by two consultant physicians from Raigmore and a Specialist Nurse. The report has been discussed with all Rural Practitioners and they are satisfied that they have the necessary access to consultants when it is needed. However a new Rural Physician type post is being developed which would link between Belford, Raigmore and Skye hospitals and there will be a monthly presence for clinics and ward rounds by a consultant physician. It is vital that appropriate clinical governance is in place for MMH which, although it provides some acute services in a very rural setting, it is not a Rural General Hospital. Surgeons from Belford Hospital visit MMH on a very regular basis but previously there was no acute physician input to the wards and this is now being addressed. The final action plan is about to be submitted to the SPSO.

4.4 Scottish National Paediatric Retrieval Service Cllr Gormley referred to Item 2.3 of the Mid Highland CHP Health & Safety and Clinical Governance Group notes and indicated that there was still concern around the Scottish National Paediatric Retrieval Service. Mrs McVicar confirmed that a robust review of retrieval incidents is being undertaken; NHS Highland (at Medical Director level) and SAS remain very concerned about response times for the retrieval service. The Lochaber local manager is taking forward recommendations internally at Belford Hospital.

4.5 MacKinnon Memorial Hospital Upgrade Works A paper was circulated prior to the meeting.

The first phase of the upgrade works has been completed but there are number of snags. Some of these are thought to have arisen because of the speed at which the contractors were working to complete on time and involve drains, showers and basins.

Mrs Moss, Ms Ryan and Cllr Fraser joined the meeting.

Mrs McVicar noted that problems with water ingress at the front entrance to the hospital are at last being resolved. The Estates Department have indicated that the door was originally installed in the wrong position and contractors have now been asked to rectify the problem as soon as possible.

There have been problems with boilers at Lochalsh Health Centre since it opened. The fault has now been identified and is to be repaired without delay.

4.6 Fyrish Ward Update A paper was circulated prior to the meeting. The Older Adult Mental Health Plan, which highlights some good progress on implementation of Dementia Standards and will provide an opportunity to make decisions around Fyrish, should go to the Board in June. Mrs McVicar formally handed this over to the new South & Mid Operational Unit at the final CHP Management Team meeting earlier that week.

3 Governance Committee:

. Noted the position with regard to the above issues. . Noted that all matters relating to Fyrish Ward have now been formally handed over to the new South & Mid Operational Unit.

5 NHS HIGHLAND BOARD UPDATE

The Chairman highlighted key issues from the NHSH Board Meeting on 2 April 2012:

 A copy of the North of Scotland Planning Group annual report was received. Mr McLennan highlighted remote and rural issues and the Older People in Acute Care Dementia Standards workplan.

 The financial position as at 31st January showed a continued forecast for break-even. February’s report also showed break-even for NHS Highland as a whole. This was despite a £4.7m overspend in Raigmore.

 The NHS Highland Local Delivery Plan 2012-13 was ratified. The document is available on the NHS Highland website.

 The NHS Highland Capital Plan 2012-13 – this is also available on the website.

Governance Committee:

. Noted the Chairman’s verbal update.

6 GENERAL MANAGER’S REPORT

This was circulated prior to the meeting and the following items were highlighted.

Finance The CHP showed a £61k underspend for the financial year ended 31st March 2012. Mrs McVicar congratulated staff and managers on this achievement during challenging times. eKSF A considerable improvement was noted but the CHP did not meet its target due to the inclusion of bank staff. Had these not been included the target would have been exceeded. Mrs McVicar thanked everyone for their hard work, particularly Ms Ryan, Personnel Manager.

Belford Redesign It was agreed almost two years ago that Belhaven Ward had reduced occupancy due to new ways of working and shifting the balance of care. Fewer beds were required and in its current form was unsustainable due to its isolation. The inpatient beds were moved to Belford some 18 months ago and redesign work is ongoing to relocate Physiotherapy and Occupational Therapy to hospital and community facilities. Further concerns have recently been raised in the community around inpatient beds and a meeting was held with community representatives to listen to and better understand their concerns. Cllr Gormley outlined some of these and there was a discussion around ways to

4 develop and strengthen community services. The need to keep the public consistently informed was acknowledged and a further meeting is to be arranged.

Broadford Health Centre Cllr Fraser indicated that there have been some discussions locally about who will formally open the new health centre. Mrs McVicar advised that while she was aware of the discussions she had not been involved in them. The community appeared to be split on the issue of who should undertake the opening and Committee agreed that the occasion should be marked in some way. Mrs McVicar confirmed that she will take this matter outwith the meeting and make some further enquiries regarding the discussions.

Governance Committee:

. Noted the contents of the CHP General Manager’s Report.

PERFORMANCE MANAGEMENT

7 BALANCED SCORECARD

This document was circulated prior to the meeting and the contents were noted.

7.1 Waiting Times Report The Waiting Times Report for Belford Hospital was circulated prior to the meeting. The hospital met all its targets for the month of March and statistics for Could Not Attend, Did Not Attend and Cancellations are being scrutinised with a view to improving current percentages.

7.2 Standardised Morbidity Ratio (SMR) Return Rate The SMR Return Rate Report was circulated prior to the meeting. There were some excellent performances with some units improved to 100%. However absence in other areas means that their results have deteriorated sharply and brought the overall position down. Managers must be more vigilant in these circumstances and ensure that recording is maintained in times of staff shortages.

7.3 New Outpatient Department Appointment Did Not Attend (DNA) Rates The DNA report was circulated prior to the meeting. Mid Highland CHP continues to exceed the target.

7.4 New to Review Outpatient Department Attendance The report was circulated prior to the meeting. The CHP is exceeding its target.

Governance Committee:

. Noted the contents of the Performance Management reports.

8 RISK MANAGEMENT

8.1 Health and Safety Report The report was circulated prior to the meeting. Mr Shields highlighted the following:

5 Driving in Adverse Weather Conditions Following previous harsh winters it became clear that staff driving as part of their duties should be given further support. There were calls for the provision of “winter” tyres for staff there is no clear evidence that such tyres make driving safer in themselves. A vital component of risk reduction in this area is to ensure that staff are given the knowledge and where possible the skills to drive in adverse weather. With this in mind a series of “Driving in Adverse Weather Conditions” courses were arranged in the CHP. Two courses have now been held at Fort William and Invergordon and these were a great success. A further session is planned in Portree on 11th May.

Emergency Planning Exercises Two exercises were planned for April and May. The first, an NHS Highland desktop exercise relating to an accident in the East Ross area, took place earlier this week. May’s event will be a multi-agency live exercise on Skye involving a road traffic accident in a remote area of the island. Other agencies involved will be Northern Constabulary, Scottish Ambulance Service, Red Cross, Highlands and Islands Fire and Rescue Service, Coastguard, Mountain Rescue, Emergency Medical Retrieval Services and Highland Council.

8.2 Health & Safety Workplan 2012-13 The workplan for the new operational unit was circulated. This was developed to ensure that business carries on with the least disruption to continuity.

8.3 Slips, Trips & Falls Analysis, February 2012 The report was circulated.

9 CLINICAL GOVERNANCE

9.1 Lead Pharmacist’s Report

The report was circulated prior to the meeting. Mr Hickey noted that the financial position in prescribing was improving as the year progressed. He anticipates that the CHP will finish approximately £100k over the total prescribing allocation. In the current climate this represents a significant achievement. A small but welcome bonus came in the form of the addition of two generic medicines to the Scottish Drug Tariff. Coupled with a reduction in the cost of prednisolone, this has been worth about £18,700 to the CHP.

As part of the Scottish Quality Prescribing Initiative GP practices will be asked to look at two areas of prescribing in addition to the other elements using a series of national therapeutic indicators. This relates to volume of prescribing, for example in antibacterial prescribing where there is a wide range in volumes of prescribing. The aim is to reduce variation and shift the average prescription level in favour of better practice.

9.2 Mid Highland Complaints Report February’s report was circulated prior to the meeting. The CHP is not meeting the target for responding to complaints and delays are sometimes caused by difficulties in contacting the relevant clinicians or where more than one clinician is involved. Mrs McVicar noted however that the overall quality of responses is much improved.

9.3 Control of Infection and Hand Hygiene The Control of Infection Report was circulated prior to the meeting. For the reporting period 2011/12 there have been five cases of Staphylococcus Aureus Bacteraemia (SAB) infections since April 2011, three on Skye and two in Belford Hospital.

There were five hospital cases of Clostridium difficile infection (CDI) during the period 2011/12 (down from 18 in 2009/10) and six community cases (down from 16 in 2009/10).

6 With regard to hand hygiene the CHP continues to exceed the national objective to achieve a minimum of 95% compliance.

Mrs McVicar thanked Mrs Hudson for her leadership and commended the work of Jo Watt who, until recently, held the post of Infection Control Nurse in Mid CHP. She also recognised the work of the Pharmacy Team in helping to bring about changes in prescribing and adherence to the antimicrobial prescribing guidelines. The Chairman also commended the significant improvement in infection control issues over the past year. Estates were also commended for their support with environmental improvements.

9.4 Scottish Patient Safety Programme (SPSP) Belford Hospital The report was circulated prior to the meeting and Mrs Ligema highlighted areas of concern. Recently the Clinical Services Manager has found it increasingly difficult to get dates in diaries for leadership walk-rounds. There are also challenges around the Failure Mode and Effects Analysis (FMEA) as a lead has not yet been established; the issue has been escalated. The work on SPSP and ownership by clinicians is otherwise positive.

9.5 Lead Nurse Report The report was circulated prior to the meeting. Mrs Hudson highlighted the Care of the Elderly Standards (OPAC Standards). Health Improvement Scotland are to carry out a programme of inspections to look at the care of older people in acute care; this will include the issues that matter most to patients, namely privacy, dignity, compassion and respect. Alzheimer Scotland is funding the appointment of an NHS Highland-wide Nurse Consultant, Dementia, Mental Health and Learning Disability which is to be advertised soon. The post holder will provide professional nursing leadership, strategic direction and expert consultancy on all aspects of clinical nursing practice and care of people with dementia across the patient pathway in NHS Highland, with a specific remit to develop practice and services in the Acute Care and Community Hospitals in NHS Highland. This will involve working across professional and organisational boundaries, in partnership and collaboration with others including service users, carers, health professionals, social work, voluntary sector staff and local education providers.

The National Dementia Champions Programme for 2012/13 is intended to enable NHS Boards advance planning for full engagement in this initiative. Nominations are also sought from people who will be in a position to champion good practice from across the Health and Social Care Partnership.

Mrs McVicar noted that the although the standards are initially aimed at acute hospitals, the Mid Highland CHP considered these to be so important that it will be rolling them out to all of its care establishments. This will be progressed by the new Operational Units.

10 STAFF GOVERNANCE

10.1 HR Report The report was circulated prior to the meeting. Ms Ryan noted that overall the sickness levels for both short and long term absence has shown a month on month decrease since reaching a peak in December. Short term absence for Mid Highland CHP for February was reported at 1.55%, compared to the overall NHSH short term sickness level of 1.9%. Although long term sickness levels fell by 0.95% between January and February (from 4.27% to 3.32%) this is still significantly higher than the NHSH figure of 2.62%. Ms Ryan undertook to explore the reasons for absence in more detail and has concluded that the responsibility and processes for reporting absence vary widely across the CHP and that there are flaws in the reporting system. This issue will be taken to the NHSH Personnel Forum in the first instance to see if a central solution can be identified.

An immense amount of work has been undertaken around eKSF (electronic Knowledge and Skills Framework). The CHP’s target last year was 80% of staff, excluding bank staff. If the target had remained the same for this year, the CHP would have achieved 93%. However the inclusion of

7 bank staff in this year’s target resulted in the actual level achieved being 64.55%. Ms Ryan noted that although the aspiration to have an eKSF for every member of bank staff was commendable there were significant challenges to this. All managers are aware that the work is required to start now for next year and the suggestion that reviews are carried out during birthday months is being supported.

10.2 Mid CHP Monthly Workforce Reports – February 2012 The reports were circulated prior to the meeting and the contents were noted.

11 HEALTH IMPROVEMENT

11.1 Health Improvement Performance Report The report was circulated prior to the meeting and the contents were noted.

Mrs McVicar highlighted the enormous amount of work which had been undertaken on Smoking Cessation and Alcohol Brief Intervention to achieve the targets. The success was mostly due to the efforts of one or two individuals who worked extremely hard to turn the situation around. She thanked and congratulated the Health Improvement Team particularly although she acknowledged that many other staff had been involved in achieving the target.

The CHP has always been clear that meeting the target for Children’s Healthy Weight interventions would be a major challenge. While the programme is excellent the commitment it requires is beyond what most families are able to achieve and this has been escalated to the Scottish Government. Collaborative work through the Lead Agency model will be helpful in the future.

12 PARTNERSHIP WORKING

12.1 Delayed Discharges A report was circulated prior to the meeting. Although no patients were breaching 42 days at census date the underlying issues are being masked and need to be addressed as a matter of urgency. Mrs McVicar emphasised that such delays are inexcusable and much more work needs to be done. Care at Home is causing issues for delayed discharge, prevention of admission and reablement in the community. It is hoped that integration will help to achieve some meaningful progress and this will be a high priority for the new Operational Unit. Care at Home and care home budgets that have come across from Highland Council as part of the integration process are now sitting with the Directors of Operations in the new organisation rather than centrally and eventually the management of these will be devolved to district level. This should result in a much more responsive service through local teams although it will take time to achieve this.

13 FINANCIAL GOVERNANCE

A full report and addendum were circulated prior to the meeting. This showed the first draft financial position for the CHP as £61k underspent for the year ended 31 March 2012. The CHP identified schemes to achieve its entire Cash Releasing Savings (CRS) target of £1.336m on a recurring basis and this has been withdrawn from respective budgets. This is of note as it had not been achieved in other parts of the system. The greatest financial risk relates to budget holders being able to manage within the reduced financial resource whilst still maintaining provision and quality of frontline services. Other risks include Out of Hours which at the time of reporting showed a £384k overspend. Discussions are ongoing with providers to establish a more cost-effective service whilst continuing to maintain a high quality, safe and sustainable service.

Mr Slavin noted that over the past six years the CHP had achieved CRS totalling over £7.3m which was an immense achievement. Mrs McVicar thanked everyone for all the hard work that had made

8 this possible but noted that there were further significant challenges ahead. An enormous amount of work has been done around efficiency savings over the past few years but the next round of efficiency and cost improvement programmes will be far more stringent. Community engagement will be absolutely critical as changes to the way services are delivered are implemented through the Highland quality approach.

Governance Committee:

. Noted the contents of Performance Management Reports

SERVICE REPORTS

14 OUT OF HOURS

14.1 Out of Hours Report The report was circulated prior to the meeting.

Governance Committee:

. Noted the contents of the Service Reports.

SERVICE IMPROVEMENT & REDESIGN

15 REVIEW OF SERVICES FROM ROSS MEMORIAL HOSPITAL

Mrs Phimister’s detailed update paper was circulated prior to the meeting. Mrs McVicar congratulated her on her work in leading this project and noted that this has now been formally handed over to the new South & Mid Operational Unit.

16 TAIN HEALTH CENTRE

The project to build the new health centre in Tain is being taken forward as part of a “bundle” of projects with two others in Grampian. These projects are being developed through HubCo, an initiative developed by the Scottish Futures Trust on behalf of the Scottish Government as a means of improving the planning, procurement and delivery of infrastructure in support of community services.

There were no objections to the planning process and appropriate governance arrangements have been approved. Approval has also been given for a project board and team to be established for the Tain Health Centre Project.

Governance Committee:

. Noted that both these projects have now formally been handed over to the South and Mid Operational Unit.

9 17 PLANNING FOR INTEGRATION

Copies of the information provided to Highland Council staff transferring across to NHS were circulated prior to the meeting for information.

18 UIG SURGERY

Mrs McVicar reported that the premises at Uig are no longer required. She confirmed that the cost to modernise the building would be prohibitive and Governance Committee was asked to approve the declaration of surplus to requirement.

Governance Committee:

. Approved a declaration of surplus to requirement for the premises at Uig Surgery.

19 ANY OTHER BUSINESS

The Chair took the opportunity to thank members of the Committee for their contributions. He noted that while some of the discussions had been challenging, they had always been constructive and the level of engagement excellent.

The Chairman and Director of Operations encouraged members to stay and participate in the showcase event at which staff would be presenting excellent work done.

These included the following presentations:

Learning & Development to Support the Transition to a Reablement Approach to Care in Highland  Amanda Trafford, CHP Clinical Specialist Occupational Therapist, Professional Lead Occupational Therapist New Patient Service Models  Marie Law, Clinical Services Manager, Belford Hospital & Shahid Barlas, Consultant Physician Health Improvement  Tina Barrows, Public Health Practitioner/Public Health Nurse &  Jane Groves, Public Health Network Co-ordinator Lochaber Community Staff Nurse Development Pilot  Claire Savage, CHP Learning & Development Facilitator and Nancy  Campbell, Public Health Practitioner (Lochaber Area) Lochaber Falls Service  Sheila Morris, Occupational Therapist, Belford Hospital &  Kirstie Ross, Physiotherapist

Posters included: Combined Assessment Unit, Belford Hospital New Health Centre Developments Alcohol Brief Interventions Healthy Weight Programme Smoking Cessation Tissue Viability Midwifery Achievements Falls Prevention

10 Highland NHS Board 5 June 2012 Item 3.3 North Highland Community Health Partnership Caithness General Hospital Bankhead Road Wick KW1 5NS Telephone: 01955 605050 Fax: 01955 604606 www.nhshighland.scot.nhs.uk

DRAFT MINUTE of MEETING of the NORTH HIGHLAND CHP COMMITTEE 17 April 2012 – 2.00 pm The Seminar Room, Caithness General Hospital, Wick

Present: Mr Colin Punler, Chairman, North Highland CHP Committee Mr Bob Silverwood, North Area Manager, Caithness and Sutherland Mrs Sheena Macleod, Highland Council, Head of Health (until 2.30pm) Dr Bobby Echavarren, Lead Clinician, Caithness LHP Cllr David Flear, Highland Council - Landward Mr Ranald MacAuslan, Voluntary Sector Member Mr Ross Mackenzie, Head of Finance, North Highland CHP Mrs Elizabeth Smith, Public Partnership Forum Member Mr Ray Stewart, Non-Executive Board Member, NHS Highland Mr Allan Tubb, Public Partnership Forum Member Via VC from JD Building: Dr Cameron Stark, Consultant in Public Health, NHS Highland Inverness

Bettyhill: Mrs Clare Morrison, Lead Pharmacist, North Highland CHP (until 2.45pm)

Lawson: Ms Lorraine Coe, Lead Nurse/Clinical Nurse Manager, Sutherland Ms Christian Goskirk, Long Term Conditions Manager, North Highland CHP

Dingwall: Mrs Gill McVicar, Director of Operations, North and West Highland (from 3.15pm)

In Attendance: Mrs Pauline Craw, Locality General Manager, Caithness Ms Maimie Thompson, NHS Highland Head of Public Relations and Engagement Ms Kay Oswald, CHP Support Manager (Minutes) Gordon Calder, Member of the Press Ian Grant, Member of the Press

Vacancies: Dentist

Chairman’s Welcome

The Chairman, Colin Punler, welcomed everyone to the meeting and formally welcomed Bob Silverwood in his new capacity as Area Manager within the new integrated structure.

Declarations of Interest  Mr Punler declared his interest as a board member of Pentland Housing Association, contracted by Highland Council to deliver services to support adults in the community.  Ray Stewart advised that as well as being a Non Executive Board member of NHS Highland he was also a Trade Union Representative for Unite and an NHS Highland member of staff.  Ranald MacAuslan advised that he was a Board Member of Laurandy Day Centre in Wick.

1 APOLOGIES

Apologies had been received from Mrs Mary Burnside, Cllr Bill Fernie, Mr Paul Fisher, Mrs Pam Garbe, Dr Andreas Herfurt, Mr Mark Kerr, Cllr Deirdre Mackay, Mr Alan Miller, Mrs Margaret Moss and Cllr Linda Munro.

2 MINUTES OF MEETINGS HELD ON 21 FEBRUARY 2012

The minutes of the meeting held on 21 February 2012 were approved as an accurate record.

3 MATTERS ARISING (from minutes)

Liz Smith asked whether Cabinet approval had been given for the new governance structure and the integration of NHS Highland and Highland Council. Mr Punler confirmed that the approval had been received enabling the signing of the new agreement. The CHP Committee will continue as a governance committee during the transition phase.

Ranald MacAuslan asked whether there was any update on the Change Fund arrangements. It was confirmed that further guidance is expected but local arrangements will continue in the interim.

As Sheena Macleod was required to leave early to attend another meeting it was agreed to take agenda item 7.2 at this point.

7.2 General Manager’s Report

Mrs Macleod advised that she was no longer General Manager of the CHP but had taken up her post as Head of Health for Highland Council on 1 April 2012. Mrs Macleod apologised for the briefness of the report and highlighted the following:-

 The management appointments into the NHS Highland and Highland Council posts following the integration.  Medical Staffing issues at CGH - It was noted that the situation is more stable this year regarding the appointments into the junior doctor rotation and the two consultant physician posts are about to go out to advert.  Lawson Memorial Hospital update on the reconfiguration of the in-patient beds and the improvement of the facilities.  Valuing Services Award – it was noted that a member of staff with 40 years service had not had a day’s sickness during this time or any other special leave. It was agreed that this outstanding achievement should be recognised and Colin Punler indicated that he would send a letter of appreciation on behalf of the Committee to the member of staff.

During discussion the following was raised:-  Ranald MacAuslan asked which posts remained to be filled locally and what was the timescale for this. Bob Silverwood confirmed that the District Manager for Caithness and Sutherland and the Hospital Manager posts still had to be filled. He advised that the timescale was dependent on other factors and some matching was still being done.

2  Liz Smith asked whether the hospital manager post would cover the other community hospitals in the area. Mr Silverwood advised that this had still to be concluded but was a possibility.  Cllr Flear commented that there were a lot of buildings needing money spent on them but reflecting on a statement made in the press by NHS Highland that reductions in capital funding would result in a cost-cutting programme he queried what effect that would have locally. Mr Punler advised that a revised capital plan had been approved at the Board meeting in April with prioritisation of needs put in place for 2-3 years. It was indicated that Caithness and Sutherland had no specific projects on the list other than their share of equipment requirements. There was recognition of backlog maintenance within NHS Highland - locally the roof at Caithness General Hospital was in the process of being replaced and minor electrical work was taking place within Caithness and Sutherland.  Cameron Stark asked for clarification on a former point made regarding the role of the Hospital Manager within Caithness and whether they would be covering the other hospitals. Bob Silverwood confirmed that this was being considered. Mr Silverwood also acknowledged the work of Pauline Craw and Ross Mackenzie during the current transition phase and for filling the gaps vacated by those staff who had moved to other areas.  It was confirmed that the Chief Operating Officer (COO), Debra Jones had been appointed and would start in July. Gill McVicar, Director of Operation for North and West Highland and Nigel Small, the Director of Operations for South and Mid Highland will report to the COO.  Allan Tubb asked whether that was an indication of how the beds in Lawson would be divided. Mrs Macleod confirmed that it would be a combination of single rooms and 3 bedded wards.

Mr Punler thanked Sheena Macleod for her report and for her contribution to the CHP over the previous years.

4. FEEDBACK FROM BOARD MEETING

Colin Punler confirmed that the under noted information had been distributed to members of the Committee following the Board Meeting on 3 April 2012:-

 A review is being carried out of accommodation available to support people who travel to Raigmore. The existing facilities at Kyle Court are considered to fall below modern standards.  Dr Paul Davidson was appointed as Clinical Director for North and West by the Highland Health and Social Partnership.  Every Board produces a Local Delivery Plan, setting out performance measures and standards that reflect the national priorities of NHS Scotland. NHS Highland’s plan for 2012/13 was approved. CHP Committees will be expected to monitor and drive performance against the plan.  Finance – saving of £23.8m are required in the 2012/13 financial year as increases in operating costs continue to outstrip increases in funding. Of this target, approximately £9m is a result of non-recurring savings from 2011/12.  The revised Capital Plan was agreed.  Amendments to the Gaelic Language Plan were approved.  Clinical Advisory Group – first annual report was presented to the board. A key purpose is to focus on the clinical appropriateness and cost-effectiveness of existing and proposed treatments.

Web links to the various documents had been given.

The Committee:

 Noted the information provided.

3 5. CLINICAL GOVERNANCE

5.1 Prescribing Issues

5.1.1 Prescribing Report by Clare Morrison, Lead Pharmacist

The prescribing report had been distributed for information. The report was based on data for April to January 2012 and showed that the CHP is forecast to overspend on its prescribing budget by 1.8% on its prescribing budget in 2011/12 which is an improving position compared with the previous reported forecast.

Clare Morrison highlighted the following:-  Patterns across localities remain the same as previous positions with no major changes in the GP practice performances.  CHP position is now more in line with other CHPs in Highland with the gap down to 0.2%.  All CHPs continue to face a challenging time with rising prescribing costs and this is reflected across Scotland.  The volume of prescribing remains a challenge.  QOF projects were completed in December.  The Prescribing support team has also completed the following work this year to control prescribing expenditure: review of the prescribing of special products, Wound Formulary audit, review of stoma prescribing, dose optimisation of pregabalin, review of gluten free foods prescribing, audit of ScriptSwitch acceptance rates, temporary residents audit, Highland Formulary compliance audit and cost-saving switches (to generic medicines, alternative brands and different formulations).

The Committee acknowledged the huge amount of work which had been going on to bring down the prescribing expenditure and hoped that Clare Morrison would be able to continue with this good work following the restructuring of posts.

5.1.2 High Risk Medicines Project

A report by Clare Morrison had been distributed and she sought endorsement of the project by the Committee. The report indicated that 5% of all hospital admissions are caused by adverse drug reactions and the rate is much higher in frail populations (approximately 15%). The aim of the project is to reduce two types of hospital admissions:  Those caused by adverse drug reactions  Those caused by falls where medicines contribute to the fall. The project involves targeted medication reviews to identify patients being prescribed high risk medicines with a view to stopping the medicine(s) unless continuation is appropriate and necessary. The project is a joint initiative between primary and secondary care and reflects the close collaboration that exists between the CHP prescribing support team and Caithness General Hospital pharmacy. The project is being funded through the Change Fund and is due to start at the end of April.

During discussion the following was raised:-  It was confirmed that this would be voluntary to the GPs but the main work would be carried out by the prescribing support team.  Ranald MacAuslan indicated that he was delighted that the project was being progressed but suggested that lay people assumed this would have been standard practice for GPs. Clare Morrison advised that patients often start off on medication and over time additional items get added for other ailments making it difficult to see the whole picture.  It was clarified that the potential benefits were based on national research.

The Committee:

 Endorsed the High Risk Medicines project.

4 5.2 Infection Control Report Report by Pam Garbe, Lead Nurse/Clinical Nurse Manager Caithness and Lorraine Coe, Lead Nurse/Clinical Nurse Manager Sutherland

The infection control report had been distributed for information. Lorraine Coe highlighted the following:-  Norovirus Virus season – no reported incidences to date, but remain on high alert.  Clostridium difficile – 14 cases of CDiff to date this year. Investigations completed and no links between cases.  Continued good attendance at North CHP Infection Control committee.  The North CHP Infection Control and Annual Work Plan 2011/12 was updated in March.  No new cases of Staphylococcus Aureus Bacteraemias (SAB) since November 2011.  Hand Hygiene audits continue with good results.  MRSA screening continues at Caithness General Hospital (CGH) with 100% compliance reported in January. Currently carrying out audit in community hospitals and working towards being fully implemented.  Looking at learning points from outbreak of CDiff at Raigmore. A check of all commodes has been completed and compliance with cleaning schedules is ensured. Silicone sealants on toilets, showers and sinks are being checked.  Work around decontamination processes continues Highland wide.  The assessment of the endoscopy services by CGH by the National joint advisory group was generally positive.

It was noted that the capital costs around the endoscopy work is part of an NHS Highland review and will be carried forward for the new Committee to review.

The Committee:

 Noted the information provided.  Agreed that the progress on the endoscopy services should continue to be reviewed by the future governance committee.

5.3 Scottish Patient Safety Programme (SPSP) Verbal update by Pauline Craw, Locality General Manager

Pauline Craw, Management Sponsor for SPSP at Caithness General Hospital (CGH) advised that the SPSP programme continues to be embedded at CGH. Two new areas of high morbidity being looked at are Sepsis and Venous Thromboembolism (VTE) prophylaxis. A learning session has been arranged for 26 April and CGH has seven staff attending. There is a Highland wide VTE group and a local group has also been set up. The next learning set to be considered locally will be the Global Trigger Tool which looks at adverse events and mortality reviews.

Cameron Stark confirmed that SPSP is extending into Mental Health Services and will be focussing on acute psychiatric hospitals. It is not expected to reach the community setting until 2013.

The Committee:

 Noted the information provided.

5 5.4 Review of West Caithness Redesign Report by Pauline Craw and Maimie Thompson

A report by Pauline Craw and Maimie Thompson had been distributed for information. The report confirmed that at the previous CHP Committee meeting it was agreed that all options around re-design of services in West Caithness should be taken off the table. There was clear support to commission further work including setting out an approach and supporting actions to review and re-design services in West Caithness. It was also agreed that some further immediate work should be progressed to discuss with local clinicians, including GPs, how to build a clinical consensus.

It was confirmed that various meetings had been held with GPs, AHP and community staff and staff at Dunbar Hospital. General issues were considered, including challenges around the ageing population, buildings, finance and shifting the balance of care. An interim project plan had been prepared and was attached with the report. It was suggested that the specific next steps needed to be considered based on any decisions around a move towards strategic commissioning of services across West Caithness. A draft control plan towards strategic commissioning was also attached with the report.

Pauline Craw confirmed that the re-ablement training for staff at Dunbar was continuing and staff had also undertaken COPD training. Work with Bayview had not yet started and when it does it will run in conjunction with other services to trial it. Dedicated assessment beds in Dunbar and Queen Elizabeth Unit at CGH will be trialled with the referral criteria similar to that used for the Bluebell beds in Sutherland. The aim is to have a safe environment for a patient to be assessed and looked after for up to a maximum of 48 – 60 hours. During this period appropriate care and services will be put in place to allow them to be discharged home safely.

During discussion the following issues were raised:-  Liz Smith asked whether the option for using Bayview for Palliative Care was being reviewed. It was confirmed that the existing palliative care services will remain but as part of the integration process the work in nursing homes will be reviewed and an ongoing rolling programme of training for staff will take place. The opportunities available from the integration of NHS Highland and Highland Council will be explored.  Liz Smith asked for clarification on the assessment beds at Dunbar and whether it had been stated that this had not been successful at CGH. Pauline Craw confirmed that the pre admission assessment has been trialled in the acute medical and surgical wards but not in the frail elderly ward. The assessment beds would be more like a step down facility.  Cllr Flear suggested that more information on the GP meeting should have been made available to enable the Committee to exercise scrutiny. It was agreed that a copy of the notes from the meeting would be distributed. Cameron Stark confirmed that they had asked the GPs to volunteer their thoughts and priorities as to what they wanted to see. Palliative care, rehabilitation, emergency cover, ambulance services and transport were among the issues discussed. Dr Stark confirmed that the engagement was not about trying to sell any vision but sought agreement as to reasons why the services needed to change.  Ray Stewart commented that lessons had been learned and the Committee were now reassured that the GPs were being engaged.  Maimie Thompson confirmed that there was ongoing dialogue and there was a plea to broaden out the discussions as it was not just about Dunbar hospital. There was a desire to extend discussions to look at the next 5 – 10 years and what people need and want.  Colin Punler advised that they did not want to raise people’s expectations as there were still constraints but as part of the wider engagement process the groups would need to define terms of reference for themselves and who should be involved, identifying the work to be carried out. The GPs would form part of this wider stream. It was acknowledged that the work of the various group meetings would need to be brought together.  Liz Smith asked that consideration in future documents be given as to terminology used as vocabulary needed to be simple so that folks could understand it.

6  Allan Tubb cited the success of Care in the Community within Sutherland and suggested that this should be used as evidence for implementing in Caithness.  Ranald MacAuslan asked whether the views of the voluntary sector would be reflected and if they would be involved in the process. Pauline Craw confirmed that members of the voluntary sector had successfully been involved through Caithness Voluntary Group in the previous consultation and there was no reason to expect this would not continue. Gill McVicar advised that whilst she was new to the process, the involvement of the voluntary sector at all stages of the development was crucial.

Colin Punler summed up the discussion confirming that the Committee noted the update presented and endorsed the recommendation. He suggested that the Committee needed to allow the Management team to get on and progress the agreed actions, allowing work to evolve naturally but exercise governance over whether the agreed output is taking place. Regular updates will be provided to ensure the appropriate process is ongoing.

The Committee:

 Noted the information provided and the project plan presented.  Approved the continuation of day to day improvement work linked to West Caithness re- design.  Endorsed the recommendation to form a Commissioning Group.

6 STAFF GOVERNANCE

6.1 Workforce Report Data

The Monthly Workforce Report for February 2012 had been distributed for information.

The Committee:

 Noted the information provided.

7 FINANCE AND PERFORMANCE REPORTS

7.1 North Highland CHP Financial Position Report by Ross Mackenzie, Head of Finance

The Finance Report for the period to 29 February 2012 had been distributed for information and Ross Mackenzie tabled a year end report to 31 March 2012 which he advised was subject to audit verification.

Ross Mackenzie confirmed that the year end position for the CHP is an over spend of £780k with a favourable movement of £127k in March mainly being attributed to prescribing, prescribing discounts and GMS enhanced services. The £1.066m of unmet savings target will be carried forward resulting in a savings of £1.475m being carried forward into 2012/12. This is reflected in the £23.8m savings highlighted in the NHS highland position in April and reflects a significant reliance on non-recurring savings to meet the financial target. Due to timing the specifics of the report were not available but a more comprehensive report will be prepared.

Colin Punler indicated that the information had been noted but it was unsatisfactory that the CHP had not delivered on one of the core Government targets.

7 During discussion the following was raised:-  Cllr Flear suggested that whilst the financial target was important, one of the other priorities was quality and it was difficult to provide quality and achieve savings. He reflected that public comments on a local website counter balanced recent negative media reports and reflected positive patient experiences.  Ranald MacAuslan queried the Place of Safety funding and it was confirmed that this budget had been allocated to pay staff when required to escort patients detained under the Mental Health Act. Mr MacAuslan also queried why there was no reference to Change Fund monies. It was confirmed that specific funding had been received from NHS Highland to cover change fund costs and as this was balanced out there was no reference in the paper.

The Committee:

 Noted the information provided and expressed disappointment at the failure to achieve the financial target. 

8. ENGAGING WITH PATIENTS AND COMMUNITIES

8.1 Issues from PPF Members

Mrs Liz Smith confirmed that she had nothing additional to add.

Mr Tubb queried the arrangements for the new Highland CHP Committee. It was confirmed that terms of reference and membership would be according to statute as set by the Scottish Government. The process was underway for appointment to the Committee but these would be held up pending the outcome of the council elections. The process for appointment of public and voluntary representatives had yet to be determined.

8.2 Issues from Voluntary Sector

Ranald MacAuslan thanked the Committee for their support and understanding in his role and looked forward to continued working together on the change fund group.

The Committee:

 Noted the information provided.

9. ANY OTHER COMPETENT BUSINESS

Colin Punler thanked everyone for their contributions over a number of years to the work of the Committee.

10. DATE OF NEXT MEETING

Depending on progress of transition to the new CHP Committee, the next scheduled meeting of the North Highland CHP Committee is Tuesday 19 June 2012 at 2.00 pm in the Seminar room at Caithness General Hospital. Video conferencing facilities will be arranged.

The meeting closed at 3.50 pm.

8 Highland NHS Board 5 June 2012 Item 3.4 Raigmore Hospital Inverness IV2 3UJ DRAFT MINUTE OF MEETING OF THE Telephone 01463 704000 RAIGMORE GOVERNANCE www.nhshighland.scot.nhs.uk/ COMMITTEE

Multi-purpose Room Centre for Health Science 16 April 2012

Present: Mr M Evans, Non-Executive Director (Chair) Mr C Lyons, Director of Operations Dr R Harvey, Associate Medical Director Ms D Janssens, Endoscopy Manager Mr D Flear, Highland Council Representative Mrs L Smith, Public Representative Mrs P Dobbie, Patients Council Representative Mrs A Rodgers, Head of Finance (Interim) Mrs E MacKay, Partnership Forum Representative Ms S Wedgwood, Non-Executive Director

In Attendance: Miss E Greig, Communications Manager Mrs L Morrison, Senior Personal Assistant

Apologies: Mrs U Lyon, Lead Nurse Ms Rosie McGee, Health and Safety Manager Mr Calum Munro, Voluntary Sector Representative Mrs Cathie Walker, Personnel Manager

1. Welcome and Introductions

Mr Mike Evans welcomed everyone to the meeting and introductions were made around the table.

Ms Sarah Wedgwood joined the meeting today in place of Ms Pam Courcha.

It was noted that Ms Wedgwood was there to contribute to the meeting but was not an official member of the Governance Committee.

2. Conflicts of Interest

There were no declared conflicts of interest.

3. Apologies

The apologies were noted as above.

4. Minute from the Previous Meeting (20th February 2012)

The minutes from the previous meeting were accepted as a true and accurate record. 5. Matters Arising

It was noted that all matters arising are covered in the Committee agenda.

6. NHS Highland Board Feedback

Mr Evans fed back to the Committee key issues discussed at the NHS Highland Board Meeting held on Tuesday 3rd April 2012.

Mr Evans advised the Committee that NHS Highland’s budget balanced for the financial year 2011/2012.

It was noted that the Local Delivery Plan has been submitted to the Board and is available for download on the NHS Highland website.

Mr Evans feedback concerns raised by some member of the Board with regards to Raigmore Hospital’s partnership working. Mr Evans reported that some members had expressed concern that the current joint working was not as robust as it could be or has been in the past. Mr Evans asked Mrs MacKay how she felt about her partnership relationship with Mr Lyons and the Raigmore Management Team. Mrs MacKay advised that she has not encountered any problems and has a good knowledge of most the issues that occur. Mrs Mackay confirmed that she attends as many of the important meetings as she can within the available 2.5 days per week.

Mr Lyons informed the Committee that Mrs Mackay is a member of the 2 key decision making meetings which Raigmore has i.e. The Senior Management Team and the Quality and Patient Safety Group. Mr Lyons confirmed that any major decisions that Raigmore makes are agreed and decided at either of these meetings therefore Mrs MacKay is involved at all times.

Ms Wedgwood inquired as to the mechanism in which Mrs MacKay receives information regarding Raigmore Hospital. Both Mrs MacKay and Mr Lyons confirmed that they communicate direct almost daily. Mr Lyons advised that he has an open door policy, and if any staff wanted to see him he would make time available at some point during that day.

Mrs MacKay advised the Committee that if she is unable to attend a particular meeting she arranges for another Partnership Representative to attend in her place. Mrs MacKay confirmed that her partnership working relationship with Raigmore is better than last year and that it continues to develop.

Mr MacKay confirmed that she and Chris’s working partnership working is very good.

Mr Evans requested that this issue should be kept on the agenda of the new Highland Health and Social Care Partnership Committee.

ACTION – Highland Health and Social Care Partnership Committee.

Mr Evans advised that the membership for the new Highland Health and Social Care Partnership Committee has been finalised and now has 29 members including representation from the voluntary sector and patient / public representatives. Mr Evans advised that the Raigmore / CHP Committees will continue to meet until the new structure is fully implemented.

The Chair of the Mid Highland Governance Committee (Mr Okain McLennan) raised concerns at the Board meeting regarding lack of Discharge Care Plans for patient

2 leaving Raigmore Hospital.

Following debate it was agreed that Mr Lyons would discuss this potential issue with Mr Bill Alexander, Head of Social Work at the Highland Council, to investigate whether he has experienced any concerns. Mr Lyons agreed to feedback to Mr Evans prior to the next Board Meeting.

ACTION – Mr Chris Lyons

Mr Evans advised that a detailed paper regarding capital budgets was discussed at length at the Board Meeting highlighting the difficult financial times ahead. It was noted that Raigmore Hospital’s impending fire upgrade development programme would cost between £2.5M - £3M. In addition there would be hidden revenue costs associated with the scheme such as portering costs etc. Mr Lyons advised that these additional cost pressures are very worrying for Raigmore’s Senior Management Team.

Mr Lyons advised that there are very limited funds available this coming financial year for equipment replacement and repair. This will inevitably become issues for Raigmore as it is the most technical and equipment reliant hospital in NHS Highland. The Senior Management Team will be in a difficult situation if anything breaks down as we currently have no budget allocation, and money may have to be taken from revenue.

Mr Lyons also advised that The HAI Task Force Group (established to review the C. Diff Outbreak which occurred in February) requested that a costing exercise was carried out by Dr Emma Watson Consultant Microbiologist, Dr David Parratt Consultant Microbiologist, Alison MacLean Senior Infection Control Nurse and John Scott Estates Manager. The aim of the costing exercise was to identify the costs involved with ensuring that Raigmore Hospital is fully “microbiologically” compliant with the HAI Standards expected of all Hospitals across NHS Scotland. Mr Lyons circulated a copy of this document to members of the Committee for their information.

Mr Evans advised the Committee that he would like to discuss this item at its appropriate point in the agenda.

Mr Evans concluded that the other item which he wished to provide feedback from the Board meeting was Kyle Court. The Committee noted that NHS Highland should look at the possibility of outsourcing accommodation from places like the Premier Inn. Mr Evans advised that this item will be discussed in detail further down the agenda.

Mr Maurice Cowan joined the meeting has a member of the public in attendance for the item on Kyle Court.

7. General Manager’s Report

The Committee discussed the General Managers Report and feedback was provided by Mr Lyons. Mr Lyons advised the Committee that updates were requested on the following 4 items which have each been given separate agenda items.  Kyle Court  JAG accreditation  Significant event review C. Diff  CAMHS Waiting Times The Committee noted that the new Divisional General Manager for Surgical Services has been appointed, and Mr Carl Hope joined the team last week.

Mr Lyons confirmed that the front entrance Coffee Bar project has been completed and the facility opened last week. Mr Lyons advised that he thinks hospitals are social

3 environments as well as clinical areas, and work will continue to be undertaken to improve the environments for the benefit of staff, patients and visitors.

The new reception area at the main entrance has also been improved and will be staffed from 9.00am – 5.00pm. This facility will be of great benefit to visitors of the hospital, as the receptionists will be able to assist with general enquiries and provide information and locations of patients staying within the hospital.

Mr Evans asked for clarification from Mr Lyons with regards to concerns he had recently read about the shop at the main entrance of the hospital. Mr Lyons confirmed that the WRVS have the shop at the main entrance which has recently been extended. Mr Lyons stated that the WRVS used to also have the small paper shop around the corner, but this space is hoped to be allocated to the Friends of Raigmore as they have requested physical space within the hospital. It was noted that this development has been stopped until appropriate fire compartmentation works have been completed, then it is anticipated that the Friends of Raigmore will move into the space.

The Raigmore Governance Committee requested that their thanks and appreciation were noted for Sheila Cascarino who has recently left Raigmore to take up a new post in England.

7.1 Monthly Quality and Performance Report

Mr Lyons provided a brief update on adherence to performance targets as outlined on the Raigmore Hospital Dashboard for month of February.

My Lyons advised that as this issue is of significant interest to the committee he has written a commentary on the dashboard highlighting Raigmore’s position for the end of March for both inpatients and outpatients.

Mr Lyons advised the Committee that the 21 week target which used to be in place has recently reduced to 18 weeks. This reduction resulted in a backlog of Orthopaedic patients which were required to be seen within the 18 week target at an additional cost of £430K. Mr Lyons advised the committee that this addition unexpected cost pressure will be incurred in this year’s budget allocation, and the backlog of patients will be cleared between now and the end of June. Mr Lyons confirmed that a bid has been submitted to the Scottish Government requesting for funding assistance.

The committee were assured that the Senior Management Team conducted a thorough investigation of this issue before deciding to spend the £430K on our own consultants and support staff to clear the backlog. This method is the most cost effective and it will ensure that we meet the needs of our patients by enabling them to receive their treatment in NHS Highland.

Following discussion Mr Lyons advised that Raigmore Hospital appointed 2 new Consultant Orthopaedics last year and the Senior Management Team have worked in collaboration with Service Planning to review the Consultant job plans to ensure that this problem does not occur again in the future.

Dr Harvey advised the committee that there was a backlog in patients waiting to be seen prior to the new Consultants appointment. Raigmore Hospital’s Consultant Orthopaedic capacity should now be sufficient to ensure that once the backlog is cleared we then have the correct consultant capacity to continue to meet the needs of our patients.

Mr Brian Beattie Support Services Manager joined the meeting.

4 The committee agreed that Mr Lyons paper should be attached to the minutes for the Boards information as Appendix 1.

ACTION – Mrs Leah Morrison

Mr Lyons continued to talk to his report and advised the committee that there is currently no National Target for DNAs. Raigmore Hospital has set its own target which is 6% and a detailed analysis of DNA figures is conducted monthly. Mr Lyons advised that specialities in which clinic appointments are booked through Patient Focused Booking (PFB) in general have significantly reduced. Equally for those specialities which are not booked via PFB the DNA figures have generally either increased or remained static.

Mr Lyons confirmed that every speciality is different, and DNA information is now being submitted to the Service Managers for them to investigate and provide reassurance that they are reducing DNAs where possible. Mr Evans confirmed that it is very positive that the Senior Management Team are self measuring, but it is equally important that the information collected to used to encourage patients to attend appointments or to make appropriate changes to the services provided to accommodate patient needs.

Mr Evans feedback concern from the Board Meeting regarding Raigmore Hospital’s KSF figures. It was noted that NHS Highland’s target is 100% and it is important that as an organisation it looks after it biggest resource which is Staff. Mr Evans emphasised that KSF Targets are important and a structural change may be required to improve our targets as they are currently being consistently failed.

It was noted that Mr Lyons report states that breaches in the Medical Division are expected in April. Mr Lyons advised that he was not expecting breaches and agreed to investigate and submit a revised paper to be attached with the minutes. (Note this was a clerical error and the document should have read “zero breeches expected” throughout)

ACTION – Mr Chris Lyons

8. Quality and Patient Safety Report

The Committee noted that comprehensive report submitted by the Quality and Patient Safety Division.

Dr Harvey took questions from the Committee on the contents of the report.

Mrs Wedgwood sought clarity and reassurance that the findings and outcomes from the 90 day initiative would be utilised and implemented across the Hospital. Following discussion it was agreed that Mr Una Lyon would contact Mrs Wedgwood out with the meeting and proved her a brief written note regarding progress to date, and whether or not this programme could be rolled out across the board.

ACTION – Mrs Una Lyon

The Committee agreed that the Quality and Patient Safety Meeting minutes attached to the report as Appendix 2 were very comprehensive and useful.

Mortality case note review is now established on a monthly basis, but capacity problems

5 continue to limit the proportion of cases that can be reviewed in detail to approximately 10% of all hospital deaths. The number of cases reviewed each month this year are shown in the table below

Mr Evans raised concern that only 10% of hospital deaths are reviewed. Dr Harvey advised that a workshop will be taking place shortly to review and agree a methodology which can be undertaken for mortality reviews as it is a Board wide topic. At present there is a lack of capacity to carry out reviews on more than 10% as the process is detailed and quite time consuming. Currently patient notes are reviewed 48 hours after the time of death and an analysis is made as to whether the patient requires further investigation.

Following discussion it was agreed that an update will be brought to the next meeting of this committee or the Highland Health and Social Care Partnership Committee.

ACTION – Next Raigmore Governance Committee or Highland Health and Social Care Partnership Committee.

Mr Evans advised the Committee that there was discussion at the Board meeting with regards to Pressure Area Care and the high costs involved with providing this service for NHS Highland. It was noted that NHS Highland has one Tissue Viability Nurse Specialist who is based in Argyll and Bute CHP. Due to the geographical distances across NHS Highland and the amount of patients required to be seen it is unfortunate that the Nurse has limited time to see patents in North Highland. Dr Harvey advised that Mrs Una Lyon leads on tissue viability for Raigmore Hospital and is working with and receiving support from colleagues in NHS Grampian to help meet the additional requirements or our patients.

Mr Evans confirmed that the Board have concerns the each Operational Unit should be working towards improving the level of care which it provides for its patients, and aim to reduce costs to the organisation where possible. Mr Evans requested an update report from Mrs Una Lyon detailing the recommendations from the 90 day improvement programme with regards to tissue viability.

ACTION – Mrs Una Lyon

9. Raigmore Hospital Patient Lodge (Kyle Court)

As mentioned on the agenda Mr Lyons’s paper on Kyle Court was circulated to the committee.

My Lyons introduced Mr Maurice Cowan a patient currently receiving Oncology Treatment at Raigmore Hospital. Mr Cowan contacted him with regards to the lack of facilities at Kyle Court. Mr Cowan informed the Committee that he has written to Mr Lyons, Mr Garry Coutts and the Chair of the Raigmore Governance Committee. Mr Lyons was the only person to respond. It was noted that Mr Lyons responded on behalf of Mr Coutts. Mr Evans stated that he had not yet had sight of this letter.

Mr Evans stated that he was not prepared to accept this paper as he has not had sufficient time to read through it. Mr Flear objected to this as he initially raised the issue previously, and as this would be his last meeting he would like the committee to hear the paper.

Mr Evans advised the committee that he was prepared to listen to Mr Cowan’s comments and discuss his letter. Mr Cowan’s letter was read out to committee members.

6 Mr Cowan presented a signed petition by fellow cancer patients, and members of the public from the Western Isles objecting to the halt in refurbishment of the Kyle Court Facility. Mr Cowan stated that in its current state it is not fit for purpose as there are no en-suite rooms available for patients. Mr Evans confirmed that this committee has had concerns about the maintenance of the facility previously, and there were suggestions that alternative accommodation could be potentially sought.

Mr Lyons confirmed that this committee is not expected to make a decision regarding Kyle Court at this time and the aim of the paper is to set out the costing and options available as NHS Highland does have a responsibility to provide en-suite facilities for patients.

Mr Evans suggested that this committee requests a formal consultation and review of the current facilities which we provide for patients. Mr Evans advised that he and Mrs Wedgwood are Non-Executive Director’s of the Board and have been appointed by Nicola Sturgeon, Cabinet Secretary to represent the public.

Dr Harvey stated that during the duration of the time spent debating whether this committee has time to discuss the paper regarding Kyle Court, he has had sufficient time to read the paper which simply outlines 3 proposals for consideration:

1. Do nothing 2. Refurbish the current facility 3. Source alternative accommodation from a private company

The committee agreed that further research and investigation should be undertaken to review the current facilities and a business case proposal presented to the Board Senior Management Team. It was also agreed that un update on progress should be brought to the next meeting of this committee or the Highland Health and Social Care Partnership Committee.

ACTION – Next Raigmore Governance Committee or Highland Health and Social Care Partnership Committee.

It was suggested and agreed that the NHS Highland Governance Transitional Committee should also be made aware of this issue to ensure that progress is made.

ACTION – Mrs Liz Smith

10. Update of JAG Accreditation (i.e. Provision of Endoscopy Services)

Ms Janssens gave the committee an overview of the paper which was circulated with the minutes.

Mr Evans confirmed that this committee sought clarification as to whether NHS Highland would achieve accreditation. The committee agreed that at present they do not feel reassured that this will be the case.

Mr Lyons advised that he has written a report for the Improvement Committee as they are seeking assurance regarding the management of return patients in Endoscopy. Mr Evans proposed that this item is deferred to the next meeting of this committee or the Highland Health and Social Care Partnership Committee to follow up on outcome from the Improvement Committee.

ACTION – Next Raigmore Governance Committee or Highland Health and Social

7 Care Partnership Committee.

Mrs Janssens informed committee members that the following an HEI inspection a fortnight ago the Endoscopy Unit has been deemed unfit for purpose. Initially the HEI identified that the small treatment room within the unit is not fit for purpose due to the current ventilation system, unfortunately the same ventilation system is used in the main treatment room therefore it suggests that this area is also unfit for purpose.

Mr Evans requested that Mr Lyons gets fully appraised on the current situation and informs the Board Senior Management Team, Improvement Committee and Clinical Governance Committee of this matter urgently.

ACTION – Mr Chris Lyons

11. Update on the Significant Event Review in Relation to the C. Diff Outbreak

Dr Harvey circulated the minutes from the CDI Debrief Meeting to the committee, and explained that the outcome from the Significant Event Review is not yet available as the review is still underway.

Mr Evans suggested that this item should be deferred to the next meeting of this committee or the Highland Health and Social Care Partnership Committee for further discussion once the review has been completed.

ACTION – Next Raigmore Governance Committee or Highland Health and Social Care Partnership Committee.

12. HEI Structural Improvement Requirements Update

As referred to above under agenda item 6 Board Feedback, the committee were circulated a document detailing a list of HAI Defects which have been identified across Raigmore Hospital.

Mr Lyons confirmed that this agenda item is also on the agenda for NHS Highland’s Control of Infection Committee on 16th May for discussion. It was noted that the Control of Infection Committee is accountable to the Clinical Governance Committee which is chaired by Mrs Wedgwood.

Dr Harvey confirmed that when the HEI inspected Raigmore Hospital in 2011 the full infrastructure and fabrication of the building was not fully taken into consideration.

Mr Lyons advised that the audit was carried out by Dr Emma Watson Consultant Microbiologist, Dr David Parratt Consultant Microbiologist, Alison MacLean Senior Infection Control Nurse and John Scott Estates Manager. The aim of the audit was to identify the costs involved with ensuring that Raigmore Hospital is fully compliant with the HAI Standards expected of all Hospitals across NHS Scotland.

It was noted that the total estimated in the document was in excess of 1.2M for the whole of Raigmore Hospital.

Ms Wedgwood advised that she did not think it was appropriate for this document to be circulated to this Governance Committee. Instead an explanation as to what C. Diff is and what Raigmore Hospital is required to do to prevent it would have been more appropriate than a “shopping list”.

8 Mr Evans agreed that this document should not have been circulated to the committee at this point in time without relevant supporting information, and a rationale that spending this money will prevent future outbreaks. Mr Evans suggested that this item is brought to the Control of Infection Committee in the first instance, and then returned to this committee with appropriate narrative and description.

Mr Lyons advised that it would have been remiss of him if he had not at least brought this important issue to the attention of the Governance Committee. Mr Lyons confirmed that he did not expect this committee to agree expenditure, but to the raise awareness of the significant ongoing cost implications which Raigmore hospital faces in the future to resolve this matter.

The Committee accepts that this is an important issue which they should be aware of, and agreed that it should be raised at the Control of Infection Committee in the first instance to be professionally assessed before the Raigmore Governance Committee can comment.

ACTION – Mr Chris Lyons / NHS Highland Control of Infection Committee.

13. CAMHS Targets – Report on Achieving Targets for Access

This item was deferred to the next Raigmore Governance Committee or Highland Health and Social Care Partnership Committee.

14. Staff Governance Report

This item was deferred to the next meeting.

15. Financial Governance Report

Mrs Rodgers gave a brief overview of the Raigmore Financial Governance Report, and confirmed that Raigmore Hospital was overspent by 4.65M for this financial year.

Following discussion Mr Evans suggested that the Raigmore Senior Management Team should take into consideration the views of patients and members of the public in financial planning.

16. Partnership Working

This item was deferred to the next meeting.

17. Health and Safety Report

This item was deferred to the next meeting.

18. AOCB None

19. Date of next meeting

9 To be confirmed

Appendix 1 Raigmore Hospital Governance Committee 16th April 2012 Agenda Item 7.1

Review of February 2012 Monthly Quality and Performance Report

Report by Chris Lyons, Director of Operations, Raigmore Hospital

 The Raigmore Governance Committee is asked to note the contents of this Raigmore Quality and Performance Dashboard Report for February 2012.  Commentary below on performance against Access Targets for March 2012.

Members of the Committee are asked to note the contents of the Raigmore Hospital monthly Quality and Performance Report (The Raigmore Hospital Dashboard). The February report is the most recent one available.

Members are reminded that this report is the direct result of an internal initiative taken by the Senior Management Team of Raigmore Hospital. The purpose of this report is to bring together into one overall composite document on a monthly basis, the performance indicators and the quality standards with the hospital aim to adhere to on an ongoing basis. Some of the standards e.g. Section one - HEAT Standards and Section 5.1 Scottish Patient Safety Programme Standards are part of a national programme of reporting. Other standards are internal to NHS Highlands e.g. Section 2.2 Patient Satisfaction Surveys, whilst other standards are entirely internal to Raigmore Hospital. This final group of standards i.e. those ones which are entirely internal to Raigmore Hospital are additional standards which the management team believe to be useful in fully describing and monitoring the quality of patient services available on the Raigmore Hospital site. It should be noted that in relation to Section 6 Clinical Effectiveness that many of these standards are currently in development mode. The over all aim here is to identify a set of clinical indicators specific to each speciality/clinical department which attempt to measure the quality of Patient Services in terms of achievement of clinical outcomes for patients and minimisation of risk associated with a provision of care.

Access to Services –

New Outpatient waiting times / maximum wait 12 weeks and Inpatient Day Case waiting times – maximum wait 9 weeks

Outlined below is the current position in relation to achievement of new outpatient waiting times target. This target states that no patient should wait more than 12 weeks for an initial outpatient appointment. Outlined below is the level of performance achieved in relation to February/March and the expected performance for April. A commentary is provided in relation to each speciality.

Committee members are asked to note current performance in relation to both day case and admissions across all of the specialities.

10 Surgical Services - Waiting List Breaching Patients

March 2012 Admissions Outpatients Notes

The Starting position for March was 89. This is projected to be 63 by the end of April. The surgical department continues to work on the stage of treatment recovery plan for Orthopaedics 89 0 orthopaedics.

General Surgery 0 0

Surgical Paeds 0 0 The admission was due to failure to plan for the required 2 doctors to be available within the required timescale. The outpatient was due to an administrative Urology 1 1 error.

Breast 0 0

Gynaecology 0 0 2 breaches were due to complex patients of a consultant who was not able to be replaced at short notice. 1 was due to a child who had to be cancelled due to exceptionally high emergency admissions in the Children’s Ward ENT 3 0 resulting in no available beds for this patient.

Ophthalmology 1 (cataract) 0 This was due to an administrative error.

Restorative This was due to consultant sickness and Dentistry N/A 2 unavailability of a replacement.

OMFS 0 0

Orthodontics N/A 0

Plastic Surgery 0 0

Neurosurgery N/A 0

Endoscopy 0 N/A

11 Medical and Diagnostics - Waiting List Breaching Patients

March 2012 Admissions Outpatients Notes

Zero breaches expected in April Clinical Oncology 0 0 Zero breaches expected in April Electrophysiology 0 0 Zero breaches expected in April Neurophysiology 0 0 Zero breaches expected in April Clinical Genetics 0 0 Zero breaches expected in April Endocrine 0 0 Zero breaches expected in April General Medicine 0 0 Additional capacity has been delivered by Neurology 0 0 Medinet and Dr Adam Zeman in order for the 12 week target to be met. This will need to continue in order to achieve no breachers. Zero breaches expected in April Paediatrics 0 0 There were 2 breachers at the end of March Respiratory 0 0 due to Consultant sick leave late in the month. Both patients have been booked in April. New Consultant Respiratory Physician takes up post on 8 May 2012. Zero breaches expected in April Rheumatology 0 0 One Consultant Cardiologist has picked up Cardiology 0 0 additional sessions. 9 weeks has been achieved. Extra clinics will be required to sustain this. Zero breaches expected in April Dermatology 0 0 Zero breaches expected in April Diabetic 0 0 Zero breaches expected in April Elderly Care 0 0 Additional capacity has been delivered by Gastroenterology 0 0 Medinet and synaptik. One consultant’s sick leave has also made the situation worse. Additional capacity will be required on an ongoing basis. Additional clinics are often held at weekends with a large throughput of patients which can have a significant knock on effect on Endoscopy. Zero breaches expected in April Haematology 0 0 Zero breaches expected in April Rehab Medicine 0 0 Zero breaches expected in April Renal 0 0 Challenges can arise if elective patients are Angiography 0 0 cancelled close to their target date due to the need to prioritise emergencies

12 In relation to adherence to cancer access targets the following is the current situation:

For the quarter ended 31 March we (NHS Highland) expect to have achieved a

 96.7 % performance against the 62 target (number of days between referral and treatment). A total of 5 patients out of 153 breached

 98 % performance against the 31 day target (number of days between decision to treat and treatment). A total of 6 patients breached

(These are provisional figures only and subject to ISD validation prior to public release at the end of May)

Of the 5 patients who breached the 62 day target 4 were in Colorectal/Bowel Cancer where there continues to be delays in patients receiving their first appointment/scope. This then impacts on the number of days left to treat any patient with confirmed cancer and comply with the 62 day target. Action Plans are being developed to address these issues.

The performance would have resulted in a failure were it for the 100% achievement of the cancer targets within Breast Surgery. For the first time since the targets were introduced there have been no breachers in this specialty.

In the previous quarter ended 31 December 2011 the achievement was 97.7% and 95.1 for the 62 and 31 day targets respectively.

Chris Lyons General Manager Raigmore Hospital

13

Highland NHS Board 5 June 2012 Item 3.5

South East Highland Community Health Partnership Alder House Cradlehall Business Park Inverness IV2 5GH Tel: 01463 – 706948 www.nhshighland.scot.nhs.uk

DRAFT MINUTE of MEETING of the SOUTH EAST HIGHLAND COMMUNITY HEALTH PARTNERSHIP COMMITTEE 29 March 2012 – 2:00 pm Nairn Town & County Hospital, Nairn

Present Mrs Gillian McCreath, Non-Executive Director, Chair Dr Kate Adamson, CHP Patient & Public Representative Mr Brian Downie, CHP Patient & Public Representative Mrs Hilda Hope, CHP Lead Nurse Mrs Ailsa MacInnes, Community Optometry Representative Mrs Margaret MacRae, Staff Side Representative (RCN) Mr Kenny Rodgers, CHP Head of Finance Dr Ian Scott, CHP Clinical Director Mr Nigel Small, CHP General Manager Mr Hamish Wood, CHP Patient & Public Representative

In Attendance Mrs Sue Blackhurst, CHP Committee Administrator Dr Adrian Baker, GP & Clinical Lead, Nairn & Ardersier Locality (from Item 8.1) Ms Marie Close, Scottish Health Council Local Officer

1 WELCOME

Mrs McCreath welcomed all to the meeting. Mr Small advised that the Chief Executive had announced at the NHS Highland Senior Management Team meeting earlier in the day that the Cabinet Secretary had formally dissolved the CHPs, and today’s CHP Committee meeting would therefore be the final meeting of the SE Highland CHP Committee.

2 APOLOGIES

Apologies were received from Miss Jackie Agnew, Mrs Morag Bramwell, Cllr Margaret Davidson, Cllr Jaci Douglas, Mr William Gilfillan, Dr Robert Henderson, Ms Emily Macintyre, Ms Rhiannon Pitt and Mr Thomas Ross.

3 CONFLICTS OF INTEREST

The Committee Noted that no new conflicts of interest were declared. 4 MINUTE OF MEETING HELD ON 26 JANUARY 2012

The Committee Approved the minute of the meeting held on 26 January 2012.

5 MATTERS ARISING

There were no matters arising that were not full items on the Agenda.

The Committee Noted the position.

6 INTEGRATION / REORGANISATION

It was reported that at the NHS Highland Special Board Meeting on 21 March 2012, all formal partnership agreements with the Highland Council were signed off and commission agreements completed. From 1 April, NHS Highland will be the lead agency for adult services and the Council will be the lead agency for children’s services. To support the move a new Highland Health and Social Care Partnership will be set up which will see 1400 Highland Council staff transferring across to NHS Highland.

Mr Small outlined the new organisational structure and the appointments that had been made so far. He confirmed that it was to be a ‘business as usual’ approach from 1 April whilst the new districts are embedded.

Tier 1 Deborah Jones, from the North West of England, was appointed as Chief Operating Officer, the day previously. It is expected that Ms Jones will take up her appointment in June 2012.

Tier 2 – Senior Management

NHS Highland:  Director of Operations North and West Highland (Remote and Rural) Operating Unit – Gill McVicar.  Director of Operations South and Mid Highland (Inner Moray Firth) Operating Unit – Nigel Small.  Head of Adult Social Care – Brian Robertson.

The Highland Council:  Director of Health and Social Care – Bill Alexander  Director of Education, Culture and Sport - Hugh Fraser  Head of Health – Sheena Macleod  Head of Social Care – Fiona Palin  Head of Education – Calum MacSween

Tier 3 – Area Managers

NHS Highland Area Manager - West – Tracey Ligema  Area Manager - Mid – Georgia Haire  Area Manager - South – Jean-Pierre Sieczkarek  Area Manager – North – Bob Silverwood

2 The Highland Council Area Managers – Further information to be given.

Professional Leadership Posts Appointments, Lead Nurse and Lead AHP

NHS Highland Lead Nurse - North and West Operational Unit – Alison Hudson Lead Nurse - South and Mid Operational Unit – Hilda Hope Lead AHP - North and West Operational Unit – Margaret Moss Lead AHP - South and Mid Operational Unit – Rhiannon Pitt

The Highland Council Principal Officer (AHP’s) - Claire Wood Principal Officer (Nursing) – Susan Russell

Tier 4 – District Managers

NHS Highland (South / Mid Operating Unit) Nairn, Ardersier, Badenoch & Strathspey – Margaret Walker Inverness – Frances Gair East & Mid Ross – Alison Phimister Lead Social Work Officer - Vacant

There is ongoing discussion regarding services such as Pharmacy, Primary Care, Hotel Services, Finance, Health and Safety and Long Term Conditions.

As reported previously, there will be no change to management arrangements for New Craigs and Raigmore Hospitals and Dental Services, but the reporting arrangements for Dental Services are still being discussed. There will also be no change regarding reporting arrangements for the Substance Misuse Service.

Integrated Teams

Work is ongoing on the exact configuration of integrated teams. In the meantime, the District Implementation Teams (DIGs) have been reformed into mini DIGs. The following managers will be taking a leadership and mentoring role to support frontline work until such time as firmer arrangements are in place:  Inverness East – Hilda Hope  Inverness West – Margaret Loughlin  Nairn – Rhiannon Pitt  Badenoch & Strathspey – Kate Patience-Quate

Mr Small advised that it will be necessary to review the operational requirements of the overall Steering Group and the format for its continuance. It had been suggested that it would be more practicable for each operational unit to have a steering group.

Mr Rodgers reported that he is currently working with Highland Council Finance colleagues to ascertain the situation with regard to budgets and savings requirements transferring to NHS Highland.

It was reported that some business support functions of the Highland Council staff will be moving over to health. Discussion needs to take place on training needs and allocations for these staff for mandatory and other training requirements.

The new overarching committee of the Highland Health and Social Care Partnership has been laid down by statute according to the CHP Statutory Guidance 2004. Much discussion took place on the membership of this committee and, in particular, patient and

3 public representation. All three CHP patient and public representatives present expressed concern around the current perceived low number of patient and public representation at the same time as the Board is promoting public and patient engagement. Mr Small reassured patient and public representatives by stating that the following groups are planned / are currently in existence:  District / Local Partnership Forums with patient and public representation are planned, as are public forums in all districts. The timescale for the start-up of these groups was not known, but as they are due to include elected representatives, it was understood that representatives will be sought after the local council elections in May 2012. June or July 2012 was considered to be a realistic start date.  Mrs McCreath added that there patient and public representative sit on the Board’s Governance Committees.  The CHP Patient Participation Group, which has been developed following the dissolution of the Highland Community Care Forum, that provided facilitation to patient groups, will continue.  There are topic specific groups in the area, with patient and public representation.

Dr Adamson enquired about the involvement of the Third Sector, especially with regard to care in the community, to which outlined some of the proposals being mooted. Mr Wood, as a member of Highland HealthVOICES, welcomed the new Highland Health and Social Care Partnership and the engagement with the patient and public representatives from the outset.

Finally, Mrs Hope reported on the positive discussions with Highland Council colleagues around clinical and care policies. Mr Small also advised of the many discussions taking place around the financial aspects of the integration, particularly with regard to the £4M savings to be found from the Highland Council budget transferring across to NHS Highland.

The Committee:

 Noted the discussions that took place.  Noted the concerns of the CHP Patient and Public Representatives around the low number of patient and public representatives currently planned for the new Highland Health and Social Care Partnership Committee.  Noted the challenging financial aspects of the Integration process.  Demitted to the General Manager to circulate the details of the organisational structure and Terms of Reference for the new District / Local Partnership Forums, when available.

Post meeting note: Details of the posts appointed to were updated after the date of the meeting so as to reflect a more accurate picture to be reported in the minute.

7 FINANCIAL GOVERNANCE

7.1 CHP Finance Report

Mr Rodgers referred to his circulated paper. He was pleased to report that after much work undertaken on budgets, there was a £100,000 improvement on the financial position from the last report to the Committee, and that an underspend of £216,000 is forecasted. As always, there have been prescribing pressures; this is currently standing £100,000, which has been offset against generic prescribing costs. A breakeven position is forecasted for NHS Highland.

4 With regard to savings, Mr Rodgers advised that the CHP has plans in place to recurrently achieve the £2,139,000 savings target supported by a non recurrent bridging plan of £1,400,000. The CHP has achieved the 2011/12 savings target in full through recurrent and non recurrent means. However, a recurrent balance of £447,000 remains outstanding and will be carried forward into 2012/13 to be added to any new savings targets for the new financial year. Budget meetings are planned with service/locality managers during March to further explore opportunities for recurrent savings to reduce the £447,000 carry forward into 2012/13.

Mr Rodgers then stated that at the NHS Highland Board meeting the following week, the Director of Finance would be presenting his report outlining the budget for 2012/13. It is expected that £8M of savings will be carried forward from 11/12 to 12/13 in addition to £12M of new savings. There will also be £4M of savings attached to the older adult budgets transferring from the Highland Council.

Mr Downie enquired about the effect of the abolition of prescription charges on the prescribing budget. On behalf of Mr Ross, Mr Rodgers outlined the situation whereby the volume of prescriptions has increased but the CHP has managed to reduce spending on prescribing, due to prescribing costs. Much discussion then took place on this issue.

Mr Small congratulated Mr Rodgers, the Finance Teams and CHP managers for their sterling work in bringing about the current favourable financial situation. Mrs McCreath concurred.

The Committee:

 Received the CHP Finance Report.  Commended the current forecasted underspend of £216,000 and the work undertaken to bring about this positive figure.  Noted the challenges to the Budget for 2012/13.  Noted the discussions on the effect of the abolition of prescription charges on the Prescribing Budget. 

Dr Baker joined the meeting.

8 ORGANISATIONAL ISSUES 8.1 NHS Highland Board Meeting of 7 February 2012

Mrs McCreath advised that the main focus of discussions at the Board meeting centred around the financial report, the capital plan and governance arrangements. Mr Rodgers outlined the views of the Board’s Asset Management Group and the attendant challenges in the reduction of capital spending. Much discussion took place on capital spending issues, especially on requirements for updating medical equipment at Raigmore Hospital.

Mrs McCreath also reported on the discussions around the Highland Alcohol & Drugs Partnership report, and the Strategic Framework report on communications. A further report on the Strategic Framework would be submitted to the Board at its next full meeting.

The Committee:

 Noted the discussions reported from the Highland NHS Board meeting held on 7 February 2012.

5 8.2 CHP Committee Annual Report

Mrs McCreath reminded the Committee that they are required to submit an Annual Report to the Board’s Audit Committee. The circulated Annual Report was agreed.

The Committee:

 Agreed the CHP Annual Report 2011/12.  Demitted to the Committee Administrator to submit the same to the NHS Highland Audit Committee by the required date.

9 PARTNERSHIP WORKING

9.1 Patient & Public Involvement

Dr Adamson emphasised the concerns of the CHP Patient and Public Representatives around the level of patient and public engagement within the new organisational structure.

Mr Wood advised that he had attended a Health Improvement Scotland meeting in Glasgow the previous day where discussion on anti-microbial prescribing had taken place. He questioned whether the general public were aware of the potential implications of some prescribed medication which could cause lead to susceptibility to certain infections, e.g. MRSA and C.difficile. Mrs McCreath considered that Mr Ross had undertaken much work with practices in highlighting appropriate prescribing. Dr Baker offered a clinical view in that much work was ongoing by general practitioners in discouraging patients requesting antibiotics for conditions that sometimes did not necessarily need such medication. Dr Scott added that there had been many public campaigns highlighting this subject. Much discussion took place around these issues.

The Committee Noted the comments made by the CHP Patient and Public Representatives.

10 IMPROVING SERVICES AND CLINICAL ISSUES

10.1 Prescribing and Pharmacy

In the absence of Mr Ross, Dr Scott referred to the circulated Prescribing and Pharmacy Report and the tabled update. Whilst the performance against budget looked disappointing, Dr Scott advised that actual year-on-year spend on medicines across the CHP had reduced, despite an increase in prescribing volume. Although the prescribing budget data was anonymised, the Committee noted the significant improvement in the prescribing performance by the practice which was previously an area of concern in respect of their prescribing activity. Mr Ross had also presented the prescribing data in a format which showed the volume and cost of prescribing per 1000 weighted patients, which gave a more accurate picture of prescribing activity.

Mr Small outlined the work being undertaken as part of the Care Homes Project, which has evolved as a result of monies awarded from the Change Fund, in that additional pharmacist resource is now available within the CHP pharmacy team. With this resource a project is being developed to look at improving medicines management and medicines reconciliation within care homes.

6 It is hoped much of this work will be informed by the Improving Pharmaceutical Care in Care Homes report published earlier this month by the Royal Pharmaceutical Society in Scotland. NHS Highland was represented on the working group for this report by Dr Martin Wilson, Consultant Physician and Mr Ross.

The Committee:

 Noted the content of the Prescribing and Pharmacy Report.  Noted the work ongoing with the Care Homes Project.

11 PERFORMANCE MANAGEMENT

11.1 General Manager’s Report

Mr Small referred to his circulated report and outlined the following issues:  There was a backlog of maintenance issues with the fabric of the buildings housing the community hospitals within the Badenoch & Strathspey locality. He noted that, realistically, the funding will not be available to address these maintenance issues and thus other options are being considered. Discussions on these matters have taken place with staff in the area and also at public meetings, when the possibility of a single site hospital was suggested. Mr Small described the HUBCO model through the Scottish Government which could, potentially, fund capital projects. Mr Rodgers outlined further details of this scheme. Dr Adamson spoke on behalf of the Badenoch & Strathspey locality and said that there was a need for public education in the area. Mr Small advised that he could make himself available to attend further meetings, if required.  SE CHP currently had the highest percentage of eKSF completions out of all the operational units. The completion figure was 61% of all staff for the previous week, and 74% if bank staff (who appeared on several occasions) were removed.  The waiting time for access to Psychological Therapies was outlined. It was anticipated that the key target that no patient should be waiting over 18 weeks for treatment by a psychology therapy service will be achieved by the end of December 2014. There is an interim target which aims to have no patients waiting over 12 months by the end of March 2012. The current position is that 12 patients are waiting over 12 months in northern Highland as at 19 March 2012. This figure may change by 31 March 2012. The largest wait being approximately 13 months. It should be noted that this represents a significant improvement from the position around two years ago where some patients were waiting up to 60 months for treatment. Work continues to try and drive the waiting time down in order to achieve the national target.  The rollout of implementation of Anticoagulation Point of Care Testing services within practices is almost complete and has been seen as a great benefit to patients to be tested locally rather than visit Raigmore Hospital. At the end of February 17 practices were providing the service to approximately 750 patients. A further practice will implement the service for a further 22 patients. The CHP protocol developed at the start of this process will be reviewed and re-issued in the near future highlighting any changes that have been required.  Dr Scott advised that discussions continue to take place around the future organisation of the Diabetes service within Highland. This focuses on the balance of care between Primary and Secondary Care.  There were currently four patients whose discharge was delayed. The annual census date for delayed discharges will be 16 April 2012, whereby no patients should be waiting more than six weeks for aftercare placement. However, there are a few patients who are excluded from the census due to the complex nature of their

7 needs and requirements. In 2012/13 the target will be four weeks. Mr Wood commended all those members of staff involved in reducing the number of delayed discharges from an unacceptable situation 18 months ago. Mr Small reminded the Committee that a considerable amount of work and resources have gone into reducing delayed discharges, with additional spot purchasing of care. It is hoped that the situation will be more favourable with the integrated service.

The Committee:

 Noted the content of the General Manager’s Report.  Noted the comments made by the CHP Patient and Public Representative on the improvement in Delayed Discharges.

11.2 Balanced Scorecard

Mr Small referred to the circulated Balanced Scorecard and noted that the information was slightly out-of-date due to reporting timescales. Details around the target for less than 4% sickness absence was outlined; it was noted to be a challenge generally across NHS Scotland to achieve this level, especially during the winter months and with some members of staff having long lasting medical conditions. The number of patients who did not attend for their out-patient appointments was considered to be higher in Mental Health Services than other services, but initiatives are being developed to reduce this number. Mr Small advised that the issue of Healthy Weight of Children had been raised at Board level and at the Improvement Committee due to the challenges being face with achieving this target. It was recognised to be a national problem. Mrs McCreath added that work was ongoing within schools to highlight this health issue.

The Committee:

 Noted the challenges faced with timely completion of eKSF outlines for staff and the target relating to the Healthy Weight of Children.

12 STAFF GOVERNANCE

12.1 HR / Partnership Issues

Mrs MacRae reiterated concerns previously made known around the staff governance aspects of the integration and organisational structure changes.

The Committee Noted the position.

13 CLINICAL GOVERNANCE

13.1 CHP Infection Control

Mrs Hope referred to the circulated CHP Infection Control report, which included the CHP Infection Control Work Plan 2011/12, and advised that the work plan was on schedule / complete, with the exception of a short delay in the provision of training to support the implementation of best practice guidelines for cannulation, asceptic technique and for urinary catheters. The delay was due to the CHP Infection Control Nurse being required to cover other operational areas due to a vacancy in those areas.

8 Current infection control policies used within NHS Highland and Highland Council services will continue to be kept in place until such time as the new organisation was fully operational and policies are reviewed. Mrs Hope advised the Committee that HEI Environmental Audits of CHP Community Hospitals are on schedule with no outstanding issues.

The Committee:

 Agreed the CHP Infection Control Work Plan 2011/12.  Noted the delays in delivering the training required by the Work Plan.  Noted the ongoing HEI Environmental Audits of CHP Community Hospitals.

13.2 CHP Clinical Governance & Risk Management Report

It was noted that there was a revised reporting structure for clinical governance issues and that regular reports to managers are available on line. There were no comments upon the circulated report.

The Committee Noted the Clinical Governance & Risk Management Report.

13.3 CHP Clinical Governance & Risk Management Group

Dr Scott said that the governance structure for the new organisation was currently unknown, but that a robust clinical governance structure had been developed during the past two years by positive engagement by colleagues in the CHP Clinical Governance & Risk Management Group. A question was raised as to whether feedback was given on comments made in the recent inpatient survey, but Mrs Hope was unsure of such feedback facility.

The Committee Noted the minutes of the meetings held on 19 January and 8 March 2012.

14 AOCB

Mr Wood gave a note of thanks to the Committee for their professionalism in listening and reporting back to him during his six-year tenure as CHP Patient and Public Representative.

The Committee Noted the comments made by the CHP Patient and Public Representative.

The meeting closed at 3:50 pm

9

Highland NHS Board 5 June 2012 Item 3.6

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

DRAFT MINUTE of MEETING of the NHS Board Audit Committee Tuesday 15 May 2012 – 10.00 am Board Room, Assynt House

Present: Mr Ian Gibson, Chairman Mr Bill Brackenridge, NHS Board Non-Executive Mr Mike Evans, NHS Board Non-Executive Mrs Gillian McCreath, NHS Board Non-Executive Mr Okain McLennan, NHS Board Non-Executive

Also Present: Mrs Myra Duncan, NHS Board Non-Executive Mr Alasdair Lawton, NHS Board Non-Executive Designate Mr Ray Stewart, Employee Director Ms S Wedgwood, NHS Board Non-Executive

In Attendance: Mr Iain Addison, Head of Area Accounting Mr Chris Brown, Audit Partner, Scott-Moncrieff Ms Angela Canning, Assistant Director of Performance Audit, Audit Scotland (for Item 3) Mrs Barbara Hurst, Director of Performance Audit, Audit Scotland (for Item 3) Mr Nick Kenton, Director of Finance Mr Brian Mitchell, Board Committee Administrator Mr Stephen O’Hagan, Audit Scotland Mr Bill Reid, Head of eHealth (for Item 5.1 Info. Management) Mr Brian Robertson, Head of Operations, Community Care (for Item 5.2) Ms Suzanne Sutherland, Audit Manager, Scott-Moncrieff Ms Pearl Tate, Senior Audit Manager, Audit Scotland

1 WELCOME AND DECLARATION OF INTERESTS

1.1 Apologies

Apologies for absence were received on behalf of Mrs Jan Baird, Mr Bill Brackenridge, and Ms E Mead.

1.2 Declaration of Interests

Members were asked to consider whether they had an interest to declare in relation to any Item on the Agenda for this meeting. Mr A Lawton declared that he had been involved as part of the Gateway Review Team relating to the Planning for the Integration project. 2 MINUTE AND ACTION PLAN OF THE MEETING HELD ON 13 MARCH 2012

The Committee:

 Approved the Minute of the meeting held on 13 March 2012 subject to the following amendment:  Page 5, Item 4.2 – Replace Heading “Information Management” with “Information Governance”.  Noted the associated Action Plan, which would be updated for the next meeting.

3 ATTENDANCE BY AUDIT SCOTLAND REPRESENTATIVES

The Chair welcomed those representatives from Audit Scotland present at the meeting and advised there had been previous discussion at Audit Committee in relation to national Audit Scotland reports. There had been concern that some reports were not subject to clear direction for NHS Boards as to next steps and also in relation to perceived linkages between national and local Audit Scotland teams. The Audit Committee was keen to learn from best practice elsewhere and questioned how this was currently reported. Mrs B Hurst thanked the Committee for the chance to address this meeting and took the opportunity to advise as to the background relating to the Audit Scotland Performance audit programme. She indicated programme coverage, outlined the relevant strategic themes, appropriate sources of information and intelligence utilised, criteria for selection of review topics, current performance audits, and how local follow-up was achieved/impact was measured. She emphasised that authors of individual reports were available to attend Audit Committee meetings and discuss findings as required and stated that there were no existing constraints in terms of confidentiality when sharing information from other NHS organisations.

There followed discussion on a range of areas of interest including the independence of Audit Scotland to produce national reports, assisting organisations such as NHS Highland to gain added value through consideration of reports, local engagement, and contribution to establishing the national work programme. On this latter point Mrs Hurst urged that the NHS Board continue to identify areas of concern where review by Audit Scotland may be of benefit. On the issue of utilising reports in a proactive manner at local level it was stated that the checklist approach had proved beneficial and that a key element for the NHS Board was the ability of reports to provide shared learning from other organisations. On this point Mrs Hurst advised that a balanced judgment is taken when producing reports as to whether practice evidenced elsewhere is transferrable to other organisations although she did accept that providing further detail on process, for example, may prove beneficial. There was also discussion in relation to reporting on environmental issues and it was stated that further consideration in this area, with a particular focus on finance, would be useful. There was discussion about the scope of specific projects and the Chair agreed to provide further information to Mrs Hurst in relation to one report which, in the Committee’s opinion, had not identified significant implications for NHS performance and costs.

Members of the Committee were keen to promote greater engagement with Audit Scotland and suggested a process for informing the focus of future reviews would be welcome, perhaps through an annual discussion. Audit Scotland were also investigating the option of providing a web-based reporting system that would enable a far greater level of detail to be provided which NHS Board members may also find of particular interest. There was general agreement Non-Executive members of NHS Boards should be more coordinated in identifying particular areas of focus for reviews. Mrs Hurst agreed audit scope, and the associated area(s) of focus were key internal considerations prior to reviews being undertaken. Direction from external sources, on occasion, is sought to provide relevant expertise and advice. 2 The view was expressed that in addition to this element more direction for end users would assist organisations to utilise review findings most effectively, and this would be enhanced through local meetings and discussion with report authors.

After discussion, the Chair thanked Mrs Hurst and Ms Canning for attending the meeting and participating in discussion.

4 MATTERS ARISING

4.1 Revised Committee Role and Remit

There had been circulated revised Committee Role and Remit, this incorporating revisions relating to Executive attendance as previously discussed.

The Committee Agreed the revised Role and Remit document.

4.2 National Shared Instance Ledger Update

Mr I Addison advised the new ledger system had gone live. Issues relating to reporting functions were being addressed and it anticipated that first reports to managers would be issued at the end of May 2012.

The Committee so Noted.

4.3 Radiology Service Waiting List Initiative Review Update

The Chair advised assurance had been given in relation to the outstanding actions. In terms of assessment of the weekend working pilot, information relating to Radiologists activity is monitored on a weekly basis, including monitoring of workloads undertaken whilst working over weekends. In relation to the production of a job description for the Duty Radiologist, this had now been completed by the Radiology Head of Service. All actions would be subject to review by internal audit.

The Committee Noted the position.

4.4 Risk Register Update

The Chair advised that an appropriate allocation for review of Planning for Integration had been included within the draft Internal Audit Plan. In relation to incorporating relevant risks into the NHS Highland Corporate Risk Register, this had yet to be evidenced.

The Committee Noted the position and Agreed it be requested that the Corporate Risk Register be updated in time for the June meeting of the NHS Board.

3 5 INTERNAL AUDIT

5.1 Internal Audit Workplan Progress Report

There had been circulated a copy of the progress report, which summarised Internal Audit work undertaken up to 15 May 2012, including seven reports. There was one Red Control Objective Assessment and two Grade 4 issues raised, all in relation to the Consultants Contracts Review. The report indicated 97% of the Internal Audit timetable for 2011/2012 had been completed, and work had commenced on the 2012/2013 programme. The report indicated those Reviews in relation to which fieldwork was in progress or now complete and it was advised the review of NMAHP Establishment would be reported to the next meeting.

The Committee then considered the following reports:

 Information Management

Mr C Brown spoke to the circulated report which concluded that good progress had been made on the systems surrounding Information Management. Progress was being made toward an electronic patient record system that will support clinical decisions through reliable and up to date information. An integrated information management system, via the intranet, also provides management with up to date information and the next stage will be to integrate Argyll and Bute data. It was stated there was a need for action to formalise the arrangements and to demonstrate to stakeholders that information needs have been understood and will be met. The report indicated that the arrangements over Information Management would be strengthened through full implementation of recommendations from previous reports, including in relation to project management. Mr B Reid confirmed that he was committed to providing an updated Information Strategy by December 2012, and current focus of activity related to provision of required data, where progress was being made in relation to providing this in a web based format. On the question raised, as to ensuring information was provided on a needs led basis, Mr Reid advised that eHealth was working with ISD to determine stakeholder requirements in addition to those of a statutory nature. There was greater line reporting now taking place than before. PAS data from Argyll and Bute would require to be incorporated. On the issue of an Asset Register, the key was to be able to make best use of this and was achieved through provision of a Core Information Dataset.

Mr B Reid left the meeting at 11.00am

 Consultants Contracts

Ms S Sutherland spoke to the circulated report, which represented a compliance review, and which concluded that improvements are required to the arrangements surrounding Consultant’s contracts to ensure they fully comply with the terms and conditions of the national Consultant Contract. The report identified three areas, which if addressed would support the Board in ensuring Consultant job plans are in line with the national Contract.

The Committee was disappointed that misunderstanding had resulted in no management representation being available to clarify elements of the management response. During discussion on the process for reviewing contracts the Committee felt that the management response lacked clarity as to where ultimate responsibility lay. There was agreement that positive dialogue was required between management and Consultants and this was considered a strategic issue for the NHS Board to consider. It was stated this was a complex matter to address and the matter of participation was of concern as there should be a formal process whereby by that aspect was assessed and formally signed-off. This report added to previous issues that had been highlighted to the Committee, such as Consultant leave arrangements, and it was clear there was a need to plan service delivery on a patient-needs 4 basis, especially in light of the future service delivery changes that would be required in NHS Highland. It was acknowledged that job plans were in place; however there was need for these to be adequately reviewed and signed-off to ensure these were fit for purpose in light of NHS Board strategy etc. The Committee was looking for assurance that individual job plans were not signed off in isolation without the appropriate strategic overview. There was a need for assurance at NHS Board level that appropriate decisions were being taken by the appropriate officers.

 GMS Payments

Ms S Sutherland spoke to the summary report which concluded that the arrangements and controls in place for monitoring and reviewing payments to GP practices for enhanced services are in place and generally working effectively. The report indicated a number of areas, which if addressed, would strengthen the arrangements over enhanced payments as indicated. In addition, in relation to previous recommendations there had yet to be progress made on the issue of HCH Payments in Argyll and Bute CHP which is included in the NHS Board Action Plan.

 Out of Area Care

Ms S Sutherland spoke to the circulated summary report which concluded the relevant process for managing out of area care for Highland residents is operating effectively, with good practice evident throughout the process. The report indicated two areas, if addressed, would strengthen the approach for agreeing and monitoring Service Level Agreements (SLAs) as indicated. A similar review would be undertaken in 2013/2014 in relation to care where NHS Highland was the provider. During discussion, the view was expressed that the use of SLAs should be reviewed in cases of high volume patient numbers, and that a robust costing methodology was required. Mr C Brown advised it would not be possible to introduce legal, costed, enforceable contracts, and further stated Health Service costings was an issue across NHS Boards. He did advise, however that the system of data capture within NHS Highland allowed for effective discussion on these points and robust negotiation. Mr N Kenton advised previous national tariff discussion had stalled due to the complexity of the issues involved, that NHS Highland data had proved invaluable in discussion/negotiation to date, and agreed this subject did pose a risk to NHS Highland. Any move to replace existing SLAs with an alternative approach carried associated organisational risks.

The Committee adjourned at 11.30 am and resumed the meeting at 11.35 am.

 Best Value Assurance Model

Mr C Brown spoke to the circulated summary report which found that NHS Highland is delivering against each of the Scottish Government’s seven themes of best value, as indicated. There was however no framework in place to demonstrate how the organisation was delivering against each of these themes. The circulated report incorporated a draft best value framework which would allow the NHS Board to evidence delivery of best value and to identify if further work was required in specific areas to drive through continuous improvement. Continuous improvement, management, and governance were the key issues to consider in relation to best value and NHS Boards were required to have an Accountable Officer approach in place. There was a need to build on existing assurance delivery activity and provision of this to Committee level may form part of the next stage of consideration. During discussion, a number of points were raised in relation to the utilisation of Audit Scotland Best Value Toolkits, the inclusion of evidence in the draft framework relating to complaint management, and overall level of evidence included to date. Mr C Brown emphasised the framework was a first draft at this stage. Ms S Wedgwood stated there was a need for the NHS Board to input into this overall process given the significant organisational risks involved as there was a need to be able to challenge Accountable 5 Officers as required. Mr C Brown stated that a range of appropriate activity can be evidenced, and the next stage would be to provide support to management to fulfil the governance role, this being an issue for NHS Boards across Scotland, and may include elements that would be undertaken by relevant Committees. The Chair welcomed the potential involvement of Committees. Ms P Tate stated the work to date represented a good starting point for Best Value activity, encouraged the use of relevant toolkits to develop specific areas, and stated the evidence process should be taken forward with a view to ensuring continuous improvement. There was agreement as to the importance of this activity in light of the current Integrating Care agenda. Internal Audit agreed to help take this framework forward to the next stage of development.

 Governance Statement Readiness 2011/2012

Mr C Brown spoke to the circulated report which concluded that NHS Highland has a framework of controls in place that includes the key documentation and internal controls expected in relation to the four strands of governance outlined in Scottish Government guidance. The Governance Statement varied from the Statement of Internal Control required in previous years. The Scottish Public Finance Manual (SPFM) Internal Control Checklist had been completed, the detailed findings in relation to which were outlined. The report highlighted three issues to be considered in preparation of the Governance Statement 2011/012 and these related to assessment of compliance with the UK Corporate Governance Code, Self-assessment in relation to Board and Committee effectiveness, and a framework for providing the Accountable Officer with overt assurance on Best Value in year. The latter point had been discussed under the previous Item. With regard to self assessment, there was a recommendation that this be completed in advance of the Governance Statement being presented to the next Audit Committee and NHS Board meeting, or that disclosure be made in the Statement that this will be completed in 2012/2013.

 Follow Up

Ms S Sutherland spoke to the circulated report summarising progress made in implementing agreed management actions arising from internal audit reviews. It was advised that 51 actions had been closed and a further 20 removed where management had deemed the associated risk acceptable. A number of outstanding actions were partially complete and it was noted no updates had been received for 26 recommendations, an issue that would be raised with the Senior Management Team to encourage greater future engagement. The current audit tracker now contained a total of 77 recommendations, 62 raised in 2010/2011 and 15 in 2009/2010. Ms Sutherland advised that a number of items may require further review rather than follow up action. The process for ensuring follow up should be more robust, and the audit tracker updated on a more regular basis.

The Committee:

 Noted the circulated review summaries.  Agreed the Consultant Contract review findings be referred to the Director of Human Resources and Board Medical Director.  Agreed an update on the Consultant Contract Review be brought to the next meeting.  Agreed the Senior Management Team ensure a system is established to ensure that audit recommendations are implemented timeously.  Agreed a response be sought for the next NHS Board meeting in relation to HCH payments.

The Committee agreed to consider the following two Items at this point in the meeting.

6 5.2 Integrating Care in the Highlands – An Audit Perspective

Mr I Addison spoke to the circulated report advising budgets for areas of responsibility transferring between organisations had been determined for each particular area, broken down to budget managers and integrated within respective organisations. Expenditure is therefore to be included as an integral part of reporting to budget managers and reliance will be made on existing systems. Performance measures will be put in place to measure the quality of service delivered and reported to the commissioning partner. It was advised that relevant audit resources would targeted at areas of highest risk and there was also circulated the proposed internal audit plan for activity in this area in 2012/2013 and 2013/2014. The three new key risk areas for NHS Highland were in relation to the Highland Council delivering on the statutory responsibility in relation to safe and effective children’s services, adult social care expenditure, and delivery of adult services as per the contractual agreement with Highland Council. It was advised the delegation of delivery of children’s services will be measured and assessed through a performance framework. Similarly NHS Highland would be subject to performance measurement for delivery of adult social care services. Relevant inherent risks were, as previously discussed, being scoped and incorporated into the NHS Highland Risk Register. The report indicated that some support services would continue to be delivered from within their original host organisations and as such there would be liaison between respective internal audit teams to ensure all relevant reports are shared and available to the Audit Committee. Ms S Sutherland advised she had met with the Highland Council internal audit team, and the Head of Operations for Community Care to gain a better understanding of the relevant audit areas. It was clear that a risk existed in relation to adequacy of transferring financial resource relating to future service delivery, as well as ensuring the safe and effective delivery of those services. The circulated proposed audit plan remained in draft at this stage and as such members were invited to provide feedback. Mr B Robertson advised there were cultural issues between the two partners agencies and stated that definition of risk required to be clarified with the Head of Quality. It was anticipated that a NHS Highland high level risk register would be completed by June 2012. Mr S O’Hagan confirmed that Audit Scotland was also working with Highland Council to ensure evaluation of risk areas.

During discussion, there was concern that reliance would be placed on systems outwith the immediate control of the NHS Board and that there would be a need for access to all relevant data to gain assurance and provide appropriate governance where appropriate. There was not full confidence that data needed for assurance would be available. Mr C Brown emphasised these areas were part of the current audit plan activity relating to Integration Project Management arrangements. Mr M Evans voiced concern that six weeks after moving to the new integrated arrangements all relevant risks had yet to be identified and this point was echoed by the Chair, who restated the need for the NHS Board to ensure a comprehensive, integrated Risk Register is established and put in place at an early date. Mr C Brown stated that the key element was to ensure appropriate transparency between organisations to enable required assurance to be given that enables appropriate action to be taken as and where required. There was reference to the measurement of outcomes and benefits of integration and it was agreed this was an issue for the NHS Board to consider. On the point raised by Mr O McLennan, it was advised reference to financial assessments related to those undertaken in relation to individual care packages for adult services.

After discussion, the Committee:

 Agreed that reliance can be placed on the Performance Framework for the delivery of children’s services delegated to the Highland Council and that detailed audit of those services is not required.  Agreed similar, reverse, principles will be applied in relation to adult social care services.

7  Agreed the need for an integrated Risk Register to be established at an early date.  Agreed the need for the NHS Board to consider issues relating to outcome measurement and benefits realisation.

Mr B Robertson left the meeting at 12.15pm

5.3 Internal Audit Plan 2012/2013

Mr C Brown spoke to the circulated Internal Audit Plan for 2012/203, an earlier iteration of which had been considered by the Clinical Governance Chair and Senior Management Team. The plan was submitted for approval by the Audit Committee. The Chair referred to the Waiting Times audit that had been directed by the Scottish Government and on the point raised was advised that the audit period was to the end of June 2012, was reliant on ISD data that was not released until August 2012, and as such activity would be delayed until that point. Mr I Addison advised that NHS Boards were required to submit audit results by mid December 2012 and were also required to have had these considered by a meeting of the Audit Committee and NHS Board prior to submission. It was proposed that meetings be held on the same day as the NHS Board Development Strategy Event on 6 November 2012. There was agreement that assurance previously received in relation to waiting times at the Improvement Committee negated the need for early additional assessment. The issue of associated leadership and cultural issues was raised and it was advised that the NHS Board Chair was establishing a working group to examine this. There was also reference to the removal of the review of Budget Management from the 2012/2013 plan and the Committee was advised that given a previous review had been conducted this activity could be undertaken as part of the relevant follow up activity, incorporating elements relating to Raigmore and North Highland CHP budgets. The review of savings plans would also incorporate related activity. Mr M Evans emphasised the need for assurance in relation to relevant budget processes.

After discussion, the Committee:

 Agreed that Audit Area B1 be re-designated as “Identifying and Managing Risk”.  Noted special meetings of the Committee, and NHS Board would be convened on 6 November 2012 to consider review findings relating to Waiting Times.  Otherwise Approved the Internal Audit Plan 2012/2013.

5.4 Laboratory Managed Service Contract Review

Mr N Kenton spoke to the circulated report relating to review of a contract for the provision of laboratory services within a managed service contract. The annual contract value had been assessed and subsequently actual costs had exceeded those expected. Given this was the first contract of this nature entered into by NHS Highland, Messrs Scott-Moncrieff had been requested to conduct an appropriate audit review. This review sought to establish that the initial contract had been established correctly and in line with best practice, that service levels were consistent with contractual arrangements, and that incurred costs were in line with the terms of the contract. The circulated review raised a number of specific areas to be considered. Findings indicated these issues required to be addressed both in respect of this particular contract and to ensure appropriate controls are in place to prevent these issues emerging again. Additional recommendations sought to address issues relating to contract administration, performance reporting, contract management, and contractual position. Work was underway to address all the recommendations raised and would involve General and Service Managers, Finance and appropriate legal advice to establish a detailed action plan that will provide the appropriate level of assurance that matters have been addressed. 8 A new Laboratory Service Manager, with relevant contract management experience had been appointed and was to take the lead role in developing and implementing the Action Plan. The Action Plan would be available for submission to the next meeting.

During discussion, Mr N Kenton confirmed discussion with senior management of the relevant contractor had resulted in agreement that future issues would be discussed as appropriate, helping to ensure maximum benefit from the remaining tender period. The Head of Procurement would help provide training to personnel involved in future tender arrangements of this type. In response to points raised in relation to the award of the tender, it was advised this had been signed off by an appropriately authorised officer, evaluation had been extremely complex, and there had been a lack of coordinated expert discussion between relevant staff during the overall process. Mr R Stewart stated the report highlighted a number of important aspects in relation to the award of this particular contract that required to be considered further. There was agreement that procurement and contract management required to be subject to expert consideration, with engagement of third party expertise where required.

After discussion, the Committee:

 Noted the content of the review of the Laboratory Managed Service Contract.  Noted work was underway to address the recommendations and develop an appropriate Action Plan.  Noted a progress report would be submitted to the next meeting.

6 ASSURANCE REPORTS

6.1 Audit Assurance Reports on External Systems

It was advised that National Services (NSS) internal audit reports relating to national systems which are operated on behalf of all Health Boards will be reported to the next meeting.

7 INTERNAL AUDIT

There were no matters discussed under this Item.

8 ANNUAL ACCOUNTS 2011/2012

8.1 Draft Accounting Policies

Mr I Addison spoke to the circulated paper outlining the accounting Policies applied in the preparation of financial statements for 2011/2012, in conformity with International Financial Reporting Standards. There were two prior year end adjustments, due to legislative changes, that would impact on a number of NHS Boards, relating to the elimination of the Donated Asset Reserve and the Transfer of Prisoner Healthcare to NHS Scotland. NHS Highland financial statements for 2012 would comply with all the versions of IFRS effective as at the reporting date of 31 March 2012. Mr M Evans raised the issue of Depreciation and was advised all NHS Boards in Scotland applied the same Policy

The Committee Approved the draft Accounting Policies.

9 9 COUNTER FRAUD

There had been circulated CEL15(2012) document announcing an updated Partnership Agreement between NHSScotland Counter Fraud Services (CFS) and NHS Board and special Health Boards. In addition, Mr O McLennan advised there were two cases currently under investigation.

The Committee Noted the position.

10 CORPORATE GOVERNANCE

10.1 Annual Reports

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

 Audit Committee  Staff Governance Committee  Remuneration Sub Committee  Clinical Governance Committee  Improvement Committee  Risk Management Steering Group  Endowments Fund Committee  North Highland CHP  Mid Highland CHP  South East Highland CHP  Argyll and Bute CHP  Raigmore Hospital Governance Committee  Spiritual Care Committee  Control of Infection Committee  Health and Safety Committee  Pharmacy Practices

The Committee:

 Noted the Annual Reports received.  Noted that a further Audit Committee report would be submitted to the meeting to be held on 11 September 2012.

10.2 Standing Financial Instructions

The Committee was advised no changes are required to the SFI’s previously approved in May 2010. The SFI’s are a permanent set of instructions which do not change over time and they are also subject to review as part of the audit process. With regard to Delegated Levels of Authority, these continue to be monitored and adjusted monthly to reflect staffing changes, including those under Integrating Care in the Highlands and changes in authorisation levels. 10 The Committee Noted the position.

11 FINANCIAL GOVERNANCE

11.1 Tender Waiver Register

There had been circulated Tender Waiver Register 2011/2012. Mr R Stewart stated it was unusual to see waivers in relation to staffing positions.

The Committee otherwise Noted the Tender Waiver Register 2011/2012.

12 AUDIT SCOTLAND

12.1 Action Sheets for National Audit Scotland Reports

There had been circulated report incorporating actions sheets relating to the Audit Scotland reports submitted to the March 2012 Audit Committee in relation to the Review of Cardiology Services, the Overview of NHS Performance in Scotland 2010/2011, and the Commissioning of Social Care.

The Committee:

 Noted the report relating to Cardiology would be submitted to the Quality Board and thereafter to the Clinical Governance Committee.  Noted the report on NHS Performance would be considered by a future Development Session of the NHS Board.  Noted the report on Social Care would be discussed with the Head of Quality.

13 ANY OTHER COMPETENT BUSINESS

There were no matters raised under this Item.

14 DATE OF NEXT MEETING

The next scheduled meeting was due to be held on 29 June 2012 however the Committee was advised Annual Accounts are required to be submitted by a specified due date and given the calendar in 2012, and the associated availability of key personnel, there may be a need to revise the date and time of that meeting.

After the meeting it was agreed that the next meeting be held on the morning of 18 June 2012. The Annual Accounts will be presented to this meeting, after which a special meeting of the NHS Board will be held in order that these may be signed off accordingly.

The meeting closed at 1.10 pm.

11

Highland NHS Board 5 June 2012 Item 3.7

CLINICAL GOVERNANCE COMMITTEE

Report by Mirian Morrison, Clinical Governance Development Manager

The Board is asked to:

 Note that the Clinical Governance Committee met on the 8 May 2012 with attendance as noted below.  Note the Assurance Report and agreed actions resulting from the consideration of the specific items detailed below.  Note the items for discussion at the next meeting to be held on the 7 August 2012.

Committee Members Ms Sarah Wedgwood, Chair Dr Ian Bashford, Medical Director Dr Paul Davidson, Clinical Director, North & West Highland Operational Unit Dr Michael Hall, Clinical Director, Argyll & Bute CHP (videoconference) Mrs Liz McClurg, Infection Control Manager Ms Heidi May, Nurse Director Ms Elaine Mead, Chief Executive Mr Michael Roberts, Public Member Mr Brian Robertson, Head of Adult Social Care Dr Vivian Shelley, Non-Executive Director Mr Alan Simmons, Public Member Dr Lesley Anne Smith, Head of Quality Dr Margaret Somerville, Director of Public Health Mr Ray Stewart, Employee Director

Also Present: Mr Ian Gibson, Non-Executive Director

In Attendance: Ms Catherine Brogan, Internal Audit Mr Bill Reid, Head of eHealth (item 6.4) Ms Christine McArthur, Falls Prevention Coordinator (item 7.0) Mr John Mackintosh, Clinical Governance Facilitator (item 7.0) Ms Lynn Garrett, Tissue Viability Nurse Specialist, Argyll & Bute CHP (item 7.0)) Mrs Mirian Morrison, Clinical Governance Development Manager Miss Irene Robertson, Board Committee Administrator

Apologies - Mr Garry Coutts, Dr Iain Kennedy, Dr Roderick Harvey, Mrs Una Lyon, Dr Ian Scott and Mrs Katherine Sutton

1. ITEMS FOR DISCUSSION The items discussed at the meeting are noted below: i. Number of hospital deaths occurring at weekends compared to during the week ii. Clostridium difficile Outbreak, Raigmore Hospital iii. Case Study iv. Annual Work Plan v. Evaluation of the Committee’s Effectiveness vi. Clinical Governance Committee Annual Report 2011-12 vii. Performance Report – Complaints viii. Performance Report - Incidents ix. NHS Highland Information Governance and Area Medical Records Committee x. NHS Highland Information Governance Review – response to Internal Audit Report xi. NHS Highland ehealth Delivery Plan 2011-2014 xii. Older People’s Services/Dementia Standards xiii. Falls Prevention xiv. Tissue Viability – Pressure Ulcer Prevention xv. Healthcare Improvement Scotland xvi. Strategic Clinical Risk Register xvii. Reports from the Operational Units

2. ITEMS FOR DISCUSSION AT NEXT MEETING ON 7th August 2012  Emerging Issues  Case Study  Questions from lay members  Evaluation of the Committee’s Effectiveness  Scottish Patient Safety Programme Report  Clinical Governance and Risk Management Report  Patient Bill of Rights  Annual Report Clinical Ethics Committee  Feedback on experiences of Highland residents treated out of area  Medical and Surgical Profiles  Quality and Patient Safety Framework  Measurements and Monitoring  Quality Dashboards  Clinical Governance Forum  SPSO  Integration Agenda and implications for the Clinical Governance Committee  Clostridium Difficile Outbreak  Annual Report Clinical Ethics Committee

3. CONTRIBUTION TO CORPORATE OBJECTIVES

This performance report demonstrates how NHS Highland is achieving its corporate objective of ensuring that services delivered are of high quality and clinically effective.

4. GOVERNANCE IMPLICATIONS

This performance report has a direct impact on clinical governance and demonstrates performance against responding to complaints, clinical effectiveness activity, patient safety and NHS Healthcare Improvement Scotland reviews.

5. IMPACT ASSESSMENT

This report does not require impact assessment.

Mirian Morrison Clinical Governance Development Manager

25 May 2012

2 CLINICAL GOVERNANCE COMMITTEE – ASSURANCE REPORT Meeting – 8 May 2012

1. ISSUE: Number of hospital deaths occurring at weekends compared to during the week

Issues/Risks Assurance Actions

The Committee’s role The Committee requires The committee was informed of the The findings of this work would be and remit includes assurance that the number of review of data being undertaken in presented to a future committee meeting. review outcomes. deaths at the weekend was not Raigmore Hospital and the ongoing higher than during the week. work being undertaken to analyse deaths over the course of the year.

This work would be extended to the community hospital in due course. Action- Dr Lesley Anne Smith, Head of Quality The committee was assured that the death rate in NHS Highland hospitals was monitored on a regular basis as part of the Scottish Patient Safety Programme and reported quarterly as HSMR figures.

2. ISSUE: Clostridium difficile Outbreak , Raigmore Hospital

Issues/Risks Assurance Actions

The Committee’s role The Committee requires The committee was informed of the The findings of the investigation would be and remit includes assurance that action was been outbreak in Raigmore Hospital and presented to a future committee meeting. receiving reports on taken to address the problems. the ongoing investigation. A task any problems that force team had been set up for this emerge. purpose and would be reporting on the findings, identifying actions and Action – Heidi May, Board Nursing learning points. Director 2. ISSUE: Case Study

Issues/Risks Assurance Actions

The Committee’s role The Committee requires The committee was circulated with a  It was agreed that a full report and and remit includes assurance that action was been case study regarding a complaint actions taken would be brought to receiving reports on taken to address the problems. regarding medication. the committee meeting in any problems that November. emerge. Action was being taken to address the issues identified in the complaint. Action – Heidi May, Board Nursing Director

3. ISSUE: Clinical Governance and Risk Management Performance Report - Complaints

Issues/Risks Assurance Actions

The Committee’s role The Committee requires The committee received a detailed A complaints performance report would and remit includes assurance that clinical report on performance against the 20 be presented to each committee meeting. providing assurance governance systems and process working day target and an analysis of that clinical are in place all complaints received in February. governance systems are in place and From this analysis a number of working. complaints should have been responded to within the target and this Action- Mirian Morrison, Clinical would have result in the 80% target Governance Development Manager being achieved.

Further work was ongoing to provide further support for managers who investigated complaints.

4 4. ISSUE: Clinical Governance and Risk Management Performance Report - Incidents

Issues/Risks Assurance Actions

The Committee’s role The Committee requires The committee received a report in a An incident performance report would be and remit includes assurance that clinical dashboard format of incidents presented to each committee meeting. providing assurance governance systems and process reported for the 4th quarter in 2011/12. that clinical are in place. governance systems All incidents that are identified as are in place and having a consequence of major or working. extreme required to be robustly investigated. A report on such incidents in the 4th quarter was included in the report, for the committee to review what had happened as a result of the incidents and action taken. Action- Mirian Morrison, Clinical The committee were informed of the Governance Development Manager ongoing work to improve the dashboard report.

Further training on the use of DATIX was being organised.

5. ISSUE: NHS Highland Information Governance and Area Medical Records Committee

Issues/Risks Assurance Actions

The Committee’s role The Committee requires The committee received a report on The Information Governance and Area and remit includes assurance that clinical proposed revised reporting Medical Records committees would report providing assurance governance systems and process arrangements for the two committees. to the committee. that clinical are in place. The recommendation was that these governance systems committees should report to the A learning and development session on are in place and information governance would be

5 working. clinical governance committee. organised in the future.

This proposal was agreed on the Action- Bill Reid, Head of eHealth understanding that the committee would provide high level scrutiny of information governance.

6. ISSUE: NHS Highland Information Governance Review – response to Internal Audit Report

Issues/Risks Assurance Actions

The Committee’s role The Committee requires The committee was informed that the It was agreed that a report on the and remit includes assurance that clinical Board’s Internal Auditors had carried progress with the development of an providing assurance governance systems and process out a review of information Information Asset Register would be that clinical are in place. governance arrangements. A report brought to a future meeting. governance systems had been prepared with agreed action are in place and being approved by the Audit working. Committee.

The committee was assured that robust arrangements were in place Action- Bill Reid, Head of eHealth plan.

It was noted that one of the recommendations was the development of an Information Asset Register.

6 7. ISSUE: Older People’s Services/Dementia Standards

Issues/Risks Assurance Actions

The Committee’s role The Committee requires The Board Nurse Director updated the A presentation on Food, Fluid and and remit includes assurance that clinical committee on the key work streams to Nutritional Care would be given at future providing assurance governance systems and process improve care for older people. committee meeting. that clinical are in place. Regular reports would be submitted to governance systems the committee. are in place and working. She continued by informing the Action – Heidi May, Board Nursing committee that HEI would be Director inspecting Raigmore Hospital in the near future.

8. ISSUE: Falls Prevention

Issues/Risks Assurance Actions

The Committee’s role The Committee requires The Falls Prevention Co-ordinator and remit includes assurance that systems and gave a presentation on the work that interrogating clinical processes in place to ensure safe has ongoing to reduce harm to governance systems. and effective patient care. patients.

Information on falls was now available in a dashboard format to enable comparisons to be made at hospital and ward level.

7 9. ISSUE: Tissue viability – Pressure Ulcer Prevention

Issues/Risks Assurance Actions

The Committee’s role The Committee requires The Tissue Viability Nurse Specialist and remit includes assurance that systems and gave a presentation on the work on interrogating clinical processes in place to ensure safe reducing the risk and prevention of governance systems. and effective patient care. pressure ulcers.

10. ISSUE: Strategic Clinical Risk Register

Issues/Risks Assurance Actions

The Committee’s role The Committee requires The committee was informed that the An update on progress would be and remit includes assurance that clinical Audit Committee had approved the submitted the next meeting. providing assurance governance systems and process NHS Highland Risk Register and had that clinical are in place. agreed the arrangements for the governance systems management of risks. are in place and Action- Sarah Wedgwood, Chair, Clinical working. A number of risks had been identified Governance Committee that the committee would be responsible for seeking assurance that work was being taken forward to minimise or eradicate the risk.

The chair advised that she would be having further discussions on the risk register with the Head of Quality and chairs of the Staff and Audit Committees.

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

DRAFT MINUTE of MEETING of the Clinical Governance Committee 8 May 2012 - 9.15am Board Room, Assynt House

Present: Ms Sarah Wedgwood, Chair Dr Ian Bashford, Medical Director Dr Paul Davidson, Clinical Director, North & West Highland Operational Unit Dr Michael Hall, Clinical Director, Argyll & Bute CHP (videoconference) Mrs Liz McClurg, Infection Control Manager Ms Heidi May, Nurse Director Ms Elaine Mead, Chief Executive Mr Michael Roberts, Public Member Mr Brian Robertson, Head of Adult Social Care Dr Vivian Shelley, Non-Executive Director Mr Alan Simmons, Public Member Dr Lesley Anne Smith, Head of Quality Dr Margaret Somerville, Director of Public Health Mr Ray Stewart, Employee Director

Also Present: Mr Ian Gibson, Non-Executive Director

In Attendance: Ms Catherine Brogan, Internal Audit Mr Bill Reid, Head of eHealth (item 6.4) Ms Christine McArthur, Falls Prevention Coordinator (item 7.1a) Mr John MacKintosh, Clinical Governance Facilitator (item 7.1a) Ms Lynn Garrett, Tissue Viability Nurse Specialist, Argyll & Bute CHP (item 7.1b) Mrs Mirian Morrison, Clinical Governance Development Manager Miss Irene Robertson, Board Committee Administrator

1 WELCOME AND APOLOGIES

Apologies were noted from Mr Garry Coutts, Dr Iain Kennedy, Dr Roderick Harvey, Ms Una Lyon, Dr Ian Scott and Ms Katherine Sutton.

The Chair advised that she had invited the Clinical Directors of the Operational Units, the Associate Director – Allied Health Professions, and the Head of Adult Social Care to join the Committee in recognition of the revised structure and governance arrangements. She was pleased to welcome Dr Paul Davidson, Clinical Director, North & West Highland Operational Unit and Dr Michael Hall, Clinical Director, Argyll & Bute CHP to their first meeting of the Committee. A welcome was also extended to Catherine Brogan from Scott-Moncrieff, the Board’s Internal Auditors, who have been asked to undertake a review of the clinical governance process within NHS Highland and its effectiveness. With regard to the survey on the Clinical Governance Committee’s effectiveness the Chair proposed to defer this item to the next meeting to allow members more time to respond and enable an evaluation to be undertaken, the report to be circulated to the members in advance of the meeting. This was agreed.

Before the commencement of business Sarah Wedgwood wished to thank Dr Vivian Shelley, whose term as a Non-Executive Director of the Board would expire on 31 May 2012, for all her help in steering her through her first year as Chair of the Clinical Governance Committee. Dr Lesley Anne Smith thanked Dr Shelley on behalf of all her colleagues in the Quality Team and the Clinical Governance Support Team for her support and input to the clinical governance agenda.

2 DECLARATIONS OF INTEREST

There were no declarations of interest made.

3 MINUTE OF MEETING HELD ON 14 FEBRUARY 2012

The Minute of meeting held on 14 February 2012 was approved.

The Committee noted the rolling action plan which had been circulated with the Minute. It was remitted to Dr Lesley Anne Smith and Mirian Morrison to review the document in terms of its content and format. The Chair noted a number of topics to be added to the plan and would liaise with Dr Ian Bashford regarding identifying lead officers for each piece of work.

4 MATTERS ARISING

4.1 Questions from Lay Members a. Living Wills

The Chair advised that this topic would be addressed at the next meeting. b. Numbers of hospital deaths occurring at weekends compared to during the week

Dr Lesley Anne Smith reported on a review of data being undertaken in relation to deaths at Raigmore Hospital during January – March 2012 by day of the week. She referred to a UK wide study which, because of the very large sample size, was able to identify significant differences. For example, the findings showed that there were fewer deaths at the weekend but that there was a statistically significant increase in the number of deaths occurring within 30 days of patients admitted at the weekend. Where the sample size was small, as was the case with the Raigmore study, Dr Smith advised that analysis of the data was complex and that it may not identify any differences. A further piece of work was to be carried out analysing deaths over the course of a year at Raigmore to see if a statistically significant difference was found in relation to patients being admitted at the weekend. She was able to assure the Committee that the death rate in NHS Highland hospitals was monitored on a regular basis as part of the Scottish Patient Safety Programme and reported quarterly as HSMR figures. Dr Smith confirmed that it was the intention to extend the methodology in due course to community hospitals.

2 The Committee Noted the ongoing activity and would look forward to receiving a report of the findings in due course.

4.2 Clostridium difficile Outbreak, Raigmore Hospital

Heidi May updated the Committee on this incident and a further outbreak that had occurred in another ward at Raigmore. She agreed to arrange for Una Lyon, Lead Nurse, Raigmore to present the findings to the Committee on completion of the investigations. The importance of taking forward the actions and rolling out learning points from these incidents was highlighted. It was noted that a task force had been established for this purpose. In response to a concern expressed by Alan Simmons, who was a member of the task force, Heidi May undertook to follow up on scheduling arrangements and attendance at meetings of the task force to ensure priority was given to its work.

The Committee:

 Noted that Heidi May would arrange for the findings of the investigations to be presented to a future meeting.  Noted that Heidi May would follow up on the working arrangements of the task force to ensure they were given the necessary priority.

5 PERSON CENTRED

5.1 Case Study

The Committee noted the circulated case study together with a copy of NHS Highland’s response to the issues raised by the complainants relating to medication. Mirian Morrison advised that feedback from the family concerned had been positive. The Committee also gained assurance from the response that all the issues were being addressed and learning from the incident was being applied. The importance of communication between clinical staff and adherence to nursing standards and principles was emphasised. Heidi May reported on the ongoing work regarding medication errors in terms of training and monitoring. Dr Lesley Anne Smith noted the arrangements for reporting incidents on the Datix system and outlined managers’ responsibilities at operational level in relation to accessing the data and feeding back to ward/departmental staff on relevant issues. At strategic level she advised that she would be attending the Area Drug and Therapeutics Committee (ADTC) to highlight the incident and reinforce the message in relation to operational responsibilities. It was noted that the issues had already been discussed at the Medicines Safety Sub Group of the ADTC. The Committee agreed to have a follow up report at the November meeting to provide assurance that actions arising from the incident had been implemented and learning points shared across the area.

The Committee:

 Noted the issues identified in the case study and the actions being taken to address them.  Agreed to have a follow up report on the incident at its meeting in November 2012.

5.3 Questions from Lay Members of the Committee

There were no issues raised. 3 6 STRUCTURES AND PROCESSES

6.1 Clinical Governance within the Quality Strategy and Implications for Integration a. Annual Work Plan

There was circulated copy of the Committee’s work plan for 2012 – 2013. This was noted and approved.

The Committee Agreed its work plan for 2012 – 2013. b. Evaluation of the Committee’s effectiveness

The Committee noted the feedback report which Dr Lesley Anne Smith had prepared based on the responses received to date to the survey. As agreed earlier in the meeting, this item would be discussed at the next meeting.

The Committee Agreed to defer this item to its next meeting in August 2012.

6.2 Clinical Governance Committee Annual Report 2011 – 2012

There was circulated draft Annual Report summarising the Committee’s activity during 2011 – 2012. The Chair took the opportunity to reiterate her thanks to Dr Vivian Shelley for her advice and support during the year, she also wished to thank the Clinical Governance Support Team for all their work.

The Committee Approved the content of its Annual Report for 2011 – 2012 which would be submitted to the Audit Committee meeting to be held on 15 May 2012.

6.3 Clinical Governance and Risk Management Performance Report - Complaints

Mirian Morrison spoke to her circulated report detailing performance against the 20 day response target and providing an analysis of all complaints received in February 2012. During this period six complaints were not responded to within the target time, largely due to their complexity which required more detailed investigation across several units. In this connection the Chair confirmed that there would be a learning development session at the August meeting around clinical pathways and the patient’s journey in the context of integration.

Mrs Morrison referred to the revised arrangements that had been put in place, as a result of which the complaints procedure and processes were now more robust. Dr Paul Davidson noted that the position in the former North and Mid Highland CHPs required some improvement. Mrs Morrison reported that the process for identifying lead investigating officers and rolling out the Datix complaints module had been put on hold in that area pending the new structure and governance arrangements being established. She acknowledged the need for further training and support for investigating officers and advised that a complaints resource pack was being developed. There may be some learning from other units that could be shared. Dr Michael Hall reported on the robust system in place in Argyll & Bute CHP for dealing with complex complaints. There were also cultural and behavioural issues to be addressed and it was suggested the Staff Governance Committee may wish to give consideration to this aspect.

4 The Committee Noted performance against the 20 day response target and the work ongoing in relation to training and support for complaints officers to further improve the position.

Bill Reid joined the meeting

6.4 Information Governance

Welcoming Bill Reid, Head of eHealth, the Chair advised that he would be in attendance for the whole of future meetings and not just for specific information governance items, given the integral nature of IT and eHealth to the quality and safety agenda. a. NHS Highland Information Governance and Area Medical Records Committees

Bill Reid spoke to his circulated paper which described the background to the establishment and reporting arrangements of the NHS Highland Information Governance and Area Medical Records Committees. Both of these groups currently reported to the eHealth Strategy Group. Consequent on the development of the eHealth Strategy Plan 2011 – 2014 a review of governance arrangements, in particular around the eHealth Strategy Group, was undertaken and it was proposed that the Information Governance Committee and the Area Medical Records Committee would now more appropriately report to the Clinical Governance Committee. Discussion followed on the function of Information Governance, the various different elements within Information Governance (data protection, electronic systems, etc) and the legislation governing these. It was clarified that the role of the Clinical Governance Committee was not to oversee but to provide a high level scrutiny of Information Governance. Bill Reid would keep the Committee advised of the activities of the Information Governance Committee and the Area Medical Records Committees and relevant developments and issues.

The Committee agreed the proposed revised reporting arrangements and recommended that the Information Governance Committee become a sub committee of the Clinical Governance Committee. It was suggested that it would be helpful to have a learning development session around Information Governance.

The Committee:

 Endorsed the proposal that the NHS Highland Information Governance and Area Medical Records Committees should report to the Clinical Governance Committee.  Recommended that a learning development session around Information Governance be arranged, the date to be confirmed. b. NHS Highland Information Governance Review – response to Internal Audit Report

The Board’s Internal Auditors had carried out a review of Information Governance across NHS Highland earlier in the year. The final audit report incorporating the management response and agreed actions was considered by the Audit Committee in March 2012. It was noted there were no material findings. In response to query about the action plan Bill Reid clarified that lead individuals had been identified for the various areas of work but that he had overall accountability for ensuring their implementation. A robust process was being established for monitoring performance against the action plan.

5 The Chair referred to the development of a comprehensive Information Asset Register, as recommended by the Internal Auditors to support effective Information Governance in terms of access to and control and use of information, and requested that a progress report be brought to a future meeting.

The Committee:

 Noted the content of NHS Highland Final Internal Audit Report D.5 – Information Governance, the management response and action plan.  Requested that Mr Reid prepare a report on progress with the development of an Information Asset Register for a future meeting. c. NHS Highland eHealth Delivery Plan 2011 – 2014

There was circulated eHealth Delivery Plan 2011 – 2014 which had been formally approved by the Scottish Government eHealth Directorate. Bill Reid advised that the Board’s Senior Management Team was monitoring implementation of the Plan, noting that progress had been made in most of the areas. He highlighted the following projects:-

 Digital dictation: implementation had been completed  Electronic Document Transmission (EDT): this was currently being rolled out to all general practices in North Highland  Community Base Project – to review existing equipment and infrastructure and upgrade to agreed standard: financial constraints were impacting on progress with maintenance work.

On the point raised by Michael Roberts in relation to paediatric unscheduled care, Elaine Mead advised that this initiative was being pursued through the North of Scotland Planning Group. Ms Mead undertook to confirm the current position with regard to NHS Highland’s participation in the DALLAS Project.

The Committee Noted the eHealth Delivery Plan 2011 – 2014 and ongoing activity against implementation.

Bill Reid left the meeting

6.5 Clinical Governance and Risk Management Performance Report - Incident Reporting

Mirian Morrison spoke to her circulated report which gave details of incident reports for Quarter 4 of 2011 – 2012 and the actions taken by the Operational Units in respect of incidents graded with a consequence of major or extreme. It was noted that the number of incidents reported in Mid Highland CHP was low in comparison to other Operational Units. It was acknowledged that there were training and education issues to address with regard to the Datix system. Further training was being rolled out to encourage and support staff to use the system and assure the quality of data being inputted.

With regard to the format and content of the performance report, Ray Stewart suggested that the inclusion of some narrative and analysis of trends would provide assurance that the data was being used appropriately to inform actions. It was acknowledged that this was work in progress and the position was improving as the use of Datix became further embedded and the data enabled areas of concern and trends to be identified and action taken as required. In addition to Datix there were other tools, such as morbidity and mortality rates, which also 6 highlighted any areas requiring investigation. Michael Roberts asked if the data relating to mental health facilities could be disaggregated and shown separately. It was suggested there should be reference to lessons learnt and shared learning. Consideration would also require to be given to the implications of integration and the processes to be put in place for the control and use of information. The Chair proposed to discuss this particular aspect at the next meeting.

The Committee:

 Noted the content of the report.  Agreed that the implications of integration and the processes relating to the control and use of information would be considered at the next meeting.

6.6 Clinical Governance Forum

There were no issues to report.

Christine McArthur and John MacKintosh joined the meeting

7 SAFE

7.1 Older People’s Services /Dementia Standards

Heidi May, who had been appointed as the Lead Executive for Older People in Acute Care had set up a steering group to take forward key work streams to improve care. She spoke to her circulated report which outlined the activities underway in Highland, among which were Falls Prevention and Management, Pressure Ulcer Prevention and Management and the implementation of the QIS Standards for Food, Fluid and Nutritional Care. It was proposed that these specific work streams should report directly to the Clinical Governance Committee to provide enhanced scrutiny. Regular reports would be brought to the Committee, and progress against the key actions would be monitored and supported. With regard to monitoring mechanisms Ms May referred to the HEI inspection process, noting that Raigmore Hospital would be visited this year. Ms May then spoke to the circulated report prepared by Jennifer Lobban, Leading Better Care/Releasing Time to Care Project Manager which provided an update on progress with implementation of the Leading Better Care Clinical Quality Indicators across Highland for all acute and community hospital inpatient areas.

Lynn Garrett joined the meeting

Presentations followed on two of the three key work streams identified above. It was agreed that Food, Fluid and Nutritional Care would be discussed at the next meeting. a. Falls Prevention

The Chair welcomed Christine McArthur, Falls Prevention Coordinator and John MacKintosh, Clinical Governance Facilitator. Ms McArthur presented data relating to patient slips, trips and falls in Quarter 4 of 2011-12 (1 January – 31 March 2012), noting a reduction in the number of reported falls compared to the same period in the previous year. She referred to the consequences of both ‘falls with harm’ and ‘falls with no harm’, the use of the Datix dashboard to identify areas for improvement and the development of methodologies to reduce the falls rate.

7 b. Tissue Viability – Pressure Ulcer Prevention

The Chair welcomed Lynn Garrett, Tissue Viability Nurse Specialist, Argyll & Bute CHP who gave a presentation on the incidence of pressure ulcers, both hospital and community acquired, the collection and use of data through the Datix incident management system, and the various improvement initiatives underway to reduce risk and prevent pressure ulcers occurring. On the point raised by Michael Roberts regarding patients who have been treated out of area who may have developed a pressure ulcer or experienced some other incident, Heidi May advised she was following up the issue of assurance from other providers in relation to the quality of service delivered.

The Committee:

 Noted the work streams underway to improve the care for older people in acute hospitals.  Endorsed the revised governance arrangements for these work streams.  Agreed to have a presentation on Food, Fluid and Nutritional Care at the next meeting.

Ms Garrett, Ms MacArthur and Mr MacKintosh left the meeting

7.2 Healthcare Improvement Scotland (HIS) Update

The Committee was advised that representatives from Healthcare Improvement Scotland had attended the April Board Development Session when they had introduced the new organisation, outlined its aims and objectives and gave details of its work programme.

The Committee Noted the update.

7.3 Strategic Clinical Risk Register

At its meeting on 3 April 2012 the Board had approved the NHS Highland Risk Register and agreed the management and assurance arrangements for the risks identified. Following on from this Dr Lesley Anne Smith had drafted a register, copy of which was tabled, setting out a range of clinical risks for which the Clinical Governance Committee would have responsibility in terms of seeking assurance regarding their management. The Chair advised that she would be discussing the further development of this strategic clinical risk register and the associated assurance arrangements with Dr Smith and the Chairs of the Staff Governance and Audit Committees. An update on progress with this work would be brought to the next meeting.

The Committee:

 Noted the development of a Strategic Clinical Risk Register and the Clinical Governance Committee’s responsibilities in relation to governance of risk.  Noted the further work to be done on the document with an update on progress to be submitted to the next meeting.

8 8 FOR INFORMATION

8.1 Reports from Operational Units

The following minutes were circulated:-

 Argyll & Bute CHP Clinical Governance and Risk Management Group minute of meeting held on 7 February 2012

 Mid Highland CHP Health & Safety and Clinical Governance Group draft minute of meeting held on 7 March 2012

 North Highland CHP Clinical Governance and Risk Management Group minute of meeting held on 24 February 2012

 Raigmore Hospital Quality and Patient Safety Management Team minutes of meetings held on 21 December 2011 and on 9 February 2012

 South East Highland CHP Clinical Governance and Risk Management Group minutes of meetings held on 19 January and 8 March 2012

In terms of links with the Operational Units, the Committee agreed the importance of having the Clinical Directors of the Operational Units, or when they cannot attend their deputies, present at its meetings to alert it to, and feed back on, local issues. The Argyll and Bute Clinical Governance and Risk Management Group had found it helpful having a Non- Executive present at its meetings, it was suggested that the other groups might give some consideration to this.

The Committee Noted the Minutes.

9 DATE OF NEXT MEETING

The next meeting will be held on Tuesday 7 August 2012 at 9.15am in the Board Room, Assynt House, Inverness.

The meeting concluded at 1.10 pm

9

Highland NHS Board 5 June 2012 Item 3.8

IMPROVEMENT COMMITTEE Report by Elaine Mead, Chief Executive

The Board is asked to:

 Note that the Improvement Committee met on Monday 30 April 2012 with attendance as noted below.  Note the Assurance Report and agreed actions resulting from the review of the specific topics detailed below and the Balanced Scorecard (attached).

Panel: Mr Garry Coutts, Chair Dr Ian Bashford, Medical Director Mr Ian Gibson, Non-Executive Director Dr Iain Kennedy, Non-Executive Director

In Attendance: Ms Margaret Brown, Head of Service Planning Mrs Myra Duncan, Non-Executive Director Mrs Linda Kirkland, Business Transformation Manager Mr Angus MacKiggan, Public Health Business Manager (part meeting) Mr Kenny Oliver, Board Performance Manager Ms Sarah Wedgwood, Non-Executive Director Miss Irene Robertson, Board Committee Administrator

Apologies: Mr Okain McLennan and Ms Elaine Mead

Respondents: Mr Bill Brackenridge, Chair, Argyll & Bute CHP Mr Mike Evans, Chair, Raigmore Hospital Mrs Gillian McCreath, Chair, South East Highland CHP Mr Colin Punler, Chair, North Highland CHP (videoconference) Dr Roderick Harvey, Associate Medical Director, Raigmore Hospital Mr Derek Leslie, General Manager, Argyll & Bute CHP (videoconference) Mr Chris Lyons, General Manager, Raigmore Hospital Mrs Gill McVicar, General Manager, Mid Highland CHP Mr Nigel Small, General Manager, South East Highland CHP Dr Margaret Somerville, Director of Public Health Mr Nick Kenton, Director of Finance (item 1a) Ms Sally Amor, Child Health Commissioner/Public Health Specialist (item 2.1c) Mrs Anne Gent, Director of Human Resources (item 2.2a) Ms Moira Paton, Head of Community and Health Improvement Planning (item 5)

TOPICS DISCUSSED

1. Review of Board Assurance Report Actions a. Financial Position - Highland b. Raigmore Quality Plan 2. Balanced Scorecard 2011 – 2012

2.1 Heat Targets a. Cancer Access Targets b. Endoscopy Return Patients c. Child and Adolescent Mental Health Services (CAMHS) d. A&E Attendance Rates e. Reduction in Emergency Bed Days for Patients aged 75+

2.2 Standards a. eKSF – Plans for 2012 – 2013

3. Integration – Quality and Improvement a. Draft Scorecard for Adult Social Services

4. Waiting List Management – Use of Unavailability

5. Planning for Fairness

6. Improvement Committee Annual Report 2011 – 2012

7. Service Improvement Group Update

DATE OF NEXT MEETING

The next meeting will be held on Monday 2 July 2012 in the Board Room, Assynt House, Inverness at 1.30pm.

2 IMPROVEMENT COMMITTEE – ASSURANCE REPORT Meeting on 30 April 2012

The Committee’s role and remit is to scrutinise NHS Highland’s performance and ensure remedial action is taken, as required.

1 REVIEW OF BOARD ASSURANCE REPORT ACTIONS Issues/Risks Assurance Actions Interim Financial Position at 31 The current out-turn for 2011/12 Issues to be explored further at the Board Development session March 2012: indicates that the Board has met its on 1 May 2012. The actual end of year position financial targets with small Action: N Kenton will be subject to audit review and underspends noted against the final allocations. Either of these Revenue Resource Limit and the To communicate financial position to all staff when annual could result in a change to the Capital Resource Limit. accounts are audited, highlighting the challenges to be met in the final position. Improvements have been achieved in next and future years and reinforcing the need for savings to The 2012/13 position remains the prescribing position. continue to be made. extremely challenging. A shortfall Work is underway to produce fully Action: N Kenton/M Thompson in recurring savings to be carried integrated budgets for adult social into 2012/13 is a key issue. care. The Capital Plan for 2012/13 and indicative plan for future years has been agreed by the Board, and the membership and terms of reference of the Asset Management Group are being revised.

Raigmore – Proposed Quality A Quality Improvement Plan has been Discussions to take place on the further development of the Improvement Approach: developed proposing a series of Quality Improvement Plan and its implementation. Considerable financial challenges measures to reduce the overspend. Action: C Lyons/N Kenton remain to be addressed.

3 IMPROVEMENT COMMITTEE – ASSURANCE REPORT Meeting on 30 April 2012

2.1 BALANCED SCORECARD 2011 – 2012 HEAT TARGETS Issues/Risks Assurance Actions Cancer Access Targets: A range of measures has been The position to continue to be monitored. A number of breaches occurred, implemented. The appointment of a Action: C Lyons in particular Quarter 2 to end consultant breast surgeon in June 2011 and mainly in the November 2011 has provided areas of breast and colorectal increased capacity. The unvalidated cancer. Key areas: figures for Quarter 1 2012 indicate  breast cancer – delays in that both the 31 and the 62 day patients receiving their first targets have been achieved. appointment;  colorectal cancers – delays in endoscopy pre-operative assessment and patients receiving first appointments / scope. Quarter 2 – 2012 is likely to be challenging.

Capacity issue in radiotherapy. A bid has been made to the Scottish Government Health Department to use Cancer Modernisation monies to pilot a number of initiatives to improve the radiotherapy position.

Endoscopy Return Patients: A decrease in the number of Agreed to set up a group involving patient and public Sustainability of service. colorectal DNAs has helped the representation and a primary care representative to discuss what Issues around clinical and position. would be a reasonable distance for patients to travel for physical capacity. A pan-Highland approach is being appointments, taking cognisance of transport issues. It was Difficulty in recruiting to vacant taken to ensure endoscopy capacity noted that national guidance will be issued shortly on this issue. Nurse Endoscopist post – this is a is maximised in all appropriate Action: G McVicar/C Lyons/I Kennedy national problem. centres. It is anticipated that the measures being taken will have a

4 IMPROVEMENT COMMITTEE – ASSURANCE REPORT Meeting on 30 April 2012

significant impact over the next 2 – 3 Discussion to take place with clinicians regarding patients months. remaining on the Raigmore waiting list when they have refused an The Detecting Cancer Early offer of appointment elsewhere. Ascertain what is happening in programme may have an impact, other Boards. however it is too early yet to be able Action: I Bashford to evidence any benefit. National guidance on definition of Follow up report to be submitted to the next meeting of the reasonableness of offer of Improvement Committee detailing progress against the actions appointment means appointments and their impact, and also the financial impact. Report also to with a Board area. include further detail of audit which showed that 95% of GP referrals were deemed appropriate. Action: C Lyons

CAMHS: An action plan has been developed to Agreed that CAMHS will be a standing item on the agenda. There is a revised HEAT target address those areas requiring Action: Committee Administrator which will require a revised improvement/more focused activity to trajectory to be developed for achieve the target. Report to be submitted to the next meeting of the Improvement June 2012. Following referral to The implementation of the Lead Committee detailing progress against the action plan and the specialist CAMHS, treatment Agency model has provided an impact of measures taken. must start within 26 weeks by opportunity to look at service redesign Action: S Amor March 2013 and within 18 weeks and skill mix. by 2015. The target will now . apply to the Tier 3 service at Raigmore and within Argyll & Bute CHP, as well as the Primary Mental Health Worker (PMHW) service in the Lead Agency. Shortfall in staffing of the Tier 3 service. Recruitment to vacant posts remains a challenge. Work needs to be done on capacity and demand. There is potentially considerable unmet need.

5 IMPROVEMENT COMMITTEE – ASSURANCE REPORT Meeting on 30 April 2012

A&E Attendance Rate: The 3-day guidance initiative is being A report of the evaluation of the pilot to be submitted to a future Currently not on trajectory. trialled at Raigmore. Over a 7 week meeting of the Improvement Committee. period 78 people were redirected from Action: L Kirkland A&E to an alternative appropriate service. Linked to this work are Ensure future pilots and initiatives have patient/public input and current developments in General are widely communicated. Practice and the Quality Outcomes Action: G Sell/M Thompson Framework (QOF) including the provision of one or two emergency appointments in GP Practices per day. Public/patient engagement activity is ongoing. ‘Know who to turn to’ leaflets are being distributed to hotels, B&B establishments etc for the information of summer visitors.

Reduction in Emergency Bed A range of initiatives are being Given the time lag in receipt of information from ISD it was Days for Patients Aged 75+ implemented and it is expected that proposed to develop a proxy measure. - South East CHP: the end of year data will show an Action: M Brown The latest available data from ISD improved position. (to end December 2011) indicated Agreed to refer to Area Clinical Forum to raise awareness of the the target was not being met. issues among clinicians. The current figure is 341 short of Action: I Kennedy trajectory.

2.2 BALANCED SCORECARD 2011 – 2012 – STANDARDS Issues/Risks Assurance Actions eKSF – Plans for 2012 – 2013: The Committee acknowledged the Agreed to remit to Staff Governance Committee and Highland The inclusion of bank staff in the considerable amount of work done, Partnership Forum to consider how we ensure effective review process has posed some noting that Highland is the highest engagement with staff and ensure they have regular discussions challenges. performing Board in Scotland. with their managers and receive appropriate training and

6 IMPROVEMENT COMMITTEE – ASSURANCE REPORT Meeting on 30 April 2012

Excluding bank staff a figure of 84% opportunities for CPD. Consideration to be given to identifying was achieved. the most appropriate performance measure(s). There is a national review of the Report to be prepared for September meeting of the Improvement technologies involved in recording on Committee. eKSF with the aim of simplifying the Action: A Gent processes. The new system to be implemented within two years. Consideration also requires to be given to integrating all new staff who have transferred from The Highland Council into the process. Action: A Gent

3 TOPIC: INTEGRATION – QUALITY AND IMPROVEMENT Issues/Risks Assurance Actions A balanced scorecard A range of actions is underway to Report to be prepared for the next meeting of the Improvement summarising adult social care further develop this scorecard. Committee on progress with development of measures and measures was presented to the trajectories. Committee. Further work Work is underway to develop a Action: K Oliver/B Robertson requires to be done on its balanced scorecard for children’s development. services. Discussions to take place with the Highland Health and Social Care Partnership to identify level of reporting required for their An issue was raised regarding the operational unit reports. need for some alignment to be Action: K Oliver made with the mental health strategy.

Challenges around data collection Issue regarding single point of access to be referred to the Senior in relation to single point of Management Team for consideration. access. Action: E Mead/L Power

7 IMPROVEMENT COMMITTEE – ASSURANCE REPORT Meeting on 30 April 2012

4 TOPIC: WAITING LIST MANAGEMENT – USE OF UNAVAILABILITY Issues/Risks Assurance Actions Adherence to New Ways As part of the recent national review Operational Units to continue to monitor the position to ensure Guidance, particularly in relation arising from the Lothian situation, strict adherence to the New Way Guidance. to the application of unavailability. NHS Highland has carried out a Action: Directors of Operations Training issues. review to ensure a consistent approach across all its sites to the New Ways Guidance and the application of unavailability. Overall compliance is good. Action is being taken to ensure a robust procedure is in place for clinical review of patients who have had more than 13 weeks of unavailability applied. A national review of all Boards has been carried out ISD. We await feedback on NSH Highland’s performance. Waiting times management is in the Internal audit Plan for 2012/13.

Urology service in Argyll & Bute - Work is ongoing to redesign the high number of patients recorded service. as unavailable. Related issue of sustainability of the service.

5 TOPIC: PLANNING FOR FAIRNESS (EQUALITY AND DIVERSITY IMPACT ASSESSMENT) Issues/Risks Assurance Actions Compliance with legislative A series of actions has been put in Operational units to provide feedback at the next meeting

8 IMPROVEMENT COMMITTEE – ASSURANCE REPORT Meeting on 30 April 2012 requirements. NHS Highland is place to support staff and help embed indicating their level of confidence in terms of being able to meet not on trajectory, progress is slow the Planning for Fairness process into the trajectory. and variable across the area. all pieces of policy/service Action: Directors of Operations There is insufficient baseline development or redesign. information to provide an accurate indication of the key pieces of Raigmore Hospital has agreed an work that have been completed approach with the Board’s Policy and signed off under the Planning Development Manager to identify for Fairness process. projects or initiatives requiring to be There may be an issue around impact assessed. recording. South East CHP is fairly confident that the process is being applied but that this is not being formally recorded.

Argyll & Bute CHP is continuing to focus on training, to ensure staff leading on pieces of work are aware of their responsibilities in relation to legislative requirements.

NHS Highland will work with The Highland Council to determine how both organisations can provide each other with the necessary assurances that requirements relating to service delivery are being met.

6 TOPIC: IMPROVEMENT COMMITTEE ANNUAL REPORT 2011 – 2012 The Committee noted and approved the content of its annual report for 2011 – 2012. The report will be submitted to the Audit Committee meeting to be held on 15 May 2012.

9 IMPROVEMENT COMMITTEE – ASSURANCE REPORT Meeting on 30 April 2012

7 TOPIC: SERVICE IMPROVEMENT GROUP UPDATE There had been no further meetings of the Group since January 2012. Linda Kirkland updated the Committee on ongoing activity, detailing progress with capacity and capability.

8 FUTURE AGENDA ITEMS

Meeting on 2 July 2011:  Endoscopy  CAMHS  Adult Social Care Balanced Scorecard  Planning for Fairness  Reduce Carbon Emissions/Energy Consumption  Children’s Fluoride Varnish/Childsmile Programme  Highland Ethnicity Recording  Anticipatory Care and Polypharmacy

Future Meetings:  Chronic Pain  eKSF (September 2012 meeting)  Scottish Patient Safety Programme (November 2012 meeting)  A&E Attendance – Evaluation of 3 Day Guidance Pilot  Patient Focussed Booking  Change Fund  New to Return Ratio  EQIA Compliance  Better Together  Quality Outcomes Framework  Detect Cancer Early Programme

10 IMPROVEMENT COMMITTEE – ASSURANCE REPORT Meeting on 30 April 2012

10 SCHEDULE OF IMPROVEMENT COMMITTEE MEETINGS 2012

The Improvement Committee will meet on the following dates in 2012:-

(Mondays, 13:30)  2 July  3 September  5 November

11 NHS Highland - "At A Glance" HEAT Targets

Summary of the Operational Units performance as per the Balanced Scorecard reported to the Improvement Committee on 30th April 2012 Targets with a delivery date by the end of March 2012 e d n t e o u t e d i t r t d B n i a

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B Target M R S M N A D Alcohol\BriefInterventions Feb-12 N/A Mar-12 InequalitiesTargetedCardiovascularHealthchecks Mar-12 N/A N/A N/A N/A Mar-12

FinancialPerformance Feb-12 Mar-12 CashEfficencies Feb-12 Mar-12

Suspicion of cancer referrals (62days) (Due for Delivery Dec 2010) Dec-11 Reported at Board Level only Dec-11 AllCancerTreatment(31days)(DueforDeliveryDec2010) Dec-11 Reported at Board Level only Dec-11 18weeksReferraltoTreatment(DueforDeliveryDec2010) Feb-12 Currently reported at Board Level only Dec-11

ReductioninEmergencybeddaysforpatientsaged75+ Oct-11 N/A Mar-12 Targets with a delivery date beyond March 2012 e d n t e o u t e d i t r t d B n i a

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B Target M R S M N A D ChildHealthyWeightInterventions Feb-12 N/A Mar-14 SmokingCessation-2mostdepriveddatazones Dec-11 N/ACurrently reported at Board Level Only Mar-14 SmokingCessation-generalsmokingpopulation Jan-12 N/A Mar-14 ChildFluorideVarnishApplications Sep-12 N/ACurrently reported at Board Level Only Mar-14

ReduceCarbonemmissions Dec-11Currently reported at Board Level Only Mar-15 ReduceEnergyConsumption Dec-11Currently reported at Board Level Only Mar-15

Drug&AlcoholTreatment:ReferraltoTreatment Dec-11 N/A Mar-13 FasterAccesstoSpecialistCAMHS Dec-11 Mar-13 No Trajectory FasterAccesstoPsychologicalTherapiesTrajectory in development Dec-14

90%ofpatientsdiagnosedwithstrokeadmittedtoastrokeunit Feb-12Currently reported at Board Level Only Mar-13 MRSA/MSSA Bacterium: 30% reduction Dec-11Currently reported at Board Level only Mar-13 C.DiffInfections:30%reduction Dec-11Currently reported at Board Level only Mar-13 RateofattendancesatA&E Feb-12Currently reported at Board Level only Mar-14 NHS Highland - "At A Glance" Standards e d n t e o u t d i r t d B n i

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B Target M R S M N A Breastfeedingat6-8week-Target36% Sep-11 N/A MMRuptakerates-target95%at5yearsold Dec-11 N/A

SicknessAbsence-4%target Nov-11 N/S SMRreturnrate-90%of SMR1returns receivedwithin6weeks Jan-12 Complaints-80%ofcomplaintscompletedwithin4weeks Jan-12 Complaints-No.over40workingdays-Target0 Jan-12 Complaints-No.ofcomplaintsreceivedTargetlessthan15 Jan-12 Complaints - No. categorised as High Risk - Target less than 20% Jan-12 Daycaserates-Target78.9% Jan-12 N/A Outpatients-DNArate-Target6.9% Jan-12 ReducePreOperativestay-Target0.65days Feb-12 N/A NewtoReturnOutpatientattendanceRatio-Target2.02 Jan-12 eKSF&PDP's-Target80% Mar-12

NewOutpatientWaitingtimes-12weeks(allreferralsources) Feb-12 N/A N/S Inpatient/DayCasesWaitingtimes-9weeks Feb-12 N/A N/S CataractWaitingTimes-assessment-9weeks Feb-12 N/A N/A N/A Hipsurgery-98%ofpatientstreatedwithin24safeoperatinghrs Mar-12 N/A N/A N/A N/A Angiography-4weekwaitingtime Feb-12 N/A N/A N/A N/A Daignostictestswaitingtimes-4weeksfor8keytests Feb-12 N/A A&E Waiting times - 4 hours Mar-12 N/S Annual AdvanceBooking-GP's N/S

CervicalScreening-80%uptakeof20-60yroldwomenscreened Dec-11 N/A ReduceOccupiedBeddaysforlongtermconditions Jul-11 N/A BalanceofcareforOlderPeoplewithcomplexcareneed Jun-11 Reported at Board Level only DelayedDischarges-noclientswaitingover6weeks Feb-12 N/S Dementia (Unvalidated -validatedpositionavailableannually) Jan-12 N/A N/S

N/S : National Standard NHS Highland - Review of Timeliness of Data for Balanced Scorecard

Targets with a delivery date by the end of March 2012 MAY BSC Data NHSH Reported Target Period Time Lag Updated to SGHD Data Source Alcohol Brief Interventions Feb-11 6 weeks Monthly Quarterly Local data used Inequalities Targeted Cardiovascular Health checks Mar-11 2 weeks Monthly Quarterly Local data used

Financial Performance Mar-11 2 weeks Monthly Monthly Local data used Cash Efficencies Mar-11 2 weeks Monthly Monthly Local data used

Suspicion of cancer referrals (62days) (Due for Delivery Dec 2010) Dec-10 3 months Quarterly Quarterly Scottish Cancer Waiting Times System All Cancer Treatment (31days) (Due for Delivery Dec 2010) Dec-10 3 months Quarterly Quarterly Scottish Cancer Waiting Times System 18 weeks Referral to Treatment (Due for Delivery Dec 2010) Feb-11 3 weeks Monthly Monthly Local Data used

Reduction in Emergency bed days for patients aged 75+ Dec-10 3 months Monthly Monthly ISD data used Targets with a delivery date beyond March 2012 MAY BSC Data NHSH Reported Target Period Time Lag Updated to SGHD Data Source Child Healthy Weight Interventions Feb-11 6 weeks Monthly Quarterly Local data used Smoking Cessation - 2 most deprived data zones N/A 6 weeks Monthly Quarterly Local data used Smoking Cessation - general smoking population Feb-11 6 weeks Monthly Quarterly Local data used Child Fluoride Varnish Applications Sep-10 6 months Quarterly Quarterly ISD data used

Reduce Carbon emmissions Dec-10 3 months Quarterly Quarterly Environment Monitoring & Reporting Tool (eMart) Reduce Energy Consumption Dec-10 3 months Quarterly Quarterly Environment Monitoring & Reporting Tool (eMart)

Drug & Alcohol Treatment: Referral to Treatment Dec-10 3 months Quarterly Quarterly Drug & Alcohol Treatment Waiting Times Database Faster Access to Specialist CAMHS Feb-11 3 weeks Monthly Monthly Local data used Faster Access to Psychological Therapies N/A 3 weeks Monthly Monthly Local data used

90% of patients diagnosed with stroke admitted to a stroke unit N/A 2 months Monthly Quarterly Scottish Stroke Care Audit MRSA/MSSA Bacterium: 30% reduction Dec-10 3 months Quarterly Quarterly Health Protection Scotland C. Diff Infections: 30% reduction Dec-10 3 months Quarterly Quarterly Health Protection Scotland Rate of attendances at A&E Feb-11 3 weeks Monthly Quarterly Local data used

NHS Highland - "At A Glance" Standards

MAY BSC Data NHSH Target Period Time Lag Updated Data Source Breastfeeding at 6-8 week- Target 36% Sep-10 6 months Quarterly ISD data used MMR uptake rates - target 95% at 5 years old Dec-10 3 months Quarterly Health Protection Scotland

Sickness Absence - 4% target Jan-11 6 weeks Monthly Local data used SMR return rate - 90% of SMR1 returns received within 6 weeks Feb-11 6 weeks Monthly ISD data used Complaints - 80% of complaints completed within 4 weeks Feb-11 6 weeks Monthly Local data used Complaints - No. over 40 working days - Target 0 Feb-11 6 weeks Monthly Local data used Complaints - No. of complaints received Target less than 15 Feb-11 6 weeks Monthly Local data used Complaints - No. categorised as High Risk - Target less than 20% Feb-11 6 weeks Monthly Local data used Day case rates - Target 78.9% Jan-11 2 months Monthly Local data used Outpatients - DNA rate - Target 6.9% Feb-11 6 weeks Monthly Local data used Reduce Pre Operative stay - Target 0.65 days Feb-11 6 weeks Monthly Local data used New to Return Outpatient attendance Ratio - Target 2.02 Feb-11 6 weeks Monthly Local data used eKSF & PDP's - Target 80% Mar-11 2 weels Monthly Local data used

New Outpatient Waiting times - 12 weeks (all referral sources) Mar-11 3 weeks Monthly Local data used Inpatient/Day Cases Waiting times - 9 weeks Mar-11 3 weeks Monthly Local data used Cataract Waiting Times - assessment - 9 weeks Mar-11 3 weeks Monthly Local data used Hip surgery - 98% of patients treated within 24 safe operating hrs Mar-11 3 weeks Monthly Local data used Angiography - 4 week waiting time Mar-11 3 weeks Monthly Local data used Daignostic tests waiting times - 4 weeks for 8 key tests Mar-11 3 weeks Monthly Local data used A&E Waiting times - 4 hours Mar-11 3 weeks Monthly Local data used Advance Booking - GP's Mar-10 3 months Annually National Audit data used

Cervical Screening - 80% uptake of 20-60 yr old women screened Dec-10 3 months Quarterly Health Protection Scotland Reduce Occupied Bed days for long term conditions Dec-10 3 months Monthly ISD data used Balance of care for Older People with complex care need Sep-10 3 months Quarterly Local data + Local Authority data Delayed Discharges - no clients waiting over 6 weeks Mar-11 3 weeks Monthly Local data used Dementia (Unvalidated - validated position available annually) Feb-11 6 weeks Monthly Local unvalidated data used

Highland NHS Board 5 June 2012 Item 3.9 Assynt House Beechwood Park Inverness IV2 3BW Tel: 01463 717123 Fax: 01463 235189 Textphone users can contact us via Typetalk: Tel 0800 959598 www.nhshighland.scot.nhs.uk/

DRAFT MINUTE of MEETING of the AREA CLINICAL FORUM 29 March 2102 – 1.30 pm Board Room, Assynt House, Inverness

Present Dr Iain Kennedy, Chair Mr Quentin Cox, Area Medical Committee Mr Adrian Hart, Area Dental Committee Mrs Cathy Lush, Clinical Dental Manager Mrs Margaret Moss, Area Nursing, Midwifery and AHP Advisory Committee Ms Rhiannon Pitt, Area Nursing Midwifery and AHP Advisory Committee Mr Ray Stewart, Employee Director Dr Boyd Peters, S E Highland CHP Dr Sheelagh Rodgers, Area Clinical Psychologist Mr Ryan Cooper, Area Healthcare Science Forum Ms Nikki Diack, Area Healthcare Science Forum Dr Moray Fraser, North Highland CHP Mr Ian Rudd, Area Pharmaceutical Committee Ms Katrina Flannigan, Argyll& Bute CHP

In Attendance Mrs Jan Baird, Transitions Director (Item 6 only) Ms Heidi May, Board Nurse Director Ms Elaine Mead, Chief Executive Dr Ian Bashford, Board Medical Director Mrs Christine Thomson, Board Committee Administrator

1 WELCOME AND APOLOGIES

Dr Kennedy welcomed those present to the meeting. Apologies were received from Ken Proctor, Anne Pollock, Margaret Somerville, Sheelagh Rodgers, Alan Jones, Ray Stewart, Duncan Martin, Pat Wells and Rob Peel.

2 DECLARATIONS OF INTEREST

There were no material declarations of interest.

3 MINUTE OF MEETING HELD ON 2 FEBRUARY 2012

The minute of the meeting held on 2 February was Agreed subject to the following amendments:  It was noted that Quentin Cox had submitted his apologies.  Ian Rudd requested that the minute be altered to clarify the fact that Iain Kennedy had been asked to take forward to the Board the question of representation from the Pharmacy. It was noted that a request for a representative from the Managed Pharmacy Service would be submitted for the Highland Health & Social Care Partnership. Dr Kennedy advised that he had apologised to Mary Morton for this omission.  On page 4 of the minute under item 7.2 it was noted that the meeting had taken place on 17 January 2012.  On Page 6 under the Psychology Advisory Committee it was noted that the word psychiatrists in the 2nd paragraph should be replaced by “psychologists”.

After discussion and noting the above amendments the minute was proposed by Adrian Hart and seconded by Boyd Peters and accepted as a true record.

4 MATTERS ARISING

4.1 Single Governance Committee

Iain Kennedy advised that a report from the Chief Executive had been submitted to a Special Meeting of the Board held on 21 March 2012 which he had been unable to attend due to clinical commitments. The paper was circulated to members and Elaine Mead advised on the status of the Highland Health & Social Care Partnership which would be established as one of the two Community Health Partnerships but would not be referred to as such. She advised that at the Board meeting on 7 February 2012 there had been polarised views and attempts had been made to ensure a balance between a reasonable governance committee and representation of as many groups as possible. She advised that the ACF had recommended the addition of a GP, an additional patient representative, a lead midwife and a salaried dentist and that Iain Kennedy had recorded his dissent at the Board meeting. At the meeting on 21 March 2012 the various issues highlighted had been addressed as follows:

It had been agreed to include the following additional members to the Highland Health & Social Care Partnership: Head of Adult Social Care, a further public/patient representative, the Chair of the Professional Executive Committee, 2 non-executive Directors of the Board chosen to reflect the geographical spread of the Partnership, 3 Directors of Operations namely Chris Lyons, Gill McVicar and Nigel Small, the Head of Financial Planning and the Lead Midwife.

It had been further agreed that the Head of Personnel and Head of Health & Safety would be included in attendance.

Elaine Mead advised that the ACF requests had been considered and it had been clarified that a GP was already represented on the Governance Committee, an additional patient representative would be provided and that the lead midwife be included. It had been considered that there was no requirement for a salaried dentist.

Boyd Peters expressed his gratitude that the views of the ACF had been considered and thanked the ACF and Elaine Mead and Heidi May for representing these views. Ian Rudd requested that thought be given as to how information from the managed service would feed into the governance committee and it was considered that the pharmacist on the group could possibly be changed or an in attendance representative be appointed.

Quentin Cox noted that the Chair of the Governance Committee would not be the Chair of the Board but rather it was up to the Board Chair to decide how this person is selected.

2 Rhiannon Pitt advised that discussions on the setting up of the Professional Executive Committee would be taking place at a future date and that Ian Bashford was working on this. She stressed that the Highland Health & Social Care Partnership would be making decisions which would require guidance from the Area Clinical Forum. It was noted that the Professional Executive Committee would advise the Partnership. It was agreed that Ian Bashford be invited to speak to the next meeting on 31 May on this matter.

Rhiannon Pitt requested more advice on membership and function and Elaine Mead advised that the aim was to bring clinical discussion closer to the committee in order that decisions are based on clinical debate.

5 REPORTS / MINUTES FROM PROFESSIONAL ADVISORY COMMITTEES

5.1 Area Nursing, Midwifery and AHP Advisory Committee

Rhiannon Pitt advised that the Committee had met on 27 March 2012. She reminded members of the resignation of Chrissie Lane and that there was no Chair of the Committee at present. Nominations had been requested but none received to date. As such two options remained as follows:

 To combine the Advisory and Leadership Committee  To separate the Advisory Committees to improve engagement with clinical staff.

Quentin Cox expressed concern at the possibility of combining the Advisory and Leadership Committee as the combined group covers a very large number of employees. The question of a co-chair for the Leadership and Advisory Committees was also discussed.

Ian Rudd queried whether there was the possibility of the leadership element being attached to the Professional Executive Committee but it was noted that these had to be kept separate.

Heidi May confirmed that the present system was not operating satisfactorily and that the key issue was repetition between the content of the Advisory Committee and the Leadership Committee. It was also noted that there was an issue of encouraging staff at grass roots level to become involved. It was noted that engagement of staff could be further achieved through video conferencing, webex conferencing etc. She stated that she would be advised by the Forum and would consider merging the Leadership and Advisory Committees back together if this was the Forum’s wish. Elaine Mead stressed the need for the Board to obtain good quality clinical advice. It was noted that the Advisory Committee structure was just one part of communication and Ryan Cooper suggested that a method of reaching staff at the coalface would be to use systems such as Facebook and Twitter.

After discussion the Forum Agreed that the Advisory Committee should seek the views of its members on the two options identified and report back to the next meeting of the Forum to be held on 31 May 2012.

5.2 Area Dental Committee

Mr Adrian Hart advised that the next meeting of the Area Dental Committee would take place on 25 April 2012.

He advised that a second maxillo facial surgeon had been appointed who was due to commence employment on 2 April 2012.

He further advised that the he had recently been elected Chair of the Scottish BDA Committee and needed to rationalise his time in order that his clinical services did not suffer.

3 He therefore wished to step down as Chair of the Area Dental Committee but there had been no willingness from other members to take on this role. This issue would be further explored at the meeting to be held on 25 April 2012. In addition attempts had been made to set up a GDP sub-committee.

At this stage it was agreed to consider the item on Planning for Integration

6 PLANNING FOR INTEGRATION

Mrs Jan Baird, Transitions Director gave an update on Planning for Integration. She advised that this was the final update prior to functions transferring on 1 April 2012.

She further advised that the next piece of work was that of integrating care in Highland and redesigning services. It was noted that over the next year the integration of central support services and corporate services would be considered as only interim arrangements have been considered to date. Mrs Baird reported that the Partnership Agreement had been the focus of attention over the last week and that this had now been agreed by the Board and the Highland Council when it had been delegated to Chief Executives to make any minor amendments on outstanding matters. She advised that the recruitment process was under way with some senior posts already filled and some moving into post as of 1 April 2012 and that an e-handbook has been compiled. She further reported that there was still a significant role for children’s staff who have moved across in informing with others a “lessons learned” log would be set up. She also advised that legislation for VAT recovery affects all parts of Scotland and that the Adult Support and Protection council officer role can now be delegated to the NHS as a result of legislative changes to the regulations.

It was noted that the Cabinet Secretary had now agreed the dissolution of the 3 Community Health Partnerships and the formation of the Health and Social Care Partnership

Quentin Cox queried whether staff would notice any difference after 1 April. Mrs Baird advised that staff should not notice any difference and that they required to know who their manager is and who they will be responsible to for professional leadership. In addition welcome letters and a DVD had been sent to all transferring staff. It was stressed that as of 1 April 2012 the responsibility for delivery of adult care will rest with Elaine Mead.

It was stressed that Highland was not a pilot but rather that if other areas felt that this model would suit them then they could consider adopting a similar model.

It was noted that Garry Coutts and Elaine Mead would consider how social workers and other care staff would have appropriate representation on the Board advisory committees. It was noted that it may be possible to have a social worker as a member of the ACF but in the interim an Area Practice Forum could exist for 1-2 years bringing together groups and providing a voice for these staff to afford them the opportunity to influence and advise. It was agreed that this possibility be further considered at the next meeting of the Forum to be held on 31 May 2012.

The Forum:

 Noted the update regarding Planning for Integration  Agreed that a report on the possibility of setting up an Area Practice Forum be submitted to the next meeting of the Forum to be held on 31 May 2012.

4 7 REPORTS / MINUTES FROM PROFESSIONAL ADVISORY COMMITTEES

7.1 Area Medical Committee

Quentin Cox reported that the last meeting of the Area Medical Committee had taken place on 20 March 2012. Donna Smith had attended this meeting and the question of follow up appointments had been discussed.

Elaine Mead expressed concern at item 7.2 of the minute of the previous meeting and this was noted by the Committee. A clarification of what was said at the previous meeting was sought.

Iain Kennedy reported that he had written to Chris Lyons requesting an update on the situation regarding prioritisation of patients and that Mr Lyons had been invited to the next meeting of the Forum.

Further items discussed had been the ownership of results, delays in GPs receiving correspondence, Patient Rights (Scotland) Act and its implications for NHS staff and pre- operative assessments. In addition Anne Pollock had attended to discuss the Specimen Acceptance Policy.

7.2 Highland Area Optometric Committee

There was no report from the Committee.

7.3 Area Pharmaceutical Committee

Ian Rudd reported that the Pharmaceutical Care Plans which had been reported on by Mary Morton at the last meeting of the Forum had now been submitted to the Pharmacy Practices Committee.

He advised that a meeting of the Area Pharmaceutical Committee had taken place on 26 March 2012 when the main items discussed had been the recently published Royal Pharmaceutical Society Report into “Improving Pharmaceutical Care in Nursing Homes” and an NHS Scotland review of NHS Pharmaceutical Care of Patients in the Community.

It was also noted that elections for the APC would take place in 6 weeks time and that several of the younger pharmacists had expressed an interest in serving on the Committee.

7.4 Psychology Advisory Committee

Doug Hutchison advised that the Committee had not met since the last meeting of the Forum and that the next meeting would take place on 15 May which would be attended by Iain Kennedy. It was noted that the constitution had been finalised and would be submitted to the Area Clinical Forum at its meeting on 31 May 2012. As regards the Mental Health Strategy Group it was noted that psychological therapies were being integrated with physical conditions. In addition it was noted that there was still an issue with waiting times. It was further noted that Ian Bashford and Margaret Somerville will be developing clinical pathways.

7.5 Healthcare Scientists Forum

Ryan Cooper advised that the last meeting of the Forum had taken place on 22 March 2012. He advised that two posts had now been filled and that Nikki Diack was now the Vice Chair.

He reported that there were issues in the laboratories regarding Point of Care Testing and that he was keen to bring this to the attention of other healthcare workers and advised that

5 Anne Pollock would be attending the next meeting of the ACF to report on Point of Care Testing Health Care Wide.

He reminded members that Health Care Science Week had taken place on 12-16 March 2012 and reported that he had been assisted by Alison Farrow, Health Care Science Development Lead for Grampian and Highland and that the Health Care Science Forum would continue the newsletter that she had started. He advised that a system had been introduced where volunteers visit schools to try to raise the profile of Health Care Science in schools.

8 CHAIR ATTENDANCE AT PROFESSIONAL ADVISORY COMMITTEES

Dr Iain Kennedy reported that he would be meeting with the Psychology Advisory Group shortly.

9 AREA CLINICAL FORUM CHAIRS GROUP

Dr Iain Kennedy reported that he had attended a meeting of the Area Clinical Forum Chairs Group on 7 March 2012 where the main items had been to redefine the core purpose of the Chairs Group and set aims for the year ahead. The core purpose was noted as being:

“To shape the development of strategic health and social care policy that will guide the provision of the best quality health services for the people of Scotland.”

The aims were noted as being to:

1. Champion quality 2. Act as an interface between clinicians and the Scottish Government 3. Tell the truth about current service provision, and 4. Provide challenge to ensure the best outcomes for every person

He further advised that the Group would be meeting the Cabinet Secretary on 17 April 2012 when it was anticipated that integration would be one of the main topics of discussion.

10 QUALITY AND EFFICIENCY PROFESSIONAL ADVISORY GROUPS / OPERATIONAL UNITS

There had been circulated CEL(2012)01 Health Promoting Health Service: Action in Hospital Settings. It was noted that the circular considered Area Clinical Fora as key routes through which the Health Promoting Health service could be championed. It was noted that Boards were being encouraged to expand the scope of health improvement activity beyond hospital settings and that the scope of health improvement activities could be broadened to include additional areas where possible, including visitors to those in secondary care. As regards smoking, alcohol and breastfeeding it was noted that these areas were already recorded by the Board. However areas such as healthy working lives, sexual health, physical activity and active travel were more difficult to monitor and record. It was noted that each of the CEL actions included objective and quantifiable measures of progress which were aligned with the Quality Measurement Framework. Ian Bashford advised that approval had not yet been taken to the AMC Reference Group.

It was generally felt that it was everybody’s business to be a health promoter and it was noted that health improvement competencies could be included in the KSF targets. It was also noted that NHS Education for Scotland (NES) was looking into the provision of training packages for midwives aimed at providing staff with skills for a generic public health improvement responsibility. 6 Boyd Peters stressed the importance of the content of the circular and it was agreed that a targeted approach was necessary. It was noted that Margaret Somerville, Director of Public Health, had been tasked as the lead for this piece of work.

The Forum:

 Noted the content of the circular.  Noted that Margaret Somerville, Director of Public Health, had been tasked with leading on the performance measurement.

11 AHP NATIONAL DELIVERY PLAN CONSULTATION PAPER

There had been circulated Scottish Government Consultation Paper “AHP National Delivery Plan from the Scottish Government”. Rhiannon Pitt advised that Katherine Sutton was collating comments on the Consultation Paper to return to the Scottish Government. Ian Bashford advised that we were slow to encompass the roll out of radiographers undertaking 80% for plain film reporting across NHS Scotland and that this had not been underpinned as a policy. Further information on the origin of the 80% figure would be required. It was noted at present that radiographers stand at 10% in NHS Highland with a figure in Lothian of 50%.

The Forum:

 Agreed that Iain Kennedy feedback the views of the Forum and the AMC to Katherine Sutton for onward submission to the Scottish Government.

12 NHS HIGHLAND BOARD MEETING - TUESDAY 3 APRIL 2012

12.1 Board Governance Committee

There had been circulated a report on Board Governance Committees by Kenny Oliver, Board Secretary on behalf of Garry Coutts, Chair.

12.2 NHS Highland Strategic Risk Register

There had been circulated a report on the Highland Strategic Risk Register by Lesley Anne Smith, Head of Quality on behalf of Elaine Mead, Chief Executive. It was agreed that Lesley Anne Smith should be invited to a future meeting of the Forum to discuss this further.

12.3 Infection Control Report

There had been circulated an infection control report by Liz McClurg, Infection Control Manager on behalf of Heidi May, Board Nurse Director and Executive Lead for Infection Control. It was noted that the Board should strive to use single rooms in hospitals as much as possible.

12.4 Local Delivery Plan

There had been circulated report on the Local Delivery Plan by Kenny Oliver, Board Performance Manager, on behalf of Elaine Mead, Chief Executive.

7 12.5 Gaelic Language Plan

There had been circulated report on the Gaelic Language Plan by Caroline Tolan, Policy Development Manager and Moira Paton, Head of Community and Health Improvement Planning on behalf of Elaine Mead, Chief Executive.

The Forum Noted the circulated internal communications.

13 FOR INFORMATION

13.1 Attendance Record

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

13.2 Dates of future meetings for 2012

Members were reminded of dates of future meetings as follows:

31 May 2012 9 August 2012 27 September 2012 29 November 2012

The Forum:

 Noted the attendance record.  Noted the dates of future meetings for 2012.

14 DATE OF NEXT MEETING

The next meeting will be held on Thursday 31 May 2012 at 1.30pm in the Board Room, Assynt House, Inverness.

The meeting closed at 3.45 pm.

8 Highland NHS Board 5 June 2012 Item 3.10 PHARMACY PRACTICES COMMITTEE MEETING Tuesday, 10 April, 2012 at 11.30 am The Board Room, John Dewar Building, Inverness Retail & Business Park, Highlander Way, Inverness, IV2 7GE

Application by LYNNE ELIZABETH CAMPBELL for the provision of general pharmaceutical services at Units 2 & 3 Cradlehall Shopping Centre, Cradlehall Court, Inverness, IV2 5WD

PRESENT Bill Brackenridge (Chair) Maureen Thomson (Lay Member) Margaret D Thomson (Lay member) Michael Roberts (Lay member) Alison MacRobbie (APC Non Contractor Nominate) Catriona Sinclair (APC Contractor Nominate) John McNulty (APC Contractor Nominate)

In Attendance Andrew J Green (Area Regulations, Contracts & Controlled Drugs Governance Pharmacist) Helen M MacDonald (Community Pharmacy Business Manager) Lynne Elizabeth Campbell, Applicant Kenneth Lawrie, Applicant Support Alasdair Shearer, Rowlands Lisa Gellatly, Tesco Peter Mutton, Area Pharmaceutical Committee

1. The Chair welcomed everyone to Inverness. He asked all members to confirm that they had all received the papers for the hearing and had read and considered them. All members affirmed these points.

2. APPLICATION FOR INCLUSION IN THE BOARD’S PHARMACEUTICAL LIST

Case No: PPC - Cradlehall_3 Lynne Elizabeth Campbell, Units 2 & 3 Cradlehall Shopping Centre, Cradlehall Court, Inverness, IV2 5WD

The Chair asked each Committee member if there were any interests to declare in relation to the application being heard from Lynne Elizabeth Campbell. No interests were declared.

3. The Committee was asked to consider the application submitted by Lynne Elizabeth Campbell to provide general pharmaceutical services from premises situated at Units 2 & 3 Cradlehall Shopping Centre, Cradlehall Court, Inverness, IV2 5WD under Regulation 5(10) of the National Health Service (Pharmaceutical Services) (Scotland) Regulations 2009, as amended.

The Committee had to determine whether the granting of the application was necessary or desirable to secure the adequate provision of pharmaceutical services in the neighbourhood in which the Applicant’s proposed premises were located.

The Committee, having previously been circulated with all the papers regarding the application from Lynne Elizabeth Campbell, agreed that the application should be considered by oral hearing. Prior to the hearing, the Committee had, as a group, attended a presentation which included a site visit at the University of the Highlands and Islands Campus which was delivered by Highlands and Islands Enterprise Senior Development Manager, Mr Ian Thorburn, to ascertain factual information regarding that development, which was within the Applicant’s neighbourhood and could be considered to have been an important factor in the Applicant’s case.

The Committee then visited the proposed premises where the Applicant and Applicant Support were on hand to guide the Committee around the premises, provide advice on the proposed plans for development and answer any questions asked of them by the Committee.

The Committee then visited the vicinity surrounding the Applicant’s proposed premises, the existing pharmacies at Tesco, Inshes and Rowlands, Culloden and facilities in the immediate area and surrounding areas of Cradlehall, Castlehill, Birchwood, Westhill where social housing, a business park, primary school, nurseries, residential nursing home and the various shops, hairdressers and beauticians were pointed out. They were then driven around the boundaries of the neighbourhood as defined by the Applicant, over the railway bridge to the neighbouring areas of Smithton and Culloden, passing the Boots Pharmacy, at Inverness Retail & Business Park before returning to the John Dewar Building where the hearing was to be held. During the tour, the situation of the NHS and private dental surgeries in Castlehill, Cradlehall and Culloden and GP surgeries in Culloden were noted (the Committee were provided the opportunity to enter into all 3 pharmacies, but decided this was not required on this occasion, as all members had visited these pharmacies before and were advised by Health Board officials there had been no further changes to any of the premises since then**).

The hearing was convened under paragraph 3(2) of Schedule 3 to the National Health Service (Pharmaceutical Services) (Scotland) Regulations 2009 as amended (“the Regulations”). In terms of this paragraph, the Pharmacy Practices Committee “shall determine an application in such a manner as it thinks fit”. In terms of Regulation 5(10) of the Regulations, the question for the Pharmacy Practices Committee is whether “the provision of pharmaceutical services at the premises named in the application is necessary or desirable to secure adequate provision of pharmaceutical service in the neighbourhood in which the premises are located by persons whose names are included in the Pharmaceutical List.”

The Applicant, Support and Interested parties were invited into the meeting at around 11.40am

4. The Chair welcomed:-

The Applicant, Lynne Elizabeth Campbell, who represented herself and was supported by Kenneth Lawrie, the Interested Parties who had submitted written representations during the consultation period and who had chosen to attend the hearing, were Lisa Gellatly, Tesco Pharmacy, Alasdair Shearer, Rowlands Pharmacy and Mr Peter Mutton, Area Pharmaceutical Committee, (“the Interested parties”). The Chair then invited the Committee members to introduce themselves. Committee members introduced themselves to the Applicant and all other parties.

The Chair asked the Applicant and the Interested Parties to confirm that they were not attending the Committee in the capacity of solicitor, counsel or paid advocate. They each confirmed that they were not.

2 5. The Chair reminded everyone that the meeting had been convened to hear the application from Lynne Elizabeth Campbell for the provision of general pharmaceutical services at Units 2 & 3 Cradlehall Shopping Centre, Cradlehall Court, Inverness, IV2 5WD. The application would be considered against the legal test contained in Regulation 5(10) of the National Health Service (Pharmaceutical Services) (Scotland) Regulations 2009, as amended.

6. Regulation 5(10) was read out:

An application shall be granted if the Board is satisfied that the provision of the pharmaceutical services at the premises is necessary or desirable in order to secure adequate provision of pharmaceutical services in the neighbourhood in which the premises are located.

7. The Chair then described the format of the hearing, reminding those attending that no new evidence could be introduced at the summing up.

The procedure adopted by the Committee at the hearing was that the Chair asked the Applicant to make her submission. There followed the opportunity for the Interested Parties and the Committee to ask questions. The Interested Parties would then make their submissions. There followed the opportunity for the Applicant and the Committee to ask questions of the Interested Parties in turn. The Interested parties and the Applicant were then given the opportunity to sum up.

The Chair then asked the Applicant to give her statement.

7.1. The Applicant’s Case

Lynne Elizabeth Campbell stated “I am truly grateful to the Committee for inviting me to attend the hearing today and appreciate being able to present my evidence and put forward Lynne Campbell Pharmacy Limited’s case. I would endeavour to keep the presentation as concise as possible; however, I have done a great deal of work that I would like to bring to the attention of both the Committee and the representatives from Tesco and Rowlands. To date, this is the third application made in respect to providing pharmaceutical services from Units 2 & 3 Cradlehall Court. The last application was made by Assura Pharmacy which was unanimously agreed to by the Committee after having heard and discussed all the evidence. The application was subsequently overturned as indicated in the submission from the Area Pharmaceutical Committee by the National Appeal Panel in 2009.

I am aware that there has been additional interest from one of the representatives opposing this new contract as well as another company in providing pharmaceutical service from these premises.

This application relates to a similar neighbourhood and detailed evidence of a significant change that is currently undergoing within it will be discussed at a later stage within this presentation.

I am here today, not only to represent my Company, Lynne Campbell Pharmacy limited, which was formed purely for the purpose of this application, but also to represent the community within the Westhill and Cradlehall neighbourhood.

3 The Chair, Bill (Brackenridge), in his introduction identified the legal test which the Committee has to discuss and focus on. This test relates to the pharmaceutical services in the neighbourhood, feedback from the local community and whether this application meets the test.

From a previous application I was made aware of helpful and legal guidance that Lord Drummond Young provided for considering an application. He identified a two stage process for considering such an application:-

1 – What is the neighbourhood; and 2 – How adequate are the services?

Until the neighbourhood has been agreed the adequacy of service cannot be identified. Once the neighbourhood has been agreed the pharmaceutical services within it can be identified and subsequently the adequacy of these services. So, what is the neighbourhood?

Neighbourhood means:-

 Community – a local community with characteristics that distinguish it from areas around it.  People living near each other – people who live near each other or in a specific neighbourhood.

There are likely to be physical aspects to boundaries within a neighbourhood which may be natural. For example, rivers or manmade such as roads or railway lines”.

The Applicant then demonstrated on a map as follows:-

“So, starting with the neighbourhood.

The proposed neighbourhood covers the area bounded by the B9006 Culloden Road, crossing the A9. From here it follows the northern edge to the right hand side of the A9 until it meets the A96 at the Raigmore interchange. It then turns 90° east along the A96 and meets the manmade boundary of the Inverness to Perth railway line. The boundary is then the line of the railway along to where it goes under Tower Road. At this point the boundary turns back 90° to the south and runs along the edge of Culloden Woods with open ground to the left encompassing Woodlands housing to the right until it reaches the B9006 Culloden Road.

The boundary then runs down the outside of Culloden Road encompassing houses in streets off the road on both the left and right hand side (including Birchwood) and back down to where the B9006 Culloden Road meets the A9.

The information supplied within my initial application on the population within the neighbourhood was not recent data, a point which was highlighted by the Area Pharmaceutical Committee in their written submission. Previous viewing of the Scottish Neighbourhood statistics had left me really confused and unable to give a more accurate estimate on the current population within the neighbourhood.

After the initial application was presented to the Board I made contact with Mr Cameron Thomas, Research Officer at the Planning and Development Service of The Highland Council. Mr Thomas researched and sourced information based on the National Records of Scotland Small Area Population Estimates 2010, which contains the latest available data up until mid 2010.

4 The potential area discussed with Mr Thomas was made up of Cradlehall, Westhill and Woodside of Culloden. In mid 2010 the population of 5,271 with 21% of the population (around 1,100) were people under 16 years of age and 14% of the population (around 678) were of pensionable age. This means that 35% of the population would require more pharmaceutical services than that of the average person.

In addition to this, Mr Thomas indicated an active building site in Woodside of Culloden with 110 plots nearly completed with another site in Resaurie with a capacity for 54 houses. This gives a total of 164 houses which are expected to be completed within the next 3 years and would increase the population with this neighbourhood by 350 or so, taking the estimated population to over 5,500.

The neighbourhood is very diverse, containing well established homes, new homes, low cost housing and has 184 properties owned and rented by housing associations (Cairn and Albyn Housing Associations),with a further 29 properties owned by The Highland Council, indication that there is a social aspect of deprivation within the neighbourhood. In the neighbourhood of Woodlands there is supported social housing for patients who have recently been discharged from New Craigs Hospital.

Tesco made a comment in its written submission stating that they believed the neighbourhood to be broader than that described. If we were to look at a broader area covering Cradlehall, Westhill, Smithton, Culloden and Balloch, it is a much larger area and has a population of 13,500. This area is too large in terms of size and population to be regarded as a neighbourhood on its own and needs to be broken down into a smaller more defined neighbourhood and those people living in Culloden would not say that they were neighbours with Cradlehall. Cradlehall and Westhill are recognised areas with a growing business park, primary school, nursery, residential nursing home all within close proximity to the busy, well used focal centre of Cradlehall Court. Therefore, Cradlehall is a neighbourhood and not part of a larger area.

If I am to define the neighbourhood as being broader than initially described I would include the area of Smithton. From the Scottish Index of Multiple Deprivation (which identifies small area concentrations of multiple deprivation across all of Scotland), Smithton’s relative measure ranking is 1,399 within the 6,505 data zones identified, with one being the most deprived and 6,505 being the least deprived.

The index is relative as it shows whether an area is more or less deprived than another one but not how much more or less deprived. The least deprived area is not necessarily the most affluent, it just lacks deprivation and, not everyone living in a deprived area is deprived.

Mr Thomas also discussed the area around Stratton between Smithton and the A96 as being identified as one of the next growth areas for Inverness with planning permission granted for the first phase of 750 houses with an anticipated population of 2,500. A population of 2,100 is expected with another 350 houses still to be completed in Milton of Leys. The Planning Department have set a requirement that before planning permission is granted, the developer of a site must agree to provide 25% of these homes as low cost housing.

From The Highland Council’s area demographic fact sheet of data collated from the National Records of Scotland, the population within Highland is expected to increase by 15% compared with 10% projected for the whole of Scotland. Across the UK, and Scotland, there is a growing trend towards an ageing population and an increased amount of prescriptions.

Highland households headed by 60-70 year olds are projected to increase in numbers by 35% and those headed by the 75+ years of age are projected to increase in numbers by 106% between the years of 2008 and 2033.

5 From an article in the Press & Journal Newspaper, just recently, in the Wednesday, 28 March, 2012 edition, it was printed that “since prescriptions became free in April, 2011, the number of prescriptions dispensed in Scotland has risen by 2.8 million in a year, which is a 3.1% increase from the previous year”.

Now that the neighbourhood has been defined, the next step is to consider the pharmaceutical services in the neighbourhood. There are currently no pharmaceutical services provided in the neighbourhood. If we look outside the neighbourhood for where pharmaceutical services may be accessed – Rowlands Pharmacy at Culloden is 1.9 miles away, Tesco Pharmacy is 1.4 miles away and Boots Pharmacy at the Retail Park is 2.6 miles away.

I would like to highlight some of the points included in written submissions. The Area Pharmaceutical Committee indicate that Cradlehall is an area of high car ownership with good bus links and are unaware of patients having difficulty accessing pharmacies. Rowlands Pharmacy also indicate that the area houses residents who are financially secure, have high car ownership levels and can easily access local services.

All the residents of the Cradlehall/Westhill area need the use of transport to reach a pharmacy. In relation to access of a car, not everyone will have one and since the last application in 2009, the cost of fuel has risen by 35%. With at least a 3 mile round trip to visit a pharmacy, I would suspect that the majority of individuals – even those of us who are financially secure – will consider the necessity of such journeys.

Although there is a regular bus service, Stagecoach introduced changes in the Inverness area from November, 2011. The proposed changes to the bus service were to provide improved frequencies to many areas. As a result the new service number 3 runs every 20 minutes and requires patients who live along the length of Caulfield Road to get off the bus at the top of Tower Road and wait for the new service number 2/2A which will taken them down to Rowlands Pharmacy at Culloden. This means that for a selected number of individuals who do not own a car, they must either rely on good neighbours or be physically able to hop on and off a bus four times to access pharmaceutical services at Culloden. With a population of around 5,500 the pharmaceutical services are inadequate.

In the case of all new community pharmacy applications, a public consultation must be completed before an application can be submitted to the Board. Before conducting this, advice and views from the Westhill Community Council, local community and staff at the local Co-operative store at Cradlehall Court was taken and it was decided that the newspaper of choice for most local residents would be the Inverness Courier.

The public consultation appeared in the Inverness Courier, Courier 2 supplement on Friday 18th November, 2011 and ran for a total of 20 working days, ending on Friday 16th December, 2011.

A copy of this advert was also placed in the dental surgery, nursery, bakery, hairdressers and beauticians, after consulting with the proprietors of these businesses, which are all within the busy, well used focal hub at Cradlehall Court.

In addition, a copy was placed on the notice board at the local primary school – Cradlehall Primary, and within the Cradlehall Nursing Home.

Over the 20 day consultation period a total of 14 responses were received and, after completion of this consultation, it became evident that the Inverness Courier had not assigned an address to the PO Box number. Subsequently, any letters that the local community sent via the post were never received. The Post Office was contacted to see if they would be able to source or find any letters, however, to date nothing has been obtained.

6 The Inverness Courier indicated to me that they would re-run the public consultation advert free of charge as it had been their error. The incident was report to Helen MacDonald, NHS Highland Community Pharmacy Business Manager, who advised that it would be unnecessary to do this, as the requirements of completing a consultation before making an application to the Board had been fulfilled.

Due to the limited responses received during the public consultation process it was decided that a small survey would be required to collate further views from the local community on the adequacy of pharmaceutical services provided from existing pharmacies with interpretation of the neighbourhood in a question and any further comments from the local community. The survey was designed from the website www.surveymonkey.com and was based on a survey that reviewed the current service provision from a medical centre. A total of 200 surveys were handed out door to door with 122 returned to date.

The Committee received a copy of the survey results to date of the completed surveys, additional comments made on the surveys returned and the actual 122 surveys completed by the local community in and around the neighbourhood. From the surveys returned, all were included within this submission and no comments were excluded from the table supplied to the Committee.

Comments from the survey indicate that there are patients who are experiencing difficulty in accessing a pharmacy and it is the sheer inconvenience of having no other option but to use transport to reach a pharmacy that this raises the desirability for a local pharmacy at Cradlehall Court.

Looking at the result of the survey and, as the Committee has seen the results of the survey, there are four questions that I would like to bring to the attention of representatives from the APC and Tesco, who both made submissions indicating that they were not aware of any complaints or did not see any gaps within the current level of service provision within the neighbourhood (at this point the Applicant furnished the Interested Parties with a copy of the pie charts summarising the survey results referred to).

Question 1 – How adequate are the pharmaceutical services currently provided by your existing pharmacy?

From the pie chart, does this indicate that there is an inadequacy with the pharmacy provision by the existing pharmacies? With 65% of the survey respondents indicating that the pharmacy services currently provided by their existing pharmacy was moderately accurate or below, this led me to research the word “moderately” within the UK English Thesaurus – meaning fairly, reasonable, more or less, sort of. From this definition I believe that a fairly, reasonable service does not constitute an adequate service provision.

Question 2 – Overall are you satisfied with the service provision from your current pharmacy?

The pie chart indicates quite clearly that 69% of the population surveys are moderately satisfied or below with the service provision from their current pharmacy.

Question 8 – If our new pharmacy were available today, how likely would you be to use it instead of your existing pharmacy?

81% of the population said that they would use our new pharmacy if it were available today.

7 Question 9 – What do you consider to be the neighbourhood that the proposed pharmacy would serve?

I was very surprised to see the results of this question with 40% of the population considering Milton of Leys to be part of the neighbourhood.

As discussed earlier, a major significant change that will be occurring within the neighbourhood is the development of the 215 acre Inverness Campus site at Beechwood Farm. Inverness Campus is one of the most exciting and important projects being developed in the Highlands and Islands over the next 20 years, playing a pivotal role in both the defined neighbourhood and in the region’s future. The Campus will create up to 6,000 jobs over the next 30 years and generate £38 million per year for the area. I am aware that the Committee had a presentation at the site earlier today so, forgive me if I go over what was already covered there.

Key to the next 5 years of development is the Scottish Government granting Enterprise Area Status for Life Sciences to the Campus. This project represents a huge boost for the local economy and will bring a significant opportunity for local businesses across a wide range of sectors, whilst bringing education, business and the community together.

Morgan Sindall started work on the infrastructure construction in January 2012, which is aimed to be completed by Spring 2013. This will allow construction of Phase I of the Inverness Campus to begin with an expectation of around 20 months to complete.

A new junction to join the existing junction between the A9 slip road and the B9006 Culloden Road has been proposed, with a secondary access point planned to connect the Campus to Caulfield Road North, which will have considerable effect on patients accessing pharmaceutical services.

Phase I on the Inverness Campus envisages a wide range of business, education and community benefits including:-

 Over 600 student residences have been planned within Phase I of the Campus.  Inverness Campus will help to create the infrastructure necessary to deliver a University for the region.  Scottish Agricultural College  A training hotel. A partnership between Albyn Housing and the Calman Trust will provide opportunities for disadvantaged young people in a real business environment.  Centre for Health Science. The Centre for Health Science plan to expand its Inverness operation onto the Inverness Campus and plans include a multi disciplinary health centre.  Also sports facilities. A high quality sports facility is planned, aspiring to create a regional venue catering for a diverse range of sports, attracting users from across the Highlands.  Community centre. A pivotal site on the Campus is earmarked for community use and the views of the local community are being sought.

At present, I am aware of 2 health centres with over 16,000 patients who are currently in discussions with Highlands and Islands Enterprise on moving their practices out to the Campus. I had hoped to be able to present to you today the practices with which this concerns. To date the press release for the public consultation with regard to this relocation will be released on or after the 17th April, 2012.

8 In addition to the academic aspects of the Campus, the project includes an innovative science park for the private sector research and development and business incubation which will stimulate new employment and bring greater economic benefits to the Highlands.

In relation to core services and prescription numbers. Pharmaceutical care is changing and the new contract services which the pharmacist is required to deliver, such as the Minor Ailments Scheme, Chronic Medication Service, Public Health Service and the Unscheduled Care can be time consuming, although will help in achieving health and wellbeing but only if delivered properly. These new services can add extra strain on the pharmacies in the area and it is important to consider not just the needs now but also in the future. The neighbourhood needs a pharmacy both now and in the future.

A Freedom of Information request was made to the Information Services Division of the Common Service Agency. When reviewing the prescription numbers and the core services of all the pharmacies contracted in respect to this application and sadly, with the recent closure of Lloyds Pharmacy in Church Street, it becomes evident that the pharmacies that we see on the High Street appear to be experiencing the challenging conditions of being there.

I would like to comment on the information received, looking at the prescription numbers. I was provided with information on the number of paid items from December 2010 to December 2011and I divided these by 12 to obtain an average for each pharmacy. When you look at the number of items being dispensed you get a picture of those being dispensed from the high street, for example, Boots, Eastgate do an average of 12,500 items per month – these will not be acute prescriptions but Boots have a very high number of nursing home business, therefore, I would suggest probably only 4-5,000 are acute prescriptions.

There are similar situations at Tesco Inshes and Rowlands, with Rowlands, Culloden averaging at just over 10,000 items dispensed per month and Tesco at just over 8,500 and Rowlands Park Pharmacy with just over 8,500 items per month.

What I find interesting, when you look at Boots at the Retail Park, setting it apart from Lloyds, Church Street, whose average was just over 2,000 items dispensed per month, is that, although their monthly average dispensings are just over 4,800, they are the ones who are most effectively delivering the other core services compared to the others, with 1,224 Minor Ailment Service prescriptions dispensed on average each month, pushing them into the next bracket up for payment, Smoking Cessation Service payment being the highest for all the pharmacies and a very high rate of patient care records for the Chronic Medication Service completed.

Compared to the figures for Rowlands, Culloden and Tesco, Inshes, they are actually doubling what they are doing who I would say are not necessarily delivering as effectively all the core services, including the Minor Ailments Service. With dispensing figures of over 10,000 items per month, I would expect to see more than150 patients registered for smoking cessation services and for them to be at the top end of the payment bracket for the Minor Ailments Service. What you are seeing is that they are delivering a good dispensing service but that it is difficult for them to provide the other core services. I believe that the reason Boots at the Retail Park provide the highest proportion of core services than other pharmacies is because the number of paid items per month is lower than the rest and that they have two pharmacists on the premises during extended opening hours. This is not the case in Culloden or Tesco, insofar as I am aware and 10,000 items is a “hell of a lot” of items for one pharmacist to dispense.

9 I am working in a pharmacy which fills over 8,000 items a month but this is only possible because I have a good team which allows me to provide all the services, so I would suggest for a single pharmacist to deliver all the core services and dispense 10,000 items is pretty tough going.

That said, Culloden are doing well with core services but Tesco, in its own submission indicates that it has extended hours, however, I would expect a similar proportion of core services as Boots Retail Park, but there is really not much happening there. If they were to review comments made not only within my survey but from letters received from the local community with respect to their premises they may want to take action.

I did get an opportunity to visit the Practice Manager to introduce myself within the Culloden Practice and have been asked to give a presentation on the Chronic Medication Service and the stage pharmacy is at within it. This leads me to conclude that there is not much consultation happening between the GP practice and the pharmacy at the moment.

Although not part of the core services, I am aware that the appointment of two new pharmacy contracts outwith Inverness are supplying weekly dosette boxes to patients and these pharmacies are being contacted to provide this from within Inverness. I think this indicates the inadequacy of services within and outwith the neighbourhood, resulting in a 13 mile trip for either the pharmacy or the patient to receive these in Inverness.

So, what is pharmacy about. Pharmacy is about delivering patient centred care which is respectful, compassionate and responsive to an individual’s preferences, needs and values. This application is not only about delivering a full pharmaceutical service but also providing a centre of wellbeing where all aspects of health could be addressed.

In summary, the neighbourhood has been clearly defined and the pharmaceutical services within the neighbourhood are inadequate as there is no current provision. There are services outwith this neighbourhood but these are not accessible to everyone. Although the Area Pharmaceutical Committee indicates in its submission that they believe that Rowlands Pharmacy, Culloden and Boots at the Retail Park have the capacity to provide pharmaceutical services to a growing population, with the up and coming Inverness Campus, the proposed relocation of GP surgeries into the Campus and the transient and working population who will visit the area, extra strain will be placed on these existing pharmacies – and I would suspect would not be able to provide adequate services.

As indicated in a letter of support from Mr Ian Brown, the boom in Inverness’ population over the last 10 years has not been reflected in its pharmacy provision, with the re-opening of a store at Balloan Park (a contract which previously served the Hilton area), a new contract at Boots Retail Park on the outskirts of the city and, most recently, the closure of Lloyds Pharmacy in Church Street means, with respect, there has been no increase in the number of pharmacies in the Highland capital for over 10 years.

As this community expands through future housing developments in the neighbourhood, together with the development of the Inverness Campus at Beechwood, the requirement for direct patient services under the community pharmacy contract will increase and the current lack of provision will become a more acute problem. Therefore, I feel that the present and future case for a local pharmacy within the defined neighbourhood, which would include the provision of pharmaceutical services is a strong and indeed desirable one.

The use of the term “desirable” includes the concept of improving existing pharmacy cover and, as this application will improve services to the area, the services available outwith this neighbourhood may not be easily accessible to everyone. The services are, therefore, inadequate and I would hope this application should be granted.

10 The Chair thanked Miss Campbell for her statement and invited the Interested Parties and then members of the Committee to ask questions of her.

7.2 Questions from Lisa Gellatly, Tesco Pharmacy to the Applicant

Ms Gellatly advised that in relation to the survey she had carried out, 45% of respondents had said that current services were moderately adequate with only 20% combined total saying services were slightly or extremely inadequate. How did she feel these figures proved inadequacy?

Miss Campbell replied that was the reason she had tried to define the word moderately in her presentation.

Miss Gellatly commented that it could be said that 35% of the people surveyed feel that current service provision is extremely inadequate service but 35% of those think it is good enough. Did Miss Campbell think that was high enough to prove inadequacy?

Miss Campbell replied that surely the 20% would tell you if it were inadequate in that case and advised Miss Gellatly that it was identified in the response if she looked at it and clearly people were not happy with current services but advised that she had to do a survey to find that out and that the survey reflected that. It was up to Ms Gellatly to interpret the results as she wished.

7.3 Questions from Mr Alasdair Shearer, Rowlands Pharmacy to the Applicant

Mr Shearer had a few questions to ask regarding the statistics the Applicant had referred to. He stated that she had mentioned neighbourhood statistics, which he felt were based on the Scottish Neighbourhood Statistics website figures. He had accessed these figures himself and noted that the Applicant made reference that 36% of the population was of pensionable age. He asked the Applicant if she had compared that to the Scottish average.

The Applicant replied she had not.

Mr Shearer advised that this was actually 21% less than the Scottish average and asked where she had accessed her information from.

The Applicant advised that Mr Cameron Thomas of The Highland Council had accessed the information from the most accurate website available to him.

Mr Shearer asked the Applicant to confirm if 122 surveys were the total number completed and returned.

The Applicant affirmed that was the number of surveys returned to her.

Mr Shearer then enquired if the Applicant agreed that this resulted in a return for only 2.2% of a population of 5,500, whether she felt this was a true representation.

The Applicant replied that she could not say, however, she was at work, full time, five days a week and ran a busy herbal medical practice advising that she had managed to get round 200 homes but had simply not had the time to get round all the places that she would have liked. That said, she felt it was a good representation but was done on the back of, and complimented the public consultation.

Mr Shearer then asked whether the Applicant would agree that a community would always wish a pharmacy application to succeed.

11 The Applicant agreed with Mr Shearer’s supposition.

Mr Shearer then enquired whether this was more so, probably, when she was standing in front of the member of public at their front door.

The Applicant advised that she had left the surveys with people and went back to collect them or they had forwarded them to her in a stamped addressed envelope she had left with them. She refuted that she stood in front of them while they completed the survey, however, advised that there were additional comments from 88 people commenting on the travel time to existing services and their provision.

Mr Shearer wanted to touch on the capacity issues the Applicant alluded to for current pharmacies and asked of her how many prescriptions she felt a pharmacy should do every month.

The Applicant replied that a very well run, efficient pharmacy could deliver fantastic service, however, to actually dispense over a certain amount of items, there would become a point where it would require to be considered if one pharmacist can actually deliver all that would be required to them. She advised that if they were processing 12-15,000 prescriptions per month, she would say they would not be able to provide all of the services expected from them as the pharmacist absolutely has to check everything, even with a dispenser or ACT (Accredited Checking Technician). In her opinion, to deliver core services, while dispensing those amount of items, you would require an extra pharmacist.

Mr Shearer acknowledged that but asked the Applicant if she agreed that any pharmacy would be able to make the necessary changes to support a busy pharmacist and recruit the relevant staff, i.e. an ACT or an extra pharmacist.

7.4 Questions from Mr P Mutton, Area Pharmaceutical Committee to the Applicant

Mr Mutton had no questions for the Applicant.

7.5 Questions from the Committee to the Applicant Margaret Thomson advised that she was particularly interested to hear about the survey the Applicant had carried out and asked her to recap for her how she had done this, asking if she had said that she had gone out and left leaflets. The Applicant advised that she had designed a survey through the website www.surveymonkey.com and in doing so had adapted a survey to become fit for pharmacy specifics from the site which had previously been used in the review of medical practice. She advised that as, she did not have postcodes, nor know individuals from within the proposed neighbourhood it felt right for her to go out and knock on people’s doors but that she had left a stamped addressed envelope which could be used for them to return the questionnaire to her at their convenience. She advised that she was assisted in this by her very good neighbours but had carried around 80% of this door to door herself.

Margaret Thomson asked for clarification that the survey was an actual piece of paper.

The Applicant confirmed this was the case and she had distributed this by knocking on doors and introducing herself, advising what her intentions and proposals were. She did have one individual who did not wish to participate in completion of the survey but she wanted to knock on the doors of her potential customers and let them see her, their potential pharmacist who would be working in the pharmacy and for her to see the customers she might be caring for.

12 Margaret then asked for confirmation that out of the 200 surveys dispatched, was it the case 122 were returned which was around a 60% return rate and yet there was more than 60% shown on one of the pie charts?

The Applicant replied that the comments were based purely on the 122 returned so the 60% was 60% of the 122, not the 200. Unfortunately, due to work commitments, she was unable to obtain any more surveys.

Margaret Thomson asked the Applicant what her thoughts were about how to use the information received and was she happy with the response.

The Applicant replied that the results had been disappointing but acknowledged that in reality, it was not that often that people actually took the time to complete and return a survey. She advised that she had visited the Westhill Community Council, nurseries and the Senior Citizens Club – not just gone round the doors, so quite a few surveys went to them but not all responded so she then recognised she would have to give out stamped addressed envelopes if she wanted to receive responses.

Margaret Thomson then acknowledged that the Committee could be convinced that she had looked for the views in her survey from the elderly and nursery ages but, in doing so, could they assume she had missed the age group in between – those who were mobile.

The Applicant replied that she had addressed this by going about the neighbourhood on a Sunday afternoon and she had spoken to those with cars in their drive and children.

Margaret Thomson asked the Applicant if it was that population which did not return the questionnaires.

That Applicant replied that she did not know.

Maureen Thomson asked the Applicant to describe how the pharmacy would operate and how she would see it functioning in staffing levels.

The Applicant replied that it would not be just a pharmacy for her but a place for alternative treatments such as herbal medicine, massage, and aromatherapy and that she would bring her current herbal experience into practice there. She advised that the Drug Information Department at Aberdeen Royal Infirmary advise they receive enquiries from affluent people looking for information with regard to herbal medicines and that often she consults with the Highland Hospice and nursing staff. She advised that she envisaged pharmacy being the centre of health and wellbeing centre and intended to look at chiropody, well men, well women and travel clinics and obtaining locally accessible services for the local community. She advised that it was a big site and that pharmacy would be the focus with one consultation and two treatment rooms but that these may not be built straight away as she wouldn’t be able to do everything immediately. She advised that she knew many individuals of high calibre willing to come and work with her but initially her staffing would comprise 2 dispensers and a part time ACT.

She further advised that if the business grew to where she hoped then she would recruit a second pharmacist and probably sooner than the multiple contractors. She would not wait until 10,000 items a month were dispensed and would seek to do so at approximately 6,000 items, to enable consistent delivery of the services that pharmacy is all about. Pharmacy is changing.

13 Maureen Thomson then enquired of the Applicant how she was able to inform patients about what pharmacy is actually all about, remarking that most of the comments received about pharmacy relate purely to dispensing and how she felt it was possible to get people to understand that pharmacy is about more than that.

The Applicant advised that she had learnt so much through the experience and, quite rightly, agreed that the public have no idea about what pharmacy is all about.

Maureen Thomson then asked, in that case then, how could adequacy actually be measured.

The Applicant replied that she was not sure it could as the public don’t know what services were delivered through pharmacy and they didn’t even know about the Minor Ailments Service. She had gone back to the pharmacy in which she works after the experience and said “right girls - we need to inform the public”! She advised that from the pharmacy they could see when patients were just turning to pensionable age who did not think such services are for them but that it absolutely was. The Applicant further reported that 40% of consultations which take place within the GP surgery could be done from pharmacy and that this would be the best outcome for the patient rather than having to perhaps wait up to 3 weeks for an appointment.

John McNulty asked the Applicant to clarify her opening hours.

She replied that she had made a change to those initially applied for as she had learnt that other businesses within the Shopping Centre would be open until 6pm so made the decision that she would extend her hours to open 8.45am – 6pm, Monday to Friday and 9am-1 pm on a Saturday but advised she may further extend her hours for the purposes of herbal therapy over and above that but not for pharmacy services.

John McNulty enquired if the Applicant was of the view that services would be in more demand when the GP surgery was closed at the weekend, either on a Saturday afternoon or Sunday.

The Applicant replied that, looking at the Information Services Division figures, and, in particular at Boots in the Retail Park, it can be seen that they are delivering all the services, but actually when you review this in line with the extended opening hours at Tesco Pharmacy, Inshes, these core services are not being done as well. She advised that when she had worked for Boots she had carried out a survey between 6-8 pm and they were lucky if 2% of their custom came in 6-7pm, dropping to 1% between 7-8pm. In her experience, she suspected that core service provision happens, in the main, between Monday and Friday and, although still provided at the weekend, not always the core services.

Catriona Sinclair highlighted that the Applicant had not made much mention of the Chronic Medication Service (CMS) and how did she imagine this would work through pharmacy.

The Applicant replied that it was evident that the service providers had fulfilled what is required of them, apart from 3 contractors where shortfalls were recognised in the figures. Tesco, Inshes; Superdrug, High Street and Lloyds, Church Street, both Inverness City Centre. Lloyds, Church Street is now closed.

14 The Applicant thought that Superdrug was running on locums but advised that she could be wrong in saying that and that was why their figure for CMS might be low. She advised she felt that CMS was a fabulous Service for patients but, having spoken to practice managers, it would appear there was a lack of communication between pharmacists and medical practices. For Culloden, she felt that if this were improved, the practice there had advised that they have 1,500 patients they know would absolutely go on to use the Service and that was what she felt was required to be done. To go to the medical practices and tell them that we are now allowed to become more involved in patient care. She advised there were more nurse practitioners but not so many pharmacy practitioners and there was a real need to get into the medical practices to let them see what can be delivered and to then work together, hand in hand, with everyone out there.

Michael Roberts enquired where the Applicant had measured the point of distances to the other pharmacies from.

The Applicant replied that these had been measured from the actual proposed pharmacy premises.

Mr Roberts highlighted that the Applicant had talked a lot about alternative therapies and asked if a person came into the Applicant’s pharmacy with a problem, such as a rash, how likely she would be to advise that patient to use an alternative therapy rather than a traditional medicine.

The Applicant replied that she was able to gauge what was best suited to a patients needs, advising that she receives a plethora of enquiries for various conditions and that she had extended her knowledge because she had listened to patients who were asking about homeopathy, aromatherapy and herbal remedies. She advised that some patients moved towards healthcare and that some individuals have tried that and had not got what they thought and were looking for something else. She advised that she has also studied nutrition, advising that this was what pharmacists did and that they had a wealth of information and could steer people in the direction which was right and best for them. This could be nutrition, a bath in lavender or an orthodox treatment. That is when you see you have a community backing you when you have that wealth of knowledge.

Alison MacRobbie asked the Applicant what she meant when she talked about perhaps extending the boundaries of her neighbourhood into Smithton.

The Applicant advised that she had meant that residents of Smithton could easily use the services of her pharmacy in Cradlehall and that the Business Advisory Team had assisted her in deciding her neighbourhood. She advised that patients in Smithton could come through and use facilities and if she were to look at a broader neighbourhood, I would only look to Smithton, which is more deprived. In her considerations she had made contact with John Glenday of NHS Highland Harm Reduction Services, who has since retired, to see if that was a factor in the application. It was clear that the population was ageing, albeit the figures did not agree and it was apparent that now, Inverness was developed around car ownership. On the High Street there was evidence to show a slow down and not much happening there which was more apparent with the current economic climate.

Alison MacRobbie advised that one of the issues following on from that was the distances by car and although reasonable car ownership, had the Applicant viewed the ways in which people might move around the proposed neighbourhood and in what proportion.

15 The Applicant replied that she could not say but she thought that this would be a high proportion as it was a very busy local hub for the local community containing a grocers, dentist, bakery, beautician, nursery and hairdressers, adding that people like to get out and about if they are able to walk and access services but, in addition, it was good to walk. In my presentation I advised that the population would increase by 106% for those 75 years and older so something like that where they can walk and see someone – which may be on their way to something, would enhance the local community.

The Chairman advised that he was very, very interested to hear about the Applicant’s conversation with Culloden Medical Practice and to hear they had requested her to do a presentation. That said he wondered if, in the opinion of the Applicant, this implied that they were not happy with the current service offered by Rowlands Pharmacy there.

The Applicant replied, no, as she advised that when she was there to introduce herself, they had said they were happy with the service they currently received, however, when she had gone to meet the Practice Manager in person, he had no awareness at all of CMS.

8. The Interested Party’s Case – Ms L Gellatly, Tesco Pharmacy

Ms L Gellatly stated “thank you for allowing me the chance to speak today.

Firstly I would like to refer to the legal test which requires a pharmacy to be necessary or desirable in order to secure adequate provision of pharmaceutical services in the neighbourhood for an application to be granted.

We do not agree that this application passes the legal test. First of all let’s discuss the neighbourhood as defined by the Applicant. While we understand why the neighbourhood was defined as such, we don’t agree with the definition. This is because in Inverness pharmaceutical services are often accessed from outwith the patient’s local neighbourhood and already several pharmacies deliver medication into the area proposed by the Applicant. Patients can be registered at any of the GP surgeries in Inverness and can, and do, access pharmaceutical services on the other side of the City. For example, we have several patients at Tesco who are registered at Kinmylies Surgery on the other side of the City.

Within the neighbourhood of Inverness there are already 11 GP surgeries whose prescriptions are already dispensed by 11 pharmacies, who have all worked hard to develop and maintain good professional relationships. There are no pharmacies currently situated in the defined neighbourhood, but neither are there any GP surgeries, therefore the residents will already be accessing such services elsewhere and the area is one of high car ownership.

We believe that the pharmaceutical services offered across these 11 pharmacies are adequate.

Much has been made in the application of the development of the Inverness Campus, however, this won’t be completed until at least 2015 and, as there are no plans for a residential component, this development will have no effect on the population of the neighbourhood. The people who work or study there will already access both medical and pharmaceutical services from the area in which they live so the impact on the neighbourhood would be negligible. In fact, many parts of the new pharmacy contract rely on patients being registered at one pharmacy, for example to use the Chronic Medication Service.

We do not believe that it is necessary nor desirable to grant the application in order to secure the adequate provision of pharmaceutical services in the neighbourhood.

16 To illustrate this, I’d now like to go on to tell you a bit about our pharmacy at Tesco, Inshes and the services we offer, ranging from blood pressure, diabetes and cholesterol testing to prescribing for travel health and erectile dysfunction. We also offer health checks and flu injections. We offer all of the core NHS services including eMAS, EHC, CMS, Public Health and AMS and run a very successful nicotine replacement therapy service.

Access to our pharmaceutical services is greatly affected by our extended opening hours. We are open from 8am to 8pm six days a week and between 10am and 4pm on Sundays. Therefore, many of our services are accessed by people after their own working hours, or at weekends when other pharmacies (including the one proposed by the Applicant) will already be closed.

I would like to point out that there is 3-4 hours cross over per day allowing two pharmacists to provide all the services.

The pharmacy was recently refurbished and now has a much larger dispensary to allow our capacity for offering services like methadone supervision and dispensing of dosettes to grow. While the refurbishment was taking place, the pharmacy operated from a portakabin and it is a credit to both the service provided by the pharmacy and the loyalty of their patients that they managed to maintain 60% of their business during this period, a much greater figure than usual. Where patients choose to use other pharmacies during the refit, we have now noticed that the vast majority of them have returned to use our pharmacy which again proves the perception of great service and convenience offered at Tesco, Inshes.

The staff at Tesco, Inshes do value their patients and customers greatly and reflect on the standard of services that they offer on a regular basis. It is for this reason that we recently conducted a patient satisfaction survey, which was submitted to Helen (MacDonald, NHS Highland Community Pharmacy Business Manager). We asked a range of questions, from the convenience of the pharmacy to the friendliness and professionalism of staff, and satisfaction with services that we offered and myself, Emily (Macintyre, Tesco Inshes Pharmacy Manager) and all the staff were overwhelmed by the response we got. Out of 186 questions asked, 156 were graded as “excellent”, 29 “good” and only one as “average”.

A few examples of comments are:

“excellent staff, very caring”, “I am at the pharmacy a lot and I find that I always leave with a smile”, “I was going to get my medicines from the pharmacy beside my house but I would rather spend half and hour extra to get here”.

We are very proud of the level of excellent service that we’ve built into our business and believe it is a clear and direct result of mix of existing experienced staff and the addition to the team of newer staff who came from other pharmacies in the area.

I do hope from your visit to Tesco that you did earlier today (**) that you saw our great pharmacy and consultation room facilities and realise the potential and capacity we have to take on more services like dosettes, methadone supervisions and nicotine replacement therapy patients. We are currently investing in additional hardware for the pharmacy after listening to patient feedback about waiting times.

In conclusion, we feel that we offer a fantastic pharmaceutical service at Tesco, Inshes which is greatly appreciated by patients and the other healthcare professionals that we enjoy close relationships with.

17 To refer back to the legal test, we feel that this application does not pass the legal test as it is not necessary, nor desirable for this pharmacy to be granted a contract in order to secure adequate provision of pharmaceutical services in the neighbourhood as defined.

Thank you all very much for your time”.

The Chair thanked Ms Gellatly for her statement and invited the Applicant, Interested Parties and then members of the Committee to ask questions of her.

8.1 Questions from the Applicant to Ms L Gellatly, Tesco Pharmacy

The Applicant had no questions for Ms Gellatly.

8.2 Questions from Mr A Shearer, Rowlands Pharmacy to Ms L Gellatly, Tesco Pharmacy

Mr Shearer had no questions for Ms Gellatly.

8.3 Questions from Mr P Mutton, Area Pharmaceutical Committee to Ms L Gellatly, Tesco Pharmacy Mr Mutton had no questions for Ms Gellatly. 8.4 Questions from the Committee to Ms L Gellatly, Tesco Pharmacy

Maureen Thomson wondered if Ms Gellatly thought that the neighbourhood should be wider than had been defined by the Applicant as that was how she felt it worked in Inverness but asked, if that scenario was turned on it’s head, because people would also be able to go to the new pharmacy from other side of town so did she not feel that the point she was trying to make was negative in that respect in that people could use any GP and any pharmacy they wished seemed to point out that people can access services from wherever they want. The other point she noted from Ms Gellatly’s presentation was that did she not seem to think that it had come across that patients were having to leave the proposed neighbourhood to access medical service but that was not necessarily a factor in a pharmacy application and did she not agree that you don’t need to go to GP to access services. Therefore, did Miss Gellatly see the lack of medical provision as being a negative factor which was how Maureen Thomson had felt it had come across in what had been said.

Ms Gellatly replied that the core part of pharmacy services was still dispensing. Dispensing was the “bread and butter of what we do” and that, if people are already going to a pharmacy, then they will already use one closest to the GP practice.

Maureen Thomson enquired if Ms Gellatly had evidence to support that, to which Ms Gellatly replied she had none.

Maureen Thomson then enquired how much of making up of the prescriptions was done out of hours and at the weekend.

Ms Gellatly replied that the bulk of normal GP work was done in core hours, between 8-6 pm with a lot of walk-ins, in and out of hours because of their proximity to the Out of Hours Centre.

Maureen Thomson asked if some of the points made by Ms Gellatly could be looked at both ways. Ms Gellatly agreed that, yes, they probably could.

18 Alison MacRobbie pointed out that Ms Gellatly had stated that there was no residential accommodation planned within the UHI Campus and for her information there were plans for 400 and a social hotel. The Committee had also heard there would eventually be 6,000 employment opportunities and those people would register with a pharmacy which often is at the place most convenient to their workplace which is often now built in a large retail park. In terms of that with that level of opportunity did Ms Gellatly think there was potential for a great deal of business in the neighbourhood as defined.

Ms Gellatly replied that that depended on who this population comprised and what services they required to access and of their needs which may not be as great if it were a young population as opposed to that of an elderly one.

9. The Interested Parties’ Case – Mr Alasdair Shearer, Rowlands Pharmacy

Mr A Shearer stated “thank you, Chair and panel for allowing me to present my views on the application at Cradlehall on behalf of Rowlands Pharmacy today.

As always, I’ll first come to neighbourhood. I would like to take the neighbourhood given at previous PPC and NAP hearings, but will actually accept the slight adjustment made by the Applicant for the purposes of this hearing, which has obviously been made to incorporate the Inverness Campus. To confirm, the boundaries I would give are:- to the west, the A9 running north to where it meets the A96; to the north, the train line running east to where it meets Tower Road; to the east, running from the train line south to Culloden Road, through the open land to the west of Culloden Woods; and to the south, Culloden Road, including the housing that runs directly off the south of it.

Using this neighbourhood boundary, you can see there is no pharmacy service within this neighbourhood but, not every neighbourhood needs it’s own pharmacy. An adequate service can easily be provided by pharmacies in adjoining neighbourhoods and, on that basis, we have ourselves at Rowlands in Culloden, Tesco at Inshes and Boots at the Retail Park.

I also think it is worth noting at this point that the population of Inverness can be registered at any GP across the City, so people from this area may be registered with a GP on the other side of the City and, as a result, most people will quite often access a pharmacy outwith their “home neighbourhood” as such, anyway.

Now, looking at the population in this neighbourhood, I would class this as an affluent area, with certainly a number of new housing developments being created here at various points over the last 10+ years. It has lower than average claimants of income support, a higher than average percentage of households with cars and a lower than average percentage of pensionable residents. So, the community is mixed as always, on the whole. I believe young families with children would probably dominate this area. In fact, you just have to drive into this area first thing in the morning to see the queues of commuters driving out of the neighbourhood towards Inverness, sometimes as far back as Birchwood. This is a transient population, very used to travelling out of the neighbourhood to live and to work. I would argue if you asked these people, they have no problem accessing current pharmacy services.

Both Boots at the Retail Park and Tesco, Inshes are open extended hours on weekdays and at weekends, so any working member of the population can easily access services at a time to suit them.

19 As a whole, I believe that the working families, generally young and older residents will generally have access to a car and find no problem with using existing pharmacies but we must remember that those who may not have access to a car during the day. Again, touched on, the public transport method of choice here – and there is a regular bus service every 20 minutes connecting residents with Culloden, the Retail Park at Inshes and on into Inverness. A service as often as this would be the envy of many residents in this country. These buses stop at a number of stops throughout the neighbourhood and there is a stop just outside Rowlands Pharmacy and the main surgeries in Culloden. On the whole, I can see no problem with access to pharmacies from this neighbourhood.

Again, a lot is made in the application around the development of the Inverness Campus and the changes that will bring to the area. I don’t think there is no doubt that this is a thriving development. We have to be realistic about what is being offered here. The College itself is relocating from Harbour Road and this is not due to happen until 2015, as with the Scottish Agricultural College. The Centre for Health Science is just an expansion of current services at Raigmore. Again, this isn’t due for completion until 2016. I was not aware until today that the development included living accommodation but, a Hotel is not permanent residents so that population is negligible. Obviously, workers will still use services around where they work but, let’s be honest, I don’t see many seeking out services in a small row of community shops, they are far more likely to head over – going to the Retail Parks, and there are plentiful pharmacy services there.

All 3 pharmacies around the neighbourhood are providing full pharmaceutical services. I certainly don’t see the Applicant bringing anything new, nor is there anything to say that current provision is poor. At Culloden, we have a pharmacy kitted out with a consultation room and a further room through the back used for MDS and homes. This gives us plenty of room to work in and certainly plenty of space to grow. We are constantly reviewing the service we give. We provide a full collection service from all the surgeries and a full delivery service to the surrounding area including the defined neighbourhood. Gayle MacDonald, the Pharmacy Manager, has been there for almost 3 years and has developed fantastic links with the locals and GPs alike. She currently runs an asthma clinic with Dr Kelly at Southside Road. The pharmacy comprises a full trained team and has an ACT who, as a whole team work very well, exceeding average service figures for providing eMAS, CMS and smoking cessation. To their credit, they won Community Pharmacy Team of the Year at the Scottish Pharmacist Awards this year. I would certainly like to ask what else we could do if this was not deemed adequate. This is not a pharmacy struggling to cope now and nor would I see it struggling to cope in another 10 years.

So the Applicant is bringing no new services to the area in relation to NHS pharmacy services, and the opening hours offer nothing in addition to what is already being provided. The population in this neighbourhood move freely around the city and access services where they need them. The development of the Campus area will not have a dramatic effect on this locality and their access to pharmacies and I don’t believe this application is necessary nor desirable.

The Chair thanked Mr Shearer for his statement and invited the Applicant, Interested Parties and then members of the Committee to ask questions of him.

9.1 Questions from the Applicant to Mr A Shearer, Rowlands Pharmacy

The Applicant enquired that with regard to the Inverness Campus at what stage would Mr Shearer say there would be a need to look at inadequacy of the provision of pharmaceutical services, highlighting that there would be an influx in the population through its development, although that may be transient and asked if we needed to wait to see the inadequacy prior to providing additional services.

20 Mr Shearer replied that “in a sense, yes”. He felt that the existing services could handle the influx and that access to the Campus when it was fully open would probably be closest to Tesco than trying to negotiate a maze of roads, in reality.

The Applicant then enquired how the pharmacy service at Culloden would be affected if the GP practice sited there were to relocate.

Mr Shearer considered that this might have a small effect – perhaps on collections and the loss of acute prescriptions which may be lost but that that would happen in a situation where any GP relocated to new premises and, in reality, this may, or may not happen so couldn’t base a decision on it at this stage.

The Applicant advised that she was aware that the residents at Milton of Leys have just started receiving a delivery service from Rowlands since an application was made to open a new pharmacy there and that prior to that application being made was it true that there was no delivery service to that neighbourhood.

Mr Shearer replied that Rowlands had actually always covered that area between the Balloan Park and Culloden pharmacies but that this often interchanged as that area lay between the two areas.

The Applicant enquired whether then, Mr Shearer now thought that as there was now evident notice and this was making customers more aware of the services was not previously offered but now being promoted.

Mr Shearer replied that the service was always offered but that the situation had changed promotion-wise and that it was a service available which could be used but was not dedicated to this application.

9.2 Questions from Ms L Gellatly, Tesco Pharmacy to Mr A Shearer, Rowlands Pharmacy

Ms Gellatly had no questions for Mr Shearer.

9.3 Questions from Mr P Mutton, Area Pharmaceutical Committee to Mr A Shearer, Rowlands Pharmacy Mr Mutton had no questions for Mr Shearer.

9.4 Questions from the Committee to Mr A Shearer, Rowlands Pharmacy

Alison MacRobbie enquired that, in terms of the Campus, Mr Shearer had made reference to talking about crossing busy roads but was he aware there were a number of structured walking routes integrated into planning of the site and with the promotion of healthy working lives did he not agree that this would encourage people to get out and about.

Mr Shearer replied definitely that locally this would happen but primarily not lead into a small neighbourhood.

10. The Interested Parties’ Case – Mr P Mutton, Area Pharmaceutical Committee

Mr P Mutton stated “after reviewing and discussing the application and supporting documentation the Area Pharmaceutical Committee does not feel the application to be necessary nor desirable.

21 The Area Pharmaceutical Committee agrees with the Applicant’s definition of her neighbourhood, however, understands that patients access pharmaceutical and GP services from across Inverness. In addition, many pharmacies within Inverness also deliver within the Applicant’s neighbourhood and therefore the Area Pharmaceutical Committee believes it is important to consider the services of pharmacies outwith the Applicant’s neighbourhood. The Cradlehall area has several bus services and we believe a high car ownership.

The Area Pharmaceutical Committee are not aware of pharmaceutical service inadequacy within the Applicant’s neighbourhood or any complaints being made to the Board. The supporting documents provided as an outcome to the initial public consultation, in the Area Pharmaceutical Committee’s view do not highlight an “inadequacy” in pharmaceutical services but note the point of failure of the Courier to assign the PO Box may impact on that.

Some of the supporting letters for the Applicant mention supply issues of medication. There has been, and still are, national supply issues within the pharmaceutical industry, ear drops and suppositories are currently products “on quota”. These are issues affecting all community pharmacies and the Area Pharmaceutical Committee believes it is important that the Pharmacy Practices Committee are aware of these national supply issues when making their decision as this may impact on patients’ perception of services obtained through pharmacy.

An appeal for an application at this site was overturned by the National Appeal Panel in 2009. At that time the National Appeal Panel believed Rowlands, Keppoch Road were in a position to adapt to the growing population. The applicant has not provided any recent data to highlight any change in population since this appeal.

Since this decision was made by the National Appeal Panel, Boots the Chemist, Eastfield Way has had a refit, improving their facilities and capacity. Both Rowlands, Keppoch Road and Boots the Chemist, Eastfield Way, currently service the Applicant’s neighbourhood and the Area Pharmaceutical Committee believes that between them they have the capacity to provide pharmaceutical services to a growing population.

Although, on the whole, the Area Pharmaceutical Committee believe pharmaceutical services across Inverness to be adequate, Public Health reports and current HEAT targets are currently directing NHS Boards to review services in areas of deprivation; allowing individuals in these areas to improve their health in line with more affluent areas. The Area Pharmaceutical Committee would support this view and acknowledge that there are deprived areas in Inverness that would benefit from additional pharmaceutical services. NHS Highland’s Pharmaceutical Care Services Plan also highlights these areas and the Area Pharmaceutical Committee, along with the Pharmaceutical Care Services Plan, would not classify Cradlehall as an area of deprivation. The Area Pharmaceutical Committee believes there is a need to support development of pharmaceutical services within these deprived areas rather than in areas where pharmaceutical services are already adequate.

The Chair thanked Mr Mutton for his statement and invited the Applicant, Interested Parties and then members of the Committee to ask questions of him.

10.1 Questions from the Applicant to Mr P Mutton, Area Pharmaceutical Committee

The Applicant had no questions for Mr Mutton.

10.2 Questions from Ms L Gellatly, Tesco Pharmacy to Mr P Mutton, Area Pharmaceutical Committee

Ms Gellatly had no questions for Mr Mutton.

22 10.3 Questions from Mr A Shearer, Rowlands Pharmacy to Mr P Mutton, Area Pharmaceutical Committee

Mr Shearer had no questions for Mr Mutton.

10.4 Questions from the Committee to Mr P Mutton, Area Pharmaceutical Committee

The Committee had no questions for Mr Mutton.

11. Summing up The Applicant and Interested Parties were then given the opportunity to sum up. 11.1 Mr P Mutton, Area Pharmaceutical Committee stated “to summarise I would say that the application is not about whether the application will provide a better service than is currently available, but is about whether the current services are adequate. The Area Pharmaceutical Committee believe current services are adequate and therefore are of the view that this application should not be granted”.

11.2 Mr A Shearer, Rowlands Pharmacy stated “a small cohort may have indicated that they need a pharmacy which is for convenience rather than need. There are no issues with the current pharmacy contracts already in place who can meet future provision and, as such, the application is neither necessary nor desirable”.

11.3 Ms L Gellatly, Tesco Pharmacy stated “we do not believe that this passes the legal test. Across the 11 pharmacies there is access to adequate pharmaceutical services therefore this application is not necessary nor desirable in order to secure adequacy”.

11.4 Miss Lynne Elizabeth Campbell, Applicant stated “I would like to take the opportunity to thank everyone very much for their help in my application. I have learned a lot during the process.

What is Pharmacy – pharmacy is about delivering patient centred care which is respectful, compassionate and responsive to an individual’s preferences, needs and values.

The neighbourhood has been clearly defined and the pharmaceutical services within the neighbourhood are inadequate as there is no current provision. There are services outwith the neighbourhood but these are not accessible to everyone. With the up and coming Inverness Campus the proposed relocation of GP surgeries into the Campus extra strain will be placed on these existing pharmacies.

As this community expands through future housing developments in the neighbourhood, together with the development of the Inverness Campus at Beechwood, the requirement for direct patient services under the community pharmacy contract will increase and the current lack of provision will become a more acute problem. Therefore, I feel that the present and future case for a local pharmacy within the defined neighbourhood, which would include the provision of pharmaceutical services is a strong and indeed desirable one”.

At the conclusion of the summing up, the Chair asked the Applicant and all of the interested parties if they considered that they had had a fair hearing. Miss Campbell, Mr Lawrie, Ms Gellatly, Mr Shearer and Mr Mutton replied yes, that they did consider they had had a fair hearing. . The Chair advised that a written decision would be sent out within 15 working days. A letter would be included with the decision advising of the appeal process. The Chair then thanked the parties for attending.

23 Miss Campbell, Mr Lawrie, Ms Gellatly, Mr Shearer and Mr Mutton left the meeting.

12. DECISION

Having considered all the evidence presented to it, and the Committee's observations from the site visits, the Committee had firstly to decide, the question of the neighbourhood in which the premises to which the application related, were located. The Committee took into account a number of factors in defining the neighbourhood including the natural and man-made boundaries, who resides in it, neighbourhood statistics, the location of existing shops, health services and schools, land use and topography, and the distance and the means by which residents are required to travel to existing pharmacies and other services. In addition it anticipated future developments including firm plans for the further expansion of housing estates and the Inverness Campus. Special regard was made to the requirements of the Equality Act 2010:

 the need to eliminate unlawful discrimination, harassment and victimisation and other conduct prohibited by the Act;

 advance equality of opportunity between people who share a protected characteristic and those who do not;

 foster good relations between people who share a protected characteristic and those who do not.

The Committee considered the Applicant's definition of the neighbourhood and how this compared to those put forward by the Interested Parties as well as comments received from the public consultation, and it was unanimously agreed that it should be as that defined by the Applicant.

12.1 Neighbourhood: The Committee agreed that the neighbourhood had been clearly defined by the Applicant and supported the Applicant’s definition of the neighbourhood and considered the detail of that neighbourhood and where the boundaries would lie.

The Committee considered that the neighbourhood should be defined as follows:-

North: The northern edge of the A9 until it meets the A96 at the Raigmore Interchange and the boundary of the Inverness to Perth railway line as these mark physical boundaries to the neighbourhood. For local people there is clear definition between the Smithton area and the Cradlehall and Westhill areas defined by the route of the railway.

East: From Culloden Road along the edge of the Westfield housing development adjoining Culloden Woods until it meets the railway line at the bridge on Tower Road as this represents the extent of residential housing and the start of wooded countryside.

South: The B9006 Culloden Road and incorporating the Woodlands housing and Inshes Wood and Easter Muckovie until the Woodside development and the edge of Culloden Woods as this represents the extent of residential housing and the start of countryside.

West: The A9 from the Inshes exit below the B9006 flyover to the Raigmore Interchange as this marks a physical boundary to the neighbourhood.

24 12.2 Adequacy of Existing Provision of Pharmaceutical Services and Necessity or Desirability:

Having reached that decision, the Committee was then required to consider the adequacy of pharmaceutical services within that neighbourhood, and whether the granting of the application was necessary or desirable to secure adequate provision of pharmaceutical services in that neighbourhood.

The Committee noted the content of the 15 letters of support, some of which were in email format, received by the Applicant and submitted to the Board with the application as a result of her initial public consultation in the Inverness on Courier on 18 November, 2011. It should be noted that one of the letters of support received by the Applicant was from the Westhill Community Council in support of the application addressed “To Whom It May Concern” although a copy of this letter was not sent to the Health Board by that Community Council as a result of the letter addressed specifically to them as referred to in the next paragraph. Another of the 15 support letters, addressed directly to the Applicant, was received from the President of the Westhill Senior Citizen’s Club in support of the application but no reply was sent by them to the Health Board either in response to their consultation referred to. In any event all letters were included in the application pack and submitted to the Pharmacy Practices Committee for their consideration.

The Committee also noted that out of 34 letters sent by the Health Board to Community Councils, Senior Citizen’s Club, Highland Councillors, MPs and MSPs and the Public Notice posted on the NHS Highland Website only one response was received by e-mail. This e- mail, received from a Highland Councillor, but was written in a personal capacity and supported the application. Although this response was supportive of the staff at Tesco Pharmacy it took issue with the size and layout of the pharmacy tucked into the back of the supermarket and lack of privacy during consultations.

Whilst there was evidence submitted as a result of the consultations which indicated that access to pharmacies is not always convenient for residents in the neighbourhood, with people having to travel to access a pharmacy, the Committee felt there was not sufficient evidence submitted to judge the current service inadequate.

Unfortunately the Committee were of the opinion that the door-to-door survey undertaken, despite all the personal effort by the Applicant, could only have limited bearing on the decision making process as it represented a limited sample of the total population, may have been biased (by the nature of the applicant personally handing the form to the survey households and discussing what she was proposing as we as by the non random approach in handing them out), reporting had been against the forms returned rather than those issued and the results could not be shown to reflect the target population with any confidence. It was felt that the survey could have been conducted in a more systematic way to produce scientifically valid results. The same could be said for the survey mentioned by Tesco which showed high levels of customer satisfaction. However, that aside, the Committee considered that the Applicant’s survey did not demonstrate inadequacy in the provision of pharmaceutical services.

It was noted that the total population was more likely to be in the region of 7,000 within the neighbourhood as defined by the Applicant. This information was obtained by the Health Board from datazone information from Scottish Neighbourhood Statistics as at 2010 and, although could not be taken as completely accurate as some of the datazones overlapped into other datazone areas slightly, it was perceived that the population was significantly higher than the 5,271 intimated by the Applicant in her statement. This is not a deprived neighbourhood in fact it is quite affluent and there is a lower than average older population therefore the aging population will affect this neighbourhood less than many others. There are many families with young children. The Committee recognised that it was required to determine the adequacy of existing 25 provision of pharmaceutical services in the defined neighbourhood at the time of the oral hearing and that in reaching its decision it needed to consider future developments. It was recognised that there are still new houses being built within the neighbourhood and this will result in a further population growth. The Committee also discussed the likely impact of the Phase I development of the Inverness Campus and although it was acknowledged that this could potentially lead to a transient increase in the daytime population there was currently only a small part of the development which was zoned for accommodation. In addition, the infrastructure of the Campus had clearly marked access and exit routes which would tend to lead users of the site away from the proposed neighbourhood. At the current time it was felt that any effect on the existing services was speculative, including the possible relocation of GP practices, and the Committee decided that there was insufficient evidence to suggest that the existing pharmacies would not be able to cope with the expected increase in demand for pharmaceutical services. It was felt by the majority of the Committee that any increase in the population could be managed by the existing pharmacies adjacent to the neighbourhood.

None of the 3 nearest pharmacies are particularly easy to access without transport from the defined neighbourhood. For instance a fit person walking from Cradlehall Shopping Centre to Boots would take at least 40 minutes, however, although not an NHS service, all these pharmacies offer a prescription collection service from all Inverness GP practices. This means that patients do not have to travel to their GP to collect repeat prescriptions. All 3 adjacent pharmacies also provide a delivery service to housebound patients in the defined neighbourhood. The levels of car ownership are high and the bus services are frequent. Most households were able to travel out of the neighbourhood for work or to access services to meet their daily needs. The population in this neighbourhood were generally considered to be able to move freely around the City and access services where they need them.

The Committee noted that within the neighbourhood as defined there are no pharmacies and that pharmaceutical services are currently being provided from pharmacies outwith the neighbourhood including 3 pharmacies adjacent to the boundaries of the neighbourhood, Tesco Pharmacy, Milton of Inshes, Rowlands Pharmacy, Keppoch Road, Culloden and Boots, Eastfield Way, Inverness Business & Retail Park. Consequently, the Committee recognised that they needed to consider whether an adequate pharmaceutical service was being provided from these pharmacies, bearing in mind that residents can and do choose to access pharmacies throughout Inverness.

The Committee then considered the pharmacy services provided by these 3 pharmacies adjacent to the boundaries of the neighbourhood in more detail i.e. the monthly number of prescriptions dispensed from April 2006 to December 2011 and also data related to the four core services of the Scottish Pharmacy Contract i.e. Minor Ailments Service (MAS), Chronic Medication Service (CMS), Acute Medication Service (AMS) and the Public Health Service. This data indicated engagement of varying degrees with the core services from these pharmacies. It was noted that Tesco Pharmacy had recently commenced offering NHS Emergency Hormonal Contraception (EHC) but had a lower level of Pharmacy Care Records (PCR) for CMS. It was felt that by the Committee that a pharmacy with extended hours and some double pharmacist cover might have achieved more registrations and PCRs, however, there may have been initial technical difficulties which might explain this. The evidence showed that these pharmacies were all providing the core elements of the contract.

Tesco had confirmed that they have capacity to provide monitored dosage systems to patients requiring them.

26 It was recognised that Tesco Pharmacy are not currently engaging as actively with the pharmacy contract and there were some worries about the level of staffing and skill mix at Rowlands Pharmacy at Culloden where there is only one pharmacist. However the figures provided on the current provision of pharmacy services indicate that the pharmacies are delivering the required services in line with their peers.

Reference was also made to the Pharmaceutical List 2011 to establish the locally negotiated services each pharmacy offers. These were considered to offer an appropriate range for the population of the neighbourhood.

Tesco Pharmacy and Boots, Retail Park both have extended hours in the evening and on Sundays enabling them to offer pharmaceutical services beyond those expected by the NHS Highland Board Scheme and provide local access to healthcare services during the GP Out- of Hours period for this population.

There have been no complaints to NHS Highland about current pharmaceutical services within the neighbourhood. Neither has the Pharmaceutical Care Services Plan, 2012/13 identified a potential gap in pharmaceutical service provision in this neighbourhood.

The increase in the Inverness population over recent years and the increased need for pharmaceutical services had and is being met by the existing pharmacies. There can be economies of scale which allow a single larger pharmacy to efficiently manage more than twice the workload of two smaller ones.

The Committee, in determining the adequacy of existing provision of pharmaceutical services in the defined neighbourhood, took account of the evidence provided by the Applicant, and made available from other sources and concluded that the level of existing pharmaceutical services was adequate and granting the application was not necessary.

The Committee then considered whether it would be desirable to grant the application to maintain adequacy into the future and concluded that predicted increased demand could be managed by the existing pharmacies adjacent to the neighbourhood and granting the application was not desirable.

The non-voting pharmacists then left the room.

27 12.3 In accordance with the statutory procedure the Pharmacist Contractor Members of the Committee, and Board Officers were excluded from the decision process:

DECIDED/-

The Pharmacy Practices Committee (PPC) was satisfied that the provision of pharmaceutical services at the premises of the Applicant were not necessary or desirable in order to secure adequate provision of pharmaceutical services in the neighbourhood in which the premises were located by persons whose names are included in the Pharmaceutical List and in the circumstances, it was the majority decision of the PPC that the application be refused.

The non-voting pharmacists were invited back into the room and were advised that the application had been refused.

The Hearing then was closed.

Bill Brackenridge as Chair of the PPC Date: 18 April 2012

28 Highland NHS Board 5 June 2012 Item 3.11

GOVERNANCE COMMITTEE ANNUAL REPORTS

Report by Kenny Oliver, Board Secretary, on behalf of the Chief Executive

The Board is asked to:

 Note the views of the Audit Committee on the attached Annual Reports of the Governance Committees.

1 Background and Summary

As part of the Annual Accounts process a number of Annual Reports relating to NHS Highland Committees are produced, including a specific declaration that the systems of control within their respective areas are considered to be operating adequately and effectively. These Annual Reports form part of the framework of assurance supporting the Statement of Internal Control which is part of the Annual Accounts process.

At the Audit Committee meeting to be held on 15 May 2012, the Committee reviewed these Annual Reports in detail. The Chair of the Audit Committee will report to the Board at the meeting on any issues that the Committee consider should be brought to the attention of the NHS Board.

All Annual Reports considered at the meeting of the Audit Committee are attached:

 Appendix 1 – Audit Committee  Appendix 2 – Staff Governance Committee  Appendix 3 – Remuneration Sub-Committee  Appendix 4 – Clinical Governance Committee  Appendix 5 – Improvement Committee  Appendix 6 – Risk Management Steering Group  Appendix 7 – Endowment Funds Committee  Appendix 8 – Argyll & Bute CHP Committee  Appendix 9 – Mid Highland CHP Committee  Appendix 10 – North Highland CHP Committee  Appendix 11 – South East Highland CHP Committee  Appendix 12 – Raigmore Committee  Appendix 13 – Spiritual Care Committee  Appendix 14 – Control of Infection Committee  Appendix 15 – Health & Safety Committee  Appendix 16 – Pharmacy Practices Committee

2 Contribution to Board Objectives

The above reports form a key part of the statutory requirement for NHS Highland to submit an Internal Statement of Control which is included in the Boards Annual Accounts. 3 Governance Implications

The production of these Annual reports forms part of the assurance framework for the Board regarding the way in which its Committees discharge their delegated responsibilities. This encompasses all areas of Governance including: Staff Governance; Patient and Public Involvement; Clinical Governance; and Financial Governance.

4 Planning for Fairness

This paper describes a reporting system that in itself does not require an Equality and Diversity Impact Assessment.

5 Engagement and Communication

These reports have either already been approved by their Committees in at least draft format. They will public documents both as part of the Board papers and as part of the Annual Accounts process.

Kenny Oliver Board Secretary

25 May 2012

2 APPENDIX 1

AUDIT COMMITTEE ANNUAL REPORT PERIOD APRIL 2011 – MARCH 2012 DRAFT Report by Ian Gibson, Chair, Audit Committee

1. Background

In line with sound governance principles, an Annual Report is submitted from the Audit Committee to the Audit Committee. This follows the procedure for all Governance Committees, but in the case of Audit Committee is undertaken in two parts:–  A report is submitted to the May Audit Committee to cover the period from April to March.  A report is submitted to the September Audit Committee to cover the closure of Annual Accounts/Reporting process to ensure full coverage of the Financial Year.

2. Overview

This first report covers the period April 2011 to March 2012 during which time there were five meetings of the Audit Committee, including the specific meeting in June 2011 to consider and approve the Annual Accounts.

The Audit Committee exists amongst other things to:-

 ensure that the activities of the Board are within the law and regulations governing the NHS  verify that an effective and comprehensive system of Internal Control is implemented and maintained  ensure the audit, presentation and consideration of the Annual Accounts

The Audit Committee agrees the work-plan at the beginning of each financial year, operates with a formal agenda and written papers which are circulated in advance of the meeting. These circulated papers include written reports by both the Internal and the External Auditors. These Audit Reports detail the work undertaken, the key issues emerging and the steps being taken by management to address any weaknesses identified.

The Audit Committee is chaired by myself as an independent non-Executive, with five other non-Executives as members. Although not Committee members, the meetings are usually attended by the Director of Finance, often by the Board Chair and sometimes by the Chief Executive. All Board Members are able to attend as observers and Executives and other officers attend as appropriate to provide further detail and information and to answer specific questions from the Committee.

In addition to considering the work of the Auditors, the Committee also maintains an overview of a number of Internal Control areas on behalf of the NHS Board. An example of this is the overview of Risk Management - which although devolved to Organisational Units – is subject to overall Audit Committee Review prior to submission to the Board.

A separate section of the Audit Committee agenda is dedicated to Counter Fraud, allowing the Committee to discharge this responsibility on behalf of the Board 3. Internal Audit Service

Following competitive tender Scott Moncrieff were appointed as our new internal auditors at the start of the financial year. The transition from the former internal auditors was managed smoothly.

A major part of the work of the Audit Committee relates to Internal Audit, whereby the Committee consider and approve the Audit Plans arising before monitoring the delivery of this plan and consideration of the key points arising. During the year, the Audit Committee received a formal written summary on 30 Audit Reports, together with full copies of 14 Audit Reports which contained at least one Priority 4/5 or High/Very High recommendation.

The details of reports considered are in the Audit Committee Papers and the Audit Committee minutes which are subsequently presented to the full NHS Board. With the volume of reports it is not possible to list, or detail all work undertaken but some are highlighted below.

eHealth – Project Lifecycle Management - the report highlighted improvements required in project management, developing business cases, identifying benefits, risk management throughout projects – management responses indicate that plans are in place to implement the improvements recommended

Review of medical locums - the report highlighted that improvements were required in the pre-employment checks undertaken and monitoring of locum costs - management responses indicate that plans are in place to implement the improvements recommended

Fleet Management - non-conformance to procedures for approval of lease cars were highlighted. A number of improvements were needed and a full review of the lease car scheme is expected within the next year.

Planning for Integration - a report was commissioned by the Audit Committee in year partly to provide assurance on the process of integration, but principally to identify learning that will assist the Board as it takes on responsibility for adult social care.

Strategic Risk Framework – following an internal audit report the Strategic Risk Framework was substantially revised and now incorporates risks transferring from Highland Council. The revised framework was subsequently approved by the Board.

The internal auditors are responsible for monitoring the management action plan that is produced with each report and reporting progress in implementing the agreed recommendations back to the Audit Committee.

4. Sub Groups

The Audit Committee do not operate with any formal sub groups, but do, on at least an annual basis, meet with both sets of auditors in private session without any non- Audit Committee members present. In 2011/12 the private meeting with the auditors was at the June Meeting.

The Audit Chair also has ongoing direct contact with the Chief Internal Auditor between meetings and internal audit are included in the agenda planning meeting. When appropriate, the Chair meets with internal and external auditors immediately before the Audit Committee. The Chair also meets at least twice a year with the Chairs of the Clinical Governance and Staff Governance Committees to ensure

2 coordination. The Chair also has at least one meeting a year with the chair and also separately with the chief executive.

Okain Maclennan, a member of the Committee, maintains contact with the Counter Fraud Services Team on a regular basis as part of his role as Fraud Champion.

5. External Reviews

The work of the Audit Committee is different from most other committees in that the work of the Committee is influenced and delivered by independent input through Internal and External Audit. This review is further enhanced by the Annual Internal Audit Statement of Assurance, and the review of Audit arrangements undertaken by the External Auditors as part of the verification of the Annual Accounts.

As part of their work, the External auditor submits an update on work undertaken to each Audit Committee, summarising not only the work undertaken, but also highlighting to the Committee any areas of significant interest. This includes any National Reports for each of which the Audit Committee considers what action is required by the Board.

In addition, as part of the review of the Board governance, it was agreed that it would not be appropriate to hold audit committees in public. However, it was agreed that, in order to help maximise transparency and to add to the skills base of the audit committee, two public members with appropriate experience would be recruited. This has been delayed pending the wider recruitment of public members to a number of governance committees.

6. Issues to Address

The Audit Committee will continue to develop and respond to organisational needs, building on the work of the last few years which has maintained the move away from focus solely on financial controls to the wider consideration and evaluation of controls in the operational environment. Specific items include –

 ensure ongoing review on responsibility for specific issues with other governance committees  review audit plans with Highland Council auditors to ensure all areas within the Integrating Care in the Highlands Programme are covered in the plans  the committee has been concerned at the length of time it has taken to ensure that some audit recommendations are implemented by management. This will be a particular focus in the next year and will be assisted by the appointment and attendance of the Chief Operating Officer at the Audit Committee  undertaking a facilitated self assessment to identify what improvements can be made to the way the committee discharges its responsibilities  recruitment of public members with appropriate experience

7. Conclusion

2011/2012 has maintained the progress of recent years for the Audit Committee, including unqualified accounts, increasing emphasis on counter-fraud initiatives, systematic follow up of recommendations and spreading the scope beyond traditional accounting issues.

The Audit Committee has fully discharged its duties to date and has therefore been able to contribute to the Board operating within the appropriate framework of Internal Control. As noted above, a second part of the Audit Committee Annual report will be presented to the September Audit Committee to facilitate full reporting and

3 accountability over the complete cycle of the financial year, including the consideration and approval of the Annual Accounts.

Ian Gibson Chairman Audit Committee NHS Highland May 2012

4 Annual Report APPENDIX 2

NHS Highland Staff Governance Annual Report:

To: NHS Highland Audit Committee From: Pam Courcha, Chair, Staff Governance Committee Subject: Staff Governance Committee Report – April 11 – March 12

1 Background

In line with sound governance principles, an Annual Report is submitted from the Staff Governance Committee to the Audit Committee. This is undertaken to cover the complete financial year, and forms part of the supporting arrangements for the Statement of Internal Control, ending with the certification and submission of the Annual Accounts.

The Staff Governance Committee is a formal Committee of the Board. The role of the Staff Governance Committee is to:

‘Support and maintain a culture within NHS Highland, where the delivery of the highest possible standard of staff management is understood to be the responsibility of everyone working within the system and is built upon partnership and collaboration. It will ensure that this is achieved by ensuring robust arrangements around the implementation of the Staff Governance Standard’.

The Committee has met on 4 occasions during the year on 24th May, 23rd August, 22nd November and 21st February. The minutes of the Committee have been submitted to the appropriate Board Meeting and in addition an Assurance Report was submitted alongside the minutes of the meetings.

2 Activity

The Staff Governance Committee considered the following key items at its meetings throughout the year.

24th May 2011

 Reports from other Committees – Remuneration Sub Committee, Highland Partnership Forum, Health and Safety Committee  Workforce Work Programme  Planning for Integration  Staff Governance Standard SAAT Report and Action Plan  Staff Governance Committee Annual Report  Workforce Report  Staff Governance/Workforce Reports from Operational Units  Implementation of KSF  Workforce Planning – NHS Highland Workforce Rolling Action Plan 2010/11 and Workforce Plan 2011/12 and Management of workforce Risk  Hospital Locums

23rd August 2011

 Report from other Committees  Workforce Work Programme  Workforce Plan  Planning for Integration  Staff Governance Committee – Revised Role and Remit  PIN Policy Review – National Work Programme  Occupational Health Service Provision and Development  Whistleblowing Policy 1  Secondary Employment and Working Time Regulations  Workforce Report  Staff Governance Workforce Reports from Operational Units  Staff Leaving Arrangements – Internal Audit  Implementation of KSF

22nd November 2011

 Reports from other Committees  Staff Governance Committee Revised Role and Remit  National Review of the Staff Governance Standard  Feedback from the Annual Review  Workforce Report  Staff Governance/Workforce Reports from Operational Units  Partnership Working – Raigmore Hospital  Implementation of KSF  Electronic Employee Support System  Promoting Attendance – A&B CHP  Workforce Planning - Rolling Action Plan - Workforce Savings Plan  Planning for Integration

21st February 2012

 Reports from other Committees  Workforce Plan  Staff Governance Standard Self Assessment Audit (SAAT) 2010/11  Workforce Report  Implementation of Knowledge and Skills Framework  Planning for Integration

3 Sub Groups

Remuneration Sub Group

The Remuneration Sub Committee is a formal Sub Group of the Staff Governance Committee and abridged minutes of the meetings are submitted to the Committee in a timely manner. The Remuneration Sub Committee produces its own Annual Report.

The Highland Partnership Forum acts as the operational Sub Group of the Staff Governance Committee and considers the majority of Agenda items prior to submission to Staff Governance Committee. The Highland Partnership Forum has a number of Sub Groups (see Appendix I), all with their own work Programme.

Other Substantive Sub Groups

 Human Resources Sub Group

The HR Sub Group is one of the standing sub groups of the Highland Partnership Forum (HPF). It is Co- Chaired by the Head of Personnel and the Employee Director and meets monthly. The membership of the group is “tripartite” in nature with members drawn from Staff Side Organisations, Personnel and Operational Managers which allows the fullest possible discussion on items on the agenda. Primarily this agenda is connected with development of new HR policies, implementation of the NHS Scotland PIN Policies as well as offering interpretation and guidance on both these where issues are raised in NHS Highland.

Over the last year (2011/12) which will continue into the new year (2012/13) with the release of a number of reviewed NHS Scotland PIN Policies a large amount of work has been taken up with putting these 2 policies into a NHS Highland format. Other items on the agenda have included – Promoting Attendance FAQs, Annual Leave FAQs, Dignity at Work, Exit Interview/End of Employment Policy, Flexible Working Requests Policy, Employment Break Policy.

As a sub group of the HPF it does report back and a number of policies are taken to it for final ratification but mostly the group operates with a degree of autonomy and issues are likely by exception to be taken to the HPF.

 Terms and Conditions Sub Group

The Terms & Conditions Sub Group is a standing Group under the HPF. It is co-chaired by the Head of Personnel and a Partnership Representative (currently Adam Palmer of UNISON). Meetings are programmed on a monthly basis but dependant on outstanding business, the group does not always meet. In the last 12 months the group has met on 8 occasions and progressed issues relating from interpretations of National Terms & Conditions and individual pay and conditions related matters which require local consideration. The Group has also reviewed NHS Highlands approach to the implementation of National Terms and Conditions Circulars to ensure that appropriate action is taken to implement agreed National Policy. The Group has representation from Payroll, HR and partnership representatives with co-opted members from management as required, or submitting evidence for consideration.

 Learning and Development Sub Group

The Learning and Development (L&D) Subgroup is co-chaired by the Director of Operations, South and West CHP and a Staff Side Representative, and its membership is drawn from operational units, L&D team leads, clinical leaders, staff side representatives and Union Learning Representatives. Its key purpose is to have an oversight of all L&D activity within NHS Highland; monitor and report on learning activity to enable compliance with the “appropriately trained” component of the Staff Governance standard; make recommendations on the allocation of the L&D budget and monitor its usage; support the implementation of KSF and PDP&R; and monitor equity of access; and ensures that all L&D activity supports and is aligned to NHS Highlands corporate objectives.

During 2011-12 the key activities that the subgroup has overseen include: the development of a refreshed Learning Strategy; further embedding KSF; allocating and monitoring the L&D budget (ensuring that this is also discussed and monitored within Local Partnership forums); reviewed the L&D Endowments process; supported the Learning Partnership agreement; supported the development of a Learning Information Point within Raigmore; used the reports now available within AT-L and other L&D systems to monitor L&D activity; overseen the review of the Induction process; and set up a Mandatory and Statutory Working group (which will co-ordinate and oversee all activity in this area and so work towards reducing organisational risk).

 Workforce Planning and Development Sub Group

The Workforce Planning and Development Sub Group have overseen the development of the NHS Highland Workforce Plan 2011/12 and its associated Workforce Plan Rolling Action Plan, which is updated with a quarterly progress report. In addition progress against workforce productivity and efficiency and contribution to Board savings has also been overseen by the group and reported to the SGC on a quarterly basis throughout 2011/12.

The Workforce Planning and Development Sub Group is chaired by the Director of Human Resources and membership includes senior operational management, clinical leadership, financial planning, service planning, service and quality improvement, staff side, workforce planning and learning and development representatives. This ensures that the workforce planning function is delivered through an integrated and broad approach and aligned to the delivery of Board objectives and its overall Strategic Framework.

 Equality and Diversity Sub Group  Healthy Working Lives Sub Group

Staff Side Representatives also sit on CHP and Raigmore Governance and Management Committees.

3 4 External Reviews

4.1 Staff Governance Self Assessment Audit 2010/11

The Staff Governance Self Assessment Audit was completed and along with the Mandatory Statistical Information and a revised Staff Governance Action Plan was submitted to the Scottish Government Health Department at the end of April 2011 and feedback was received in December 2011.

4.2 Staff Survey

NHS Highland participated in the National Staff Survey in the Autumn of 2010 and integrated actions arising from the survey will be added into the Staff Governance Action Plan for 2011/12.

5 Key Performance Indicators

5.2 Knowledge and Skills Framework – HEAT Target

The HEAT Target E10 - required NHS Boards to ensure that staff on Agenda for Change permanent contracts took part in an annual review against their KSF post outline and that information on levels of competence and identified training needs were required to be made available through Boards recording summary information from at least 80% of development reviews on e-KSF by end of March 2011.

In NHS Highland on the 31st March 2011 - 83% of staff had a development review recorded on e-KSF. For 2011/12 the Board set its own local target for all staff to have a KSF PDP&R and for 80% to be recorded on eKSF, this was to include Bank Staff. By the end of March 2012 66% of all staff had a completed PDP&R recorded on eKSF. However if Bank Staff are excluded then 84% of permanent staff had a completed PDP&R recorded on eKSF. In addition we have been advised by SGHD informally, that we are the only Board in Scotland to have reached last year’s target of 80% of permanent staff having a completed PDP&R recorded on eKSF.

Clearly there is more work to do on this and we need to reflect on the most effective way to ensure that PDP&R is fully embedded in NHS Highland, as a core activity that supports the provision of high quality care and a positive patient and staff experience.

5.3 Sickness Absence

NHS Boards were asked to reduce sickness absence to 4% by March 2009 and NHS Highland has continued to work towards this standard. Overall NHS Highland had reduced its sickness absence rates from a rolling average of 5.03% in April 2008, 5.01% in March 2009, 4.81 % in March 2010 and 4.8% in March 2011 to 4.44in March 2012.

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

The Workforce Agenda continues to grow and a NHS Highland Workforce Work Programme has been developed to support the Board Strategic Framework. The Committee will need to continue to focus on the full utilization of eKSF, reducing sickness absence, as well as taking an overview of the changing shape and size of the workforce and the Workforce Savings Plan. In addition the impact of Planning for Integration and now Integrating Care in the Highlands for the Workforce has been overseen by the Committee and will continue to provide challenges in ensuring full integration for transferred staff in 2012/13.

7 Conclusion

I can conclude that the systems of control within the respective areas within the remit of the committee are considered to be operating adequately and effectively.

Pam Courcha Chair Staff Governance Committee March 2012 4 APPENDIX 3

Annual Reports

NHS Highland Remuneration Sub Committee Annual Report:

To: NHS Highland Audit Committee

From: Garry Coutts, Chair, Remuneration Sub Committee

Subject: Remuneration Sub Committee Report – April 11 – March 12

1 Background

In line with sound governance principles, an Annual Report is submitted from the Remuneration Sub Committee to the Staff Governance Committee and from the Staff Governance Committee to the Audit Committee. This is undertaken to cover the complete financial year, and forms part of the supporting arrangements for the Statement of Internal Control, ending with the certification and submission of the Annual Accounts.

The Remuneration Committee is a formal Sub Committee of the Staff Governance Committee. The Role of the Remuneration Committee is:

 To agree all the terms and conditions of employment of executive directors of the Board, including

- job descriptions - job evaluation - terms of employment - basic pay - performance related pay - benefits (e.g. Removal Expenses) - agreeing objectives for executives before the start of the year in which performance is assessed - reviewing performance mid year and at the end of the year - ensuring that effective arrangements are in place for carrying out the above two functions in respect of all other senior managers - conducting a regular review of the Board’s policy for the remuneration and performance assessment of executive directors and other senior managers in the light of guidance issued by the SGHD.

The Role and Remit of the Sub Committee was updated in November to include reference to Medical Consultants, in relation to regularly reviewing the Boards Policy for their Remuneration and Performance Assessment.

The Remuneration Sub Committee has met on 3 occasions during the year on 24th May, 28th June, and 22nd November. Abridged minutes of the Remuneration Sub Committee have been submitted to the appropriate Staff Governance Committee.

1 2 Activity

The Remuneration Sub Committee considered the following key items at its meetings throughout the year.

24th May 2011

 Outcomes of Audit of Staff earning £100K per annum – Implications for the Remuneration Sub Committee  Feedback from National Performance Management Committee (NPMC)  CEL(2001)7 – Pay and Conditions of Service – Executive and Senior Management Pay 2010/11  Executive Cohort – End of Year Review Outcomes 2010/11  Remuneration Sub Committee Annual Report  Review of Corporate Objectives 2010/11 and Corporate Objectives 2011/12

28th June 2011

 Outcomes of Audit of Staff Earning £100K per annum – Implications for the Remuneration Sub Committee  Role and Remit of the Remuneration Sub Committee  Post of Chief Operating Officer  Executive Cohort End of Year Review Outcomes 2010/11  Senior Management Cohort End of Year Review Outcomes 2010/12  Executive Cohort Objectives 2011/12  NHS Scotland – Senior Managers Numbers Reduction Target  NEC Guidance – letter to Director of Human Resources, Guidance for Chairs, Job Description Guidance and Model Job Description

22nd November 2011

 Progress Report on the £100K Salary Audit  Revised Role and Remit of the Remuneration Sub Committee to include Medical Consultants  Remuneration of Clinical Directors and Clinical Leads, Raigmore Hospital  Report to the National Performance Management Committee (NPMC) for 2009/10 Performance Year  Discretionary Points Advisory Committee (DPAC) Award of Discretionary Points – 1 April 22011  Executive Cohort – Mid Year Reviews

3 Sub Groups

The Remuneration Sub committee does not have any Sub Groups.

4 External Reviews

The outcomes of the End of Year Reviews for the Executive Cohort were submitted to the National Performance Monitoring Committee and approved. The Remuneration Sub Committee has considered the National Remuneration Committee Self Assessment Pack and had concluded that the performance of the Remuneration Sub Committee was in line with National Guidance.

2 5 Any relevant Key Performance Indicators

There are no Key Performance Indicators for the Remuneration Sub Committee. An External Audit has been progressed in year to Review Staff Earnings over £100K per annum which was satisfactory.

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

The Remuneration Sub Committee is well established with a clearly defined Role and Remit and Work Programme, in the main set by national requirements. Attendance at the Sub Committee has been very good and Non Executive Directors demonstrate the appropriate scrutiny required.

7 Conclusion

I can conclude that the systems of control within the respective areas within the remit of the Remuneration Sub Committee are considered to be operating adequately and effectively.

Garry Coutts Chair Remuneration Sub Committee March 2012

3 APPENDIX 4

NHS Highland Clinical Governance Committee Annual Report

To: NHS Highland Audit Committee

From: Mrs Sarah Wedgwood, Chair, Clinical Governance Committee

Subject: Clinical Governance Committee Report – 1st April 2011 to 31st March 2012

1 Background

In line with sound governance principles, an Annual Report is submitted from the Clinical Governance Committee to the Audit Committee. This is undertaken to cover the complete financial year, and forms part of the supporting arrangements for the Statement of Internal Control, ending with the certification and submission of the Annual Accounts.

The committee met on four occasions during 2011/12, on 17th May 2011, 16th August 2011, 8th November 2011 and 14th February 2012. Its minutes and assurance reports were submitted to NHS Highland Board at its public meetings during this period.

The committee’s Role and Remit and Work Plan are detailed in appendices 1 and 2. As the recommendation made in the Board’s Internal Auditor’s review of the effectiveness of the committee, two public representatives were appointed to the committee in May 2011. At the end of the year a questionnaire was issued to the committee to identify further areas of improvement in the effectiveness of the committee. In August 2011, a paper was submitted to the committee setting out a revised role and remit to take account of the new Healthcare Improvement Scotland quality standard and that the work plan would be based around three quality areas: person-centred, safe and effective. Regular performance reports were received from the Clinical Governance Support Team on behalf of the operational units to provide assurance to the committee that systems were in place to monitor safe and effective care. These reports included areas of good practice and concern, lessons learnt, performance against responding to complaints within the agreed timescale and performance following Healthcare Improvement Scotland reviews.

During the course of the year, the committee were alerted to a number of serious/important issues that had occurred both within and outwith the Board’s area, the actions implemented following reports and the learning from these. These included:  Surgical Profiles  Scottish Public Services Ombudsman Reports laid before Parliament  Mid Staffordshire NHS Foundation Trust Reports  Better Together In Patient Survey 2011  Audit of Decontamination Standards ( Dental Services)  Tissue Viability-Pressure Ulcer Prevention  Use of Hospital Locums  Screening Programmes Annual Report  Highland Quality Approach

2.0 Activity 1st April 2011 to 31st March 2012

2.1 Incident Management System

During 2011/12 the DATIX Dashboard module was purchased to improve the access to and analysis of incident data. The Dashboard Module has provided the CGST the ability to create purpose built Dashboards for DATIX users (those with a login) throughout NHS Highland. Essentially a Dashboard is a screen in DATIX that will display a set of reports (ie: run charts, bar charts, pie charts) on one page. The Dashboard simultaneously analyses several different sets of data at the same time to provide an overview of incident information. This has been in development since September 2011 and Highland wide and Operational Unit Dashboards have already been built and access to these has been provided to the existing Operational Units. New Dashboards have been built in preparation for the new Operational Units.

In addition the top 10 category of incidents have also been built into the Dashboard module which allows all users to compare data on a Highlandwide, Operational Unit and Hospital / Ward level basis. Additional work has gone into preparing Tissue Viability and Patient Falls Dashboards to ensure they help to support the programmes of work being carried out in Highland. These are to be made available to all DATIX users at the start of May 2012. Work is now underway to produce specialist Dashboards for Health & Safety.

2.1.1 Incidents 2010/2011

Incident Data – 1 April 2011 to 31 March 2012

t P e s r c s P t a e H a o e r i

u H

l t c C o d l i h m m i l

B h C l t r

t y t i p n v a g P P r r i u a t s r d c a g d i r r H o H a o o a h e a o n A a C M N C R e S E F P y C e S G T 1277 555 963 1690 1333 106 62 21 6007 LOW (39.1%) (57.3%) (49.0%) (57.5%) (71.1%) (73.8%) (55.3%) (53.3%) (59.6%) 788 784 622 1471 899 30 20 11 4625 MEDIUM (36.8%) (55.3%) (37.0%) (42.7%) (38.8%) (20.1%) (23.8%) (28.9%) (41.0%) 11 28 9 56 51 155 HIGH (0.5%) (2.0%) (0.5%) (1.6%) (2.2%) (1.4%) 2 1 3 VHIGH (0.1%) (0.7%) (0.1%) Not 67 51 85 229 36 12 2 6 488 Graded (3.1%) (3.6%) (5.1%) (6.6%) (1.5%) (8.1%) (2.4%) (15.8%) (4.3%) Grand 2143 1418 1679 3448 2319 149 84 38 11278 Total

2.2 Complaints

Performance against the 20 working day target has remained a challenge throughout the year and on average only 56% of complaints have been responded to within target. There has been ongoing monitoring by the Improvement Committee and with operational units being tasked to identify how improvements can be made.

From 1 July 2011 the Clinical Governance Support Team commenced utilising the complaints module within DATIXweb to manage complaints received within NHS Highland.

The benefit of moving to a web based system is that all operational units will be able to monitor the progress of complaints on line, and will also be able to access reports for performance monitoring. On the 21st and 22nd November the SPSO ran two courses on investigating complaints. This course was aimed at managers who act as investigating officers for their operational unit. The feedback from those who attended was extremely positive.

Nationally, the NHS complaints procedure is being reviewed to take account of the Patients Bill of Rights. There will be no change to the target for responding, however there will be reference to the guaranteed waiting times and changes on how complaints are dealt with by family health services. The new procedure will come into effect on the 1st April 2012.

Activity 2010/11 2011/12 Total Number of Complaints 381 389 % Responded to within 20 working days 48% 56%*

* Data only available to February 2012 2.3 Clinical Effectiveness Activity

A wide range of audit and evaluation work continues to be supported. A lot of this work involves gathering feedback from patients, staff and service users, capturing experiences to inform improvement. Examples of such work audits to support the QIS Neurology Standards by capturing feedback from patients attending

2 headache clinics and neurology clinics. A further project is the P41 service user feedback tool which is being used to capture feedback from service users and carers attending and will be subject to further development over coming months.

A large scale project has been the roll out of the ‘How did we do’ patient feedback tool across acute and community hospitals. This supports staff to capture real-time local feedback which can also provide comparable data across the organisation.

The Team evaluated the Health Check newspaper to identify if this was a viable and valuable way of reaching public and staff. A Patient Safety Culture Survey was issued across the organisation to capture staff views on safety culture in their areas with reports going to CG&RM groups for action. Work is ongoing around record keeping and care planning audits across specialties.

2.4 Scottish Patient Safety Programme

The Scottish Patient Safety Programme (SPSP) is using the Model for Improvement to improve the reliability and safety of everyday health care. The two high level aims are to reduce mortality by 15% and reduce adverse events by 30%.

NHS Highland has committed to achieving the objectives of the Scottish Patient Safety Programme (SPSP) initially within pilot sites and now in spread wards across the four acute hospital settings (Belford, Caithness, Lorn & Isles and Raigmore). Each hospital site delivers within five separate work streams (Leadership, Medicines Management, Critical Care, General Ward and Perioperative).

The Board is required to assess progress against the National IHI (Institute of Healthcare Improvement) assessment scale. NHS Highland was the first Board in Scotland to achieve a 3.5 – defined as:

“Sustained improvement (three months without sliding backwards) is noted in process and outcome measures for pilot populations in all five work streams. Spread (including testing, training, communication, etc.) of all key changes is underway beyond the pilot populations” NHS Highland has further assessed themselves at a 4.0 and is awaiting confirmation of this from the National team.

The Scottish Patient Safety Programme has now expanded into Paediatrics and plans are in place for a Mental Health and Primary Care Programme. SPSP are also delivering against a 3 year Venous Thromboembolism (VTE) and Sepsis collaborative.

NHSH have plans in place to increase capacity and capability by ensuring integration with other improvement programmes and alignment of Quality Improvement methodologies and measurement. NHSH continues to develop robust SPSP data management and reporting systems with a view to integrate with other quality improvement data management systems.

3.0 Operational Clinical Governance and Risk Management Groups and Clinical Governance Forum

The operational unit clinical governance and risk management groups continue to work pro-actively to make positive progress in dealing with clinical governance and risk management issues. All groups consider incidents, complaints, infection control and patient experience.

At each Clinical Governance Forum meeting, each of the operational units is asked to present an incident/complaint for discussion, to identify Highland wide action and to share learning. A number of clinical issues have been discussed at this meeting including incident management procedures, management of litigation, reporting arrangements to the Procurator Fiscal and the approval of a policy to support staff involved in complaints, incidents and legal claims.

4.0 External Reviews

During the course of the year, Healthcare Improvement Scotland reviewed endoscopy services at Caithness General Hospital, Mackinnon Memorial Hospital, Lorn and Islands Hospital and Cowal Community Hospital. Following these reviews detailed action plans were developed and are being monitored by Healthcare

3 Improvement Scotland on a three monthly and sixth monthly basis. In February, a peer review panel assessed Neurology services against some of there clinical standards. Although significant improvement has been made over the last three years, a number of areas for improvement were identified.

5.0 Better Together In Patient Survey 2011

In January 2011, over 6,000 patients in Highland were sent questionnaires at part of the National In-Patient Survey. The response rate was 58%, with overall results being good. The areas identified for improvement including ensuring patient who knew who was in charge of the ward, help with arranging transport, being told how long the wait would be in A&E and being bothered by noise at night. Each of the operational units received results for each of their hospitals and they have prepared improvement plans to address areas of concern. The survey is being repeated in 2012.

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

In prepared for integration of services the committee will be widening its remit to reflect changes within the Board and to ensure that robust links are made into the new operational governance arrangements. In addition the committee is increasing its membership to include clinical and professional representation.

 Older People’s Services  Clinical Risk Register  Planning for Integration –implications for clinical governance  Quality Dashboards  New NHS Scotland Complaint Policy “Can I Help You”  Patient Bill of Rights  Medical Profiles  Scottish Patient Safety Programme

6.0 Conclusion

The Clinical Governance Committee is confident, through the scrutiny of internal and external reports and minutes, systematic review of the reporting mechanisms and regular presentations that the systems of internal control for the delivery of safe clinical care are adequate. However it will continue to focus on assuring that any identified weaknesses in the system are addressed and that a culture of continuous improvement in clinical governance is fostered across the Board area.

Ms Sarah Wedgwood Chair Clinical Governance Committee April 2012

4 Appendix 1

Revised Role & Remit – Clinical Governance Committee

Quality should be managed, monitored and measured – what gets counted gets done! The healthcare organisation provides person-centred, safe and effective care for every patient, every time.

Committee Role

1. To act as guardian/custodian of the quality aims and ambitions contained within NHS Highland Quality & Patient Safety Framework 2. To carry out the statutory duties as outlined in NHS MEL(1998~)75, MHS MEL (2000)29 and NHSMEL (2001)74 3. To give the Board assurance that clinical governance systems are in place and working throughout the organisation

Committee Remit

1. To interrogate the clinical governance systems to ensure that the principles and standards contained within the Quality & Patient Safety Framework are being implemented 2. To challenge evidence gathered across the organisation to raise areas of concern, ensure that these are properly addressed, and to monitor and review the effect of actions taken and report outcomes to the Board 3. To review outcomes against local and national standards and to ensure compliance with national regulatory requirements 4. To set clinical quality targets and outcomes and ensure an appropriate audit and reporting framework is adhered to across the organisation 5. To receive exception reports from its reporting committees e.g. Infection Control on relevant areas of concern and the submission of action plans of amended practice 6. To receive annual accounts from its reporting committees on the delivery of the ambitions of the quality & patient safety framework in order to spread good practice 7. To receive regular reports from the clinical governance/risk management/health & safety groups within Raigmore and Community Health Partnerships on the implementation of the quality & patient safety framework and on an agreed range of quality targets and outcomes 8. To receive a clinical risk register on an annual basis for consideration by the Committee

Boundaries and Accountabilities

The Committee is authorised to investigate any activity within its Remit. It is authorised to seek any information required from any employee and all employees are directed to co-operate with any requests made by the Committee. Furthermore, independent external advice may be accessed in respect of matters within the Committee’s remit.

The Committee is accountable to the Board and will report to the Board through the issue of Assurance Reports

The Committee will present an annual account to the Board in execution of its duty to provide assurance that NHS Highland’s statutory duties with regard to clinical governance are being fulfilled.

An assessment of the performance of the Committee will be undertaken annually.

A number of committees and groups are accountable to the Clinical Governance Committee and will provide assurance to the Committee. Such assurance is given by the submission of annual reports of activity and areas of good practice, exception reports on areas of concern, and work plans. Areas of concern identified by

5 these committees will be addressed specifically on the agenda of the Clinical Governance Committee. In addition the Executive Lead for each reporting Committee will be asked to give a brief verbal update of any current issues to each meeting of the Clinical Governance Committee under “Emerging Issues”. The minutes of each of the reporting committees will be circulated to members of the Clinical Governance Committee for information.

Committee Membership

The membership of the Committee is agreed by the full NHS Board and consists of:

Members 1. 3-4 Non Executives, one of whom would Chair the Committee 2. Area Clinical Forum Representative 3. Staff side Representative 4. 2 public/lay members, one from Argyll & Bute PPF and one from North Highland PPF

Ex-officio members 5. Chief Executive 6. Medical Director – the Lead Executive for the Committee with devolved accountability from the Chief Executive 7. Director of Public Health 8. Nurse Director 9. Head of Clinical Governance and Risk Management

The Committee Chairman is appointed by the full Board and a quorum consists of a minimum of two non-executive Directors.

The Board Chairman is not a Member but has the right to attend meetings. Other Executive Directors and Board employees may be invited to attend as required.

Work Programme

An annual work programme will be prepared and will form the annual report to the Board.

A set of quality outcomes and indicators will be agreed by the Committee and monitored throughout the year.

Agenda

The agenda will be agreed 3 weeks in advance of each meeting and will comprise Matters Arising, Emerging Issues and items grouped under the 3 Quality Ambitions i.e. Patient Experience, Patient Safety and Clinical Effectiveness.

Items will be added to the agenda with the agreement of the Chair and/or Medical Director.

An action plan will be produced after each meeting within 5 working days to ensure business of the Committee is progressed and implementation of agreed actions takes place as soon as possible where appropriate.

All papers received by the Committee will be presented in person.

An assurance report will be compiled by the Clinical Governance Manager within 5 working days of each meeting for submission to the Board.

6 Administrative Arrangements

The Committee will meet at least 4 times a year. The Chair may convene ad hoc meetings to consider business requiring urgent attention.

The NHS Board Committee Secretariat will service the Committee and minutes will be included within the formal agenda of the NHS Board.

August 2011

7 Appendix 2

Work Programme 2011- 2012

Each agenda will contain a mix of emerging issues and exception reports together with a number of annual reports in addition to the items listed below.

PATIENT EXPERIENCE  Case study  Complaints/incidents/Ombudsman reports  Better together

SAFE  Scottish Patient Safety Programme  Regulation and Reviews  Surgical Profiles, National Audits  Risk Register

EFFECTIVE  Clinical Governance and Risk Management Performance Report  Outcomes & Targets, Quality Indicators  Clinical Governance Forum  Critical Incident Reviews  Annual Reports/exception Reports

8 APPENDIX 5

NHS Highland Improvement Committee Annual Report

To: NHS Highland Audit Committee

From: Garry Coutts, Chair, Improvement Committee

Subject: Improvement Committee Report – 2011/2012

1 Background

In line with sound governance principles, an Annual Report is submitted from the Improvement Committee to the Audit Committee. This is undertaken to cover the complete financial year, and forms part of the supporting arrangements for the Statement of Internal Control, ending with the certification and submission of the Annual Accounts.

The remit of the Improvement Committee is as follows:

 To undertake detailed, high level scrutiny of NHS Highland’s performance against the LDP and local targets

 To focus on those areas of performance where improvement is required to meet targets and improve outcomes

 To focus on impact and outcomes of actions taken by NHS Highland

 To identify areas of good practice and ensure the dissemination of that good practice across NHS Highland.

The Committee undertakes an annual risk assessment of the local delivery plan and respective HEAT targets. This process identifies areas of high, medium and low performance risk which are taken as agenda items for the Committee.

The Balanced Scorecard, which measures NHS Highland’s performance against HEAT targets is presented to the Committee on a two monthly basis. The scorecard identifies areas of suboptimal performance and emerging issues which will be scrutinized by the Committee.

The Committee receives rigorous, accurate and relevant information in advance of meetings to allow it to undertake timely review of activity and performance. Reports are provided 1 week in advance of the meeting, highlighting proposed corrective actions and impacts anticipated from these actions.

The Committee considers other performance issues as they emerge during the course of the year.

The Committee receives regular reports from each operational unit on examples of good practice in their area that they judge could be rolled out across the Board During 2011/12 the Improvement Committee has met on the following 6 occasions -

Monday 9th May 2011 Monday 4th July 2011 Monday 5th September 2011 Monday 31st October 2011 Monday 9th January 2012 Monday 27th February 2012

Following each meeting of the Improvement Committee a Board Assurance report is completed and submitted to the subsequent NHS Highland Board meeting. The assurance report identifies the issues and risks associated with the delivery of the HEAT targets, then outlines the assurances given by the operational units as to the actions being taken to improve performance, and any actions identified from the Improvement Committee.

2 Activity 2011/12

The Improvement Committee considered the following key items at its meetings throughout the year

9th May 2011 4th July 2011  Healthy Weight of Children  Breastfeeding  Alcohol Brief Interventions  New Outpatient Appointments DNA Rates  Smoking Cessation  Dementia  Same Day Surgery  Reduce Carbon emissions/Energy  Pre-operative Stay Consumption  Carbon Emissions/Reduce Energy  All Cancer Treatment Consumption  Review to New Outpatient Attendance Ratio  Drug Treatment: Referral to Assessment  Alcohol Brief Interventions  Rate of Attendances at A&E  Inequalities Targeted Cardiovascular Health  Immunisations – MMR Checks  Sickness Absence  Smoking Cessation  Patient Funds  New Outpatient Waiting Times  18 weeks RTT  Inpatient/Day Case Waiting Times  Financial Update  Highland ethnicity recording  Annual Report  Healthy Weight of Children  Patient Focused Booking  Scottish Patient Safety Framework  Dental Services  Complaints  CAMHS  Financial Update

5th September 2011 31st October 2011  Smoking in Pregnancy  Financial Position  Breastfeeding  Healthy Weight of Children  New Outpatient Appointment DNA rates  All cancer treatments  Dementia  18 weeks RTT  Healthy Weight of Children  CAMHS  Dental Registrations  A&E attendance rates  Alcohol Brief Interventions  Sickness absence  Smoking Cessation  SMR Recording  All Cancer treatments  Complaints  18 weeks RTT  Mental Health DNA’s  New Outpatient Waiting Times  eKSF  Inpatient/Day Case waiting times  New Outpatient Waiting Times

2  Scottish Patient Safety Programme  Inpatient/Day Case Waiting Times  Dental Services  Stroke  CAMHS  Financial Update

9th January 2012 27th February 2012  Financial Update  Financial Position  eKSF  eKSF  All Cancer treatment  All Cancer Treatments  18 weeks RTT  Complaints  Alcohol Brief Interventions  Same day surgery & reducing pre op stay  Sickness Absence  New outpatient appointment DNA rates  New Outpatient Waiting Times  New Outpatient Waiting times  Inpatient/Day case waiting times  Inpatient/Day Case Waiting times  Dementia  Dementia Registration  Dental Services  Stroke  Highland Ethnicity recording  Planning for Integration  Reduce Carbon emissions/energy consumption  Scottish Patient Safety Programme  Keep Well North  Screening Data

3 Sub Groups

No sub groups of the Improvement Committee were established during 2011/12.

4 External Reviews

During the 2011/12, 2 formal reviews were undertaken of our performance against our HEAT targets as part of the Scottish Government Health Department (SGHD) Annual review process. The formal Annual Review of 2010/11 performance was held on 3rd October 2011 – a summary letter including actions was received from the Minister for Public Health.

On Friday 25th November 2011 the SGHD held its mid year review for 2011/12.

5 Key Performance Indicators

The core remit of the Improvement Committee is the review of performance against the HEAT targets and progress on the actions resulting from the Annual review. Attached is a copy of the summary of the NHS Highland Balanced Scorecard which demonstrates how performance against planned trajectories is presented to the Committee and the Board.

The attached “At A Glance” document, recently presented to the Improvement Committee demonstrates that the HEAT targets due for delivery in 2011/12 are all progressing well

Following each Improvement Committee an Assurance Report is prepared which is presented to the Board. This provides the Board with the assurances that our HEAT targets are either on track or actions are being taken to address any shortfall in performance. Where a shortfall in performance is identified, the Improvement Committee seek regular updates until assured that all necessary steps are being taken and performance is improving, recent examples of this are smoking cessation and eKSF.

3 6 Emerging issues and key issues to address/improve the following year

6.1 Performance The key issues for next year will be the monitoring of the HEAT targets due for delivery during 2012/13. Two key areas will be the reduction in waiting times for Child and Adolescent Mental Health Services and ensuring we develop new strategies for the delivery of child healthy weight interventions.

The Committee is also keen to build on its key role of identifying areas of good practice and ensure the dissemination of that good practice across NHS Highland.

6.2 Effective Performance Management The Committee is required to review the effectiveness of performance management arrangements – this will form part of the programme of activities for 2012/13. One area where the Improvement Committee during 2011/12 has been seeking to improve is the quality of the reports being submitted to it. This is to ensure that key elements such as actions being taken to improve performance are clear and concise and provide the Committee with assurance that performance will be back on trajectory as soon as possible. During 2012/13 the Committee aims to re-emphasise this to ensure all reports meet this standard.

6.3 Integrated Health and Social Care With the integration of adult social care into NHS Highland, the Improvement Committee will receive a range of new measures to reflect adult social care. The measures form part of the Partnership Agreement and will be subject to regular review to ensure that they reflect the service delivery and services improvements NHS Highland Board are seeking to achieve.

7 Conclusion

I can conclude that the systems of control within the respective areas within the remit of the Improvement Committee are considered to be operating adequately and effectively.

Garry Coutts Chair Improvement Committee April 2012

4 APPENDIX 6

NHS Highland Risk Management Steering Group Annual Report

To: NHS Highland Audit Committee

From: Elaine Mead, Chair, Risk Management Steering Group

Subject: Risk Management Steering Group Report – 2011/12

1. Background

1.1 In line with sound governance principles, an Annual Report is submitted from the Risk Management Steering Group to the Audit Committee. This is undertaken to cover the complete financial year, and forms part of the supporting arrangements for the Statement of Internal Control, ending with the certification and submission of the Annual Accounts.

1.2 The role of the Risk Management Steering Group is to provide re-assurance to the NHS Board that all systems, processes and procedures relating to Risk Management are operated in an appropriate manner. This duty is discharged through directing and integrating the relevant work within the Board’s Governance Committees, with input from Executive Groups.

1.3 It is recognised that risk is an inherent and integral part of all organisations and the Risk Management Steering Group provides the lead role to advise on, and manage all risks to an acceptable level.

1.4 Responsibility for operational delivery of risk management lies with Operational Unit (Community Health Partnership and Raigmore Hospital) Clinical Governance & Risk Management Groups.

1.5 The Risk Management Steering Group met formally on two occasions during the year, on 28th July 2011 and 18th October 2011. In addition a sub-group consisting of the Director of Human Resources, Head of Quality and Clinical Governance Development Manager met on several occasions between November 2011 and February 2012 to develop the Strategic Risk Register and this was formally discussed by the Audit Committee at its meeting on 13th March 2012 and approved by the NHS Board at its meeting on 3rd April 2012 (see Section 4).

2. Activity between 1st April 2011 and 31st March 2012

2.1 During the year the focus of the Risk Management Steering Group was on:  Review of the Corporate Risk Register;  Overview of the Operational Unit Risk Registers;  The options for the future arrangements in relation to risk management within NHS Highland; and  Response to the Internal Audit Review of risk management arrangements (see Section 3).

3. External Reviews

3.1 NHS Highland’s Internal Auditors, Scott Moncrieff, carried out a review of our risk management arrangements in August 2011.This review has built on that previous work to examine whether the arrangements for identifying and managing risk at a departmental and regional level are robust and consistently applied across the organisation, and that risks are both escalated upwards and delegated downwards as appropriate within the risk management hierarchy.

3.2 The main findings of the review were that there is a clear commitment to improving the risk management framework within NHS Highland. The Risk Management Steering Group has

1 identified the need to develop a consistent approach to risk management across NHS Highland, and recognises the benefit in doing so.

3.3 The Internal Auditors concluded that the arrangements surrounding the risk management process require improvement. However, the issues highlighted in the report had, to a large extent, been self-identified by those currently involved in the management or application of the risk management process at NHS Highland.

3.4 The management response to the review confirmed that the risk management system is currently being reviewed by the Risk Management Steering Group. This review is led by the Head of Quality and will ensure that risk management is integrated into NHS Highland’s decision-making arrangements to create an environment for learning and continuous improvement. This will include the development of a Risk Management Strategy and update of the Risk Management Policy.

3.5 A revised Risk Management Strategy and supporting policy and procedure documents has been drafted in conjunction with key stakeholders. This is currently being consulted on more widely and will be finalised by the end of June 2012.

3.6 The Internal Audit Review also identified that Raigmore Hospital’s Risk Register was in development at the time of the review. The Raigmore Hospital Risk Register has since been further updated and its review is a standing item at their Quality and Patient Safety Group.

4. Management of Strategic Risks

4.1 The Director of Human Resources, Head of Quality, and the Clinical Governance Development Manager met on several occasions during the year and reviewed the existing Corporate Risk Register, the feedback on current risks which had been identified when speaking with Executive Directors, the Service Delivery Characteristics and the Corporate Objectives 2011/12 and the NHS Grampian approach to risk management.

4.2 The resulting Strategic Risk Register and revised management and assurance arrangements ensure that:  Strategic risks are linked to the organisation’s overall objectives;  Individual risk owners are allocated to all risks, this is documented in the risk register and the role of the risk owner is clearly understood; and  The assurance source in relation to any individual risk is agreed and clearly documented within the Risk Register.

4.3 At its meeting on 3rd April 2012 the NHS Board:  Approved the NHS Highland Strategic Risk Register (attached as Appendix 1);  Agreed to the process for integrating risks associated with Adult Social Care Services;  Agreed the management and assurance arrangements for NHS Highland’s Strategic risks;  Recommended that the Strategic Risk Register should be a standing item on future Board agendas;  Noted the ongoing review of the risk management process within NHS Highland and that a further report would be submitted to the next meeting of the Board regarding Adult Social Care Services; and  Noted the proposal for a future discussion on the key priorities for the Board in relation to risk management and the governance of risks.

5. Operational Unit Clinical Governance & Risk Management Groups and the Clinical Governance Forum

5.1 The Operational Unit Clinical Governance and Risk Management Groups continue to work pro-actively to make positive progress in dealing with clinical governance and risk management issues. All groups consider their Operational Unit Risk Registers, incidents, complaints, infection control and patient experience.

2 5.2 At every Clinical Governance Forum meeting, each of the Operational Units is asked to present an incident/complaint for discussion, to identify Highland wide action and to share learning. A number of clinical issues have been discussed at this meeting including incident management procedures, management of litigation, reporting arrangements to the Procurator Fiscal and the approval of a policy to support staff involved in complaints, incidents and legal claims.

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

6.1 There are a number of key areas relating to risk management which are priorities for completion during 2012/13. The key focus of these activities is to ensure that risk management is integrated into NHS Highland’s decision-making arrangements to create an environment for learning and continuous improvement. These include:

 Incorporating the risks resulting from the integration of Adult Social Care Services from the Highland Council Risk Register into the NHS Highland Risk Register both at Strategic and Operational level.

 Finalisation of the Risk Management Strategy and associated procedures. These procedures will cover:  Key steps of the risk management process along with associated tools and techniques to assist with identification of risk;  Risk assessment;  Risk escalation procedures, ensuring clear links are made between Operational Risk Registers and the Corporate Risk Register;  Guidance on the risk matrix, including setting parameters around the likelihood and impact categories to ensure a more consistent approach to risk assessment; and  Guidance on measurement and management of residual risk.

 Review of the Risk Register template used for both strategic risks and operational risks, with consideration being given to use of the Risk Register module within the DATIX system.

 Review of training in risk identification to key individuals in the risk management process.

 Development of a template for risk management action plans to ensure that these are reported to the appropriate assurance committees in a consistent manner.

 Review of the terms of reference of the Risk Management Steering Group and of the Operational Unit Clinical Governance & Risk Management Groups

7. Conclusion

7.1 The Risk Management Steering Group is confident, through the scrutiny of internal and external reports and minutes, systematic review of the reporting mechanisms and regular presentations from Operational Groups that the systems of internal control for the management of risk are adequate.

7.2 However it will continue to focus on assuring the Board that the effectiveness of risk management arrangements is being monitored in order to provide information that supports continuous improvement. It will focus on ensuring that, where necessary, improvements to the arrangement have been made on the basis of such evaluations.

Elaine Mead Chair Risk Management Steering Group 8th May 2012

3 Appendix 1 NHS HIGHLAND STRATEGIC RISK REGISTER - EXCLUDING RISKS RELATING TO ADULT SOCIAL CARE RELEVANT FROM 1 APRIL 2012 ID Risk Title Serv Corp Description Risk Owner Conse- Likeli- Risk Accep- Conse- Likeli- Risk Assurance Last Char. Obj. quence hood Level table quence hood Level Source Review (Initial) (Initial) (Initial) Risk (Current) (Current) (Current) Level Meeting 1 5 There is a risk that the Board Director of Major Likely HIGH MEDIUM Mod. Likely HIGH Improvement March 1 expectations of the does not focus sufficiently on Public Committee 2012 heath improvement continuing to improve the Health agenda health of the Highland population or on reducing the (Better Health) inequalities gap 2 Impact of the 1,3 6 Failure to take account of the Chief Major Likely HIGH MEDIUM Mod. Unlikely MEDIUM NHS Board ageing population impact of the ageing Executive population when planning (Better Health, services may put at risk the Better Care) ability to deliver on the strategic objectives 3 Failure to deliver 4 6 Failure to deliver on the Transitions Major Likely HIGH MEDIUM Major Possible HIGH NHS Board February on the integration fundamental reconfiguration Director 2012 agenda ( Primary of health and social care Care/Secondary services across the Highland Care: Planning for area will put at risk the ability Integration Health to deliver on the NHS and Social Work; Highland Strategic Integration of Argyll Framework within the and Bute increasingly limited financial resources available (Better Care) 4 Difficultyin 2 2 There is a variety of Medical Mod. Likely HIGH MEDIUM Mod. Possible MEDIUM Clinical February measuring information available that Director Governance 2012 effectiveness and may not be used to support Committee quality of the delivery of strategic interventions and objectives particularly in services relation evidencing the delivery of high quality, safe (Better Care) and effective care 5 Sustainability of 3 2 Failure to maintain clinical Medical Major Likely HIGH MEDIUM Mod. Possible HIGH Clinical March services in the skills will put at risk the Director Governance 2012 Rural General sustainability of services at Committee Hospitals RGHs

( Better Care)

5a Sustaining 3 2 Failure to recruit and retain HR Director Mod. Likely HIGH MEDIUM Mod. Likely HIGH Staff March workforce in the staff in RGHs and sustain Governance 2012 Rural General services Committee Hospitals 6 Risks associated 2 2 There are potential delays Medical Major Possible HIGH MEDIUM Major Possible HIGH Clinical Nov with anti-coagulant relating to Warfarin patient Director Governance 2011 monitoring dosing requirements being Committee fed back to GPs to enable (Better Care) appropriate communication to patients and the effective management of patients’ coagulation status

4 ID Risk Title Serv Corp Description Risk Owner Conse- Likeli- Risk Accep- Conse- Likeli- Risk Assurance Last Char. Obj. quence hood Level table quence hood Level Source Review (Initial) (Initial) (Initial) Risk (Current) (Current) (Current) Level 7 Risks associated 2 2 The capacity to support Director of Major Possible HIGH LOW Major Possible HIGH NHS Board? March with current young people with severe Public 2012 CAMHS provision mental illness and complex Health mental health issues is often (Better Care) less than optimal due to lack of capacity within CAMHS, difficulty in delivering intensive services across a wide geographical area, limited access to specialist assessment and treatment services and poor access to inpatient beds in a timely fashion when required 8 Ensuring that 2 2,3 There is a risk that given the Medical Major Possible HIGH MEDIUM Major Possible HIGH Clinical March achieving financial financial pressures on NHS Director Governance 2012 balance has no Highland to achieve financial Committee detrimental effect balance there will be a on quality and reduction in the quality and patient safety safety of patient care

(Better Care) 9 Insufficient funds to 6 1,2 Reduction in availability of Chief Major Unlikely MEDIUM MEDIUM Major Likely HIGH NHS Board October fully implement the capital funding has resulted in Executive 2011 Equipment a gap between known Replacement equipment replacement Strategy requirements and funds available meaning essential ( Better Value) clinical equipment may not be replaced as planned 10 Inabilitytofully 6 1,2 NHS Highland has a Chief Major Possible HIGH MEDIUM Major Likely HIGH NHS Board October implement Property significant level of backlog Executive 2011 Strategy maintenance resulting in buildings that are dilapidated (Better Value) and require urgent maintenance. There is a significant capital programme for investment in the asset base but due to limited resources not all buildings are fit for purpose 11 Failure to deliver 7 3 There is a risk that NHS Finance Major Possible HIGH MEDIUM Major Possible HIGH NHS Board/ March the Financial Highland fails to break even Director Improvement 2012 Strategy through due to an inability to deliver Committee failure to deliver the agreed efficiency targets, agreed efficiency reliance on non-recurring programme or funding or increased through additional expenditure expenditure

(Better Value)

5 ID Risk Title Serv Corp Description Risk Conse- Likeli- Risk Accep- Conse- Likeli- Risk Assurance Last Char. Obj. Owner quence hood Level table quence hood Level Source Review (Initial) (Initial) (Initial) Risk (Current) (Current) (Current) Level 12 Impact of the 6 1 There is a significant capital Finance Major Possible HIGH MEDIUM Major Possible HIGH NHS March capital reduction programme for investment in the Director Board/Asset 2012 asset base including equipment Management but due to limited resources not (Better Value) all buildings are fit for purpose and some equipment is coming to the end of its useful life 13 Failure to comply 5 7 There is a risk of failure to fully HR Mod. Possible MEDIUM LOW Medium Possible MEDIUM Health & March with Health and implement the health and safety Director Safety 2012 Safety Legislation policy due to lack of ownership Committee throughout the Board and (Better Value, competing priorities. Workforce) 14 Failure to meet All 4 There is a risk that the Board Chief Mod. Unlikely MEDIUM MEDIUM Mod. Unlikely MEDIUM Improvement March HEAT targets fails to deliver on the key Executive Committee 2012 objectives detailed in the Local (Better Health, Delivery Plan Better Care, Better Value) 15 Lack of an 2 1,2 There is a variety of information Chief Likely Major HIGH MEDIUM Likely Major HIGH NHS Board Dec 2010 information available that may not be used Executive strategy to support to support the delivery of delivery of the strategic objectives particularly strategic objectives in relation evidencing the delivery of high quality, safe and (Better Health, effective care Better Care, Better Value) 16 Failure to ALL 1 There is a risk that if there is Chief Likely Extreme VERY MEDIUM Likely Extreme VERY NHS Board February2 effectively engage insufficient involvement and Executive HIGH HIGH 012 stakeholders in the engagement with the large scale way services will projects and service redesign, be delivered in the the projects may be more future difficult to deliver.

(Better Health, Better Care, Better Value) 17 Failure to ensure 5 7 There is a risk that there will be HR Mod. Possible MEDIUM LOW Medium Possible MEDIUM Staff March sustainable a reduction in service quality due Director Governance 2012 workforce to the financial constraints Committee requiring a reduction in (Workforce) workforce costs and an ability to sustain the workforce in the future 18 Failure to protect 5 7 There is a risk that we fail to HR Mod. Possible MEDIUM LOW Mod. Possible MEDIUM Staff March staff from injury or effectively focus on the health Director Governance 2012 illness as a result and wellbeing of our staff that Committee/ of work subsequently leads to illness Health and and injury at work. Safety (Workforce) Committee

6 APPENDIX 7

NHS Highland Endowment Funds Committee Annual Report

To NHS Highland Audit Committee

From Ian Gibson, Chair, Endowment Funds Committee

Subject Endowments Fund Committee Report for the year to March 2012

BACKGROUND

In line with sound governance principles, an Annual Report is submitted from the Endowment Funds Committee to the Audit Committee. This is undertaken to cover the complete financial year and forms part of the supporting arrangements for the Statement of Internal Control, ending with the certification and submission of the Annual Accounts.

The Committee:

All Board members are Trustees of the Endowment Funds and carry attendant responsibilities. The mechanism of informing, giving ability to influence and providing assurance to all Trustees, is for Committee minutes to be issued to all Board members within 10 days of the meeting, if possible, with members having the right to advise disagreement of Committee proceedings within 21 days (i.e. before action is finalised) otherwise agreement is assumed.

All Board members as Trustees have the right to attend Committee meetings with agendas and papers sent to them with an invitation to attend. The Committee membership itself as at 31st March 2012 comprised five Non-Executive Directors (including the employee Director) and a member of the Highland Partnership Forum also attends. Five Committee meetings were held during the year.

Remit and Work Plan:

The Committee Remit and Work Plan was used as the framework for the Committee activities during the year.

ACTIVITY

Administration:

The administration of the funds is integrated for the whole of the NHS Highland within the Inverness-based team. Investments are monitored and reviewed and individual fund balances are managed within the Trojan financial system. All receipting of donations, including Gift Aid advice and correspondence with donors is undertaken by the Endowments team.

Support and advice for fund managers and the Committee is provided throughout the year by the Endowments team which also included awareness sessions, rationalisation of funds, provision of guidelines through the intranet and regular direct communication with fund managers and staff. DEVELOPMENTS AND ISSUES THROUGHOUT THE YEAR :-

1. Projects funded from Endowments (General Fund) in the past year include:- a. Research projects b. Bursaries for staff to attend Non-core learning courses/training c. Healthy Working Lives program in operational areas d. Retirement Fellowship e. Coffee lounge improvements Raigmore Hospital

2. Total Activities funded from Endowments in 2010/11 include:- a. Medical and other Equipment – total value £689,000 b. Staff Welfare, training and development - £320,000 c. Patients Welfare and Amenities - £303,000

Budget Funds for 2012/13:

£180,000 was allocated to Budget funds out of the General Unrestricted fund as agreed by the Committee and approved on 2nd April 2012. This reflected the expected returns on the Funds’ investments and is in line with 2011/12 budget. This was allocated to the operational units and a number of projects were specifically approved by the Committee. Amongst these was continued funding for :- Non-core Learning and Development £50k Research projects £15k and Valuing Service Award £25k The basis for distributing the budget funds is consistent across the whole of NHS Highland and reflects the balances held locally of specific funds. Budget fund managers are expected to fund developments and expenditure by approaching specific fund holders initially before utilising the budget funds.

Use of Restricted Funds

The committee has for several years had a drive to ensure that restricted funds are utilised where possible with unrestricted funds used more to support those areas and services that do not have access to restricted funds. The Office of the Scottish Charity Regulator’s [OSCR] report on Lothian Health Board Endowments recommended a reduction in the number of restricted funds. The committee had already been engaged on this agenda for some considerable time and is pleased to report that there has been a further reduction in the number of restricted funds. Plans are also in place for the majority of restricted funds as to how these are to be utilised.

Investment and Bank Deposits:

Adam & Co act as investment advisers to the Committee and produce regular statements showing the financial position of the fund. This has been monitored closely during the year with the current economic climate and the value of the portfolio of investments is reported to the Committee regularly. Investment in low risk stocks with fixed rate returns continues to reflect the risk-averse policy of the committee together with a wide spread of investments within the UK and worldwide shares. This has ensured that the performance of the portfolio of investments has been better than the performance of the overall Stock Market. Donations:

The level of donations over the past five years has shown a downward trend. Income has fallen from £875,000 in 2007/08 to £655,000 in 2011/12. However it should be recognised that nearly 2,000 donations are received annually which has only reduced marginally – one specific donation in 2010/11 was for £124,000. Every donation is gratefully received and is used according to the wishes of the donor to support patient and staff amenities throughout NHS Highland. Managers are encouraged to use these funds as soon as practicable rather than saving the funds, particularly given the low levels of income available from investing the funds.

Partnership

During the year a partnership was developed with the Archie Foundation in which they launched a high profile appeal for an initial £1m to enhance the facilities in the Raigmore children’s ward. This arrangement has the potential to lever in benefits to the board far in excess of what would be possible by the committee undertaking its own more proactive fundraising. Discussions are ongoing to develop a longer term relationship with the Archie Foundation and we will be able to report on the success of the initial appeal this time next year.

Consolidated Accounts

The decision to incorporate Endowment Fund Accounts into the Boards Financial accounts from April 2013 has been considered by the committee, alongside the OSCR report mentioned above and subsequent additional legal advice on the appropriate use of and governance of Endowment funds. The Trustees have fed into national discussions on the issue of the future of Health Board Endowment Funds.

The Trustees have expressed a preference for a legislative change to allow Endowment Funds to be governed by a Trustee body that is not appointed by Ministers [as a consequence of them approving members of the Health Board] and that is consequently independent of the Health Board, but with Board representation.

EXTERNAL REVIEWS

Trustee Report and Financial Statement 2010/11: The Report and Accounts for the year ended 31st March 2011, audited by MacKenzie Kerr, were approved by the Committee and the Board in July 2011, when authority was given for the Chairman of the Endowments Committee to sign the Report and Statement on behalf of the Trustees. The overall value of the funds had increased from £7.8 million to £8.0 million reflecting the upturn in the stock markets since the low position in 2008/09. The auditors provided an unqualified opinion for the Report and Accounts.

Trustees Report and Financial Statements 2011/12: A timetable has been agreed with the auditors for the production and approval of the Final Accounts by July 2012. The value of the funds as at 31st March 2012 is £7,730,000 subject to final adjustments and audit. The Committee has a reserves policy on unrestricted funds of a minimum balance of £2.5 million and the unrestricted reserves are comfortably above this level. EMERGING ISSUES FOR 2012/13

 monitoring the investment position and the relative performance of our financial advisors – re-tendering for financial advisors  monitoring the changes resulting from the review of the status of the Endowment funds nationally – and the related legal advice supporting the changes  issues arising from consolidation with exchequer accounts from April 2013  considering a more proactive approach to fund-raising and attracting additional income particularly in partnership with third parties like the Archie Foundation  working closely with the Archie foundation donations to support the Children’s services developments in Raigmore and other proposals throughout the NHS Highland.  ensuring that the staff transferred from Highland Council have equal access to the opportunities that endowment funding can offer.

SUMMARY

The committee members have a good understanding of the responsibilities of managing the donated funds under their stewardship. Delegation to managers has developed whilst continuing oversight of significant expenditure occurs at each meeting. The systems of control within the remit of the Committee are considered to be operating adequately and effectively.

Ian Gibson

Chair, Endowment Funds Committee May 2012 APPENDIX 8

NHS Highland Argyll & Bute CHP Annual Report

To: NHS Highland Audit Committee

From: Bill Brackenridge, Chair, Argyll & Bute CHP Committee

Subject: Argyll & Bute CHP Committee Report – April 2011/March 2012

1 Background

In line with sound governance principles, an Annual Report is submitted from the Argyll & Bute CHP Committee to the Audit Committee. This is undertaken to cover the complete financial year, and forms part of the supporting arrangements for the Statement of Internal Control, ending with the certification and submission of the Annual Accounts.

The Argyll & Bute CHP Committee had its inaugural meeting on 17 August 2006 and fully operates under the framework of its Scheme of Establishment approved by the Scottish Government on 21 June 2006 and is in full compliance with Scottish Executive Guidance for CHPs (2004). The CHP Committee reports directly to the NHS Highland Board through routine submission and presentation of minutes by the CHP Chair. It is chaired by non- executive of the Board. Its membership, in accordance with the approved Scheme of establishment comprises :

 Board non-executives and CHP Officers  Council elected members and officers  Voluntary sector, staffside, patient and public partnership representatives  Professional Committee and clinical representation

2. Activity 2011/2012

2.1 Corporate Governance – Role of the CHP Committee

The Committee met on 6 occasions during 2011/12. Notices of meetings, held in public, and which take place in venues throughout the CHP’s geographical area, were announced on the NHS Highland website with posters distributed to local information points throughout the CHP’s geographical area.

Topics examined at Development Sessions which precede the formal meetings and provide a less informal setting for a more detailed examination and scrutiny of issues include :

. Local Delivery Plan . Scottish Patient Safety Programme . Audit Scotland Review of Community Health Partnerships . Director of Public Health Annual Report 2011 . Pharmacy . CHP Risk Register . Standards for Older People in Acute Care . Getting it Right for Every Child . Reshaping Care for Older People . Update on the Windfarm, Isle of Tiree Formal CHP Committee Meetings generally follow a structured standing agenda, the core of which comprises standing agenda items including :

 Declarations of Interests  NHS Highland Board and Organisational Issues  Financial governance  Performance Management  Clinical governance and risk management  Staff governance  Health improvement  Service modernisation and redesign and other topical initiatives  Partnership Working  Minutes of meetings provided for information include :

o Public Partnership Forum (PPF) o Staff Partnership Forum o Health & Care Strategic Partnership o eHealth Steering Group o Vale of Leven Monitoring Group

Meetings conclude with a half hour question/answer session open to full public participation.

2.2 Financial Governance

Comprehensive financial reports are provided and discussed at : -

CHP Committee (bi-monthly), CHP Management Team (bi-monthly), CHP Partnership Forum (monthly). Public Partnership Forum (quarterly). Community Planning Partnership (as required).

Financial responsibilities discharged include budget setting and allocations, reporting of financial performance, including expenditure monitoring and control, efficiency and cost improvement plans and delivery assurance, exception reporting of significance, capital plan and endowments. The CHP has met its financial targets in 2011-2012 subject to formal closure of accounts. This includes the delivery of a modest underspend of £43k against an annual revenue budget to £175m and the full delivery of the agreed cost improvement plan of £5.3m.

2.3 Staff Governance

The CHP has a long established Partnership Forum with an agreed role, remit and membership. It meets monthly with the Chair shared by the General Manager and CHP staffside representative. It has wide ranging management, staffside and geographical representation. Minutes of meetings are provided to and reviewed by the CHP Committee and the Highland Partnership Forum. Staffside representatives are invited and encouraged to attend a wide range of CHP based meetings, including the CHP Committee and Management team and local redesign initiatives. Reports are regularly provided to the CHP Committee and Management Team on a range of staff governance issues, including, Agenda for Change implementation, promoting attendance, redesign and organisational change issues and eKSF and PDP target achievement. A CHP specific workforce report is presented periodically which provides and opportunity for detailed scrutiny of CHP specific workforce issues, including sickness rates, staff turnover, age profile and Bank and Agency staff use. The CHP fell short of its eKSF target to be achieved by the end March 2012 achieving only 66% against the target of 80% of all NHS staff. A contributing factor was unanticipated challenges associated with ensuring all bank staff had a PDP + R on eKSF which, now identified, will be addressed in 2012/2013. Had bank staff been excluded from the percentage calculation the CHP’s achievement comparable to last year’s percentage of 83% would have been 87%. The CHP’s prevailing sickness rates improved from 5.31% at the start of the financial year 2011 to 4.40% at February 2012.

2.4 Clinical Governance

The CHP Clinical Governance and Risk Management Group met regularly during 2011/2012. It is chaired by a Locality Clinical Director and is populated by a wide range of clinical and managerial staff, including the CHP’s Head of Clinical Governance and Risk Management, together with non-executive, public and staffside representation. The work of the CHP group is complimented by locality, clinical governance and risk management groups. A clinical governance and risk management and health & safety report is presented at each CHP Committee meeting, with the following issues highlighted:-

 Risk management, including slips, trips and falls, violence & aggression and medication incidents, absconding patients, staff shortages  Proactive management of shortcomings in clinical practice  Assurance about the application and dissemination of the outcome of Significant Event Reviews  Complaints performance against target was found to be inconsistent leading to a review of processes and administration of the management of complaints throughout the CHP  The application of the Scottish Patient Safety Programme, particularly in the Lorn & Islands Hospital has provided evidence of improved safety there and indeed across hospitals in the CHP  Health & Safety, including Fire Safety and outcomes of Fire Safety Audits  Safety Action Notices and Hazard Notices  Audit outcomes, e.g. Food, Fluids, Nutritional Care; Administration, Transfer and Discharge Policy; Preferred Place Of Care/Death  NHS Quality Improvement Scotland Standards/external reviews included the Pre-joint Advisory Group Assessment on Endoscopy Services, a Scottish ECT Accreditation Network visit to Argyll and Bute. Each resulted in positive feedback and a number of recommendations that have subsequently been actioned  Health Care Acquired Infection/Hand Hygiene/Cleaning standards which reflected an on-going positive performance against standards in the CHP  HEI Inspection Reports – Lorn & Islands Hospital provided very positive results and outcomes  Patient Experience Survey findings were published resulting in a number of actions for the CHP  Seasonal Flu Vaccination Programme  A joint inspection of Services to protect children and young people in Argyll and Bute was undertaken in June 2011. This inspection recognised a number of strengths but also a number of short comings in local arrangements which are being addressed through the establishment of a Joint Improvement Group.

3. Sub Groups

No sub groups of the Argyll & Bute CHP were established.

4. External Reviews

Reference to external reviews contained under clinical governance.

5. Key Performance Indicators

The CHP Committee performance against targets is examined routinely at the Board’s Improvement Committee. This considers performance evident in the NHS Highland wide balance scorecard, with performance against relevant LDP/HEAT targets and complimentary exception reports. Particular challenges in the year included ABI’s, healthy weight, sickness absence, eKSF and PDP’s, dementia registrations. Generally, however, the CHP maintained a positive performance against the majority of key performance indicators. A sustained achievement against delayed discharge targets was reflected in the Joint Health & Social Care Performance Reports considered periodically by the Committee. In addition the Committee receives reports on the Service Level Agreement performance and relationship with Greater Glasgow & Clyde services and issues and their sustainability in the remote and rural context, including performance against waiting times.

6. Other Issues (falling outwith the prescribed governance framework)

In the course of the year other issues have featured in discussions at the Committee and have included :

 Better Health, Better Care, Better Value redesign initiatives throughout the CHP  Palliative Care in the Cowal Community Hospital  Vision for the Vale of Leven Hospital Monitoring Group. The Cabinet Secretary recognised the successful delivery of the Vision with confirmation assured from the activities of the Monitoring Group which has now been stood down.  Promoting attendance.  Reshaping Care for Older People and the deployment of the Change Fund.  The Redesign and Modernisation of Mental Health Services in Argyll & Bute – “Everyone’s Business”  Health Improvement  Creation of modern dental access centres  Planning for industrial action and lessons learned thereafter

7. Emerging Issues

The coming year is likely to be the most challenging faced by the CHP since its establishment.

The CHP Committee will undoubtedly focus on many issues in the course of the year, but in particular :

 Continuing with the implementation of agreed proposals to modernise mental health services  Overview, continuing leadership and management of redesign initiatives through the CHP under the auspices of Better Health, Better Care, Better Value with the terms of the Highland Strategic Quality Framework  Delivering a very challenging financial agenda including a £5m cost improvement programme  Delivery of the NHS Highland’s key corporate, HEAT and clinical targets and objectives  Effective management of assets (and capital) given constraints in national allocations  Work in partnership with the Argyll & Bute Council to deliver joint Health and Social Service, service delivery and integration strategies including prudent/effective deployment of the Change Fund.  The sustainability of Remote and Rural Primary/Secondary Care and Out of Hours Services (Cowal 24/7 review)

8. Conclusion

The systems of control within Argyll & Bute CHP Committee’s area of responsibility are considered to be operating satisfactorily, adequately and effectively.

Bill Brackenridge, Chairman Argyll & Bute CHP 30 April 2012 APPENDIX 9

NHS Highland Mid Highland Community Health Partnership Annual Report

To: NHS Highland Audit Committee From: Okain McLennan, Chair Mid Highland CHP Governance Committee

Subject: Mid Highland CHP Governance Committee Report (April 2010 – March 2011)

1 Background

In line with sound governance principles, an Annual Report is submitted from the Mid Highland CHP Governance Committee to the Audit Committee. This is undertaken to cover the complete financial year, and forms part of the supporting arrangements for the Statement of Internal Control, ending with the certification and submission of the Annual Accounts.

CHPs were viewed as key building blocks in the modernisation of the NHS and joint services, with a vital role in joint working, integration and service redesign, providing a focus for the integration between primary care and specialist services, and with social care, whilst ensuring that health improvement for their local population is placed at the heart of service planning and delivery. To achieve this, CHP worked on the general principles of:-

 Developing clinical team based approaches  Working in partnership with the local authority, the voluntary sector and others to support the improvement of the health of local communities  Actively involving the public, patients and carers in decisions concerning the delivery of health and social care for their communities.

The role of the Committee is that of governance and partnership and the Mid Highland CHP Governance Committee meetings review the following:

 Corporate governance  Clinical governance  Staff governance  Financial management  Performance management  Links with local government  Engaging local communities

The Governance Committee meets formally 6 times per year and also has development sessions for members. The minutes of the Governance Committee are submitted to and scrutinised by the NHS Highland Board.

The Governance Committee receives standing reports relating to the above key governance strands and also individual reports where there is variance on delivery and for matters of concern or interest, service redesign or emerging policy and strategy. A formal General Manager Report covering key issues and a summary of performance was contained in the pack for all meetings.

1 2 Activity (April 2010 – March 2011)

Key pieces of work that have been progressed during this year:

 Concentration on reducing waste in the system  Improving efficiency by making best use of all available resources  Skye service redesign  Services for Older Adults in Lochaber – use of Belhaven/Belford, progressing Reablement plans  Redesign of Mental Health Services for Older People in RC&WN – Future of RMH  Redesign of Rheumatology Services across NHSH  Development of case management approach/anticipatory care/self-management  Planning for Integration  Out Of Hours – particularly in relation to Remote &Rural areas  Environmental issues (buildings, Control Of Infection, Health care Environment Inspections)  Scottish Patient Safety Programme  Polypharmacy  Anticipatory care  Virtual Ward  Work to strengthen Patient/Public Partnerships  Developing telehealth/telecare approach  Ardnamurchan nurse on-call  Premises: Tain, Dingwall, Drumnadrochit, Broadford

3 Sub Groups

The key issues from the four formal sub groups are as follows:

Management Team

 All of the above issues were dealt with by Management Team plus  Finance and budgetary management  Mental Health Services  Dementia Care Standards  Care of Older people in acute hospitals  Public Partnership Forums and Partnership in Local Health Services  Sustaining medical workforce and service in Rural General Hospitals  Local implementation of Long Term Conditions strategy  Respiratory MCN, COPD case management  Living & Dying Well  Physiotherapy Services redesign  Unified Nursing & Midwifery Bank  HEI inspections  Midwifery services and Framework for Maternity Care in Scotland 2011  Better Together patient surveys

2 HS&CG Group  Death of a patient with C-difficile  Complaints investigation review  Significant Event Analyses reports – Midwifery  Significant Event Analyses reports- Broadford  Gap analysis following Mid Staffs Inquiry report  Potential misuse of syringe driver by member of care home staff  Control of infection/premises issues

EP&BC Group  Pandemic flu plan review  Primary Care Major Incident Planning  Business Continuity Planning  Contingency Plans  Winter planning

CHP Partnership Forum  Fixed Term Contract Policy  Planning for Integration  Facilities Time  Re design

4 External Reviews

 Audit Scotland Review of CHPs  HEI Inspections in Belford and Mackinnon Memorial Hospitals

5 Any relevant Key Performance Indicators

In common with all other business and operational units in NHS Highland, Mid Highland CHP uses the Balanced Scorecard approach to performance management. This is a combination of HEAT targets and agreed standards. The CHP Governance Committee receives the full balanced scorecard at every meeting and this is accompanied by exception reports.

Areas of concern in the past year:

 Complaints  Delayed discharges  Did Not Attend rates  Alcohol Brief Interventions  Day Case rates  eKSF  Suicide prevention  Healthy Weight of Children  Breast Feeding rates at 6-8 weeks

3 6 Emerging issues and key issues to address/improve the following year

 Financial challenges  OOH and Unscheduled Care  Older Adult/Reablement Services  Sustainability of remote and rural services  Integration and development of local teams  Medical and Surgical profiles  Skye Hospitals

7 Conclusion

Despite the challenges during 2011/12, the Mid Highland CHP has performed well on many key targets and has robust plans in place to address variances. The financial position has meant that management effort has been strongly focused on maintaining and improving quality whilst making the necessary cash releasing savings. This together with intensive community involvement work in some areas has been a particular challenge.

I declare that the Mid Highland CHP Committee has fully discharged its duties to date and can confirm that systems of control within the respective areas within the remit of the CHP and therefore the Committee are considered to be adequate and operating effectively.

Okain McLennan Chair Mid Highland CHP Governance Committee May, 2012

4 APPENDIX 10

NHS Highland North Highland CHP Annual Report

To: NHS Highland Audit Committee

From: Colin Punler, Chair, North Highland CHP Committee

Subject: North Highland CHP Committee Report – 1 April 2011 – 31 March 2012

1 Background

In line with sound governance principles, an Annual Report is submitted from the North Highland CHP Committee to the Audit Committee. This is undertaken to cover the complete financial year, and forms part of the supporting arrangements for the Statement of Internal Control, ending with the certification and submission of the Annual Accounts.

The over-arching role of the CHP Committee is to provide assurance to the NHS Highland Board against the standards of financial, clinical and staff governance. The CHP Committee met 6 times during the year with an additional extraordinary meeting held in December 2011 to discuss the West Caithness Service Redesign Proposal. The minutes have been submitted to the NHS Highland Board along with reports relating to key items including the CHP Savings Plan, West Caithness Service Redesign, Clinical Governance and Risk Management, Scottish Patient Safety Programme and the performance against eKSF targets.

2 Activity 2011-2012

Scottish Patient Safety Programme (SPSP) SPSP continues to become embedded in the Rural General Hospital with spread taking place in all appropriate areas following full sustainability of the care bundles in the pilot site. The new sepsis bundle is being introduced with training and a national collaborative taking place in June.

West Caithness Service Redesign Regular reports have been submitted to the NHS Highland Board and the minutes of the CHP Committee meeting reflects the decision made at the February 2012 CHP Committee meeting to take all management options around redesign of services in West Caithness off the table. There was clear support to commission further work including setting out an approach and supporting actions to review and redesign services in West Caithness.

Following the February CHP Committee meeting ongoing work is progressing. There have been 5 staff meetings – 4 with nursing, AHP and social work colleagues and one with GP’s. An action plan is being set up and work streams are being set up. The main focus is to be looking at reablement, rehabilitation, emergency care and palliative care.

Falls Prevention Falls prevention activity within the CHP covers three areas of work: inpatient falls reduction; identifying and supporting those identified at higher risk in the community; general public awareness raising and establishing good community approaches to falls prevention. Over the last year all inpatient wards have been issued the NHS Highland inpatient falls prevention toolkit and have had a leadership walk around to showcase their falls prevention activity and to discuss their plans for reducing their inpatient falls rate. All senior charge nurses have access to their ward run charts detailing trends around reported falls. The implementation of reablement through 2012 will support delivery of one to one falls prevention programmes for the less mobile within their own homes; and specific falls prevention groups are being delivered when numbers are sufficient. The community development officer, working in partnership with the CHP, continues to work with local communities and leisure providers to develop the expertise and the range of falls prevention activities available to the general public. As part of Age Scotland’s falls prevention week last June a successful falls prevention event was hosted in Dornoch highlighting ways of reducing falls risks to the general public. This event was held in partnership with Highland Council and included the Highland and Islands fire brigade. A follow up event was held a couple of weeks later in Wick.

Reablement Reablement is a targeted approach to support people to regain independence in day to day activity within their own homes; and is delivered in partnership with healthcare, social care and home care professionals. Goals are set with each individual and are reviewed on a regular basis to support ongoing improvement. Around 45 practitioners from Caithness and Sutherland attended lead professional training as part of the roll out of the model, made up of a mixture of community nursing; council and health allied health professionals; social workers and home care officers. Sutherland continues to provide community rehabilitation services to support people in their own homes and will support the reablement workers as the posts are appointed to. Most of the Caithness reablement posts have been appointed and over February/March 2012 four patients were supported by the team from hospital to home. Approximately 9 staff in Caithness and Sutherland have been trained to deliver reablement training to all reablement workers; health care support workers; home carers and relevant voluntary agency staff. Roll out of this training will take place over 2012/13.

Migdale Hospital The new Migdale Hospital in Bonar Bridge was completed during this year. The 22- bedded hospital (mental health for older people and GP-led beds) with outpatient facilities was occupied in June 2011.

Lawson Memorial Hospital Site Improvements An NHS Highland property condition survey identified backlog maintenance and statutory compliance costs of £3.3 million on the site in Golspie, Sutherland. Staff members, representatives of the local community and managers have been meeting to consider how to improve services for patients and address the estate issues. A preferred option has been identified and this will be considered in the near future.

Well North Project The CHP has over the last four years been involved in the Well North Project, whereby people living in North, West and Central Sutherland aged between 40 and 64 have been eligible for a Keep Well Health Check. Keep Well Health Checks have been delivered in a primary care setting either by a community or practice nurse in North & West Sutherland or by a paramedic in central Sutherland. In the year 2011/12 a total of 431 health checks were undertaken against a HEAT target of 420. This project has now come to an end as Keep Well is mainstreamed across the Board area. The focus in the north will now turn to the Wick and Thurso areas.

The project has also led to a multi agency approach to case management for people living in the community with complex health needs. This has included community nursing, Allied Health Professionals, GPs, social work and the voluntary sector.

Prescribing A significant amount of work has taken place during 2011-12 to improve prescribing within the CHP. The Prescribing Support Team has supported practices to deliver five prescribing projects as part of the GMS contract. In addition, the team has delivered the following projects: review of the prescribing of special products, Wound Formulary audit, review of stoma prescribing, dose optimisation of pregabalin, review of gluten free foods prescribing, audit of ScriptSwitch acceptance rates, temporary residents audit, Highland Formulary compliance audit and cost-saving switches (to generic medicines, alternative brands and different formulations). From a financial perspective, the CHP is forecast to overspend by 1.8% on its prescribing budget (based on prescribing data from April 2011 to January 2012). The CHP is continuing to bring its prescribing costs down and is now in line with the rest of NHS Highland. However, it is a challenging time with all areas facing an increase in the volume of prescribing and this has contributed to the small overspend. Maternity Services Total number of pregnancy bookings for Caithness maternity for 2011 was 268 and out of these, 169 births delivered locally in Henderson unit. The number of pregnancy bookings is lower than the previous year however the percentage of births delivered locally at CGH remains the same at approx 60% of the total caseload. Induction of labour for low risk parous mums re-commenced at the beginning of 2012 and to date 3 inductions have been undertaken.

The Caithness maternity team has been successful in achieving re – accreditation of UNICEF Baby Friendly status, passing with flying colours.

2 Redesign to single duty nursing and midwifery services in the NW Sutherland team is now reaching completion, with two full time single duty midwives in post for the area.

Dental Services Capital investment of £1.2m enabled the construction and equipping of a 4 surgery dental unit on the site of the Dunbar Hospital. The provision of the modern facility was intended to attract Dentists to set up an NHS committed practice in the area and to improve access to services for the community which had seen the closure of dental practices over the past 10 years, resulting in a significant waiting list for NHS dental registration and care .

The new facility was leased to an NHS independent contractor, Dr John Barry, in late 2011 and the new practice opened to patients in January 2012. The practice will have the capacity to offer in excess of 6,000 people access to NHS dental care and has already offered 1500 people from the waiting list the opportunity to register. The practice plans to build up its patient list over a number of months and to prioritise those people on the waiting list. The new Dentists are working alongside NHS Highland Salaried Dental Team in Wick to provide In Hours and Out of Hours emergency dental care for the Caithness area.

3 Sub Groups

North Highland CHP CG&RM Group The group meets every two months and continues to make good progress.

Patient experience is feature at every meeting in the form of discussion around the Better Together results and action plan and a review of the feedback gathered using the ‘How did we do?’ hospital based survey. This feedback demonstrates that patients are generally happy with the care that they receive. Specific work has been taken forward to gain a better understanding around areas of lower satisfaction such as noise. Significant complaints are also discussed in the meeting to identify where care could have been improved and trends associated.

Audits are also initiated and discussed including a medical record keeping audit and an audit of patients being transferred out of Caithness General.

Safety is at the heart of the meeting with a review of all Datix incidents reported and the initiation of specific work around categories which are in the higher levels of reporting, for example slips, trips and falls and tissue viability.

All serious event reviews (SERs) are seen by the Group and action plans are reviewed and monitored until actions are closed off. SERs from the group are also taken for discussion at the Board Clinical Governance Forum and SERs from other operational units have also been discussed in the group to promote sharing of learning.

An SPSP update is provided at every meeting, with a specific focus on HSMR. Health and Safety is also a standing item with updates being provided on key areas of concern and work being undertaken. The patient safety culture survey was discussed at the group and then cascaded down to other groups within the area.

North Highland CHP Infection Control Committee The group meets every two months and continues to be well attended. The group reviews any new cases of infection, ensuring that investigations have been carried out and establishing if there are any links between cases. Any outbreaks would automatically be reported to the NHS Highland Board. Learning points from outbreaks in other areas and from ongoing audits are discussed and recommendations implemented. An annual work plan has been drawn up and is regularly updated.

Infection Control Reports were standing agenda items at the CHP Committee Meetings, the CHP Management Team meetings and the Locality Meetings with updates given on the key healthcare associated infection issues.

3 4 External Reviews

HIS Heart Disease Improvement – following the self assessment an action plan for all of NHS Highland is being finalised. There are 18 assessment categories and it is also looking at the implementation of the Heart Failure bundle in both primary and secondary care.

HIS Endoscopy : Pre-JAG Accreditation Visit – Follow up action plan is reviewed on a monthly basis. There is a Highland wide group looking at the decontamination issues.

5 Any relevant Key Performance Indicators

Performance against key targets and indicators was reported to the Committee as part of the General Manager’s report.

Finance Position The CHP has not achieved compliance with all financial targets for 2011/12 with a year end deficit of £780k. Cash Releasing Savings (CRS) have not been achieved with £1.066m outstanding at the year end. In addition a proportion of in year savings has been delivered on a non-recurrent basis and will therefore form part of NHS Highland’s savings target for 2012/13. Locum costs in Caithness General Hospital for both consultants and junior medical staff during the financial year has resulted in an overspend of £140k.

Staff Sickness Rates Following on from the review of sickness absence by the NHS Highland internal auditors, local actions to address the recommendations were taken, resulting in improved rates of absence within the North CHP. Regular updates on the position were presented at the Committee meetings under Staff Governance.

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

 Financial Position  West Caithness Redesign  Lawson Site Improvements  Improved Public Involvement and Consultation on service changes  Effective integration of Highland Council and NHS staff in the area

7 Conclusion

The systems of control within the respective areas within the remit of the committee are considered to be operating adequately and effectively.

Colin Punler Chair North Highland Community Health Partnership Committee 2 May 2012

4 APPENDIX 11

NHS Highland South East Highland CHP Annual Report

To: NHS Highland Audit Committee

From: Gillian McCreath Chair, South East Highland CHP

Subject: South East Highland CHP Committee Report – 2011/12

1 Background

In line with sound governance principles, an Annual Report is submitted from the South East Highland CHP to the Audit Committee. This is undertaken to cover the complete financial year, and forms part of the supporting arrangements for the Statement of Internal Control, ending with the certification and submission of the Annual Accounts.

2 Activity, Sub Groups and Reviews in 2011/12

2.1 Corporate Governance – Role of the CHP Committee

The CHP Committee has been formally established since 1 April 2005 and operates fully in compliance with the Scottish Executive Statutory Guidance for CHPs (2004). It reports directly to the NHS Highland Board and is chaired by a Non-Executive Director, with an additional Non-Executive Director as a core Committee member.

The CHP Committee met five times in 2011/12 and meeting dates were arranged to link in with Board meetings. This supported the governance and communication arrangements.

Membership of the CHP Committee in 2011/12 complied with the Statutory Guidance. For example, the CHP has three Public/Patient representatives, Third Sector (formerly Voluntary Sector) representation (for part of the year until the retirral of the Third Sector representative), Primary Care contractors, Highland Council officers and elected members, as well as the required employed posts such as General Manager, Clinical Director, Head of Financial Planning and the Lead AHP, Nurse and Pharmacist posts, together with a representative from Public Health.

The CHP Committee agenda is clearly structured to encompass the main governance headings. There are standing agenda items covering:

 Financial Governance  Performance against targets  Clinical Governance  Staff Governance  Health Improvement  Service Improvement/Development

CHP Committee meetings have been publicised and open to the public throughout 2011/12.

1 2.2 Financial Governance

Detailed finance reports are produced and discussed as formal agenda items at the following meetings:  CHP Locality meetings (monthly)  CHP Management meetings (monthly)  CHP Committee meetings (five times per annum)

All of the above fora and reporting arrangements provided a pro-active financial governance infra-structure in 2011/12. The following financial responsibilities were discharged and overseen by the CHP Committee:  Budget setting and allocations  Financial expenditure, monitoring and control  Cash Releasing Savings targets  Endowments

The CHP has achieved compliance with all financial targets for 2011/12 including achievement of CRS (non-recurrent and recurrent) and financial balance. There was a small under-spend against the £84M budget.

2.3 Staff Governance

The CHP had staff governance arrangements in place during 2011/12. This included:  The CHP has a Local Partnership Forum, as a sub-group of the Highland Partnership Forum. This has an agreed role, remit and membership and meets on a bi-monthly basis.  Staff Partnership representatives are included and attend all key CHP meetings including the CHP Committee and Management Team meetings.  The Staff Governance Action Plan was applied throughout the CHP during 2011/12.  A programme of Personnel Clinics ran periodically throughout the year at various CHP locations.  A CHP specific Workforce Monitoring Report was presented, as requested, at all CHP Committee meetings. This allowed detailed scrutiny of CHP activity including sickness rates, staff turnover, age profiles, bank and agency staff use.  The CHP sickness rate was consistently below the Highland average during 2011/12.

2.4 Clinical Governance

A Clinical Governance and Risk Management Performance Report was presented at each CHP Committee meeting during 2011/12. The following issues were included:  CHP performance against complaints response times targets and summary information about complaints raised and associated outcomes. (The CHP met complaints response time targets).  Incident reports.  QIS reports and implications for the CHP.

A CHP Clinical Governance and Risk Management Group met on a bi-monthly basis during 2011/12. This was chaired by the CHP Clinical Director and comprised wide clinical and other representation including the NHS Highland Head of Clinical Governance and Risk Management. Work highlights in 2011/12 included refinement and actions associated with the CHP’s Risk Register, medication safety reviews, Infection Control/Hand Hygiene and scrutiny of high volume incidents.

2 2.5 Performance Monitoring

In addition to the governance arrangement highlighted above, a CHP Performance Monitoring Report was provided at each CHP Committee meeting during 2011/12. This included the Highland-wide Balanced Scorecard plus a specific SE Highland CHP Balanced Scorecard. CHP Performance against relevant LDP/HEAT targets was reported and compliance monitored at CHP Committee meetings. This included Health Improvement targets such as Alcohol Brief Interventions and Smoking Cessation plus delayed discharge and other targets.

The CHP Committee was also provided with a report by the CHP General Manager at each meeting in 2011/12. This included up-dates on important CHP activity including any service changes or developments.

3 Emerging issues and key issues to address/improve in the following year

The CHP Committee will not exist in 2012/13. However, the operational unit will focus on several key issues during 2012/13. These are likely to include:  Overview and leadership of re-design initiatives.  Delivering the challenging financial agenda.  Delivery of the Board’s key HEAT, clinical and other objectives.  Delivery of the Board’s Strategic Framework and vision.  Priorities associated with Adult Community Care Integration.

4 Conclusion

The systems of control within the SE Highland CHP Committee areas of responsibility are considered to be operating adequately and effectively.

Gillian McCreath Chair, South East Highland CHP 16 March 2012

3 NHS Highland Audit Committee

RAIGMORE HOSPITAL GOVERNANCE COMMITTEE Annual Report 2011/2012

1 Background

In line with sound governance principles, an Annual Report is submitted from the Raigmore Governance Committee to the Audit Committee. This is undertaken to cover the complete financial year, and forms part of the supporting arrangements for the Statement of Internal Control, ending with the certification and submission of the Annual Accounts.

The role of the committee is to ensure that:

Adequate governance arrangements are in place (financial, clinical and staff) Resources are directed to meet local needs Services are supported and delivered in a fair and equitable manner Staff, patients and the public are involved The benefits of effective partnership working are realised.

Membership of Raigmore Governance Committee is in line with statutory guidance and includes 3 public/patient representatives, voluntary sector representatives, 3 Highland Councillors and staff-side as well as the required employed posts. These posts include the General Manager, Associate Medical Director, Head of Finance, Lead AHP, Lead Nurse, Personnel Manager, Health & Safety Manager and two Non Executives. The Clinical Governance elements are taken forward and reported to the Committee by the Lead Nurse and Associate Medical Director. The Committee has been chaired by Mike Evans, Non- Executive since January 2011.

2 Activity

The Raigmore Governance Committee has met / plans to meet on the below dates:

14th February 2011 18th April 2011 20th June 2011 15th August 2011 17th October 2011 19th December 2011 20th February 2012 16th April 2012

All Raigmore Governance meetings are open to the public and in addition the minutes of the meetings are submitted to the NHS Highland Board including reports relating to key items. All papers and approved minutes are published on the NHS Highland Website via the NHS Board papers.

The Committee agenda is structured to encompass the main governance headings and there are standing agenda items which include:

General Managers Report Financial Governance (Report from the Finance Manager) Staff Governance (including partnership arrangements) Clinical Governance (Report from the Quality and Patients Safety Team) Performance against HEAT targets Health & Safety Report Infection Control Report

3 Sub Groups

There are 3 Management Groups which feed into the Governance Committee, namely:

Raigmore Senior Management Team (SMT) Quality & Patient Safety Group Local Partnership Forum

The Raigmore Senior Management Team, led by the General Manager, meets bi-weekly formally monthly to update and discuss issues that arise at individual Division and Hospital level, and to ensure timely sharing of appropriate information.

In addition the Local Partnership Forum meets once a month following the Raigmore Senior Management Team, jointly chaired by the General Manager and the Lead Staff-side Representative. Recent issues discussed by the forum include:

Raigmore Hospital Financial Recovery Plan Staff Governance Action Plan Scottish Patient Safety Programme Learning and Development Budget Allocation

Partnership representation is key for all Raigmore meetings including the Governance Committee.

The Quality & Patient Safety Management Team meets on a monthly basis and is attended by managers, senior clinicians and representatives from Health and Safety and Partnership. Robust and affective arrangements are in place to identify, monitor and address clinical risks across the organisation. Members of the team have recently been involved in the ongoing development of the newly devised Raigmore Dashboard focusing on which quality indicators should be incorporated at both strategic level and service level. This dynamic process is supported by Service Planning

A report is produced for the Governance Committee with the following issues being highlighted:

Patient Satisfaction HAI including HEI Progress with the Scottish Patient Safety Programme Complaints Statutory Training Issues Audit outcomes NHS QIS standards Incidents including Significant Events Health & Safety

6 External Reviews

Practice and processes have been subject to external review throughout the year. Those which have been formally reported to the Governance Committee are:

Healthcare Environment Inspectorate – March 2011 Professor Duerden’s Review of Microbiology and Infection Control Services – July 2011

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

Raigmore Governance Committee will inevitably have to focus on new and emerging key issues during 2012/13 which include:

Delivery of a balanced budget Older People in Acute Care Settings Inspection Review of the Kyle Court Facility Delivering all HEAT targets within a continuing challenging financial environment Delivery of 18 weeks from referral to treatment Delivery of new Cancer treatment times Bed Reconfiguration Continuing to manage HAI and Hospital Environment issues Consultant Job Planning to ensure contribution toward service planning and capacity

8 Conclusion

The systems of control within the respective areas within the remit of the Governance Committee are considered to be operating adequately and effectively.

Mike Evans Chair Raigmore Hospital Governance Committee March 2012

APPENDIX 13

NHS Highland Spiritual Care Committee Annual Report

To: NHS Highland Audit Committee

From: Chair, Spiritual Care Committee

Subject: Spiritual Care Committee Report – [2011-12]

1 Background

In line with sound governance principles, an Annual Report is submitted from the Spiritual Care Committee to the Audit Committee. This is undertaken to cover the complete financial year, and forms part of the supporting arrangements for the Statement of Internal Control, ending with the certification and submission of the Annual Accounts.

The NHS Highland Spiritual Care Committee exists to ensure the provision of good spiritual and religious care in NHS Highland by Chaplains and other NHS staff. It achieves this by monitoring and reviewing the Delivery of Service according to the Spiritual Care Policy, and the Strategy and Action Plan. During the period under review the committee met four times.

2 Activity

The committee has considered a wide range of topics in its role of monitoring the delivery of spiritual care. One major area for discussion has been Shaping Bereavement Care. Shaping Bereavement Care – a framework for action, CEL 9 (2011), was published by the Scottish Government Health Directorate in February 2011 to set out what should be expected in best practice in bereavement care for the National Health Service. The responsibility for implementing the recommendations fell to the Lead Chaplain. A draft policy has been issued for consultation with a range of staff groups and partnership organisations, training has been given to key members of staff and a network of stakeholders in bereavement care has been established.

The committee was involved in promoting Reflections of Life at a lunch in September. This is a resource for all, containing words of comfort and encouragement from many different faith and belief traditions. We were delighted to have Geoff Lachlan the project co-ordinator speak at the lunch about how this resource will make a significant contribution to the provision of quality person- centred care.

Part of the implementation of the spiritual care strategy has been providing training and awareness sessions in spiritual care for staff. The Education Facilitator has reported to the committee on the progress of this work which has not attracted many individuals but has been more effective providing it to teams of staff, such as Nairn Hospital and Extended Care Team and the Community Mental Health team at the Corbett Centre. Finding opportunities to engage with staff who have other competing priorities will continue to be a challenge and the committee will monitor the situation closely.

The committee has also been concerned about the quality of information about spiritual care needs recorded on the Patient Admission System. Discussions with e-Health and Records have significantly improved this and the new Patient Questionnaire, which is in the process of trials, contains a changed spiritual care section which along with staff training will hopefully improve this aspect of patient referral to the chaplaincy team.

While the delivery of spiritual care is every member of staff’s responsibility, chaplains are highly skilled specialist practitioners whose role is crucial in supporting staff to deliver person centred care. The committee’s role is to ensure that chaplains have the necessary resources to do the job and that they are accountable for what they do. The committee has put in place standards for chaplains to meet in accordance with the implementation of the strategy and has conducted an activity analysis of the service provided.

There have been a number of personnel changes in chaplaincy with the retrial of Ian Hamilton from Nairn Town and County after 25 years in post, and Donald Macquarrie from Belford after 20 years there. Kath Armistead retired from Caithness General serving seven years and Ruth Griffiths from Dunoon. The committee acknowledges the sterling service each has carried out in their separate areas and wishes them long and fulfilling retirements.

There will be inevitable changes as a result of these people leaving and the committee will play its part in ensuring that the delivery of high quality spiritual continues to be given in these areas.

Finally a few aspects of the work which the committee oversees, that care given by chaplains to people in need:  A lady referred by a specialist nurse to chaplaincy for bereavement care has been much helped by regular visits at home to discuss the issues arising from her previous losses.  One man who has been receiving chemotherapy had significant input from a chaplain to help him deal with his feelings of guilt which were having a detrimental effect on his treatment.  In the past couple of months there have been two memorial services for members of staff which has allowed colleagues to remember and reflect upon the contributions made by people they have worked alongside.  Words from a patient’s family: “Words cannot express how grateful we are for all the support you have offered after the death of our son C. This has been the most difficult and heartbreaking thing to have happened to us both but your unwavering support has made it that little bit easier. Thank you.

3 Sub Groups

There are currently no sub groups of the committee.

4 External Reviews

There have been no external reviews carried out.

5 Any relevant Key Performance Indicators

In meeting the principles of the Board’s Spiritual Care Policy under section 4.2.1 the committee will seek to ensure patient’s spiritual needs are recognized and met

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

The committee will continue to monitor the uptake of spiritual care training and education and audit the effect it has had on the practice of individual staff. The committee will also look for ways to learn about the patient experience of spiritual care. The committee will begin to develop a strategic plan for spiritual care over the coming year.

7 Conclusion

The committee's remit is a large one, covering the delivery of spiritual care by all members of staff in NHS Highland while ensuring equality of access to spiritual and religious care by all who use the service. It is the committee's opinion that the systems of control within this remit are operating adequately and effectively. Gary Coutts Chair Spiritual Care Committee APPENDIX 14

NHS Highland Control of Infection Committee Annual Report 01.04.11 – 31.03.12 by Okain McLennan, Chair, NHS Highland Control of Infection Committee

1 Background

In line with sound governance principles, an Annual Report is submitted from the Control of Infection Committee to the Audit Committee. This is undertaken to cover the complete financial year, and forms part of the supporting arrangements for the Statement of Internal Control, ending with the certification and submission of the Annual Accounts.

The Control of Infection Committee reports to the Board via the Clinical Governance Committee and meets bi-monthly.

2 Activity 2011/12

Cleaning and the Healthcare Environment

Compliance with cleaning and estates monitoring carried out by Domestic Services using the national monitoring tool, demonstrates an average compliance of 93% for cleaning and 95% for estates monitoring across NHS Highland April 2011 – March 2012. The national target compliance is 90%.

Following the January 2012 outbreak in Raigmore Hospital, an HAI task force was established and HEI-type inspections were carried out across Raigmore. The findings raised significant concern about the fabric of the environment in Raigmore. There are challenges around maintaining the fabric of patient areas in older buildings to enable effective cleaning which have not been picked up using the national monitoring tool. The effectiveness of the existing monitoring tool and how it is applied is under review by the Infection Prevention and Control Lead Doctor.

Antimicrobial Management

NHS Highland Antimicrobial Management Team monitors antimicrobial prescribing in terms of preferred antibiotics compared with CDI associated antibiotics and restricted agents.

NHS Highland’s progress is measured against 3 national indicators:-

Hospital-based empiric prescribing In acute admission areas, antibiotic prescriptions are compliant with the local antimicrobial policy and the rationale for treatment is recorded in the clinical case note in above 95% of sampled cases. Acute Medical Admissions Unit, Raigmore Hospital is compliant, Surgical Admissions Ward, Raigmore Hospital is non compliant at 91% but this is improving (95% February 2012). Measured by the median compliance over time means Medical have achieved the target but the Surgical Admissions Unit has not.

Surgical antibiotic prophylaxis Duration of surgical antibiotic prophylaxis is less than 24 hours and compliant with local antimicrobial prescribing policy in above 95% of sampled elective colorectal surgical cases in Raigmore Hospital. NHS Highland is continuing to meet this target each month as the team are consistently achieving 100% since measurement began in February 2011.

Primary care empirical prescribing Seasonal variation in quinolone use (summer months vs. winter months) is less than 5%. This is measured once a year in July, and compares the 6 months from October 2010 to March 2011 with April 2010 to September 2010, at which point NHS Highland had achieved the target of less than 5% variation between winter and summer use of quinolone antibiotics.

The empiric use of ciprofloxacin and other quinolone antibiotics during the winter months is attributed to the treatment of chest infections, which are more common during winter. As quinolones are not part of prescribing guidelines for community-acquired chest infections, any increase in quinolone use during the winter months indicates inappropriate use of this class of antibiotics. Achieving the 1 measure of less than 5% additional use of ciprofloxacin during the winter months compared to the summer months in NHS Highland shows that our prescribers are not using ciprofloxacin for this indication.

The Antimicrobial Management Team continues to review current antibiotic guidelines to ensure the most up-to-date evidence is reflected.

Education on antimicrobial prescribing: - The bi-monthly prescribing newsletter “The Pink One” is used to promote the prudent antimicrobial prescribing message to all prescribers in NHS Highland. The Antimicrobial Pharmacist supports medical staff with training in prudent antimicrobial prescribing. The presentation of audit results incorporates an educational element in relation to areas highlighted for improvement. Point prevalence audits of the Divisions in Raigmore and other acute hospitals are carried out at least once per year, preferably twice. The community hospitals are similarly audited once a year. Reports are written and distributed to prescribers or presented at audit afternoons/education sessions. All foundation doctors undertake the module on “DOTS” on antimicrobial prescribing and it is compulsory.

Decontamination

The Central Decontamination Unit is CE Certificated with the Medicines and Healthcare products Regulatory Agency (MHRA) which is subject to the successful application of ISO 13485:2003, Quality Management System – Medical Devices and satisfactory surveillance auditing. The next surveillance audit is due in May 2012. The unit is however vulnerable as the washer disinfectors have reached the end of their life span. The Decontamination Manager has submitted a paper to the Asset Management Group that has been noted and prioritised amongst the other capital requirements for the Board. The planned preventative maintenance programme for the washer disinfectors continues.

All of the completed NHS Highland Local Decontamination Units comply with the Glennie Technical requirements; work is ongoing to provide suitable units or contingency arrangements for locations within Argyll & Bute which as yet do not comply.

Compliance within the Independent Dental Practitioner setting is challenging as the development of decontamination units is undertaken by the individual sites. CDO(2009)01 notified GDP independent contractors that they were required by December 2011 to provide LDU facilities within their practices for the decontamination of instruments which were compliant with SHPN 13 Part 2.

Based on GDPs self assessment, as of 31 March 2012: 82% (40) practices assess themselves as compliant, 14% (7) state that they have plans in place to extend or relocate their practice to achieve compliance by December 2012 and 4% (2) practices have no plans in place and are intending to sell their practice. A paper will be submitted to NHS Highland Control of Infection Committee in May 2012 outlining the potential risks and recommendations.

There continues to be local decontamination in the theatre setting, a working group has been established to enable all local decontamination in theatres to be halted by the end of 2014.A working group commissioned by the Chief Executive has carried out an option appraisal to deliver compliant endoscope decontamination facilities for NHS Highland.

The “Decontamination Committee” has been re-established and is chaired by the Lead Infection and Prevention Control Doctor and reports to the Control of Infection Committee.

Hand Hygiene

NHS Highland Hand Hygiene Rolling Monthly Audit Programme continues across all clinical areas sustaining an average of 96% compliance. NHS Highland continues to participate in the bi-monthly National Hand Hygiene audits.

Audible signage (Speechpods) were purchased and distributed across Highland; however given the volume of the signage they are unsuitable for ward areas, as repeated messages are disturbing for patients - therefore they have limited value and are not used as extensively as first envisaged. Work

2 is ongoing to ensure the message given to staff and patients supports the WHO 5 moments for hand hygiene.

Uptake of seasonal flu vaccination with staff in NHS Highland

Despite the limitations of the workforce data it appears that most high risk areas did achieve a flu vaccine uptake of 50% or more. The objective of vaccinating more than 25% of staff overall was surpassed.

Policy Reviews

An active programme of policy reviews was carried out during the year as per work plan.

The National Infection Control Manual Part 1 Standard Infection Control Precautions was launched in January 2012. This has replaced several local policies.

Education

The Infection Prevention & Control Education Strategy was ratified by the Control of Infection Committee in November 2011. The Infection Prevention & Control Nurses and Infection Prevention & Control Doctor continue to deliver education and training to all staff groups. Infection Prevention and Control Link Nurses are in place across the organisation and Link Nurse Meetings are held regularly and include education sessions.

The Infection Prevention & Control Team in conjunction with Learning & Development, Health & Safety and Occupational Health has been developing modules for Learnpro e-learning system. This has taken longer than expected due to workload and an Infection Prevention & Control Nurse vacancy in the North & West Operational Unit; however the Hand hygiene module which includes skin care advice will be live in April 2012.

Audit

NHS Highland Infection Prevention & Control and Antimicrobial Management teams carried out the national prevalence survey in all wards in Caithness General, Raigmore, Belford, Lorn & Islands, New Craigs, Lawson and Campbeltown Hospitals during September and October 2011. This involved collecting HAI and prescribing data from the case notes of all patients in a ward on the day of the survey. It took approximately 300 hours (including travelling time) for the teams to collect the data.

Results published in April 2012 showed that HAI prevalence is lower by 40% in NHS Highland compared to the prevalence study carried out in 2005/6. However it should be noted that different protocols and inclusion/ exclusion criteria were used in 2005/6 and 2011 so exact comparison cannot be made.

A programme of regular audit is in place and includes the following:  Antimicrobial prescribing  Environmental Audits  Commode audits

Outbreaks

In January 2012, an outbreak of Clostridium difficile was confirmed in Raigmore Hospital. During the period of the outbreak a total of 8 patients were confirmed as having Clostridium difficile.

The incident was managed in accordance with NHS Highland’s Policy on Outbreak/Incident of Communicable Infection and Ward/Hospital Closure, October 2010. Daily meetings were held during this time. The debrief meeting held in February 2012 reviewed how the incident was managed and made recommendations for improvement. The critical incident review report has now been completed. A second outbreak of 3 cases of C difficile on ward 2c occurred in April this year which is out with the reporting time line of this report.

3 There was an outbreak of diarrhoea and vomiting in Nairn Town & County Hospital in July 2011. A total of 8 patients and 16 staff were affected. Of the samples sent to the laboratory 3 were confirmed as Norovirus. The outbreak was well managed by close collaborative working between clinical, estates, domestic staff and the Infection Prevention & Control Team.

3 Sub Groups

The Infection Control Improvement Group HAI Executive Lead, Lead Nurses, Head of Facilities, Health Protection and the Infection Prevention & Control Team attend the Infection Control Improvement Group which is held monthly and focuses on the operational delivery of the infection prevention and control agenda.

NHS Highland Decontamination Group The group reports to NHS Highland Control of Infection Committee and provides guidance in matters relating to decontamination and provides direction to the various operational units on how to implement and enforce decontamination policy.

4 External Reviews The HEI Inspectorate made an announced visit to Belford Hospital, Fort William and the MacKinnon Memorial Hospital, Broadford in July 2011.

Overall, the Inspectorate found evidence that NHS Highland is working towards complying with the NHS QIS HAI standards to protect patients, staff and visitors from the risk of acquiring an infection. However they found that improvement could be made in the following areas:-

• National initiatives relating to best practice for antimicrobial prescribing should be commenced. • A more structured process should be put in place for domestic staff to report to the Senior Charge Nurse when they have been unable to carry out all their required cleaning duties. • Staff should be reminded of their responsibilities to follow and implement standard infection control precautions, and • Peripheral venous catheter care bundles should be introduced

Belford Hospital had 2 requirements and 3 recommendations, MacKinnon Memorial Hospital had 2 requirements and 5 recommendations.

5 Key Performance Indicators

Staphylococcus bacteraemias

With effect from April 2011, all Boards are expected to achieve a rate of 0.26 Staphylococcus aureus bacteraemia (SAB) cases per 1000 acute occupied bed days or lower by year ending March 2013. For NHS Highland that means no more than 73 cases.

April 2011 – March 2012 there were 51 cases, a rate of 0.18 per 1000 acute occupied bed days.

Clostridium difficile

With effect from April 2011, all Boards are expected to achieve a rate of 0.39 cases of Clostridium difficile per 1000 total occupied bed days (OCBDs) or lower among patients aged 65 and over by year ending March 2013. For NHS Highland that meant no more than 86 cases.

April 2011 – March 2012 there were 59 cases in patients aged 65 and over, a rate of 0.25 per 1000 total occupied bed days.

Surgical Site Infections The Infection Prevention & Control Team continues to work closely with the Obstetric/Midwifery and Orthopaedic Teams, using improvement methodology to reduce the incidence of post-operative surgical site infections (SSI). A Root Cause Analysis is undertaken on every SSI to identify contributing factors and put effective control measures in place to reduce the risk of recurrence.

4 Colorectal Surgical Site Infection: The Rapid Improvement Programme Project has made significant improvement changes which have shown a reduction in colorectal surgical site infections. Work will continue into 2012/13.

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

The appointment this year of a new Lead Infection Prevention and Control Doctor is providing an opportunity for review of the current infection prevention and control systems, processes and structures which are currently in place, however, the Microbiology Department is down by 2.4 WTE substantive consultant posts; this creates significant risk in the delivery of infection prevention and control and the microbiology service. In the interim, the service is being supported by locum microbiologists until the substantive posts can be filled. The first advert failed to recruit to these posts. However, short term appointments do not consistently support the Head of Microbiology to develop the service.

In addition to this, what was the Mid Highland CHP has had challenges recruiting to its vacant Infection Prevention and Control Nurse post. Despite several adverts a qualified IPC Nurse has not been recruited; two part time nurses have been appointed into post and these staff will undertake the relevant training over the next year.

The IPC Nurse for the North is due to go on maternity leave later this year and cover will be required. This will put additional strain on the existing Board Wide IPC Nursing Teams.

The Infection Prevention and Control Annual Programme 2012/13 has been drafted and will be taken to the August Board meeting for ratification. The key actions are:

 Review the Infection Prevention and Control Doctor function including WTE requirements  Review the required activities of the Infection Prevention and Control Team including the IPC Manager in relation to structure, meetings and professional development requirements  Review governance arrangements for infection prevention and control  Continue to meet SAB and C difficile HEAT targets  Continue to develop and expand work on colorectal surgical site infections  Determine how much MRSA transmission occurs  Review Hand Hygiene methodology to achieve greater compliance  Revisit auditing of the fabric of the health care environment, including pseudomonas control  Progress compliance with decontamination requirements

7 Conclusion

NHS Highland continues to strive to improve its infection prevention and control systems, processes and structures achieving some significant results during the last year such as surpassing the national SAB and C difficile HEAT targets. The appointment of a new Infection Prevention and Control Doctor is providing the Board with the opportunity of seeing existing infection prevention and control structure processes and activities with “new eyes” and a comprehensive Annual Programme will be in place to address key risks which emerge and progress initiatives which will enhance patient safety. The review of the infection prevention and control governance arrangements will ensure that the Board is fully alerted to all key risks and that activities to address these risks are progressed according to time line.

I can conclude that the systems of control within the respective areas within the remit of the committee are considered to be operating adequately and effectively and will be further augmented and improved by the implementation of the recommendations made by the new Infection, Prevention and Control Doctor through the IPC Annual Programme.

Okain McLennan Chair Control of Infection Committee 8th May 2012

5 Annual Report APPENDIX 15

NHS Highland Health and Safety Committee Annual Report:

To: NHS Highland Audit Committee

From: Anne Gent and Elspeth Caithness, Joint Chairs, Health and Safety Committee

Subject: Health and Safety Committee Report – April 11 – March 12

1 Background

In line with sound governance principles, an Annual Report is submitted from the Health and Safety Committee to the Audit Committee. This is undertaken to cover the complete financial year, and forms part of the supporting arrangements for the Statement of Internal Control, ending with the certification and submission of the Annual Accounts.

The Health and Safety Committee is a formal Committee of the Board. The role of the Health and Safety Committee is:

 To ensure that the Health and Safety Committee promotes the ownership of Health and Safety as an integral part of the provision of health and health care services. Additionally it has a key role in ensuring the organisation meets the Staff Governance Standard that entitles staff to an “improved and safe working environment”.

 To ensure that Health and Safety is an integral part of the provision of health and healthcare services and that legislative and organisational requirements for the effective management of health and safety are met.

The Committee has met on 4 occasions during the year, on 19th May, 18th August, 17th November, and 9th February. The minutes of the Committee have been submitted to the appropriate Board meetings. Agendas comprise both Topics Specific items and Regular Advisor Reports.

2 Activity

The Health and Safety Committee considered the following key items at its meetings throughout the year.

Topic Specific

 Occupational Health and Safety Strategic Framework – ‘Safe and Well at Work’  Mental Health and Wellbeing  Health and Safety Strategic Implementation Plan  NHS Highland Health and Safety Rolling Work Programme 2011/12  Fire Safety Policy  Control of Substances Hazardous to Health  Health and Safety Training  Working Time Regulations  Moving and Handling Passport  Health and Safety Committee Annual Report

1  Workplace Risk Assessment Procedure  Lone Working Procedures  HSE Procedures  First Aid at Work Procedure  Planning for Integration  Reports from Operational Units  Horizon Scanning – Legislative Update

Advisory Reports

 Clinical Governance and Risk Management  Facilities  Infection Control  Occupational Health  Radiation Protection

3. Health and Safety Assurance and Management

Over the past 12 months NHS Highland has focused on improving our governance, policy, competence and statutory compliance arrangements for managing health and safety as well as improving the assurance processes from the operational frontline to Board level in order to improve staff health and reduce injury. As part of this effort, a new policy and strategy was endorsed in August 2010. In addition a non-executive director was co-opted onto the Boards Health and Safety Committee last year with an additional Non Executive being identified to sit on the Committee this year.

4. Health and Safety Sub Groups

4.1 Mental Health in the Workplace Steering Group

The main activity of this group this year was the Mental Health in the Workplace Workshop which took place on the 22 Sep 2011 in Inverness. The workshop drew together managers, staffside, personnel managers, occupational health and health and safety practitioners in one room to achieve the following outcomes:

 to review existing activity, stress risk assessments, sickness absence data etc with respect to stress  consider the legal aspects,  review the HSE’s risk assessment process,  highlight the benefits of the HSE line manager competency tool,  And then establish by operational unit a plan of action.

It was a successful workshop that initiated a number of work streams across each of the operational units

4.2 Workplace Hazards Advisory Group

Chaired by the Director of Occupational Health the purpose of the WHaG is to ensure that the management arrangements, for NHS Highlands physical, chemical and biological hazards, are in place and fit for purpose. This will be undertaken in a prioritised risk based manner and will include work in the following areas (this is not exhaustive): Noise at Work, Hand Arm / Whole Body Vibration, Chemical Substances / Processes, occupational exposure to biological agents e.g. BBV through sharp injuries etc. The objectives of the group are to:

2  To formulate policy, provide technical advice and guidance on safe working practice to the H&S Committee  To recommend and advise on policy implementation  To set the Boards priorities and work programme  To act as a Board focal point for all matters relating to hazardous substances (excluding Radiation)  To act as the focal point for all occupational hygiene matters  To advise the H&S Committee on specific issues  To advise on competence issues with respect in managing hazardous substances and materials safely  To advise on and continually review the Boards management arrangements (policy, procedure, monitoring) for hazardous substances and materials

The group has met over 8 times in the past year primarily to discuss the technical aspects of COSHH and dermatitis to good effect.

5. Health and Safety Assurance and Management

Last year NHS Highland set out to strengthen its health and safety leadership, governance and compliance, through its recently revised policy and strategic plan. Over the past 12 months much of this effort has focused on implementing the Boards health and safety objectives, through the Annual Work Programme, which has set both corporate and more importantly operational health and safety priorities.

Much of the effort early last year focused on embedding and establishing the jointly chaired Health and Safety Groups in the operational and service units, such as the Estates Department. One of the principle tasks was to ensure that each of the groups identified their key health and safety issues, as well as those identified in the work programme, and prioritise that effort in a proportionate manner. Although each unit has adopted a different approach, they are now established, with active agenda’s and are reporting and functioning well.

A number of improvements have also been made in NHS Highland Estates department. It has a responsibility for developing and implementing compliance systems associated with the built environment and property assets. Typical systems that require management and control include: water safety (e.g. legionella and pseudomonas), asbestos, working at height, confined space work, electricity at work and the management of contractors. Most of these areas are medium to high hazards, are more industrial in nature and are linked to the existing backlog maintenance deficit. In 2008 the department had no dedicated Health and Safety support. In 2010 technical support increased to 2 days per week and now, with effect from Jan 12, this stands at 4 days per week. As a result a number of safety improvements have been made over the past year with a noticeable change in safety culture, an increase in incident reporting, a host of tailored toolbox box talks, and the development of a Point of Work Risk Assessment system for tradesmen.

During 2012-2013 the major focus for health and safety will be ensuring that our governance, systems, and work processes are realigned and resourced sufficiently to meet the challenges and demands of internal reorganisation and the Integrating Care in the Highlands agenda to ensure they are “fit for purpose” and compliant with respect to the Boards health and safety risk profile.

5.1 Statutory and Mandatory Competence and Training

In 2010 – 2011 we reviewed our training needs and methods of delivery and took a more risk based, competency approach to training. Last year a new health and safety training matrix was devised and finalised, which details the purpose of the training, the target staff groups, the learning outcomes to be achieved, the delivery method and the period required for revalidation. This matrix is now integrated into NHS Highlands “Induction, Statutory and Mandatory Training” policy and induction procedures.

3 With respect to delivery methods, NHS Highland trialled “LearnProNHS” (an e-learning platform and online resource which provides access to a host of e-learning modules programmes, from statutory and mandatory to CPD related modules which are mapped with the Knowledge and Skills Framework (KSF)) last year and this is now rolled out, and early user indications are positive. “LearnProNHS” will be used as part of our blended learning approach and it will enhance the training delivery in a cost efficient manner. The LearnProNHS activity statistics below gives an indication of the system use and access to date from when it became operational in January 2012.

5.1.1 COSHH Manager and Assessor Training. COSHH training was overhauled and updated considerably last year to reflect the required need and risk. Two new courses were devised; a COSHH Manager Awareness course, aimed at enhancing the competence of managers to ensure they fulfil their duties under the COSHH Regulations and for nominated assessors, a COSHH Assessor course, the purpose of which is to support managers in the higher risk areas. To date approx 175 managers and staff have received awareness training and 30 COSHH Assessors have been established.

5.1.2 Risk Assessment Training. One of the Boards priorities set in the Annual Work Programme 2010-2011, was related to risk assessment. The previous workplace risk assessment procedure and assessment form was reviewed, updated and ratified at the Committee early last year. This has now been published and Health and Safety Managers are in the process of rolling out training to support managers to use and implement the new procedures.

For progress on Violence and Aggression and Moving and Handling competence and training see below.

6. Health and Safety Executive Visits

In April 2011, the HSE changed their inspection regime, and now they will only visit organisations and investigate incidents on the receipt of a RIDDOR notification (other than the new “over 7 day injury”) which meets their strict investigation criteria. Over the past 12 months NHS Highland has subject to a number of investigations.

6.1 Control of Substances Hazardous to Health

NHS Highland was involved in a proactive HSE intervention in early November 2010, which was part of a UK wide inspection campaign that assessed how NHS Boards / Trusts managed the risks of exposure of staff to skin harming substances and blood borne viruses, as a consequence of sharps injuries, under the remit of the Control of Substances Hazardous to Health Regulations 2002 (COSHH). The outcome of the visit resulted in a detailed report with 29 recommendations; a number dealt with the wider aspects of health and safety management whilst others were more specific to the management arrangements of COSHH, dermatitis and sharps.

Over the past the year focus has been on; improving competence (for managers and COSHH Assessors), improving workplace systems, re-validating existing COSHH Assessments for higher risk groups, and establishing appropriate procurement controls for hazardous substances and materials. A significant amount of work has been undertaken by local managers so far, but we still have additional work to complete and this will be planned over the forthcoming year.

6.2 RIDDOR Investigations

A number of RIDDOR reports were made to the Health and Safety Executive over the past year. The most extensive investigations were those related to occupational dermatitis.

4 As part of the on-going COSHH compliance work detailed above, NHS Highland improved its internal RIDDOR reporting procedures for occupational disease to the HSE. As a result between Feb 2011 and Apr 2011, four cases of occupational dermatitis were reported to the executive. At a similar timeframe, the HSE at a national level changed its visit / inspection regime, and from 01 Apr 11, all proactive visits ceased and future engagement with organisations would be through the reporting of RIDDOR’s incidents, which would involve formal investigations. NHS Highland reported the above cases which then subsequently resulted in four formal HSE investigations.

From May to Oct 2011, the HSE interviewed a range of NHS Staff whilst investigating the above cases and decided to service an Improvement Notice on 15 Nov 11 for failing to adequately control the risk of dermatitis to staff, with a deadline of 30 April 2012 for full compliance.

The Improvement Notice requirements fell into a number of areas; COSHH policy, occupational health systems and procedures, COSHH assessment of hand hygiene products and wet work, development of a definitive list of hand hygiene products and alternatives, improved information training & supervision, and improved health surveillance. All these measures have been implemented, the HSE are now content with the progress made and the Improvement Notice has been closed off.

6.3 RIDDOR Notifications

Findings

In 2010-2011, 49 RIDDORS notifications were made to the HSE and this fell to 38 in 2011-2012. Major Injuries increased from 7 to 10, Dangerous Occurrences reduced from 7 to 3 and over 3 day absences (which from the 01 April 12, will now be reported as over 7 day absences) reduced from 35 in 2010-2011 to 19 over the past year.

7. Compliance

7.1 The following policies/ procedures have been approved, implemented or reviewed in the past year:

Policy / Procedure Status NHS Highland Legal Register New NHS Highland Policy & Procedure Register New PN03 Generic Workplace Risk Assessment Reviewed PN06 Health Assessment Surveillance Procedure New PN08 DRAFT COSHH Procedure In Review – Awaiting Approval PN08.01 COSHH Managing Skin at Work Procedure Awaiting Approval PN04 HSE Reception procedure New PN14 First Aid at Work Procedure New Violence & Aggression Risk Assessment & Management Plan New Restraint procedure Awaiting Approval

7.2 COSHH

The COSHH Implementation Plan, developed last year, has been progressed more slowly than anticipated due to the magnitude and scope of the revalidation process; however significant progress has been made so far with further work to complete. To date a number of procedures have been reviewed and updated (see above), purchasing and procurement controls devised, health surveillance mechanisms improved along with other system improvements such as training and record keeping. Local COSHH Audits will begin in June / July 2012. All the above will improve and enhance the level of staff health and safety.

5 7.3 Violence and Aggression

7.3.1 Part Time Trainers

Currently there are 13 part time trainers and a .5 WTE Advisor in South Highland. Currently there are no trainers in Helensburgh or Dunoon and only 1 in Campbeltown. There are 12 part time trainers, 2 WTE Advisors and 1 WTE trainer in North Highland. Training is provided across North Highland by all the trainers.

7.3.2 Current Training Provision

We continue to provide Clinical and Non Clinical training. Clinical is any member of staff (regardless of their job title) who has face to face contact with patients, relatives or the public. In Inverness 1 day Clinical theory and breakaway training continues to be provided on the 1st and last Tuesday of every month. Non Clinical theory training is provided on the last Thursday of every month. Outwith Inverness e.g. Skye, Fort William and Wick 1 day Clinical theory and breakaway is provided on a monthly basis. Non Clinical staff can attend the morning of these 1 day sessions.

E- Learning. Non Clinical staff can now access Theory training online through Learnpro. The future plan is to provide some of the Clinical theory training on line at a later date. Clinical staff will still be required to attend face to face training.

Refresher Training. This continues to be provided on a tailored, needs specific basis as this has proved successful with good evaluations. There have been a number of sessions delivered on the Mental Health Act, Adults with Incapacity, the use of Independent Advocates and alcohol detox management. These are areas in which a training need was identified and the training was provided by a Mental Health Officer, CPN, Advocacy Highland and one of the Mental Health Liaison Team. These have been received well by those staff who were able to attend.

Risk Assessment and Management Plan. A Risk Assessment and Management Plan has been developed and ratified for use across NHSH (excluding New Craig’s who have their own documentation). This will be rolled out in partnership with the Lead Nurses.

Restraint Procedure. A restraint procedure has been developed and the draft document has been consulted upon widely and is due to be circulated in its final format prior to ratification by the H&S Committee

7.4 Moving & Handling

A service review has been completed for the moving and handling service in NHS Highland to ensure the service meets the minimum requirements of the NHS Scotland Manual Handling Passport (CEL14 2011). A report was submitted to the Health and Safety Committee in February 2012.

A key aspect of the passport is that organisations must, in addition to induction training, provide refresher or update education or formal competency assessment on an annual basis. Exceptions to education and / or assessments occurring annually must be risk assessed and evidence based.

The following actions were highlighted to improve the frequency of moving and handling input and meet the requirements of the passport.

6 . Use of Learn-Pro (e-learning package) to provide annual moving and handling theory element for all staff - It is anticipated that the M&H e-learning modules (on Learn-Pro) will be adequate to provide M&H input, in the first instance, for non-patient handling low risk staff (primarily administrative staff). Additional input would only be required where self assessments or specific risk assessments have highlighted a need. The modules will also provide additional input for staff groups who do not attend classroom update training but are competency assessed in the workplace.

. Prioritisation of update education/input using a risk-based system - A risk based approach to moving and handling input has been develop based on existing sources of information e.g. Datix information, RIDDOR data, occupational health data, local sickness absence, local risk assessment and competency assessments. The intention is that higher risk areas could expect input annually while other lower risk areas may only require input every 18 months or two years.

. All clinical staff to receive work-based input and/or be competency assessed - A pilot was carried out of formal work-based competency assessment and work-based input by the Moving and Handling Team. In reviewing the literature and evidence around manual handling interventions there is strong evidence to suggest that classroom based training on its own is ineffective. The results from the pilot confirmed the benefits to staff of more tailored work-based training or competency assessment.

Monitoring and audit of safe and effective practice will be on-going through the Operational Health and Safety Groups.

8. Emerging Issues and Priorities

8.1 Emerging issues

On the 28 November 2011 the Löfstedt Review, an independent review of health and safety legislation commissioned by the Government, was published. As part of the review the HSE have been tasked to review, update and simplify all the existing Approved Codes of Practice.

The HSE from October 2012 will introduce the Fee for Intervention Scheme. This is a cost recovery scheme for regulatory enforcement and is currently in place for sectors such as oil and gas and nuclear. After October 2012, if the HSE visit a NHS Highland premise, and discover what is classed as a material breach1 in the law, NHS Highland will charged for the amount of time that the inspector has had to spend identifying the breach, helping us put it right, investigating and taking enforcement action. The costs for a large investigation could be significant.

8.2 Priorities for 2011-2012

The key intentions for the forth coming year are:

 Articulate, through a project plan, the compliance and catch-up impacts for NHS Highland as a result of the Integration agenda  Realign and ensure an appropriate level of resource is provided to take into account the new additional risks as a result of the Integration agenda  Review our policy and strategic approach to health and safety management.  Improving compliance in line with our priorities  Facilitate the newly structured Operational Units to implement the Boards Annual Work Programme  Continue to Improve competence and training  Delivery health and safety smarter and make the wide use of technology

7  Recognise the benefits of enhancing staffside involvement on health and safety

9. Conclusion

I can conclude that the systems of control within the respective areas within the remit of the Health and Safety Committee are considered to be operating adequately and effectively.

Anne Gent and Elspeth Caithness Joint Chairs Health and Safety Committee April 2012

8 APPENDIX 16

NHS Highland PHARMACY PRACTICES COMMITTEE ANNUAL REPORT

To: NHS Highland Audit Committee

From: Bill Brackenridge, Chair, Pharmacy Practices Committee

Subject: Pharmacy Practices Committee Report – 1 April 2011 to 31 March 2012

1 Background

In line with sound governance principles, an Annual Report is submitted from the Pharmacy Practices Committee to the Audit Committee. This is undertaken to cover the complete financial year, and forms part of the supporting arrangements for the Statement of Internal Control, ending with the certification and submission of the Annual Accounts.

The remit of the Pharmacy Practices Committee (PPC) is to consider applications to provide pharmaceutical services within the Board area and to determine whether these applications will be granted, or not.

The Committee’s consideration of any application is governed by the National Health Service (Pharmaceutical Services) (Scotland) Regulations 2009 which were amended following the consultation Review of the Control of Entry Arrangements and the recommendations made in the subsequent summary report and came into force on 1 April 2011.

In these Regulations there is, at Regulation 5.10, the framework against which the Committee makes its decision. This is called the “Legal Test”.

The Legal Test states that:

“An application ………shall be granted by the Board, ……. only if it is satisfied that the provision of pharmaceutical services at the premises named in the application is necessary or desirable in order to secure adequate provision of pharmaceutical services in the neighbourhood in which the premises are located by persons whose names are included in the pharmaceutical list.”

Under the Regulations, the manner in which an application is considered shall be a matter for the Committee to determine. In all circumstances NHS Highland’s PPC holds an oral hearing. This ensures that the PPC understands the evidence and that points of clarification can be obtained from both the applicant and any other interested party through listening to evidence and asking questions of those present. The Committee convenes its meetings in accommodation in the area local to the proposed premises and undertakes a site visit to obtain, first hand, knowledge of the local area and of the suitability of the proposed premises.

The Pharmacy Practices Committee shall consist of seven members unless the application is for premises in a neighbourhood or an adjacent neighbourhood to the location of a dispensing doctor, in which case an additional member will be appointed by the Board from persons nominated by the Area Medical Committee ensuring wider representation on the committee of whom –

(a) one of whom shall be the chair appointed as such by the Board; the chair shall be a member of the Board but shall not be an officer of the Board nor shall the chair be, nor previously have been, a doctor, dentist, nurse, ophthalmic optician or pharmacist or the employee of a person who is a doctor, dentist, nurse, ophthalmic optician or pharmacist;

(b) three shall be pharmacists of whom - i) one shall be a pharmacist whose name is not included in any pharmaceutical list and who is not the employee of a person whose name is so listed; and such pharmacist shall be appointed by the Board from persons nominated by the Area Pharmaceutical Committee; and 1 ii) two shall be pharmacists each of whom is included in a pharmaceutical list or is an employee of a person whose name is so listed; and each shall be appointed by the Board from persons nominated by the Area Pharmaceutical Committee; and

(c) three shall be persons appointed by the Board otherwise than from the members of the Board but none shall be nor previously have been a doctor, dentist, nurse, ophthalmic optician or a pharmacist, or an employee of a person who is a doctor, dentist, nurse, ophthalmic optician or pharmacist.

The amendments provide that only lay members are now entitled to vote reinforcing the independence of the decisions made. The non-contractor pharmacist shall no longer be nominated by the Royal Pharmaceutical Society but by the Area Pharmaceutical Committee ensuring consistency with appointments to the National Appeal Panel and reinforcing independence.

No business shall be transacted at a meeting of the Pharmacy Practices Committee unless the chair or in the chair’s absence, the person acting as chair, one member appointed under each of (b) (i) and (ii) above, and two other members appointed under (c) above are present (a minimum of 5 persons).

The membership of the committee is specified in the Regulations. The current membership of the Committee is made up from:-

Bill Brackenridge, Non-Executive Director, Chairman Ian Gibson, Non-Executive Director, Vice Chairman Margaret Thomson, Lay Member Maureen Thomson, Lay Member Michael Roberts, Lay Member Sandy Cumming, Lay Member John McNulty, Area Pharmaceutical Committee contractor representative Gareth Dixon Area Pharmaceutical Committee contractor representative Catriona Sinclair, Area Pharmaceutical Committee contractor representative Nicola MacDonald, Area Pharmaceutical Committee contractor representative* Fiona Thomson, Area Pharmaceutical Committee non contractor representative* Alison MacRobbie, Area Pharmaceutical Committee non contractor representative Ron Shiels, Area Pharmaceutical Committee non contractor representative Dr Susan Taylor, GP Sub Committee representative* * Committee members currently in training

2 Activity in Year 1 April 2011 to 31 March 2012

There is no schedule of meetings for the PPC; it meets when an application to open a community pharmacy providing NHS services has been received. During 2011-12 the PPC met on three occasions to consider applications for new pharmacies in Fort Augustus (heard under the old Regulations as received pre April, 2011), Milton of Leys and Cradlehall, both Inverness. The Committee also attended a training day, organised by NHS Highland Officials on 24 August, 2011, which was well evaluated.

The full decisions of the Committee can be viewed via the following link and, following the amended Regulations are to be made available to the public (although not its business papers):-

http://www.nhshighland.scot.nhs.uk/Meetings/PharmacyPracticesCommittee/Pages/welcome.aspx

On 23 August, 2011, the Committee met in Fort Augustus to consider an application for the provision of pharmaceutical services at the Great Glen Trading Centre, Fort Augustus, PH32 4BH. This was heard under terms of the Regulations pre 1 April, 2011 and the application was granted.

2 On 27 September 2011, the Committee met in Inverness to consider an application for the provision of pharmaceutical services at Unit 1C, Milton of Leys Neighbourhood Centre, Milton of Leys, Inverness, IV2 4UA. This application was refused. This decision was appealed by the Applicant and submitted to the National Appeal Panel for its consideration but was dismissed by the Chair of the National Appeal Panel as he was of the opinion that the notice disclosed no reasonable grounds of appeal.

On 10 April, 2012, the Committee met in Inverness to consider an application for the provision of pharmaceutical services at Units 2 & 3 Cradlehall Shopping Centre, Cradlehall Court, Inverness, IV2 5WD. This application was refused, the Applicant and interested parties have been notified of the decision and at this present date, the decision may still become the subject of appeal.

Under paragraph 5 of Schedule 3, as identified above, decisions of the Pharmacy Practices Committee may be appealed. Any appeal should be made by submitting to the Board, within 21 days of the date of notice of the decision a concise statement detailing the circumstances or other points of law in respect of which the decision by the Board is contended to be erroneous.

The grounds of appeal are limited to the circumstances where the following have occurred or where the Board has erred in law in its application to the provision of the Regulations:-

(a) there has been a procedural defect in the way the application has been considered by the Board; (b) there has been a failure by the Board to properly narrate the facts or reasons upon which their determination of the application was based; or (c) there has been a failure to explain the application by the Board of the provisions of these Regulations to those facts.

Any appeal submitted to the Board must then be forwarded to the National Appeal Panel (NAP) whose remit, membership and procedures are set out in Regulations and these are adhered to in the management of all applications received.

National Appeal Panel members are selected from nominations put forward by Boards and the Scottish Ministers appoint the Chair. As appeals are to be more focussed on errors in law, the amendment regulations provide that the Chair shall be an advocate, a solicitor or a solicitor- advocate but shall not be nor previously have been a health professional or an employee of a person on the pharmaceutical list. A substitute Chair will be appointed in the event that the Chair is unable to attend hearings.

The National Appeal Panel will now consist of 3 members, the Chair, a non-contractor pharmacist and a lay member, who is not nor has been a health professional. All members shall have the right to vote.

The National Appeal Panel shall remit the decision back to the Board if the Chair is of the opinion that any of the circumstances above ((a), (b) or/and (c)) have occurred and the Chair’s decision is final.

Where the Chair remits the decision back to the Board, he must provide advice as to how it may remedy the defect or failure which has led to the decision to remit and the Board shall then reconsider the application. In any case where the Chair deems an appeal is justified, the NAP shall be convened and the Panel shall thereafter determine the appeal.

The NAP should determine its own procedure and may hold oral hearings and/or make local visits if it considers these to be necessary. The rules on representation before a PPC and on privacy will apply equally to the NAP’s proceedings. The National Appeal Panel shall determine an appeal as it thinks fit and its decision in respect of an appeal shall be final.

3 3 Sub Groups

This Committee has no sub groups.

4 External Reviews

There are no specific reviews of the work of the Pharmacy Practices Committee; however, this Committee follows the same procedures as the NAP. The external appeal process to the National Appeal Panel provides a proxy external review. If the NAP decides to re-hear an application then the reasons for that decision are reported to the Board and are then taken into consideration for any further applications which are considered. However, the points raised in one appeal may not necessarily readily transfer to a further application unless the points raised are generic and not specific to the particular application.

5 Any relevant Key Performance Indicators

The process, which must be undertaken on receipt of an application, is driven by time scales and requirements set out in Regulations. Similarly, the conduct of the PPC and the reporting of the decision and the appeal process are driven by processes and time scales set out in the Regulations. In all cases heard by the PPC during the last year, the regulatory time scales were met.

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

This is the fourth year that the Chair of the NAP has held a training session with Chairs, Vice Chairs and, the third year also to Board Officers, to try to help ensure that Boards and their PPCs understand and adhere to the statutory requirements involved in considering an application to provide pharmaceutical services from defined premises. Any issues raised will be used to inform and improve the functioning and decision making of the PPC and the procedures required to support the overall process.

7 Conclusion

I believe that the systems and procedures operated by and to support the Pharmacy Practices Committee meet and adhere to the statutory requirements as set out in the appropriate Regulations.

Bill Brackenridge, Chair Pharmacy Practices Committee 30 April 2012

4 Highland NHS Board 5 June 2012 Item 3.12 The Highland Council and NHS Highland

Minutes of Meeting of the Joint Committee on Children and Young People held in the Board Room, Assynt House, Beechwood Business Park, Inverness on Friday 16 March 2012 at 10.30 am.

Present:

Members:

Mrs M C Davidson ) Mrs J Campbell ) Mr D Fallows ) Mr B Fernie ) Mr B Gormley ) Highland Council Mrs E McAllister ) Mr A M Millar ) Mrs L Munro ) Mrs M E Paterson )

Mr I Gibson ) Mr M Evans ) NHS Highland Mr O McLennan ) Ms S Wedgwood )

Mr S Davidson, Youth Convener

In attendance:

Mr B Alexander, Director of Social Work ) Miss J MacLennan, Principal Administrator, Chief Executive’s Office ) HC Miss M Murray, Committee Administrator, Chief Executive’s Service )

Mr J King, Head of Integrated Children’s Services )HC/NHS

Ms S Amor, Child Health Commissioner/Public Health Specialist )NHS

Ms A Brady, Care and Learning Alliance ) Third Mr C Munro, Highland Children’s Forum ) Sector

Mrs M C Davidson in the Chair

Business

1. Apologies for Absence

Apologies for absence were intimated on behalf of Ms J Douglas, Dr M E M Foxley, Mr E Hunter, Mrs G McCreath Mr C Punler and Detective Superintendent G Greenlees. 2. Declarations of Interest

The Joint Committee NOTED the following declarations of interest:-

Item 4 – Mr B Fernie (Non Financial) Item 7 – Mr B Gormley (Financial)

3. Minutes of Meetings

The following Minutes were NOTED:-

i. Joint Committee for Children and Young People held on 20 January 2012; and ii. Youth Justice Strategy Group held on 4 January 2012.

The Joint Committee also NOTED the following in relation to the Joint Committee Minutes of 20 January 2012:-

a. the current position in relation to the Early Years Change Fund; b. the Youth Convener had met with the Senior Health Promotion Specialist (Sexual Health and Young People) at NHS Highland to discuss access to sexual health advice; and c. any outstanding actions would be allocated to the appropriate Committee under the new Lead Agency arrangements and followed up.

4. Revenue Budget 2011/12 – Monitoring Report

Declaration of Interest:

Mr B Fernie declared a non-financial interest in this item as a Director of Hi- Scot Credit Union but, having applied the test outlined in Paragraphs 5.2 and 5.3 of the Councillors’ Code of Conduct, concluded that his interest did not preclude his involvement in the discussion.

There had been circulated Report No CYP/07/12 dated 5 March 2012 by the Director of Social Work which detailed the monitoring position for the Joint Committee for Children and Young People budget for the period 1 April 2011 to 31 January 2012. At this point a year end underspend of £41,000 was projected. This improved position was as anticipated at the January Committee and resulted from continued action to achieve savings with the intention of achieving a balanced budget.

It was emphasised that the projected underspend did not mean the budgetary issues had been resolved and attention was drawn to significant variances which would present challenges in the future. In relation to the substantial underspend on the Additional Support for Learning budget, this was, in part, a result of the hiatus caused by the Council’s review of classroom support needs and Additional Support Needs budgets and would not be likely to recur in the next financial year. Purchased placements for Looked After Children remained a significant budget pressure, the current overspend being £1.658m. However, there were factors which it was anticipated would reduce the pressure such as the new contract for residential services which would come on stream in ten months.

2 In response to questions, it was explained that:-

 the predicted overspend in the Disability Teams and Services budget had been partly offset by vacancies which had arisen and not yet been filled. However, this also meant that there had been slower progress in terms of processing new applications for Self Directed Support (SDS);  the Scottish Government’s SDS and Getting It Right For Every Child (GIRFEC) Teams were impressed with the work which had been undertaken by the Council to develop SDS packages for children and it was anticipated that a large scale pilot for families with disabled children would be carried out in conjunction with Hi-Scot Credit Union. This could involve a lump sum allocation into a Hi-Scot account and a pre-paid card which families would be taught how to use;  in relation to concerns regarding the impact of the sizeable underspends on some budget headings, these were a short-term measure to balance the budget and were attributable to vacancies being held. However, there were consequences in that there was increased pressure on the remaining staff and slippage in carrying out preventive work occurred;  with regard to the format of future monitoring reports, the existing budget headings would not change until the new Adult and Children’s Services Committee came into being. There would then be a further stage of the previous rationalisation exercise whereby proposals would be presented to the Committee regarding the budget structure and what would be reflected in the monitoring reports;  the difficulties in providing adequate support for children with disabilities in Highland was one of the main reasons for the increasing overspend on purchased care. However, increased respite provision and the recruitment of two additional specialist Social Workers and five Full Time Equivalent Children’s Service Workers would have an impact on the pressure;  there was an overlap between Educational Psychology and the role of Primary Mental Health Workers and there would be opportunities, with the introduction of the integrated model, to strike a balance between using them as frontline practitioners and utilising their expertise to address low level psychological and mental health needs through training and support of staff; and  in relation to the number of children waiting to be seen by an Educational Psychologist, the basis of Highland’s practice model was an ongoing dynamic process based around the Child’s Plan therefore there was no fixed waiting list.

During further discussion, the following comments were made:-

 Carr Gomm intended to increase their promotion of SDS and it was suggested that this might lead to increased pressure in terms of new applications;  current performance indicators did not show whether they had been affected by actions to achieve savings and it was important to examine the outcomes that were being measured to ensure that service delivery issues were highlighted;  the outcome of the evidence based review of classroom support needs was welcomed and thanks were expressed to the Chairman of the Classroom Support Needs Working Group;  in relation to SDS, there had been previous models and some families found the management of funds placed an additional burden on them. The importance of continuing to provide services for those families who did not wish 3 to enter into SDS was emphasised, as was the need to provide strong support for those who did; and  it was essential to have a clearer understanding of the impact of holding vacancies and it was requested that future reports include detailed information on the number and distribution of vacancies throughout children’s services, including a narrative on any issues arising as a result.

Thereafter, the Joint Committee:-

i. NOTED the projected revenue monitoring position at 31 January 2012; and ii. AGREED that future reports contain detailed information on the number and distribution of vacancies being held throughout children’s services, including a narrative on any issues arising as a result.

5. 2011/12 Quarter 3 Performance Report (October to December 2011)

There had been circulated Report No CYP/08/12 dated 5 March 2012 by the Director of Social Work which provided the performance update on For Highland’s Children 3 key outcome indicators for the period October to December 2011 and some additional more recent information.

Further to discussions regarding staff absence at previous meetings, it was highlighted that the absence rate in children’s services for Quarter 3 was 4.95%; the lowest figure since monitoring had begun.

During discussion, Members expressed concern at the number of outcomes for which no data was available and sought a more sophisticated set of indicators which enabled progress to be tracked. The importance of electronic data sharing was emphasised and disappoint was expressed at the delays in relation to Sharepoint pilot.

In response, it was explained that there were some technical challenges to be addressed. However, it was anticipated that the secure electronic sharing of Child’s Plans with all relevant agencies, including the Third Sector, would commence in Nairnshire in April 2012. Subsequently, provided no major problems were identified, a phased programme would be rolled out. Highland would then be in a unique position in Scotland, if not the UK. However, families did not restrict their movements within Council boundaries and it was essential that a national view was reached.

Ms A Brady, Care and Learning Alliance, welcomed the inclusion of the third sector and expressed thanks for the Council’s continued support. It was highlighted that, while the third sector had limited access to secure emails and communication, the problems were not yet resolved. However, it was hoped that these would be addressed through the pilot and the third sector would take up its place as full partner.

Thereafter, the Joint Committee NOTED the issues in the report.

4 6. Play Matters – Final Play Strategy and Delivery Plan

There had been circulated Report No CYP/09/12 dated 5 March 2012 by the Director of Social Work which presented the Delivery Plan which set out the commitments of services to delivering the revised and previously agreed Play Strategy 2012-2014 which had been developed with services following approval by the Joint Committee of the review of “All to Play For” and the new Play Strategy “Play Matters”.

During discussion, the following comments were made:-

 the clear and direct Strategy and Delivery Plan were welcomed;  thanks were expressed to the organisations which formed the Play Highland Partnership and it was suggested that more opportunities to create coalitions to address topics be explored;  some parents lacked parenting skills and experience and play was the easiest way for them to engage with their children;  in relation to designated play areas in new housing estates, the importance of ensuring that developers complied with the conditions of their planning consent was emphasised;  Play Awareness Training for planners, architects and appropriate Housing and Transport, Environmental and Community Services staff should be compulsory;  broken glass and used needles were an issue in some parks and resources were required so that checks could be carried out, particularly in the morning;  it was important to reach those people who did not have families and challenge negative attitudes towards outdoor play; and  with regard to the output relating to High Life Highland maintaining a network of Youth Forums across the Highlands, it was requested that this also include a reference to the Youth Convener.

In relation to comments regarding the provision of play equipment for children with mobility or learning difficulties, it was explained that, in terms of the statutory requirements on the Council and developers under the equalities legislation, play equipment could not be installed that was not suitable for use by children with a range of abilities and needs. In addition, the review which preceded the new Play Strategy had evidenced that the quality of play had very little to do with the availability of special equipment. Basic design rules applied to play areas were likely to do more to promote inclusion and advantageous play opportunities for children with disabilities. However, special equipment was available and the procedure for accessing funding through local childcare partnerships and community groups was summarised.

Thereafter, the Joint Committee:-

i. APPROVED the Delivery Plan which had been developed by services following Committee approval of the Strategy, subject to the inclusion of a reference to the Youth Convener in the output relating to maintaining a network of Youth Forums across the Highlands; ii. APPROVED the future incorporation of performance monitoring of play outcomes into the reporting framework of For Highlands Children 4;

5 iii. NOTED that the completed Strategy and Delivery Plan would now be widely disseminated; and iv. NOTED that future reporting on the plan would be undertaken as part of the performance monitoring programme for the new Adult and Children’s Services Committee.

7. Parenting Support

Declaration of Interest:

Mr B Gormley declared a financial interest in this item as his wife was involved in parenting support through her work with Action for Children and advised that if there was any specific discussion in relation to Action for Children he would leave the room.

There had been circulated Report No CYP/10/12 dated 8 March 2012 by the Director of Social Work and the Child Health Commissioner which explained that the Highland Parenting Support Framework set out a system to help parents meet their responsibilities to raise children who were healthy, happy, confident and able to develop to their full potential. The overall aim of the Parenting Support Framework was to improve outcomes for all children (pre-birth to 16 years) in the Highlands and by ‘getting it right for every parent’ ensure that those families needing most support were helped by appropriate services at the earliest opportunity. It was proposed that over the next five years, by 2016, Highland would have a fully developed parenting support structure in place.

During discussion, the following comments were made:-

 the forthcoming report by Highland Children’s Forum, “Recipe for Parenthood”, contained input from young parents who had raised a number of issues relating to mental health, transport, housing, benefits and general support. However, they had also raised examples of good practice whereby officers had provided support beyond what was required in their substantive post and the importance of extending this good practice throughout the workforce was emphasised;  there was a lack of local authority housing and single parents had to take what they were offered, often leading to isolation from family members or support groups;  the progress in supporting parents, particularly young parents, was welcomed and it was hoped that the Framework would help to reduce the number of pre- birth babies designated as “at risk”;  communities needed to take responsibility for their young mothers and introduce activities to help them integrate;  single parents, particularly when isolated, often befriended their children and the parent/child roles became confused, leading to potential difficulties;  concern was expressed regarding the reductions in benefits which would be implemented under the Welfare Reform Bill. The Bill would have a profound effect on communities, particular young single people, and it was essential that the new Council had an action plan for managing the changes;  housing benefit for local authority housing would be paid directly to tenants in the future. Some people did not have the necessary money management skills to be responsible for paying their rent and concern was expressed that this

6 could have serious implications both for the Council and the individuals concerned; and  it was essential that the District Partnerships established under the new integrated model placed parenting support on their agendas as soon as possible.

Thereafter, the Joint Committee:-

i. NOTED the progress made in developing the Commissioning Framework for Parenting Support in Highland across agencies and services across Highland; ii. NOTED that an engagement exercise would be undertaken during April-May 2012 to further refine the Framework and support the embedding of parenting support in the Lead Agency and across integrated children’s services; and iii. NOTED that the proposed Commissioning Framework covered implementation in all Highland areas.

8. Children’s Disability Services Action Plan – Progress Report

There had been circulated Report No CYP/11/12 dated 6 March 2012 by the Director of Social Work which provided an update on the issues and work ongoing in relation to children affected by disability previously discussed by Members and initial feedback from the ongoing audit of children affected by disability not in full- time education. The report also sought approval for the draft response to the Doran Review.

During discussion, the following comments were made:-

 the issues surrounding children affected by disability should be a priority for the next Council and it was requested that a further report be presented to the new Adult and Children’s Services Committee as soon as possible;  historically, there had been no recognition of the issues surrounding the education of children with disabilities and thanks were expressed to officers for exposing the problems;  the destructive effect on a family of a breakdown in a child’s education was enormous; and  the importance of services working together to address the practical issues was emphasised.

In response to questions, it was explained that:-

 to date, the audit had identified which children were not in full-time education and what non-school based additional support they were receiving. The next stage was detailed scrutiny by Area Service Management Groups to ensure that a comprehensive Child’s Plan was in place for each child. This would take place over the next three months and it would then not take long to establish where the key pressure points and gaps were and what the resource implications might be. It was anticipated that the findings of the next stage would be reported to the first meeting of the Adult and Children’s Services Committee following the summer recess. Thereafter, it would be necessary to do a piece of work on how to respond to the consequences of that report and how services might deliver to fill the gaps; and

7  Highland Children’s Forum had been commissioned to carry out a benchmarking exercise, scheduled for completion at the end of March 2012, on the experiences of young people during the transition from children to adult services. The findings to date were mixed in that there was a good policy but it was translated into outcomes depended on the quality of individual officers.

The following comments were made in relation to the response to the Doran Review:-

 the transition from child to adult services was fundamental and surprise was expressed that there was no reference to it in the questionnaire;  central government often didn’t fully grasp the geography of the Highlands and the comments relating to the dispersal of children with additional support needs throughout the region were welcomed;  many children with additional support needs also had mental health issues as a result of their disability and it was suggested that a reference to mental health assessment and support be included in the response. In addition, it was suggested that comments be included regarding what preventative measures could be taken at an early stage;  there were two discrete groups of children with complex learning needs. Firstly, those with high end communication disorders, particularly on the autistic spectrum. Secondly, those who met the criteria for children with exceptional healthcare needs and were technology dependent. These children were living for longer and their outcomes were improving therefore the transition to adult services was vital; and  as services strove for efficiency, there was sometimes unwitting rigidity which didn’t allow frontline staff the creativity to combine services.

Thereafter, the Joint Committee:-

i. APPROVED the draft response to the Doran Review set out in Appendix 1 to the report, subject to the comments made during discussion; ii. NOTED the progress on improving services and educational inclusion for children affected by disability; and iii. AGREED that a further progress report be presented to the new Adult and Children’s Services Committee at an early stage;

9. Children’s Disability Services - Additional Residential Respite Provision

There had been circulated Report No CYP/12/12 dated 7 March 2012 by the Director of Social Work which sought approval for the development and increase of children’s residential respite provision at Thor House, Thurso and the creation of three additional posts to manage and deliver the service.

In response to questions, it was explained that:-

 current residential respite provision for children at Thor House was four places approximately 180 days per year. The proposal was to have four places all year round;  in relation to the adults who currently received respite care at Thor House; alternative provision was available in Wick and Brora. However, adults were

8 increasingly supported in their own tenancies or opted for SDS or non- residential respite.

Thereafter, having welcomed the proposals, the Joint Committee:-

i. AGREED the planned conversion of Thor House in Thurso to provide for exclusive use of the residential facility for the respite care of children and young people; ii. AGREED to recommend to the Resources Committee the consequential staffing changes; and iii. NOTED that limited capital investment would be required.

10. Payment of Allowances in Adoptions

There had been circulated Report No CYP/13/12 dated 7 March 2012 by the Director of Social Work which sought approval for a revised Adoption Allowance Scheme to be introduced from 1 April 2012.

The Joint Committee APPROVED the proposed new Adoption Allowance Scheme as set out in Appendix 1 to the report.

11. Advocacy Support to Looked After Children

There had been circulated Report No CYP/14/12 dated 6 March 2012 by the Director of Social Work which set out a proposed revision of the current contract with Who Cares Scotland? to increase the availability of advocacy to Looked After Children in Highland.

In response to a question, it was confirmed that £44,750 was the full year cost of the extension to the contract. The cost of the existing contract was £55,000 therefore the total full year cost would be £99,750.

The Joint Committee APPROVED the variation and extension of the current Service Level Agreement between the Council and Who Cares? Scotland to double the volume of independent advocacy support available to Highland Looked After children and young people, at an additional full year cost of £44,750.

12. History of the Joint Committee

The Director of Social Work gave a presentation on the history of the Joint Committee for Children and Young People, from the initial discussions in the mid- nineties to its inception in 1999 to the present day and Planning for Integration. It was emphasised that the collaborative approach and the learning which had resulted from it had been critical to the development of the new lead agency model for adult and children’s services. A number of milestones in the development of children’s services were highlighted including:-

 For Highland’s Children 1, the first Integrated Children’s Services Plan;  the first Single Outcome Agreement;  the Scottish Government’s national reform programme for children’s services which led to the publication of For Scotland’s Children in 2002;

9  the SHANARI (Safe, Healthy, Active, Nurtured, Achieving, Respected and Responsible, Included) wellbeing indicators;  the Children’s Services hierarchy triangle  the development of Area Children’s Services Forums and, subsequently, Area Service Manager Groups;  the external evaluation of Integrated Children’s Services by the University of the Highlands and Islands;  the development of the Highland Pathfinder Project;  the implementation of the GIRFEC practice model;  Highland’s core components;  the “My World” assessment triangle; and  the Statement of Intent by the Highland Partnership in 2010.

The Joint Committee had been about joined up decision making and strategic thinking. It had been challenging but its legacy was that it had produced better outcomes for Highland’s Children. In conclusion, the Director paid tribute to officers and Members, past and present, who had contributed to the Joint Committee. He also expressed thanks to the partner agencies which had played a key role, particularly Highland Children’s Forum.

Thereafter, having expressed thanks to all officers who had been involved in the Joint Committee for their commitment to children’s services, the Joint Committee NOTED the presentation.

The meeting ended at 12.50 pm.

10 Highland NHS Board 5 June 2012 Item 4.1

MEMBERSHIP OF COMMITTEES

Report by Kenny Oliver, Board Secretary on behalf of Garry Coutts, Chair, NHS Highland

The Board is asked to:

 Review the current membership and in so doing to consider forthcoming vacancies and appointments.  Agree that Sarah Wedgwood be appointed as Vice-Chair until 30/06/14.  Agree to the proposed membership for Highland Health and Social Care Community Health Partnerships and that the Chair should be appointed until 30/06/14.  Agree to the proposed membership for Argyll and Bute Community Health Partnership and that the Chair should be appointed until 30/06/14  Agree to the proposed appointment of Chairs for the main Governance Committees to 30/06/14.

1 Background and Summary

The Board will recall that at the December Board meeting the decision was made to create a single Community Health Partnership covering North Highland. This meant the dissolution of the 3 existing Community Health Partnerships – North, Mid and South East Highland and Raigmore Hospital Governance Committee and the creation of Highland Health and Social Care Partnership.

As a result of this change and the end of term for 2 experienced Board Members it was felt that this was an opportune time to review and revise the membership of NHS Highland Board Governance Committees

Due to the recent Local Government Elections we are not able to identify the Local Authority Representatives until the administrations have been agreed.

Following discussions, the following changes are proposed:

Vice Chair Appointment

Propose that Sarah Wedgwood be appointed as Vice-Chair until 30/06/14

Community Health Partnerships Current Proposed

Highland Health and N/A Ian Gibson – Chair Social Care Partnership. (until Feb 2013) Gillian McCreath Myra Duncan Argyll & Bute Community Bill Brackenridge – Chair Robin Creelman – Chair Health Partnership Vivian Shelley – Member Bill Brackenridge Elaine Robertson – LA Local Authority Member – TBA Member Governance Committees Current Proposed

Audit Committee Ian Gibson – Chair Mike Evans – Chair Margaret Davidson Michael Foxley Mike Evans Gillian McCreath Gillian McCreath Okain McLennan Okain McLennan Clinical Governance Sarah Wedgwood – Chair Sarah Wedgwood – Chair Committee Quentin Cox Iain Kennedy Margaret Davidson Alasdair Lawton Vivian Shelley Bill Brackenridge Ray Stewart Michael Foxley Staff Governance Pam Courcha – Chair Colin Punler – Chair Committee David Alston Robin Creelman Ian Gibson Ian Gibson Colin Punler Ray Stewart Ray Stewart Myra Duncan Endowment Funds Ian Gibson – Chair Ray Stewart – Chair Committee Bill Brackenridge Ian Gibson Garry Coutts Bill Brackenridge Okain McLennan Colin Punler Ray Stewart Mike Evans Remuneration Garry Coutts – Chair Garry Coutts – Chair Sub-Committee Ian Gibson – Vice-Chair Sarah Wedgwood – Vice-Chair David Alston Ian Gibson Bill Brackenridge Robin Creelman Pam Courcha Colin Punler Gillian McCreath Ray Stewart Okain McLennan Colin Punler Ray Stewart

Highland Council Committees Current Proposed

Adult and Children’s N/A Ian Gibson Committee Gillian McCreath Margaret Somerville

Joint NHS Highland and Argyll & Bute Council Committee Current Proposed

Argyll & Bute Health and Bill Brackenridge – Chair Robin Creelman – Chair Care Strategic Partnership Vivian Shelley Local Authority Member – TBA Elaine Robertson – LA Member

2 Non-Executive Representation on other NHS Highland Committees Area Control of Infection Okain McLennan – Chair No Change Committee Gillian McCreath Health & Safety Committee Bill Brackenridge Alasdair Lawton

Pharmacy Practices Committee Bill Brackenridge Bill Brackenridge Ian Gibson Okain McLennan Risk Management Steering Vivian Shelley Sarah Wedgwood Group Spiritual Care Committee Garry Coutts Sarah Wedgwood

Non-Executive Representation on other Committees/Groups National Appeal Panel for Entry to Okain McLennan Pharmaceutical Lists

2 Contribution to Board Objectives

Robust corporate governance arrangements are essential to the delivery of all of NHS Highland’s Corporate Objectives. This specifically contributes to “Better Value – All services are efficient and cost effective” – BV.1 Working systems and practices are redesigned to be fit for purpose.

3 Governance Implications

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

4 Risk Assessment

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

5 Planning for Fairness

This process does not require an impact assessment.

6 Engagement and Communication

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

Kenny Oliver Board Secretary NHS Highland

25 May 2012

3

Highland NHS Board 5 June 2012 Item 4.2

UPDATE ON THE ESTABLISHMENT OF HIGHLAND HEALTH AND SOCIAL CARE PARTNERSHIP

Report by Kenny Oliver, Board Secretary on behalf of Elaine Mead, Chief Executive

The Board is asked to:

 Note the ongoing work to establish Highland Health and Social Care Partnership and in particular the setting up of Highland Health and Social Care Partnership Governance Committee.

1 Background and Summary

The Board will recall that the decision was made at the December 2012 Board meeting to establish a single operational unit covering the whole of Northern Highland, co-terminus with Highland Council.

2 Establishment of Highland Health and Social Care Partnership

In order to comply with current legislation, the Community Health Partnerships (Scotland) Regulations 2004 and the subsequent amendments in 2010, NHS Highland are required to submit a scheme of establishment to Scottish Ministers for formal approval. The Scheme of Establishment is sets out in a prescribed template the services to be provided and the structures to support delivery. A copy of the Scheme of Establishment for the Highland Health and Social Care Partnership is attached in Appendix A. As part of this submission NHS Highland also sought permission to dissolve the 3 existing CHP’s in Northern Highland – North Highland CHP, Mid Highland CHP and South East Highland CHP.

In April the Scottish Government confirmed that the Cabinet Secretary was happy with NHS Highland’s proposal to establish Highland Health and Social Care Partnership. They did highlight the need for the voice of patients, carers and the public to be imbedded through out the Highland Health and Social Care Partnership. A copy of the letter received from the Scottish Government is attached in Appendix B.

3 Structures

See attached Appendix C for the current structure of Highland Health and Social Care Partnership.

4 Highland Health and Social Care Partnership Governance Committee

The establishment of the Highland Health and Social Care Partnership Governance Committee has been overseen by a short life working group – the Transitions Group. It has met on 3 occasions to date and looked at 5 key areas – Membership of the Governance Committee, the agenda of the Governance Committee, training for committee members, ensuring key issues are picked up the new Governance Committee and finally that a risk register is developed which encompasses the adult social care element. The group is chaired by the Board Chair and its membership is as follows: Colin Punler, Chair North Highland CHP Governance Committee Okain McLennan, Chair Mid Highland CHP Governance Committee Gillian McCreath, Chair South East Highland CHP Governance Committee Mike Evans, Chair Raigmore Hospital Governance Committee Dr Iain Kennedy, Chair Area Clinical Forum Ray Stewart, Joint Chair Highland Partnership Forum Cllr Margaret Davidson, The Highland Council Elaine Mead, NHS Board Chief Executive Dr Ian Bashford, NHS Board Medical Director Mrs Jan Baird, Transitions Director Kenny Oliver, NHS Board Secretary Brian Robertson, Head of Social Work Margaret Dakers Thomson, Lay Representative Elizabeth Smith, Lay Representative

This paper picks up on the membership of the Governance Committee, the training for Committee members and the draft agenda for Governance Committee meetings. The Risk Register is picked up in a further item on the Board Agenda and the Directors of Operations in each of Operational Units have been continuing with the previous CHP agendas.

4.1 Membership of Highland Health and Social Care Governance Committee

In line with current legislation NHS Highland is required to establish Highland Health and Social Care Partnership Governance Committee as a formal Community Health Partnership Governance Committee as per the current legislation described earlier. Therefore the membership is for the most part already prescribed – we can add to it. Therefore the current list of membership of the Highland Health and Social Care Partnership Governance Committee is as follows

Chair Chief Operating Officer Head of Social Care Chair of Professional Executive Committee NHS Board Non Executive Directors X 2 Elected Member X 3 Staff Side Representative X 2 Public/Patient Member Representative X 3 Lead Doctor (GP) Medical Practitioner (not a GP) Director of Operations – North & West Director of Operations – Mid & South Director of Operations – Raigmore Pharmacist

2 Dentist Optometrist Lead AHP Lead Nurse Lead Midwife Head of Financial Planning

In Attendance Head of Personnel Head of Health & Safety

The members identified in bold are those prescribed by the current legislation

We are currently in the process of identifying the individuals who will take up their position on this Governance Committee. It is planned that the first formal meeting of the Highland Health and Social Care Governance Committee will be in late August/September.

4.2 Training for Governance Committee Members

In the recent Review of CHP Governance Structures which was presented to NHS Highland Board in December it was identified that a robust training programme needed to be in place from the start of the new structure in order to provide the Governance Committee members with a clear understanding and expectation of their role in relation to governance. In order to ensure the committee members have the right skills to undertake this role we have been putting in place a 5 part training programme that will run over the next 2 years – it will cover the following:

 On Board  On Board +  Understanding Audit & Risk  Understanding the Finances  Understanding Statistics

4.2.1 On Board

This is a training course run by CIPFA and is targeted at Board Members of Public Bodies. It offers a 1 day course outlining the key roles for Board members in relation to:

 Introduction to Governance  Functions of Management  Functions of Governance  Roles and Responsibilities  Financial Governance  Standards and Behaviours  Accountability

This course will provide members with a broad understanding of the roles and responsibilities of a Governance Committee member.

It is anticipated that NHS Highland would contract with CIPFA to deliver this training locally in the area.

3 4.2.2 On Board +

This would follow the On Board training, but would give more detail and understanding of a Governance Committee member role, tailored to NHS Highland. Again this would be delivered locally by one of the CIPFA accredited training team. This course will specifically look at the role of governance committee members in relation to strategy and policy, performance management and constructive challenge.

4.2.3 Understanding Audit and Risk

This would be a dedicated session looking at the Governance Committee member’s role in relation to audit and risk across the whole of the organisation. This session is being put together by our local teams in Quality, Audit and Finance.

4.2.4 Understanding Finances

This training would provide Governance Committee members with a good understanding of NHS Finances, what the information presented to them is telling them and the sorts of questions Governance Committee members should be asking. It is hoped that this training can be provided by the local Finance Team. There will be a clear expectation that on completing this course all members will have the necessary competence to understand routine finance reports, demonstrate they can identify significant anomalies or variances and have an understanding of the types of mitigation they may seek to request.

4.2.5 Understanding Statistics

One of the key areas for Governance Committee members to understand is the statistical information they are presented with in order that they appreciate what the information is telling them and be able to challenge appropriately. The statistics presented would cover a wide range of topics and will use a mix of our local resources and external facilitation.

The first session – On Board has been set for 19th and 20th September (20 places on each day). The training will be available in the first instance to members of Highland Health & Social Care Governance Committee, but will be available to all members of Governance Committees including Board Members. The other four sessions will be run over the next year.

4.3 Draft Agenda for Highland Health and Social Care Partnership Governance Committee

Attached in Appendix D is a copy of the draft agenda for the Highland Health and Social Care Partnership as discussed at the Transitions Group.

5 Contribution to Board Objectives

The establishment of the Highland Health and Social Care Partnership is key to the delivery of many of NHS Highland’s key Corporate objectives. Therefore having a good governance structure to ensure delivery by the operational management is essential.

6 Governance Implications

The governance implications across are significant and impact all elements of governance – ensuring that we have good governance arrangements throughout Highland Health and Social Care Partnership will ensure that appropriate governance is in place. This will be reviewed after 1 year.

4 7 Risk Assessment

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

8 Planning for Fairness

This process does not require an impact assessment

Kenny Oliver Board Secretary NHS Highland

25 May 2012

5 APPENDIX A

HIGHLAND HEALTH AND SOCIAL CARE COMMUNITY HEALTH PARTNERSHIP

SCHEME OF ESTABLISHMENT

1. INTRODUCTION

1.1 This Scheme of Establishment (SOE) has been prepared in terms of Regulation 10 of the Community Health Partnerships (Scotland) Regulations 2004.

1.2 This proposal is presented by NHS Highland and seeks approval to establish a Community Health Partnership for the Highland Council area.

1.3 These proposals replace the current Community Health Partnerships (CHP’s) in the northern Highland area of NHS Highland established in April 2005 – these are North Highland CHP, and Mid Highland CHP and South East Highland CHP. For the avoidance of doubt, there are no planned changes at this stage to the Argyll and Bute CHP

1.4 The decision to establish the Highland Health and Social Care Community Health Partnership and the framework which provides the basis for the SOE were formally considered and approved by NHS Highland Board at its meeting of December 2011.

1.5 The operation of this SOE will be reviewed after one year of operation.

2. FUNDAMENTALS

2.1 The proposed Community Health Partnership will be called the Highland Health and Social Care Partnership and will cover the entire population living in the area defined by the Local Authority boundary of Highland Council. The total population of the Council area is 220,500.

2.2 The Health and Social Care Community Health Partnership will encompass the health responsibilities of the three existing North Highland CHP’s. The new Health and Social Care Community Health Partnership area will cover a total of 68 GP practices, 58 dental practices, 52 pharmacies and 30 optometry practises.

2.3 NHS Highland and Highland Council have approved a commitment to a pathway for integration of health and social care services that would provide both Authorities with the joint responsibility for specifying the outcomes to be achieved for service users, and the totality of the resources to be allocated to each of the two service areas, and would put in place single lead agency arrangements for Adult Community Care Services and for Integrated Children’s Services.

The Board and Council also agreed that the most appropriate single lead agency for the delivery of Adult Community Care Services is NHS Highland and that the most appropriate single lead agency for the provision of Children’s Services is Highland Council. Work is well underway to ensure that the new lead agency model is effective from 1st April 2012. 2.4 The Highland Health and Social Care Community Health Partnership will operate in three Sectors, the considerations which have informed this structure are the need to:

- Have as equal partners – primary, secondary and social care and be able to affect change across the continuum of care through one organisation. - have a more local focus for the management of services ensuring strong local connections with communities; - generate efficiency and consistency in a number of support services and in management costs, but still have a structure which ensures devolution of service delivery, health improvement, inequalities and planning activity; - provide a strong basis for better connection with primary care contractors; - achieve streamlined Committee arrangements which ensure appropriate overall governance in a consistent and efficient way;

2.5 The overall purpose of the CHP is to:

- manage local NHS and adult social care services; - improve the health of its population and close the inequalities gap; - Drive the local implementation of the quality strategy ensuring person centred, safe and effective care; - achieve better specialist health care for its population; - ensure an effective NHS process to engage in community care and children’s service planning; - lead NHS participation in joint and community planning; - modernise community health and social care services; - integrate community and specialist health care through clinical and care networks; - deliver effective engagement with primary care contractors; - Work with local communities to ensure they influence decisions; - ensure patients and frontline health care professionals are fully involved in service delivery, design and decisions.

2.6 The two geographical Operational Units will cover the populations below, a map showing the area covered is attached in appendix 1:

Sector Population North & West 70,527 South & Mid 149,973

The third Operational Unit will be Raigmore Hospital which will maintain its current structure with a Director of Operations responsible for all the acute and hosted services delivered.

3. IMPROVING HEALTH

3.1 The Health and Social Care Community Health Partnership will be resourced and responsible for making a difference to the health of its population and reducing health inequalities.

3.2 This means that the Health and Social Care Community Health Partnership will:

- lead the locally based health improvement effort, covering life circumstances and lifestyle action through the NHS; - have a strong public health focus with health improvement as a strategic priority, permeated throughout the Health and Social Care Community Health Partnership; - deliver extensive programme of geographic health improvement;

7 - Contract and commission with the voluntary sector providers and other groups and agencies for health improvement activity.

3.3 All of the management team will have responsibility for health improvement in their area, supported by the specialist resources. This connection of service delivery and health improvement will drive a focus on addressing inequalities by targeting resources and services towards those objectives. Service delivery will reflect the imperatives of health improvement. Rather than prevention and inequalities being squeezed out by the immediacies of health and social care delivery we intend that service delivery is driven by the priority to prevent ill health and improve health.

4. IMPROVING SERVICE QUALITY

4.1 Delivering improved services for the population is a fundamental objective of the Health and Social Care Community Health Partnership. The Health and Social Care Community Health Partnership will provide a fresh focus translating the direction established by the National Quality Strategy, the NHS Highland’s Quality Approach and moving towards implementing the National Care standards.

5. SERVICES MANAGED

5.1 The Health and Social Care Community Health Partnership will manage the NHS Services as previously outlined in the Schemes of Establishment for the 3 existing CHP’s – North, Mid and South East Highland. Through integration of Adult Social Care Services, there are a number of additional functions which will be delegated to NHS Highland Board, although the provision of services to deliver these functions will be through a combination of in-house (i.e. by the staff employed by NHS Highland) and by independent and/or 3rd sector through contracts with NHS Highland. For the avoidance of doubt these are for adult services.

 Respite services  Adult Social Work Teams (including Autistic Spectrum disorder, Learning Disability, Occupational Therapy)  Care at Home (including Tele-care and meals at home)  Sensory Services  Deaf Services  Care-Homes  Day Care  Community Development  Community Mental Health Teams  Housing support  Support Work  Self Directed Support  Reviewing Team  Change support Team  Handypersons service  Equipment Stores  Business Support  Recovery of charges for any delegated services (where appropriate).

5.2 There are also a number of functions detailed in the original Scheme of Establishments which will now be delegated to the Local Authority, although the provision may again be in- house (i.e. by the staff employed by NHS Highland) and by independent and/or 3rd sector through contracts with NHS Highland. For the avoidance of doubt the following are for children’s services

8  Speech and Language Therapy  Physiotherapy  Occupational Therapy  Dietetics  Primary Mental Health Workers  Public Health Nursing Health Visiting  Public Health Nursing School Nursing  Learning disability Nurses  Child Protection  Looked after Children  Public Health/Health Improvement posts re Health Promoting Schools  Sure-start early education workers & wraparound childcare  Admin and Clerical support  Service Managers

6. GOVERNANCE ARRANGEMENTS AND RELATIONSHIPS

6.1 This section outlines the key components of the Health and Social Care Community Health Partnership’s governance arrangements setting out a comprehensive approach to staff governance, financial governance, professional leadership, clinical governance, patient experience and community engagement to ensure that there are clear lines of accountability within the highly devolved structure.

6.2 The primary components will be:

- Highland Health and Social Care Community Health Partnership Governance Committee; - Professional Advisory and Executive Group structures; - Management Teams; - Public Partnership Forums; - Staff Partnership Forum.

6.3 Highland Health and Social Care Community Health Partnership Governance Committee

6.3.1 The NHS Board propose that the new Highland Health and Social Care Community Health Partnership Governance Committee is established as a formal sub-committee of the NHS Board. Formal accountability for an agreed range of functions will rest with the Highland Health and Social Care Community Health Partnership Governance Committee which will report to the NHS Highland Board.

6.3.2 Membership of the proposed Highland Health and Social Care Community Health Partnership Governance Committee is representative of the Partnership and the wider group of stakeholders and include the following members:

Chair Chief Operating Officer Head of Social Care/Professional Lead for Social Work Services Chair of Professional Executive Committee NHS Board Non Executive Directors X 2 Elected Member X 3 Staff Side Representative

9 Public/Patient Member Representative X 3 Lead Doctor (GP) Medical Practitioner (not a GP) Director of Operations – North & West Director of Operations – Mid & South Director of Operations – Raigmore Head of Personnel Head of Health & Safety Pharmacist Dentist Optometrist Lead AHP Lead Nurse Head of Financial Planning

6.3.3 The Committee Chair will be NHS Board Non Executive member.

6.3.4 The purpose of the Committee will be to set and monitor budgets within the allocations made by the NHS Board and to take a strategic overview of the Highland Health and Social Care Community Health Partnership activities, priorities and objectives. The Committee will also hold to account the management team for the delivery of the Highland Health and Social Care Community Health Partnership’s Development Plan.

6.3.5 It is intended that the Highland Health and Social Care Community Health Partnership Governance Committee will set the terms for planning, resource allocation, service management and delivery, and performance management in relation to the full range of the Health and Social Care Community Health Partnership’s responsibilities.

6.3.6 In terms of specific responsibilities the Highland Health and Social Care Community Health Partnership Governance Committee will be required to:

 Giving leadership and direction, enacting the strategic requirements of the Board;  Establishing control mechanisms to ensure best value from investment of public resources;  Supervising the overall management of activity ensuring the delivery of high quality services; and  Reporting on stewardship and performance to the Board.

6.3.7 Given the complexity and breadth of the business it is expected that the agenda of the Committee will follow a standard format, with the development of appropriate sub-groups which will take responsibility for the more detailed scrutiny of specific issues

6.4 Professional Executive Committee (PEC)

6.4.1 The PEC will bring together the full range of professional staff and primary care contractors from across the Highland Health and Social Care Community Health Partnership to ensure there is a strong professional and clinical voice at the heart of the Health and Social Care Partnership organisation.

10 6.4.2 The PEC is linked with the Highland Health and Social Care Community Health Partnership Governance Committee and an integral part of the Health and Social Care Community Health Partnership’s management arrangements. The PEC will have clear responsibilities to lead service redesign, planning and prioritisation, including:-

- service redesign and clinical developments; - contributing to service planning and prioritisation; - clinical governance; - organisational development; - Communication and consultation issues.

6.4.3 Its members will include all the professions covered by the Health and Social Care Community Health Partnership. In addition to the PEC we also see the need for clinical input across a wide spectrum of individual service, care group and team development programmes. The PEC will be the overarching professional grouping for the Health and Social Care Community Health Partnership.

6.4.4 In addition to the PEC role in engaging clinical and professional staff, each Operational Unit will give particular priority to establishing arrangements to engage their local clinicians.

6.5 Clinical and Professional Governance

6.5.1 The Highland Health and Social Care Community Health Partnership will have a comprehensive framework for clinical and professional governance which will build on the existing clinical governance arrangements within the CHPs and will reflect the management responsibilities at Operational and Health and Social Care Community Health Partnership wide levels. These arrangements will ensure that:-

- services are patient centred; - professional staff can evidence the development and application of the knowledge base to support their decision-making; - services provided by the Highland Health and Social Care Community Health Partnerships are safe and reliable; - clinical and professional effectiveness is enhanced; - appropriate quality assurance and accreditation processes and systems are a routine and organised part of the work of the Health and Social Care Community Health Partnership; - Every professional is supported in gaining and sustaining the skills, knowledge and attitude that delivers high quality care.

6.6 Staff Partnership

6.6.1 Staff participation will be facilitated by a single Highland Health and Social Care Community Health Partnership wide Staff Partnership Forum (SPF). The Staff Partnership Forum Chair will be a member of the Health and Social Care Community Health Partnership Governance Committee. Each Operational Management Team will include a local member of the Highland Health and Social Care Community Health Partnership-wide Staff Partnership Forum.

6.6.2 The Highland Health and Social Care Community Health Partnership will ensure that staff are treated as full partners in decisions that effect the planning and delivery of services in line with the objectives set out in Partnership for Care and the NHS Governance Standard.

6.6.3 In addition to these arrangements the Highland Health and Social Care Community Health Partnership will set up a range of mechanisms to fulfil the requirements of the Staff Governance Standard for NHS Employees which state that staff must be: 11 - well informed; - appropriately trained; - involved in decisions that affect them; - treated fairly and consistently; - provided with an improved and safe working environment.

6.7 Public Partnership Forum

With the integration of services between NHS Highland and Highland Council proposals have been developed for the establishment of 9 Local Partnership forums. These will meet to discuss the performance of the partnership and will involve Councillors’, relevant managers, community representatives and representatives for professional groups (social work, nursing and GPs etc.). They will have a key role in informing and influencing both NHS Highland and Highland Councils decision making. This is likely to also involve some rationalisation of existing local groups who also deal with health and social care issues, to avoid duplication and overlap.

Remit The Local Partnership Forum will consider issues relevant to the defined geographic and service delivery area covering both Integrated Children’s Services and Adult Services and will be a key element of local engagement.

 To consider issues raised in relation to local service delivery and ensure that these are addressed either by local management or required to the relevant Chief Executive’s of NHS Highland or Highland Council.  To identify key local issues and priorities in relation to the delivery of strategy and policy in services for children and adults  To consider and comment on performance management and monitoring reports on children and adult services outcomes in the local area.  To consider the development and implementation of initiatives approved by the strategic governance structure.  To propose new developments and initiatives for the consideration of the strategic governance structure.

Meetings The Partnership Forum will meet 4 times per annum, in public. The action points arising from the Local Partnership Forum will be considered by the relevant strategic governance body of both NHS Highland and The Highland Council.

The meeting will be serviced by the local Ward Manager, with focused agendas and action points.

The will be one meeting taken in two sections to deal with Integrated Children’s Services and Adult Services.

Attendance NHS Board Member (1) or other representative of the Operations Committee Adult and Children’s Services Committee Member, Highland Council (1) Elected member representative of each Council Ward in the areas of the Partnership Forum (1 for each Ward). Representation from each of the following :- Public Health Nursing; GP, Head Teacher from each Associated Schools Group; ECS Management; Children’s Services Management , Adult Services Management; Ambulance Service, Voluntary Sector, Ward Manager

12 As part of a wider process NHS Highland is in the process of reviewing all of its engagement and communications with the public, patients and staff. Further detail will be presented to the NHS Highland Board in April.

7. MANAGEMENT TEAM

7.1 The management team is outlined in Appendix 2.

8. PROFESSIONAL ADVICE

8.1 The management team will have access to a full range of professional advice at every level.

9. PLANNING AND DEVELOPMENT

9.1 The Highland Health and Social Care Community Health Partnership Governance Committee will be responsible for the planning and development of the services it directly manages and will participate in the planning and development of the full range of services to its population. This will require the Highland Health and Social Care Community Health Partnership to engage with associated, wider planning structures including corporate planning, Managed Clinical Networks and NHS regional planning.

9.2 Influence on wider service structures will ensure that specialist and non-local services and wider service planning and resource allocation activity are directly influenced by the Highland Health and Social Care Community Health Partnership.

10. RELATIONSHIPS WITH THE LOCAL AUTHORITY

10.1 As a result of integration a revised governance structure for working with Highland Council is being devised. The current outline is attached in Appendix 3

10.2 The Highland Health and Social Care Community Health Partnership will also have the lead role for the NHS in the wider relationships with the Council including community planning and working with other Highland Council Departments and functions.

11. DEVOLVED FINANCIAL RESPONSIBILITIES

11.1 The Highland Community Health and Social Care Community Health Partnership will be allocated funding on an agreed basis for the defined range of functions and services.

11.2 Detailed financial delegation and monitoring arrangements will be transitioned from the current North Highland CHP, Mid Highland CHP and South East Highland CHP and Raigmore Hospital.

11.3 The Chief Operating Officer will be responsible for remaining within the allocated budget and accounting to the NHS Chief Executive for financial probity and performance.

13 12. CORPORATE AND SUPPORT SERVICES

12.1 Corporate and Support services for the Highland Health and Social Care Community Health Partnership will be organised in the most efficient and effective way, reflecting the imperatives of focussing resources on front line services. This is the subject of an on-going review.

14 Appendix 1

15 Appendix 2

UPDATED JANUARY 2012 – NHS HIGHLAND PROPOSED SENIOR OPERATIONAL MANAGEMENT STRUCTURE HIGHLAND HEALTH AND SOCIAL CARE NHS BOARD PARTNERSHIP –

ARGYLL & BUTE CHP – CHIEF EXECUTIVE RAIGMORE HOSPITAL – GOVERNANCE ARRANGEMENTS ONLY APPLY – CHIEF OPERATING OFFICER

Director of Operations General Manager Director of Head of Adult Social Care South & Mid Highland General Manager Raigmore Hospital Operations (Inner Moray Firth) Argyll & Bute CHP Operational Unit North & West Operational Unit Highland (Remote & Rural)

North Area Manager West Area Manager Service Caithness Lochaber Mid Area Manager South Area Manager Sutherland Easter Ross Inverness Manager Skye, Lochalsh & MH&LD Wester Ross Mid Ross Nairn & Ardersier Badenoch&Strathspey

District Manager District Caithness Manager District District Manager District District District (including Rural Sutherland Manager Skye, Lochalsh & Manager Manager Manager General Lochaber Wester Ross East and Inverness Nairn & Hospital) (including Mid Ross Ardersier Belford Badenoch & Hospital) Strathspey Appendix 3

COUNCIL GOVERNANCE STRUCTURE

Council NHSH & THC Board Commissioning Group

Chief Director of ECS Executives

Director of Local Partnership Health & members Social Care Adult and Children’s (NHS, THC & 3rd sector) Services Committee 22 Council Members Local Partnerships NHS (Political Balance) (9 Council Members) Executive & 3 NHS Board members Director Local Partnerships (9)

Adult Services High Life Highland Development & Development & Scrutiny Criminal Justice Scrutiny Sub Committee Sub Committee Sub-Committee (Max 7 Members) (Max 7 Members) (Max 7 Members)

17 Appendix B

Health and Social Care Integration Directorate Integration and Service Development Division

T: 0131-244 4824 F:0131-244 The Scottish E:[email protected] Government

Mr Garry Coutts Chair NHS Highland Assynt House Beechwood Park INVERNESS IV2 3BW

Your ref: GC/RM Our ref: 2012/0008731 April 2012

Mr Coutts

Draft Scheme of Establishment

I have been asked by Ms Sturgeon to thank you for your correspondence of the 2 March 2012 and to reply on her behalf. Your letter asks for approval of a revised scheme of establishment that consolidates North, Mid and South East Highland Community Health Partnerships into a single Community Health Partnership that will mirror the geography of Highland Council and be responsible for the delivery of health and adult social care services.

I am pleased to inform you that the Cabinet Secretary has approved the Scheme of Establishment and is content for you to make the changes indicated to your Community Health Partnerships. The Cabinet Secretary noted that whilst public representation on the governance committee is in line with the Community Health Partnership regulations, the voice of patients, carers and the public are yet to be imbedded through the new structures. The seven Local Partnership forums, for example, do not include explicit representation from these groups. /' The Scheme of Establishment advises that NHS Highland is in the process of reviewing all of its engagement and communications with the public, patients and staff and the NHS Highland Board will receive details of this review in April 2012. I would draw to your attention the Cabinet Secretary's expectation that patients, carers and the public are actively involved in the design and delivery of healthcare services and in particular CEL 6 (2011) that outlines our expectations with regard to carers.

St Andrew's House, Regent Road, Edinburgh EH1 3DGwww.scotland.gov.uk 18 Appendix B

The Cabinet Secretary's approval of your scheme of establishment is contingent on this formalisation of engagement with the patients, carers and the public to ensure that these stakeholders play an integral role in developing the services that they use and deliver.

Yours sincerely;

Max Brown Integration and Service Development; Scottish Government

19 APPENDIX C Highland Health and Social Care Partnership NHS Highland and The Highland Council have recently agreed a Partnership Agreement where NHS Highland will now act as the Lead Agency in the delivery of adult social care. This opportunity has resulted in reorganisation of services and the establishment of the Highland Health and Social Care Partnership.

This new organisation, set up under current legislation, brings together for the first time community, primary, social care and acute hospital services, allowing opportunity for significant redesign. It covers the same area as the Highland Council.

The co-ordination of the planning, re-design, development and provision of health services and adult social care, will be delivered through the Highland Health and Social Care Partnership. It forms one of the two operational sub-groups of the Board (the other being Argyll and Bute Community Health Partnership).

The Highland Health and Social Care Partnership is made up of three operational units which are responsible for providing a wide range of acute services, emergency care together with primary care and community based health and social care services including:

. accident and . community nurses . physiotherapy emergency . day care . podiatry . acute hospital care . dental services . primary care . acute mental health . district general hospitals services . adult social work teams . handyperson services . respite services . equipment stores . health visitors . rural general . care at home . learning disability hospitals . care homes . midwifery services . self-directed support . community hospitals . nutrition and dietetics . speech and . community mental . occupational therapy language therapy health teams . pharmacy . tele-care

1) North and West Highland Operational Unit

This is the Remote and Rural area, and is made up of two areas and four districts:

(i) North Area 1. Caithness (including Caithness General Hospital, in wick) 2. Sutherland

(ii) West Area 3. Skye, Lochalsh & West Ross 4. Lochaber (including Belford Hospital in Fort William) Gill McVicar

Director of Operations -North and West Highland

01349 869221 [email protected]

20 South and Mid Highland Operational Unit

This is the Inner Moray Firth area, and is made up of two areas and five districts: (iii) Mid Area 5. East Ross 6. Mid Ross (iv) South Area 7. Inverness West 8. Inverness East 9. Nairn & Ardersier, Badenoch & Strathspey

Nigel Small Director of Operations – South and Mid Highland

01463 70 4622 [email protected]

3) Raigmore Hospital, Operational Unit Raigmore Hospital in Inverness is the third operational unit within the Partnership. It is the only District General Hospital in Highland. It provides high quality health care for the local and outlying populations and has close links to Tertiary Services in the central belt of Scotland and Aberdeen.

The Hospital covers all specialties and is a training hospital for Nursing, Medical and AHP staff in association with Stirling, Aberdeen and Dundee Universities. It is a Regional Cancer Centre and sited on the hospital is the innovative Centre for Health Sciences. Outreach Services are provided from Raigmore Hospital to many sites across the Northern Highlands and to both the Western Isles and Orkney.

The Hospital is organised into five divisions: 1) Surgical Specialties 2) Medical & Diagnostic including 3) Patient Services 4) Hotel Services 5) Quality and Patient Safety Assurance

Chris Lyons Director of Operations, Raigmore Hospital

01463 70 5572 [email protected]

21 Appendix D

Date of Issue: ??/??/?? Chief Executive’s Office Assynt House Beechwood Park Inverness, IV2 3BW Telephone: 01463 717123 Fax: 01463 235189 Textphone users can contact us via Typetalk: Tel 0800 959598 www.nhshighland.scot.nhs.uk

MEETING OF HIGHLAND HEALTH AND SOCIAL CARE PARTNERSHIP GOVERNANCE COMMITTEE

Time and Date Location

AGENDA

1 APOLOGIES

1.1 Declaration of Interests

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

2 MINUTE AND ACTION PLAN OF PREVIOUS MEETING HELD ON (DATE)

The Committee is asked to:

 Approve the Minute.  Note

3 MATTERS ARISING

4 QUALITY

The Committee is asked to

5 PRACTICE GOVERNANCE (Clinical and Social Care Governance)

The Committee is asked to

22 Appendix D

6 FINANCE

The Committee is asked to

7 PERFORMANCE

The Committee is asked to

8 STAFF GOVERNANCE

The Committee is asked to

9 STAKEHOLDER SATISFACTION

The Committee is asked to

10 HEALTH AND SAFETY

The Committee is asked to

11 CHIEF OPERATING OFFICER REPORT/OPERATIONAL UNIT REPORTS

The Committee is asked to

12 MATTERS FOR INFORMATION

13 ANY OTHER COMPETENT BUSINESS

14 DATE OF NEXT MEETING

23

Highland NHS Board 5 June 2012 Item 4.3

INTEGRATING CARE IN THE HIGHLANDS – FORWARD PLAN Report by Jan Baird, Transitions Director

The Board is asked to:

 Note the forward plan moving on from Planning for Integration.

 Note the proposed approach to ensure long term and sustainable arrangements are put in place to support the Integrated front-line services.

 Note the development of Programme scope for Central/Corporate services and the appointment of a Programme Manager.

1. Background

In December 2010 NHS Highland and Highland Council committed to developing integrated services with a shared statement of intent. This launched a programme of work spanning 15 months which would prepare functions for transfer of organisation and the launch of a lead agency model of service delivery.

It was recognised form the outset that this was only the first stage and in fact after the transfer date of 1 April 2012 there would follow a period of redesign which would see services evolving in an integrated way. The redesign would involve all stakeholders and focus on developing new ways of service delivery that reflected a commissioning approach and focussed on the agreed outcomes.

2. Ongoing Workstreams

As P4I reaches conclusion and integrating services in the Highlands becomes a priority, a number of actions are carried forward to ensure the development of longer term sustainable processes and procedures. These actions – most of which are captured in the Partnership Agreement – are detailed in the table below (Appendix 1) with proposed timescales and responsibilities listed also. The activity has been grouped into –

 Those actions identified for further work in the Partnership agreement or considered as operational  The Central services – detailed later in this paper.  Possible phase 2 opportunities – areas where integration may be an effective way forward in the future

During the period of P4I it was obvious that other opportunities for integration and lead agency arrangements were presenting themselves- primarily within the central support or corporate services. In many cases the decision to seek temporary solutions was to ensure that those opportunities, which would take longer to explore, would not be lost.

Work has now begun to identify those work-streams recognising previous recommendations that robust project management should apply but also that any proposals should fit comfortably and support the developing integrated services for children and adults.

1 Some of the major areas of work and proposals to take these forward are summarised below-

Property Licences to occupy for premises required for the integrated services have been agreed but on an interim basis spanning 12 months or thereabouts. This was agreed to allow the new management teams to assess the need for buildings across their span of responsibilities and as part of the redesign of services to inform the new models. It is recognised that in order to progress this to a more permanent solution beyond the 12 months there is a considerable piece of work that needs to be taken forward after April 1st and which shares a dependency with the development of both the integrated children’s and adult services.

Finance The Directors of Finance have recognised that there are outstanding financial treatments and processes that need to be resolved and that opportunities for further joint working across the organisations within the domain of Finance may be an opportunity worth exploring. In acknowledging this, plans are evolving and this will include accounting, billing and income and invoice processes.

Human Resources Discussions have begun in relation to a number of areas within HR where there may be opportunities for more joint working or there is a need to resolve issues on a more permanent basis, including Payroll, Occupational Health, Health and Safety and Personnel.

Information Management and technology At the outset, the team leading on this work in Planning for Integration were aware of the wide and ranging scope of issues to be considered, complicated in some ways by the differing approaches adopted by both organisations – in-house and external contract. To this end a longer term project plan was developed and a project manager identified. This piece of work is substantial and vital to the continuity of service delivery and will need ongoing support to ensure it delivers.

Other areas of central support services – contracts, performance management, legal services, procurement, training and facilities management must also be considered as the ethos of integrated working rolls forward. The Programme Board has approved progression of the work in Central Support services as a separate but inextricably linked project which will require robust project management. This includes much of the work detailed above

A forward plan – high level summary and detailed project plans are attached at Appendix 1 to help assess the scope of the work being carried forward.

Of course there is also the development of the integrated services for children and adults.

It is clear there will be a need to retain some oversight of these workstreams in the future to ensure they evolve in a complimentary way and deliver any opportunities that may arise. Despite this the Lead Agencies also need to be able to redesign the services and take forward new delivery models which are longer term and mainstreamed and not perceived as temporary or separate to the day job.

3. Proposal

Recognising the ongoing work detailed above and the future redesign of services which have a dependency on the work in Central Support services, consideration should be given to the extension of a Programme Board approach to ensure the overall aims of integration are achieved.

2 Although the development of the Integrated Services will be the responsibility of the Lead Agency in terms of delivery there will be benefit in these developments influencing and shaping the work progressing in the Central services projects and forward plan, as the children and adult services are the customers.

There is value therefore in considering the continuation of the Programme Board – focussed on “Integrating care in the Highlands (ICH)” with reporting of the work streams on Central Support services directly into this Programme Board. The Programme Board has considered and agreed a structure illustrated at Appendix 2.

Membership of the Board could be reviewed to ensure those taking forward the redesign of the care services are able to be active participants in the development of these services and the achievement of the anticipated outcomes.

However in line with recommendations from the Gateway review and NHS Highland Internal Audit, it has been acknowledged that appropriate programme management should be put in place along with an overall Programme Manager.

4. SUMMARY AND CONCLUSION

As NHS Highland moves from planning for Integration into Integrating Care in the Highlands, it is timely to consider outstanding and newly identified actions and opportunities .These have been captured in a forward plan and proposal for Programme management going forward. These proposals have been accepted by the Programme Board and recruitment of a Programme Manager is underway. The proposed structure ensures that not only will the new workstreams across the Central Support/ Corporate services be progressed, but also that the redesign of adult and Children’s services will be linked to the new workstreams through the Programme Board to ensure that dependencies and interdependencies are identified and considered.

Jan Baird Transitions Director

25 May 2012

3 Appendix 1 Integrating Care in the Highlands – Forward Plan

OPERATIONAL/PARTNERSHIP AGREEMENT

Responsibility Timescale Action

Scottish Government 2015 Pension direction past 2015

Scottish Government End April 2012 Confirmation of ASP regulations – change by 17 April 2012

John Batchelor September Continuity of Service for staff 2012 transferring from the Council

HR - Donald Shiach Outstanding HR issues as specified in PA (e.g. payroll, ,expenses etc)

HR – Donald Shiach April- Recommendation on which Policies September apply to transferred staff. Prioritised 2012 according to risk.

HR – Donald Shiach June 2012 Sutherland staff transfer to be resolved

Alistair Dodds/ John April 2013 Introduction of Partnership working in Batchelor/ Trades Unions Highland Council

Property-Steve June 2012 Complete current Licences to occupy Barron/Eric Green for term April 12-March 13

Property-Steve April 2013 Licence to Occupy – permanent Barron/Eric Green proposals regarding property to be developed and agreed

AHPs – Katherine Sutton April 2013 Review of AHP cradle to grave services as specified in the PA

Community learning April 2013 Review of cradle to grave CNLD disability nursing – service as specified on the PA Jonathan Gray

IM&T – Steve Byrne April 2014 Complete actions identified in P41 workplan to ensure permanent solutions. External contract term is a dependency.

Data Sharing Partnership End June 2012 Review of strategy and governance for – Bill Alexander data sharing

4 Responsibility Timescale Action

Clinical negligence End June 2012 SG underwriting this insurance for 3 insurance – Nick Kenton/ month term only Derek Yule/ Scottish Long term plan to be developed and Government implemented

Insurance –Nick April 2013 Any changes to asset ownership to be Kenton/Derek Yule reflected in insurance arrangements

Finance- Nick Kenton/ April 2013 Final confirmation from HMRC re VAT Derek Yule still required

Finance- Nick Kenton/ April 2013 Further refinement of budget allocations Derek Yule And reporting arrangements

Finance- Nick Kenton/ April 2013 Savings figures to be agreed Derek Yule

Transitions –Bill June 2012 Review of transitions protocol and Alexander/Jan Baird operational arrangements to reflect integration Performance April 2013 Further refinement of framework and management- Alistair development of Strategic Dodds/ Elaine Mead Commissioning group.

Performance June 2012 Training in Commissioning for Board management- Alistair and Elected members Dodds/ Elaine Mead

Duthac and Urray House June 2012 New contract with Parklands to be – Brian Robertson transferred

Evaluation – Cameron June 2012 Establish process of and engagement Stark for evaluation including base line data

SDS- Brian Robertson/ June 2012 Development of RAS Jennifer Campbell

Lease Cars – Alistair April 2013 Arrangements for Lease Cars from 1 Wilson and Matt Smith April 2013

5 CENTRAL SERVICES

Responsibility Timescale Action

Central services – Jan April 2013 Review and redesign of support Baird/ Michelle Morris provided by central/corporate services

Complaints – Michelle June 2012 Review and alignment of complaints Morris/ Lesley-Anne procedures Smith property Partnership Agreement – April 2013 Review of current documentation in line Alistair Dodds/ Elaine with actions detailed above Mead

Governance – Elaine April 2013 Review of effectiveness of Governance Mead/ Alistair Dodds arrangements

Fixed Assets – capital April 2013 Review of transfer of ownership expenditure Nick Kenton/Derek Yule

Finance – Nick Kenton/ Review of Finance functions Derek Yule

HR – Anne Gent/ John review of HR functions Batchelor

IM&T – Vicky Carry forward of work plan from P4I Nairn/Steve Byrne

Phase 2 – further areas to be considered for integration

Responsibility Timescale Action

Combined Child Health TBC Service

Schools and Children’s’ TBC services

Acute services TBC

Midwifery TBC

6 R.A.G. Progress Status B – Blue = completed R – Red Alert = timescale/deadline missed or major issue encountered A – Amber = unexpected delay, issue arising or on horizon G – Green = activity running to plan, no problem with timescale

HR Project Plan 2012-13

Activity: Timescale Governance Responsibility Progress Issues Status A: From Partnership Agreement

1. HR Policies for September 2012 HR Lead Donald Shiach Initial work on scoping and Relates to TUPE rights so G transferred staff: Need to be comparing policies in needs to be done by clear which policies apply. progress. agreement of all parties. First series of recommendations made April 2012. 2. Partnership Refresh April 2013 NHSH Anne Gent, Ray Identified as workstream by Additional TU (GMB) will G NHSH – to reflect transfer of Stewart HPF March 2012 form part of partnership social care staff and arrangements reconfiguration of CHPs

3. Introduction of April 2013 THC Alistair Dodds /all Agreed as part of Commitment by THC to G Partnership THC – New recognised TUs/ Partnership Agreement introduce Partnership partnership arrangements will John Batchelor (lead) arrangements to secure Working implies significant need to be compatible with the staff governance. Requires investment of time and culture of THC and the initial consideration by HC resource. THC and all TUs incoming administration SMT after formation of new (including the teaching TUs) administration need to articulate their aspirations and identify process for moving this forward.

7 4. Payroll NHSH a. Pay Frequency – April 2013 NHSH Donald Shiach/Philip Raised with TUs prior to Need to commence formal G fortnightly paid staff to be Walker 1April but no formal discussions with TUs moved to frequency proposal tabled yet. including those representing compatible with NHSH payroll transferred staff. system b. Payroll Compatibility – April 2013 NHSH Payroll Project £26k already spent on G NHSH to ensure ePayroll Manager TBC system developments but system (due Oct 2012) can need to check these work in accommodate all other T&C practice. Also need to load issues for transferred staff on all employee data c. Expenses – NHSH to April 2013 NHSH Payroll Project Covered by £26k system G ensure expenses claims for Manager TBC developments but not yet transferred staff can be tested processed via payroll d. Lease Cars – NHSH to April 2013 NHSH Payroll Project No work commenced Needs ongoing dialogue G ensure lease car deductions Manager TBC with managers in both for transferred staff can be NHSH and THC responsible processed via payroll for lease cars e. Interface with eESS - April 2013 NHSH Payroll Project Covered by £26k system G Interface with eESS system Manager TBC developments but not yet (also due Oct 2012) is critical eESS Project tested to ensure data sharing Manager f .Interface with CEDAR – April 2013 NHSH Payroll Project Covered by £26k system G NHSH to ensure outputs are Manager TBC developments but not yet compatible with CEDAR Iain Addison tested Financial System

8 5. Payroll THC April 2013 THC Charlie MacCallum a. Payroll Compatibility – April 2013 THC Charlie MacCallum Work commenced late Can build on Initial work G Ensure all T&C issues can be 2011 assuming would be accommodated effective from April 2012 b. Expenses – THC to ensure April 2013 THC Charlie MacCallum Work commenced late Can build on Initial work G expenses claims for 2011 assuming would be transferred staff can be effective from April 2012 processed via payroll c. Lease Cars – THC to April 2013 THC Charlie MacCallum Work commenced late Can build on Initial work G ensure lease car deductions 2011 assuming would be for transferred staff can be effective from April 2012 processed via payroll d. Interface with eHR system April 2013 THC Charlie MacCallum Work commenced late Can build on Initial work G – THC to ensure compatibility 2011 assuming would be to ensure data sharing effective from April 2012 e. Interface with Oracle – April 2013 THC Charlie MacCallum Work commenced late Can build on Initial work G THC to ensure outputs are 2011 assuming would be compatible with Oracle effective from April 2012 Financial System

9 Activity: Timescale Governance Responsibility Progress Issues Status B: Central Services 1. Support arrangements – Central Services a. Personnel April 2013 NHSH/THC/HR John Batchelor/Philip Interim arrangements in Need to identify long-term A Lead Walker place solution. HR Lead to oversee implementation of that solution b. Recruitment & April 2013 NHSH/THC/HR John Interim arrangements in Need to identify long-term A Employment Services Lead Batchelor/Elaine place solution. HR Lead to Barrie/ John Huband oversee implementation of that solution c. Health & Safety April 2013 NHS/HTHC/HR John Batchelor/Gena Interim arrangements in Need to identify long-term A Lead Falconer/ Bob place solution. HR Lead to Summers oversee implementation of that solution d. Employee Development April 2013 NHSH/THC/HR John Batchelor/ Interim arrangements in Need to identify long-term A Lead Cathy Christie/Judith place solution. HR Lead to McKelvie oversee implementation of that solution e. Occupational Health April 2013 NHSH/THC/HR John Batchelor/Gena Interim arrangements in Need to identify long-term A Lead Falconer/ Steven place solution. HR Lead to Ryder oversee implementation of that solution f. Payroll April 2013 NHSH/THC/HR Derek Yule /John Interim arrangements in Need to identify long-term A Lead Huband place solution. HR Lead to oversee implementation of that solution

10 Activity: Timescale Governance Responsibility Progress Issues Status C: Emerging Issues 1. Continuity of Service for Sept 2012 THC John Batchelor Raised with SPDS Exec Imminent change to A transferred THC staff: and plan to discuss at next Modification Order unlikely ensure that the Redundancy meeting in June. FAQ so interim arrangements Payments Modification Order issued to staff. have been put in place continues to apply if ex-THC involving voluntary support staff move to jobs in other from other Councils Councils 2. TU Engagement: Establish April – September HR Lead, Donald Shiach, Anne Staff Partnership Forum to G and confirm arrangements for 2012 NHSH, THC Gent, John Batchelor continue to meet, supported engagement with trade unions by Staff Governance and across agencies Policy sub-group. 3. Grading Systems : May 2013 NHSH/THC/HR Donald Shiach No work commenced Need to ensure additional G Agreement on systems for Lead JE capacity in the event of vacant posts and regrading transferring staff moving by requests on “TUPE” conditions agreement to TCS of new employer. 4. Redeployment : Develop September 2012 HR Lead Donald Shiach Initial discussions about Impact on existing A protocol for redeployment developing an “exceptional redeployment policies. Any across agencies circumstances” procedure agreement must not create risk of creating “associated employer” status. Some urgency to progress this because of Care at Home in Sutherland proposals. 5. Public Holiday April 2013 HR Lead Donald Shiach Initial discussions not Interest in both NHSH and G Harmonisation pursued as PHs covered by THC in harmonising PH TUPE arrangements through agreement with TUs 6. Registration/Regulation: April 2013 NHSH Donald Shiach No work commenced Need to ensure registration G Implications of creating requirements are clear for integrated roles in future any future combined roles (e.g. combining elements of home care worker/nursing assistant)

11 7. NHS Healthcare Support April 2013 NHSH Donald Shiach No work commenced Need to develop protocol for G Worker Induction new starts in Social care not Standards: Possible already covered by SSSC application to newly-appointed requirements social care staff 8. Recruitment: Ensuring May 2012 NHSH and John Huband, Elaine Initial meeting March 2012. Need to finalise processes G systems are in place to recruit THC Barrie, Kevin Follow-up meeting to be so managers are clear new starts on “TUPE” Colclough arranged which forms to use and conditions where appropriate. where these are sent Ensures compliance with “2- tier workforce” regulations 9. Recruitment: Internal May 2012 NHSH and John Huband, Elaine Initial meeting March 2012. THC advertises via regular G vacancies advertised to staff THC Barrie, Kevin Systems in development Bulletin, NHSH advertises in both NHSH and THC Colclough on a rolling programme. Issue re ensuring regular updating 10. Review of Business April 2013 NHSH/THC TBC Interim arrangements mean Major piece of work G Support: Review of interim some staff providing requiring separate project arrangements support across both plan. Ties in with CIP in organisations. THC and reviews of Corporate Services and of admin staff within NHSH. HR involvement required but not primarily a HR activity

12 Review of strategy and governance for data sharing

Activity Timescale Responsibility Progress Issues Status 1. Close liaison with Scottish Through 2012 Bill Alexander Emerging approach is supportive of localism, - Budget R Government regarding (DHSC) with limited additional funding, national - Capacity and technical support changing national approach Steve support and the use of some national - Agency electronic information MacGregor products. systems, and ability to share (Data Sharing information Manager) - Information sharing solution

2. Local seminar with key June 2012 DHSC Agreement for seminar with partners and A decision makers. Data Sharing Scottish Government Manager

3. Local strategy and June – DHSC governance developed and September Data Sharing A agreed. 2012 Manager Partner Agencies Scot Govt.

4. Completion of revised May 2012 Review Group Information Sharing Protocol and Data Draft developed. Some agencies still to A Sharing agree. Manager

Partner Agency Management Teams

5. Reconsideration of systems Late 2012 NHS Highland and approach, as part of Highland G integrating care in the Council Highlands.

6. Development of a Privacy June – DHSC Impact Assessment for the IT September 2012 Data Sharing G aspects of integration. Manager

13 Review of AHP Services delivered within Lead Agency under the partnership agreement

Activity Timescale Responsibility Progress Issues Status Children’s and Young People June 2012 Claire Wood G Physiotherapy services to be AHP Principle reviewed regarding the Officer distribution of resources and staffing levels across North . Highland including skill mix with a view to delivering a model that best supports delivering the Integration agenda Children’s and Young People September Claire Wood G Occupational Therapy Services 2012 AHP Principle to be reviewed regarding the Officer distribution of resources and staffing levels across North Highland including skill mix with a view to delivering a model that best supports delivering the Integration agenda. In addition the two previously separate Children’s and Young People OT services (HC & NHS H) require to be redesigned to deliver one blended service.

14 Children’s and Young People October 2012 Claire Wood G Dietetics Services to be reviewed AHP Principle regarding the distribution of Officer resources and staffing levels across North Highland including skill mix with a view to delivering a model that best supports delivering the Integration agenda. In addition the PH service and the previously separate Acute Children’s and Young People Dietetic services require to be redesigned to deliver one blended service under the professional leadership of one senior Lead Dietician. Children’s and Young People August 2012 Claire Wood G SLT Services to be reviewed AHP Principle regarding the distribution of Officer resources and staffing levels across North Highland including skill mix with a view to delivering a model that best supports delivering the Integration agenda. In addition the current Cradle to Grave service requires to be disentangled and blended with the Children’s only service to deliver one blended service under the professional leadership of one senior Lead Speech and Language Therapist.

15 Review of transitions protocol and operational arrangements to reflect integration

Activity Timescale Responsibility Progress Issues Status 1. Review of transitions June 2012 Transitions First review included in Partnership - Implications of Integrating Care in R protocol Director Agreement the Highlands DHSC - Collapse of strategic and local monitoring and review arrangements

2. Consideration and inclusion October 2012 - Need to engage and include wider G of roles of wider partnership Partnership (including Planning & Development, Skills Development Scotland, Colleges, Employers, 3rd Sector)

3. Consideration of broad multi- October 2012 - Previously scoped within THC A disciplinary operational team

4. Establishment of strategic June 2012 A monitoring and review arrangements

5. Establishment of strategic A monitoring and review October 2012 arrangements

16 Finance Activity Timescale Responsibility Progress Issues Status Finance-led issues

.

Establish a project group to 30/4/12 Nick Kenton Need to decide standing membership G oversee and ensure delivery of the issues identified below Systems - General ledger / 30/9/12 Nick Kenton Work around in place (each organisation has A PECOS retained detailed transactions of its system). Need to establish a project team to drive forward the transferring of this to the ‘new’ provider Ordering / Procurement 30/9/12 Nick Kenton Ditto A Healthcare and Non-Healthcare 30/9/12 Nick Kenton A Contracts Pensions (impact on accounting) 31/5/12 Nick Kenton Not yet checked this with SG or Audit A Scotland VAT 31/5/12 Nick Awaiting feedback from HMRC Timescale out-with our control A Kenton/Derek Yule Clinical Negligence insurance 30/6/12 Nick Currently pursuing commercial options and a A Kenton/Derek long-term SG solution Yule Budgets 31/5/12 Nick Work around in place. Need to understand A Kenton/Derek the budgets at an operational level to inform Yule discussions. Savings on adult social care 30/6/12 Nick Savings plan in place with varying degree of A budgets Kenton/Director detail and risk. Need to convert this into a s of detailed plan with a profile for delivery Operations/Bria n Robertson Audit 31/5/12 Nick Kenton/Derek Yule

17 Counter Fraud Services 31/5/12 Nick Kenton

Issues with Finance implications

Payroll Need to ensure close liaison with HR/Payroll streams of work Central Services 31/3/13 Need to ensure Finance is part of the discussions on the potential for sharing services etc Capital Funding 31/12/12 Need to liaise closely with the Property stream of work to understand / influence the options in the light of the respective financial regimes.

18 IM&T/ICT 12 April 2012

1 TECHNICAL INVENTORY

NHSH will compile a technical inventory of the IM&T hardware, software, systems, and services used by the Children’s Services staff who have transferred to THC. THC can then use this to decide how to manage and, where necessary, make changes to the technology to support the integration programme.

THC is compiling a similar inventory in respect of Adult Services staff who have transferred to NHSH.

Once the inventories have been compiled, the detailed planning process can be undertaken.

Activity Timescale Responsibility Progress Issues S

1. t a t u s

1.1. NHSH. Provide fixed and mobile 20/04/2012 Iain Ross telephony details for CS.

1.2. NHSH. List systems used by each user. 31/05/2011 Iain Ross

1.3. NHSH. List networked drive mappings 31/05/2011 Iain Ross for each user, and who they are shared with

1.4. NHSH. Quantify allocated and actual 31/05/2011 Iain Ross filestore usage for each individual

1.5. NHSH. Quantify allocated and actual 31/05/2011 Iain Ross email-related filestore usage for each individual

1.6. NHSH. Quantify allocated and actual 31/05/2011 Iain Ross filestore usage for each individual

19 1.7. NHSH. Quantify the volume of User 31/05/2011 Iain Ross Admin calls generated by CS users

1.8. NHSH. Quantify and categorise the 31/05/2011 Iain Ross volume of calls logged with ServiceDesk by CS users.

1.9. NHSH. Provide desktop hardware 31/05/2011 Iain Ross specifications for CS users

1.10. NHSH. Provide desktop software 31/05/2011 Iain Ross inventory for CS users

1.11. NHSH. Catalogue printing services and 31/05/2011 Iain Ross devices used by CS users

1.12. NHSH. Provide circuit details for all 31/05/2011 Iain Ross sites occupied by CS staff.

1.13. NHSH. Catalogue all network 31/05/2011 Iain Ross equipment installed in sites occupied by CS staff.

1.14. NHSH. Provide network topography, 31/05/2011 Iain Ross capacity etc details for all sites occupied by CS staff.

1.15. THC. Ask Fujitsu to provide details 31/05/2011 Jon Shepherd equivalent to the above in respect of AS.

20 1.16. Identify funding requirements for 20/04/2012 S Byrne eHealth technical managers asked completion of the technical inventories. to submit funding requests.

Jon Shepherd asked to obtain quote from Fujitsu. 1.17. eHealth/THC/Fujitsu review  Review the catalogues for completeness, issue identification, and initiation of detailed planning process

1.18. Dependencies/Other workstreams  Meet with business managers review to discuss option and priorities

21 2 DETAILED PLANS

When the technical inventories have been compiled it will then be possible to identify the range of options for managing ICT/IM&T integration. The approach will be pragmatic, and the solutions may vary and continue to change over time.

For example, it may not be possible to replace all network connections because they are shared by staff from both organisations. In these cases it might be decided that the current provider will continue to provide the network connection.

This arrangement would be reviewed at intervals as staff relocate and network contracts are renewed and technology replaced.

Activity Timescale Responsibility Progress Issues S

2. t a t u s

2.1. Email  Mailbox licences and Fujitsu costs (THC)  Clinical Mailboxes  Secure Mailboxes – gsx etc (THC)  Migration protocol  New email provider (NHSH)

2.2. Intranet access  SharePoint Server licence will be required (NHSH)  Inter-network access by VPV, or firewall and IP address settings, or both

2.3. Network connections  Shared sites  New networking contracts (NHSH and THC)

22 2.4. VPN Services  Licence holding may need to be Enables inter-network access, e.g. to view increased Intranets  Bridge between networks may need to be enlarged.

2.5. Networked filestore  Both organisations may incur costs for providing filestore to new staff  It may be necessary to have a protocol for transferring files  It will be necessary to review file sharing arrangements.  Could it be necessary to share filestore across the organisational boundaries?

2.6. Desktop hardware  It may be necessary to replace some hardware items because they do not conform to standards  Thin client devices might be replaced by PCs

2.7. Desktop software  Both organisations may have to replace or upgrade software to bring it into line with standards  The rules for migrating software (licences) vary from supplier to supplier

23 2.8. Print Services  Printers shared by different staff groups  Print services provided by 3rd party suppliers (NHSH and THC)

2.9. Thin client  Organisations may use different thin client software, versions etc  Citrix licence transfer could be an issue  This will also require investigation of thin server hosting environment including resilience, backup etc

2.10. Support arrangements  The balance of support will shift over time, with NHSH assuming the larger proportion  Funding, resourcing, staffing levels will have to be adjusted accordingly

2.11. ServiceDesk/Helpdesk  Users should call one number only, and not different numbers depending on the problem  Migration between services will have to be managed with minimum disruption to users  Resourcing/staffing levels will have to be addressed.

24 2.12. Telephones  Standard phones and landlines  IP phones  Mobile phones and smartphones  Interconnect with email services  THC telephony refresh/replacement project

2.13. Information Governance  Ensure that data sharing and governance arrangements continue to provide effective safeguards and management processes

2.14. Disaster Recovery and Business  Make provision for AS and CS Continuity. post transfer of support responsibility at lease equivalent to current provision

2.15. IM&T Training  General IM&T training is provided by the training team that provides non IM&T training also (THC)  CareFirst training is provided by a member of the support team (THC)  Resourcing of training teams will have to be reviewed.

2.16. Fujitsu contract renegotiation  Due to begin within 12 months  Need to decide scope of new contract, i.e. for Adult Services

25 Improvement Plan Highland Council Lead Agency Children and Young People Community Learning Disability Nurses - 2012/13

Work BRAG Responsible Timescale for Stream Description of Work Stream Action to be taken Score individuals completion Number Consultant Nurse Learning Take forward through review of Best Disability & Implementation of Appropriate Governance Practice Statements and Service Professional March 2013 Models Descriptor during 2013/2014 Lead Nurses for Learning Disability Consultant Nurse Learning Confirm professional Leadership structures Disability & and identify development needs of Options to be scoped Professional June 2012 Professional Leads for Learning Disabilities Lead Nurses for Learning Disability Ensure that services remaining in NHS Professional Highland deliver according to the Highland Lead LD Nurse Practice Model (GIR) and Child’s Plan and June 2012 Children’s that there is consistency in paperwork Services completed across all services. Consultant Nurse Learning Quality /Clinical Quality Indicators for Disability & Community Learning Disability Nursing Measures to be scoped Professional Sep 2012 services to be further defined Lead Nurses for Learning Disability

26 Consultant Nurse Learning Generic Audit tool for Community Learning Disability & Disability Nursing Services to be further Options to be explored and paper Professional Sep 2012 developed aligned to work of the Quality developed Lead Nurses for Assurance Group Learning Disability Consultant Nurse Learning Seek to identify appropriate Caseload / Scope existing caseload/workload Disability & workload management methodologies for use management methodologies in use in Professional Sep 2012 in CLDN services for children and young learning disability nursing Lead Nurses for people with learning disabilities Learning Disability  Review of case load mix and complexity in both Agencies Consultant  Identify outcomes achieved for Nurse Learning children and families in both Undertake review of CLDN ‘cradle to grave’ Disability & agencies model to inform the need for any further Professional April 2013 Determine the relative public health redesign of service as of 1 April 2013  Lead Nurses for contribution to children and young Learning people with learning disabilities Disability  Consider and capture risks of change  Map current role against and Review the School Nurse role in Drummond identify areas for development in Professional School to ensure it addresses the public addressing the public health needs Lead LD Nurse September health needs of children and young people of children and young people with for Children’s 2012 with learning disabilities in school settings learning disabilities in school Services settings Consultant Explore interface between Primary Mental  Scope roles of both services and Nurse for September Health Worker role and CLDN role for children identify areas for development Learning 2012 and young people with learning disabilities Disabilities

27 Evaluation

Activity Timescale Responsibility Progress Issues Status TBC Kenny Oliver Key measures identified for the Green Development of Performance Partnership Agreement. No significant issues. No timescale Measures Further refinement of measures in agreed, but progressing well. progress. Discussion on presentation of results. . Agreement on data available at locality level for managers.

Baseline monitoring of community Complete Moira Paton Over 350 people attended meetings. Discussion required on whether Blue views Notes were taken at all meetings, and follow-up meetings and 34 people also completed questionnaires are required, and questionnaires. It has provided a the role of the operational areas in useful indication of issues of concern this. to service users, carers and community groups which can now be incorporated in to community groups. Current Service Use TBC Simon Steer Simon Steer is liaising with Scottish It is not possible to set timescales - Government colleagues on the use of on this at present, as eHealth standard identification measures colleagues are discussing the across all HSCP databases. This possibility of the use of shared would allow identification of the systems. If this is not possible in the pattern of service use across all adult short to medium term then pursuing health and social care services. this linkage option, using computer probability matching, would be appropriate.

Ongoing use of a common identified, such as a CHI number, would have a staff training requirement.

28 Staff effects Ongoing – Pam Cremin / HR colleagues are identifying routine There are challenges relating to Green expected to Rachel Hill measures (recruitment and retention, staff who do not have routine last at least two sickness absence, turnover) that can internet access. It seems likely that years be used for routine monitoring. In a combination of paper surveys and addition, a regular staff survey is on-line responses will be used. planned, focusing on views of integration, effects on practice, and use of reablement approaches. Identification of staff training needs and incorporation into Personal Development Plans will also be reviewed. Service User views of services Ongoing – Janet Spence / Existing exit questionnaires are used Incorporating Equality and Diversity Green expected to be Simon Steer at Raigmore Hospital. Rachel Hill has monitoring requirements. routine led work to identify variants that can Managing the required work with be used to monitor satisfaction with the available resource, particularly if community care. Janet Spence and paper responses are required, with Simon Steer are working to identify consequent data entry sample frames, and the best way of requirements. disseminating and collating responses. Carer support Ongoing – Janet Spence / Measure of uptake of Carer Support Identifying resource required to Green expected to be Simon Steer Plans. extract anonymised data from routine It may also be possible to extract plans. anonymised data on needs from the plans. Co-ordination of evaluation activity Ongoing Cameron Stark A group has been established to Agreement on the role of a Green monitor technical aspects of the reference group to steer and review evaluation work. A reference group is evaluation activity. likely to be required, subject to organisational agreement.

29 Measures of service integration May 2012. Cameron Stark There are several available measures Green of service integration, but none of them have been used in Scotland. This work is reviewing the published measures, comparing them to the local work, and will establish if any of them are suitable for local use. Detailed Work Delayed discharge Expected to be Simon Steer There is detailed information already Work required to identify ways of Green over the next collected on delayed discharge, which presenting the data on all lengths of two years. includes all lengths of delay. Routine delay over time. Health Intelligence monitoring can already be conducted. and Service Planning colleagues It seems likely that some detailed will be involved in this work. case study work may also be required. Young People / Adult Service Planned – Cameron Stark/ Transitions between young people Cameron Stark and Sheena - transitions timescale TBC Sheena and adult services are important, and Macleod are meeting to identify MacLeod are a key area to understand further. ways of monitoring and reviewing transitions. Use of community care Planned – Janet Spence / Monitoring of community care Quality of care is key, and - timescale TBC Simon Steer packages is complex because of identifying methods of identifying methods of recording. This work will quality as well as volume will be identify methods of monitoring, and necessary. will undertake detailed work if required.

30 Appendix 2 Proposed Programme Management Structure

HIGHLAND NHS COUNCIL HIGHLAND

Highland Strategic Commissioning Group

Integrating Services in Staff the Highlands Partnership Programme Board Forum

Highland Council Highland NHS Highland Lead Agency Partnership Lead Agency Integrated Integrating Integrated Adult’s Children’s Central Support services services Services

HR FINANCE PROPERTY WORKSTREAM WORKSTREAM WORKSTREAM

IM &T WORKSTREAM OPERATIONAL/PA 31 WORKSTREAM

Highland NHS Board 5 June 2012 Item 4.4

INTEGRATION OF ADULT HEALTH AND SOCIAL CARE IN SCOTLAND – CONSULTATION ON PROPOSALS

Report by Jan Baird, Transitions Director on behalf of Elaine Mead, Chief Executive

The Board is asked to:

 Note the consultation proposals.  Note the consultation response drafted on behalf of NHS Highland.  Agree further circulation of this draft to gather views across leadership and management forums in NHS Highland.

1 Background and Summary

The Scottish Government has launched it’s consultation on Integration which will run until 31 July. The Highland Partnership have of course implemented integration of adult and children’s’ services under existing legislation namely the Community Care and Health (Scotland) Act 2002. The consultation document outlines the impact on current legislation and configuration of Community Health Partnerships detailing two options for partnerships to consider across Scotland. A Lead Agency model is one of the options.

The objective of the consultation is to seek views on new legislation that will be introduced in order to achieve the changes that Ministers have been proposing. This report highlights the key points in the consultation document and includes a proposed draft response (Annex G).

The full consultation document is accessible at www.scotland.gov.uk/Publications/2012/05/6469

2 Case for Change

The consultation document is laid out in a structured way beginning with the case for change. This was of course the route taken during Planning for Integration. As with our own programme of work, it was not possible to evidence the benefits of integration as this is ground breaking work but it was very possible to make the case for change. The document cites the Christie Commission report as well as the public engagement exercise of Reshaping Care for Older People and sets the debate within the context of demographic changes, the current Change fund proposals, working with the third and independent sectors, diminishing resources and the need to improve outcomes.

3 Outline of Proposed Reforms

This chapter outlines the objectives and principles of reform which are based on  Consistency of outcomes  Statutory underpinning  An integrated budget  Clear accountability  Professional leadership  Simplification of structures The proposed legislation will put a duty on statutory partners to deliver nationally agreed outcomes for adult health and social care. Health Boards and Local Authorities will be jointly and equally accountable to Scottish Ministers, Local Authority Leaders and Health Board Chairs for the delivery of those outcomes. The next chapter of the consultation document outlines the development of these national outcomes recognizing the need for different delivery mechanisms.

4 Governance and Joint Accountability

The consultation document describes what Ministers strive to achieve through these legislative changes and how this will be achieved.  Community Health Partnerships will come off the statute book.  Health Board and Local Authorities will be required to set up a Health and Social Care Partnership, the scope of which can be locally agreed but there must be an integrated budget and a governance committee to oversee the running of the Health and Social Care Partnership.  A senior jointly Accountable Officer for the Health and Social Care Partnership will be appointed reporting to the two Chief Executives. They will be responsible for commissioning and managing services with delegated authority to make decisions regarding the use of the integrated budget. Further detail on the role and responsibility of this officer is included in Chapter 6 of the consultation document.  A Partnership Agreement will be drawn up between the Local Authority and Health Board detailing the services to be delivered, outcomes to be achieved, the financial input from each partner and the mechanism to effect integration of budgets.

The Chair and Vice Chair of the Health and Social Care Partnership and the Health Board and Local Authority Chief Executives will be jointly held to account by the Cabinet Secretary, Local Authority Leader and Health Board Chair. This will deliver a community of governance overseeing the effectiveness of the Partnership especially in relation to early intervention and prevention, community planning processes and engagement of stakeholders.

The main differences are expected to be:  Joint and equal responsibility of the NHS and local government with the Health and Social Care Partnership being a Committee of Health Boards and Local Authorities  Delegation of financial authority for achievement of joint outcomes and the requirement to demonstrate value for money  Decision making authority in relation to delivering outcomes  Joint accountability of Health Board and Local Authorities in relation to performance

5 Integrated Budgets and Resourcing

As the starting point to these proposals is to improve outcomes and utilise resources to best support individual need, Health Boards and Local Authorities will be required to integrate resources for adult services as a minimum and beyond as they deem fit. The resource should lose it’s identity to allow it to be appropriately used and robust information and evidence will be shared to enable joint managing of the risks and the facilitation of planning and service design.

There are two options for integrating budgets: a) Delegation to the Health and Social Care Partnership established as a body corporate of the health Board and Local Authority. Functions and resources will be agreed by the partners and captured in the Partnership Agreement. Jointly Accountable Officer will manage the integrated budget under delegated authority form the two Chief Executives.

2 b) Delegation between partners under the current legislation - Community Care and Health (Scotland) Act 2002. The delegating partner retains its legislative responsibility for the functions that have been delegated and the financial governance system of the host partner applies to the integrated budget. A Partnership Agreement will establish the functions and resources. This model does not detail the need for a joint Responsible Officer.

This reflects the Highland Lead Agency model.

6 Professionally led Locality Planning and Commissioning of Services

The consultation document outlines a Commissioning approach which has been defined by the Social Work Inspection Agency ( SWIA) as one which refers to the activities involved in:  assessing and forecasting needs  agreeing desired outcomes  considering options  planning the nature, range and quality of future services  working in partnership to put these in place

The document goes on to emphasise the importance and benefits of strong clinical and professional leadership. It is anticipated that the Health and Social Care Partnership will afford better opportunities for professionals than was evidenced in the Community Health Partnerships. This should enable the development of local plans which will have a key input to the joint strategic commissioning plan.

The proposed legislation will place a duty on Health Boards and Local Authorities to consult local professionals across extended multi-disciplinary health and social care teams and the third and independent sectors. Scottish Government will also work to support changes in workforce and leadership development to ensure this engagement can be realized, including consideration of workload, recruitment and retention issues that can impact significantly on the capacity of GPs.

7 Annexes

The consultation document concludes with a number of annexes detailing draft National outcomes, impact on other areas of services, workforce issues, Equality Impact Assessment(EQIA) and Business and Regulatory Impact Assessment (BRIA). This is work in progress which is intended to further clarify the context in which this consultation is set and how the changes can be most effectively put in place.

8 Governance Implications

There are no additional implications for Governance as all domains have been considered in the development of the Highland Lead Agency model and detailed in the revised Scheme of Establishment for the Highland Health and Social Care Partnership.

9 Impact Assessment

The integration of adult community care has been subject to a full EQIA submitted to the Planning for Integration/ Integrating Care in the Highlands Programme Board.

3 10 Conclusion

The consultation document on Integration of adult health and social care sets out the proposals being progressed by Scottish Government in considerable detail. It highlights the responsibilities of Local Authorities and Health Boards and details how the proposed Health and Social Care Partnerships should be configured and report. Two options are described for consideration one of which reflects the model developed in Highland using the existing legislation from 2002.

As the consultation response points out there is some dubiety evident in the proposals around the requirement to have a joint accountable officer particularly in the delegated option. The response also provides feedback on the body corporate option. NHS Highland fully supports the Lead Agency model as indicated in option “b” and highlights in the consultation response, risks with option “a”.

Jan Baird Transitions Director

25 May 2012

4 DRAFT

Annex G Consultation Questionnaire

The case for change Question 1: Is the proposal to focus initially, after legislation is enacted, on improving outcomes for older people, and then to extend our focus to improving integration of all areas of adult health and social care, practical and helpful?

No

The Highland Partnership is clear that there requires to be integration across all age groups, including children, and that it would be disruptive to people who use services, and to services and organisations, if this was not the case. We also believe that this requires a whole system approach, not an incremental approach.

The significant change programme required to drive and implement integration should be considered further. To go through this more than once, could be detrimental to staff and services. In many rural areas services are arranged around all adults – and where there are co-morbidities particularly prevalent in the older population, this may create more barriers (not less) on an interim basis. The real benefits will be across all adult care groups as this will enable a more flexible and efficient approach to the deployment of staff and services. In Highland we took the view that if we were looking for the benefits from integration in one client group why would we not want to apply that to all. We therefore progressed the lead agency model across all client groups.

Outline of proposed reforms Question 2: Is our proposed framework for integration comprehensive? Is there anything missing that you would want to see added to it, or anything you would suggest should be removed?

Yes

These proposals are comprehensive and reflect not only the necessary change in focus re inputs to outcomes but also the development of strategic commissioning as the desired approach to the planning and delivery of services. This term –strategic commissioning however is subject to interpretation across the Public and Third and Independent sectors and it will be vital that organisations working together on this agenda agree the meaning at the outset. The guidance in Chapter 7 is most welcome and reflects recent reports to Highland Health Board outlining our way forward.

The Highland Partnership does not believe that some recommended aspects of the model, are only relevant to the ‘body corporate option’, involving the management of a pooled budget, and not to the lead agency model that has been implemented in Highland. We would make similar comments regarding the reporting accountabilities associated with this model, which are ‘joint’. The lead agency model involves singular accountabilities.

There remains the need to further explain the role of the Jointly Accountable Officer beyond the detail in Chapter 6, particularly in relation to the Lead Agency model. We welcome the repeated reference to engagement of the Third and Independent sectors and recognise the support that Scottish Government has given to the development of the Interface.

5 However this sector requires ongoing support to ensure they can fully contribute and be involved in a way that is effective for them and adds the value that is so needed. Highland welcome the endorsement of the model adopted across the area and referenced in section 2.7, including the recognition that this model was developed for the people of Highland and was not intended to provide a ‘one-size-fits-all’ solution for the rest of Scotland.

National outcomes for adult health and social care Question 3: This proposal will establish in law a requirement for statutory partners – Health Boards and Local Authorities – to deliver, and to be held jointly and equally accountable for, nationally agreed outcomes for adult health and social care. This is a significant departure from the current, separate performance management mechanisms that apply to Health Boards and Local Authorities. Does this approach provide a sufficiently strong mechanism to achieve the extent of change that is required?

Yes but…

This is a very welcome approach particularly as it will come with performance indicators that reflect this approach. However after many years of Public sector focus on inputs and evidencing success on numbers of staff or services this will take some time to bed in and will require a consistent approach across local, regional and National management systems. It is a very new way of working for some staff who are task focussed and who need empowered to think more flexibly about what difference their intervention will make overall. If we are confident about this approach and committed to this as a more effective way of working ad producing and evidencing results, why would we not implement this for all client groups? GIRFEC has already taken us down this route in Children’s services. This has though, to be part of agreed performance management frameworks across the Partnership, for both children and adults, that reflect local circumstances, and that enable service delivery and performance to be scrutinised.

Question 4: Do you agree that nationally agreed outcomes for adult health and social care should be included within all local Single Outcome Agreements?

Yes

This is a welcomed approach and builds naturally on the philosophy and aim of the Single Outcome Agreements. . It also needs to take account of local factors. It will be important to develop a governance structure that prevents duplication of reporting and enables scrutiny at appropriate levels. We have committed in Highland to progressing the outcomes as agreed in the SOA, Joint Community Care Plan and Children’s Integrated Plan. This is explicit in our Partnership Agreement.

Governance and joint accountability Question 5: Will joint accountability to Ministers and Local Authority Leaders provide the right balance of local democratic accountability and accountability to central government, for health and social care services?

Perhaps

6 Local democratic accountability is key if integration is to be successful and effective. In the Highland model we are developing District Partnerships by way of addressing this to ensure there are local forums which involve front line staff, managers, elected members, service users, carers, 3rd and independent sector to discuss issues in public .

However accountability for the services being delivered in the Lead Agency model in Highland is singular, within the governance structure of the lead agency, which is held to account by the commissioning agency. We believe that this does not then cut across the accountability to Ministers as is proposed.

The development of the health and social care partnership in NHS Highland is across all adult health and social care services in the Highland Council area.

This was felt to be appropriate so that no further barriers were developed across services e.g. independent contractors, secondary and tertiary care. This we believe will encourage integration across all of these areas of work and ensure that the health system is held to account as a whole. Previous experience of local health partnerships demonstrated a geographical governance structure which did not always facilitate effective integrated working across the primary and secondary care “divide”. The proposed membership of the Health and Social Care Partnership committee is helpful and goes someway to addressing the previous CHP guidance which at times produced committees of unwieldy and unproductive proportions. There is a need however to emphasise the inclusion of Secondary Care given their key role across the health and social care continuum. A failure to engage effectively with Secondary Care will result in an inability to release any return on investment – arguably one of the reasons that the Joint Future initiative failed to deliver the expected outcomes. The document should clarify that this proposed membership also applies to option b – the lead agency option, as it includes the jointly accountable officer who would not be part of that option.

Question 6: Should there be scope to establish a Health and Social Care Partnership that covers more than one Local Authority?

Perhaps

This will require further consideration given the local political element and the democratic accountability referred to previously. NHS Highland has taken the view that integration will be separate and that there is a need to explore relevant models now with Argyll and Bute as was progressed with Highland Council when Planning for Integration was initiated.

However a flexible approach would be welcomed given some of the other configurations such as the 3 Ayrshires with NHS Ayrshire and Arran.

The proposed arrangements in this consultation reflect a joint committee structure that had been present in the Highland Partnership for some time – particularly in Children’s services, and that we are now progressing beyond. The further improvement that is proposed here, regards the full integration of the budget and this will undoubtedly be of benefit.

The Highland lead agency model does not retain this joint structure but does have appropriate representation on the revised Council committee where adult services and children’s services (including Education) will be reported. Within the Health Board there are two scrutiny committees where it is envisaged that officers and members have a key role and it is at these committees that the performance against the agreed outcomes will be monitored and reported back to the Health Board.

7 Question 7: Are the proposed Committee arrangements appropriate to ensure governance of the Health and Social Care Partnership?

No

The risk with the proposed structure is that the “other” services are marginalised and the importance of integration with these services is lost. In rural areas this may be particularly difficult as services are often delivered by single handed practitioners who work across a range of client groups. As with all change it is important to ensure that new barriers are not put up that will damage existing good working relationships. Because Governance is at the health and social care partnership level the question must be asked where governance of the other services will sit and how the whole system will then be held to account.

The proposed model “a” may be perceived as introducing a third organisation with it’s own accountability and autonomy. In our view this will not be sufficient to drive the change that is required and could be more divisive.

Question 8: Are the performance management arrangements described above sufficiently robust to provide public confidence that effective action will be taken if local services are failing to deliver appropriately?

Yes

Close working with and support from the Care Inspectorate and Healthcare Improvement Scotland will be key The evidence of improvement as a result of the Child Protection Inspections under the remit of HMIe is now legendary and in the most part due to the positive, supportive and enabling approach adopted by all and led by HMIe.

However the review of scrutiny bodies did advise the development of a light touch approach and reduction in duplication.

It is also valuable to continue to build on the existing outcome framework and clarify the key performance indicators which must be SMART and adequately reflect outcomes and impacts. It is reiterated that Performance management must focus on outcomes and not delivery so that innovation can thrive and Partnerships can focus on the impact they are making across the client groups.

Question 9: Should Health Boards and Local Authorities be free to choose whether to include the budgets for other CHP functions – apart from adult health and social care – within the scope of the Health and Social Care Partnership?

Yes

If this would have an impact on the outcomes sought then there should not be legislation in the way of enabling that. Each Partnership has different issues relative to their geography, demographics and need, and must be able to seek solutions relevant to this information. The delivery of services across the private and voluntary sector is also wide and varied and local decisions and proposals need to be driven locally.

8 Integrated budgets and resourcing Question 10: Do you think the models described above can successfully deliver our objective to use money to best effect for the patient or service user, whether they need “health” or “social care” support?

Yes

The reference to resource identity and the recommendation to eliminate the need to track this is most welcome as we acknowledge that an outcome based approach will lead to significant change in the way that we deliver care . This emphasises the need to have the outcomes clear and measurable so that value for money, quality and efficiency can be evidenced. This may feel uncomfortable for staff and managers who are used to close monitoring of budget spend, and support will need to be ongoing. It will also be helpful for any in-year release of funding to be focussed on outcomes to re-enforce this approach once again.

The model adopted in Highland places responsibility for delivery in the hands of the Lead Agency and this allows for that flexible use of resource focussed on the outcomes. The agreed performance management framework and performance indicators ensure that both organisations can be held to account and evidenced through the outcomes achieved. We are therefore fully supportive of the Lead Agency option.

Option a – delegation to the health and social care partnership established as a body corporate, is in our view likely to be the less effective option. Working across two organisations has not proved overly successful and this option introduces a third dimension which could be perceived as autonomous because of it’s governance structure.

There is also a danger that this replicates the Community Health Partnership approach and from a Highland perspective this is counterintuitive.

It is important to clarify that in option b, which is being progressed in Highland, the budgets will become integrated and lose their identity going forward. The use of the term hosting could imply that budgets require to be tracked in the future. It is worth highlighting that the Highland Partnership has agreed this will not be practical nor achievable if we truly move to an outcome based approach.

Question 11: Do you have experience of the ease or difficulty of making flexible use of resources across the health and social care system that you would like to share?

Yes

One of the drivers for integration in the Highlands has been the difficulties arising in decision- making primarily around budgets. Processes in Children’s services have been streamlined into a single process with one plan, one meeting and one lead professional and now that GIRFEC model is developing across Scotland. However despite best efforts the system still required decisions that had implications on budgets and as these were separate decision-making systems, it was difficult to keep the child and family at the centre of the process.

Similarly in adult services, the example you give is all too familiar and is reflected in the average length of stay in care homes.

9 Because of historical individual budgets we have developed similar groups of staff working in very similar ways and in so doing introduced even more barriers. Our integrated plans will enable us to look at all the assistant level staff and deploy them more flexibly as a team, as well as introducing greater opportunities for training and development across this wider team to deliver the outcomes we are focussed on.

Question 12: If Ministers provide direction on the minimum categories of spend that must be included in the integrated budget, will that provide sufficient impetus and sufficient local discretion to achieve the objectives we have set out?

Yes

There must be a level of flexibility to enable that local response but if the direction is too limited the desired outcomes may not be achieved. The emphasis should be on functions and not services per se to ensure that the total resource required to deliver that function is included in the integrated pot.

Jointly Accountable Officer Question 13: Do you think that the proposals described here for the financial authority of the Jointly Accountable Officer will be sufficient to enable the shift in investment that is required to achieve the shift in the balance of care?

No

Whereas there may be some merit in having one senior officer accountable for the integrated budget, there is greater danger that decisions continue to be made in isolation and the impact across other departments, services or agencies are not considered or assessed. This was one of the barriers that in Highland we strove to eliminate and the Accountable Officer as it applies to option a of the Integration models, could be in the position of being excluded from other decisions or indeed find themselves making decisions in isolation which impact across organisations in a detrimental way. An example of this may be the development of long term condition management without cognisance of the importance of oral health on the reaction and recovery of the patient/client. Similarly the drive to meet financial savings targets and efficiencies may compromise the sustainability of services outwith the Health and Social Care Partnership on which communities are reliant.

The description of the jointly Accountable Officer in Chapter 4 specifically leads the reader to believe that this will be a mandatory appointment for both options. However the description of the options in Chapter 5 conflicts with this by not referring to this appointment at all in the detail around Option b. It would be helpful to be more explicit at the outset in relation to the governance and the requirement to have a jointly Accountable Officer.

10 Question 14: Have we described an appropriate level of seniority for the Jointly Accountable Officer?

Yes

These needs to be at a Senior level which of course will have implications for funding of posts and the numbers of senior managers in an organisation. Those “other” services will be also required to be managed at a senior level and in the more rural areas this may cause a bit of a duplication of effort.

Professionally led locality planning and commissioning of services Question 15: Should the Scottish Government direct how locality planning is taken forward or leave this to local determination?

Yes – but within certain parameters

Some guiding principles based on the benefits gained to date will be helpful.

As the Highland model developed we recognised the need for local influence not just across the professions but also within the elected members. With functions being delegated to health there was a concern that democratic accountability would be diluted. Highland is developing District Partnerships which provide an opportunity to bring together, in a public forum, practitioners, users, carers, voluntary and independent sector and local managers to discuss services for children and adults. These Partnerships will be instrumental in identifying local issues and brainstorming solutions, sharing local performance and experience, influencing future commissioning. There may be a need to reconsider how community planning functions, particularly in the context of the development of community understanding and resilience. Too much definition may restrict innovation and the development of effective communities.

Question 16: It is proposed that a duty should be placed upon Health and Social Care Partnerships to consult local professionals, including GPs, on how best to put in place local arrangements for planning service provision, and then implement, review and maintain such arrangements. Is this duty strong enough?

Yes

This is of course coupled with an outcome based approach and adopting strategic and operational commissioning. All of this together requires involvement and engagement of the full range of stakeholders. We have seen great work completed in Highland led by Clinicians in the community such as the virtual ward initiatives and anticipatory care planning. These have made significant contributions to shifting the balance of care and as this approach is adopted Highland wide, we anticipate a groundswell of enthusiasm for this new way of working evidenced by the outcomes achieved. We have learned that clinical leadership and especially the role of the GPs, is pivotal in coordinating community services.

11 Question 17: What practical steps/changes would help to enable clinicians and social care professionals to get involved with and drive planning at local level?

Often backfill availability is cited as an issue and certainly within General Practice there are not insignificant costs associated with this. Just providing backfill does not always ensure consistency of approach or contribution however, and so there is a need to not only identify leadership at local level across the clinical /practice community but also to ensure that these practitioners are adequately trained and resourced to make the commitment. Clinical and professional leadership is very valuable and an investment in it is essential, but it must be effective and practitioners must know what is expected of the role and how it contributes to the overall objectives and delivery of outcomes.

It is vital that these professionals are engaged at the outset and understand and commit to the outcomes.

Question 18: Should locality planning be organised around clusters of GP practices? If not, how do you think this could be better organised?

Perhaps

The Local Healthcare Co-operatives were developed in this way and in many ways were very successful at engaging the GPs and wider Primary Care. However the revision of the GMS contract with the emphasis on QOF and related payments tended to focus attention back on individual practices and much of the progress made was lost. There would be some benefit to this configuration where services are specific to a population say in a rural area, but in cities and larger towns where zoning of GP practices is not always so obvious this is more complex. As we develop expertise in commissioning and especially in the first phase of identifying the relevant data to inform decision making, it may make more sense to encourage groups of practices. This would again in rural areas mirror the associated school groupings in children services and aid transitions from children to adult services.

Question 19: How much responsibility and decision making should be devolved from Health and Social Care Partnerships to locality planning groups?

In Highland we would agree with the principle of having decision making as close to the point of delivery as possible but this cannot always be defined as there are a number of factors such as geography, level of need and deprivation and demography that will influence this. However we have committed to the District Partnerships being integral to the community planning process by way of engagement, local problem solving, developing local knowledge and expertise, communications and influence. The expectation of the lead agencies is that managers, acting within their delegated authority, will be expected and empowered to work with local practitioners, professional groups, public and patient representatives through these District Partnerships to implement local solutions. These Partnerships will focus on engagement and planning and must involve the 3rd and independent sectors. In addition we have an escalation route to Chief Executives where this is not happening.

12 We have found that local areas and communities often know what is best and need to be more empowered to come up with solutions. The development of self care, health improvement as well as community engagement and resilience is fundamental if we are to meet the needs of the future. Further work is perhaps needed to assess the added value of the Community Planning Partnerships as they are currently configured to ensure they are fit for purpose going forward.

Question 20: Should localities be organised around a given size of local population – e.g., of between 15,000 – 25,000 people, or some other range? If so, what size would you suggest?

No

There are too many parameters to consider in a country of the size and diversity of Scotland. No one size fits all is a good mantra when dealing with the complex landscape that faces us. It is important that there are agreed principles on which we build our models, that outcomes are agreed across Scotland so that all get the opportunity for the best possible outcomes regardless of where they live, that lines of accountability are clear and performance management frameworks are robust and effective.

13 Do you have any further comments regarding the consultation proposals?

There is limited reflection throughout this consultation of the impact on staff who remain the most important asset of the Public sector and who are fundamental to achieving the outcomes we seek. Annex C touches on this key point recognising the need to consider staff governance in this process as we did in Highland and acknowledging that the Health Board and Local Authority have quite different approaches and can learn considerably from each other.

For staff to work together effectively in a new structure established as a “body corporate” there must be consideration of how they are involved in the decision-making, supported throughout the change and to what policies and procedures they will work after integration. In developing the Lead Agency model in Highland considerable effort was directed into engaging and working with Staff and Trade Unions across the organisations. The NHS staff partnership approach was adopted and acknowledged as good practice throughout the Highland Planning for Integration and this provided wide learning for all. In NHS Highland as the Lead agency for adult services, we are progressing the development of a Practice Forum to ensure those working in Social Work and Social Care have similar support and influence as clinicians have through the Area Clinical Forum. This will need to be considered in the body corporate model.

Do you have any comments regarding the partial EQIA? (see Annex D)

This is an essential piece of work and must be viewed as ongoing to ensure any impacts are fully analysed and necessary action taken.

Do you have any comments regarding the partial BRIA? (see Annex E)

Again this is an essential and valuable piece of work. It is useful to list the legislation that will be directly affected by this new Act and that which is superseded. However it would also be useful to reference the 2002 legislation that remains extant and in fact enables the delegated option considered as Option 1.

Jan Baird Transitions Director

May 2012

14 Highland NHS Board 5 June 2012 Item 4.5(a)

Interim Financial Position at 31 March 2012

Report by Nick Kenton, Director of Finance

The Board is asked to:

 Note the financial out-turn of a £85,000 underspend.  Note this is subject to audit review.  Note the non-recurrent savings carried into 2012/13.

1 INTRODUCTION

This report is based upon the most up to date information for the end of the financial year and should be viewed as provisional as it is still subject to audit scrutiny.

The current out-turn for 2012/13 highlights that the Board has met its financial targets with a small underspend of £85,000 against the Revenue Resource Limit (RRL) and a £8,000 underspend against the Capital Resource Limit (CRL), subject to audit.

2 FINANCIAL POSITION OVERVIEW

Tables 1 and 2, attached provide a summary breakdown of the initial year end out-turn and shows a range of relatively small movements which net to an overall improvement of £85,000 on the previous estimate of break-even.

There are a number of reasons contributing to this movement and this will be detailed in section 3. The main areas are;

 Improvements in prescribing positions  Underspend in resource transfer  Increases in tertiary costs – primarily cardiology

Table 3 details the levels of savings achieved and incorporates an additional column to highlight the full year effect of 2011/12 savings and confirms a recurring shortfall as previously estimated, to be carried into 2012/13 of just under £9m.

Capital expenditure is summarised within table 4 highlighting a minor underspend of £8,000. 3 COST PRESSURES AND OPERATIONAL PERFORMANCE

Issues to note are;

 The financial out-turn at operational level (i.e. excluding corporate and central areas) has an overspend of £6.7m and this has been offset by £6.2m of non-recurrent resource as well as an underspend within Corporate Services of £0.6m.

 Raigmore, North CHP and Tertiary budgets combined have an overspend of £7.3m which is reduced to the £6.7m above, by underspends in other units. There has also been no real improvement in the full year effect (FYE) of recurrent savings for these units.

 There is a Highland-wide improvement in prescribing of around £0.4m and this is due to the benefit of some high value drugs coming off-patent a few months earlier than had been expected, along with a benefit from profits returned to the NHS under the terms of the national community pharmacy contract, efficient Purchasing and Prescribing Programme (ePPP) scheme.

Under the terms of this programme community pharmacy contractors are allowed to retain an agreed level of the purchase profit which they make when purchasing drugs they then dispense on behalf of the NHS, with the balance of the saving achieved by virtue of contractors’ purchasing activities being retained by NHS Boards.

 Resource transfer information for the end of the financial year, as provided by the Council, is £0.3m less than budgeted for.

 Cardiology activity in Grampian increased in the latter part of the year and the reasons for this are being explored.

4 CONCLUSION

The financial challenges for 2011/12 were never underestimated and the delivery of break- even is a considerable achievement given the fiscal pressures facing the NHS as a whole.

The movement to a significant reliance on non-recurrent resource is obviously less welcome and is not sustainable and this requires to be improved as we move forward into 2012/13.

5 GOVERNANCE IMPLICATIONS

Accurate and timely financial reporting is essential to maintain financial stability and facilitate the achievement of Financial Targets which underpin the delivery and development of patient care services. In turn, this supports the deliverance of the Governance Standards around Clinical, Staff and Patient and Public Involvement.

6 RISK ASSESSMENT

Financial risks, including the potential failure to deliver the necessary Financial Targets are included on the Corporate Risk register and managed accordingly.

2 7 PLANNING FOR FAIRNESS

A robust system of financial control is crucial to ensuring a planned approach to savings targets – this allows time for impact assessments of key proposals impacting on any changes to services.

8 ENGAGEMENT AND COMMUNICATION

The majority of the Board’s revenue budgets are devolved to operational units, each of which has a governance committee that includes staff-side, patient and public forum members in addition to local authority members, voluntary sector representatives and non-executive directors. These meetings are open to the public. The overall financial position is considered at the full Board meeting on a regular basis. All these meetings are also open to the public. The overall financial position was described in “Health Check” which was sent to every household in Highland.

Nick Kenton Director of Finance

25 May 2012

3 NHS Highland TABLE 1 Income & Expenditure Report as at 31st Mar 2012

Annual Plan Position to Date Prev Report Current Plan Actual Variance Forecast Movement Plan Summary Funding & Expenditure to Date to Date to Date Variance in month £000 £000 £000 £000 £000 £000

484,096 SEHD -Baseline Funding 484,096 484,096 0 0 0 15,704 - Recurring Supplemental Allocations 15,704 15,704 0 0 0 (12,743) - Non Recurring Supplemental Allocations (12,743) (12,743) 0 0 0 487,057 Sub total - SEHD Core RRL 487,057 487,057 0 0 0

25,237 - Non Core Funding 25,237 25,237 0

512,294 SEHD Funding as at March 2012 512,294 512,294 0 0 0

38,543 - FHS Non Discretionary 38,543 38,543 0 0 0 55,489 - FHS GMS Allocation 55,489 55,489 0 0 0 0 - Recurring Pending allocations 0 0 0 0 0 0 - Non Recurring Pending allocations 0 0 0 0 0

606,327 Total SEHD Funding 606,327 606,327 0 0 0 Expenditure

Direct Health Services

43,744 CHP's incl Hosted Services - North Highland 43,744 44,524 (780) (907) 127 72,772 - Mid Highland 72,772 72,711 61 0 61 88,835 - South East Highland 88,835 88,519 316 216 99 175,310 - Argyll & Bute 175,310 175,266 43 188 (144) 130,075 Raigmore 130,075 134,836 (4,760) (4,720) (40) 20,269 Facilities 20,269 20,275 (6) (3) (2) 4,816 Integrated Pharmacy 4,816 4,809 7 3 5 16,231 Health Care Purchases 16,231 18,030 (1,799) (1,600) (199) 16,219 Resource Transfer & Voluntary Organisations 16,219 15,932 287 (59) 346 (12,295) Income SLA's NCA's etc (12,295) (12,177) (118) (123) 5 12,082 Cost of Capital 12,082 12,082 0 0 0 14,924 Central Costs/Reserves 14,924 8,717 6,206 6,380 (174)

582,982 TOTAL DHS SERVICES 582,982 583,525 (543) (625) 82

23,345 Corporate Services 23,345 22,717 628 625 3

606,327 Total Expenditure 606,327 606,242 85 0 85

(0) Surplus/Deficit Mth 12 (0) 606,242 85 0 85

Finance - Monitoring 4.5a Area Finance Report Tables 2011-12 Month 12 (Feb-Mar).xls Total Summary 24/05/2012 17:00 Income&ExpenditureReportasat 31stMar2012 Table 2 Annual Budget YTDPosition PrevReport Current Plan Actual Variance Forecast Movement Plan Detailed Expenditure to Date to Date to Date Variance in month £000 £000 £000 £000 £000 £000

18,090 A&BCHP- Oban, Lorn & Isles 18,090 18,265 (175) (113) (62) 16,487 MidArgyll,Kintyre&Islay 16,487 16,776 (289) (244) (45) 7,673 A&BMHIn-patientServices 7,673 7,575 97 187 (90) 12,730 Cowal&Bute 12,730 12,855 (126) (57) (69) 5,097 Helensburgh&Lomond 5,097 5,024 73 49 24 3,773 Other clinical services 3,773 3,692 81 63 18 15,619 GMS 15,619 15,635 (16) 0 (16) 18,329 Prescribing 18,329 18,005 324 311 13 11,901 FHS Non Disc. Services 11,901 11,901 (0) 0 (0) 45,762 HCP-Glasgow&Clyde 45,762 45,632 130 82 48 3,852 HCP-Other 3,852 3,975 (123) (157) 34 4,458 Resource Transfer 4,458 4,439 19 26 (7) 11,540 Central & Corporate 11,540 11,492 49 41 8 175,310 Total A&B CHP 175,310 175,266 43 188 (144)

24,552 North CHP - Caithness 24,552 25,048 (496) (465) (31) 9,255 EastSutherland 9,255 8,885 370 300 70 3,108 NorthWestSutherland 3,108 2,868 240 198 42 6,829 North CHP Mang't/HS/OOH 6,829 7,723 (894) (940) 46 43,744 Total North Highland CHP 43,744 44,524 (780) (907) 127

32,598 Mid CHP- Ross & Cromarty 32,598 32,813 (216) (306) 90 21,807 Lochaber 21,807 22,207 (401) (360) (41) 11,975 Skye & Lochalsh 11,975 11,908 66 22 45 1,880 HotelServices 1,880 1,782 98 104 (6) 2,869 Mid CHP Management 2,869 2,262 607 667 (61) 71,128 Sub Total Mid CHP 71,128 70,973 154 127 27 1,023 SexualHealth 1,023 1,081 (57) (88) 30 621 HighlandHUB/NHS24 621 657 (36) (40) 4 1,645 Sub Total Mid CHP Hosted services 1,645 1,738 (93) (127) 34 72,772 Total Mid Highland CHP/Hosted services 72,772 72,711 61 0 61

9,009 SE CHP - Nairn/Ardersier 9,009 9,092 (84) (122) 38 9,013 Badenoch&Strathspey 9,013 8,959 54 39 15 29,746 Inverness 29,746 29,995 (250) (337) 87 3,217 SECHPCentral/HotelServices 3,217 3,026 191 255 (64) 50,984SubTotalSECHP 50,984 51,073 (88) (164) 76 18,205 MentalHealth 18,205 17,921 284 272 11 1,196 LearningDisabilities 1,196 1,138 58 57 1 17,935 Dental 17,935 17,848 87 86 1 514 SEChpUtilities 514 539 (25) (35) 10 37,850 Sub Total SE CHP Hosted services 37,850 37,447 404 381 23 88,835 Total SE Highland CHP 88,835 88,519 316 216 99

46,387 RAIGMORE- Surgical & Anaesth. Divison 46,387 51,512 (5,125) (4,864) (262) 70,718 Medical & Diagnostics Division 70,718 71,052 (334) (551) 216 4,297 RaigmoreHotelServices 4,297 4,592 (295) (260) (35) 4,805 PatientSupportDivision 4,805 4,911 (106) (84) (21) 3,868 Central Costs & Provisons 3,868 2,768 1,100 1,039 61 130,075 Total Raigmore 130,075 134,836 (4,760) (4,720) (40)

Other DHS Services 20,269Facilities 20,269 20,275 (6) (3) (2) 4,816IntegratedPharmacy 4,816 4,809 7 3 5 16,231HealthCarePurchases 16,231 18,030 (1,799) (1,600) (199) 16,219 ResourceTransfer&VoluntaryOrganisations 16,219 15,932 287 (59) 346 (12,295) Income SLA's NCA's etc (12,295) (12,177) (118) (123) 5 12,082CostofCapital 12,082 12,082 0 0 0 14,924 Central Costs/Reserves 14,924 8,717 6,206 6,380 (174) 72,246 Other DHS Services - North Highland 72,246 67,668 4,578 4,598 (20)

582,982 Total DHS Services 582,982 583,525 (543) (625) 82

23,345CorporateServices 23,345 22,717 628 625 3

606,327 Total Net Expenditure 606,327 606,242 85 (0) 85 Highland NHS Board Savings Targets 31st March 2012 Table 3

Position to DateYear End Outturn Full Year EffectTarget Achieved YTD Achieved YTD Unidentified Achieved Outstanding B/fwd 2010/11 2011/12 Total Operational CRS REC Non Rec REC FYE 2012/13 C/Fwd £000 £000 £000 £000 £000 £000 £000 £000 CHP's

896 820 1,716 North Highland CHP 241 409 1,066 83 1,392 0 1,326 1,326 Mid Highland CHP 1,326 0 0 0 492 1,647 2,139 SE Highland CHP 137 2,002 (0) 1,643 359 229 5,300 5,529 Argyll & Bute CHP 5,143 387 0 387 584 319 903 Other Health Care Purchases 138 765 0 765

2,201 9,412 11,613 Total CHP CRS 6,985 2,411 2,217 1,726 2,903

1,512 4,267 5,779 Raigmore 0 2,641 3,138 68 5,710 0 99 99 Integrated Pharmacy 33 67 0 0 67 32 435 467 Facilities 219 248 0 3 245

3,744 14,213 17,957 Total DHS Services 7,236 5,366 5,355 1,797 8,924

(40) 1,000 960 Corporate Services 774 197 (11) 200 (14) Management Action 0 0 0

3,704 15,213 18,917TotalCRS 8,010 5,563 5,344 1,997 8,910 42% 72%

SUMMARY £000's £000's £000's Rec NonRec Total CRS REC Target 18,917 0 18,917

Achieved YTD 8,010 5,563 13,574

Balance to Achieve 10,907 (5,563) 5,344

FYE 2012/13 1,997 0 1,997

C/Fwd to 2012/13 8,910 8,910

Finance - Monitoring 4.5a Area Finance Report Tables 2011-12 Month 12 (Feb-Mar).xls CRS 24/05/2012 17:00 Highland Health Board

Capital - Monitoring Statement - March 2012 Table 4

Summary

Prev Mnth Actual Curr Mnth Forecast Year to date Forecast Variance NHS Highland £000's £000's £000's £000's Funding: CRL (Formula) (4,748) (4,748) (4,748) 0 PCCPMP (3,204) (3,204) (3,204) 0 Other SG Funding (6,238) (6,230) (6,230) (9) Topslice 643 643 643 0 Capital Grants to revenue 380 380 380 0 CRL Reduced by NBV Disposals 196 196 196 0

Total funding available (12,971) (12,963) (12,963) (9)

Expenditure: All approved Schemes 12,961 12,963 12,963 (2) Contingency 10 10

Total Capital Expenditure 12,971 12,963 12,963 8

Highland NHS Board 5 June 2012 Item 4.5(b)

APPROACH TO BENEFITS REALISATION 2011/12 AND 2012/13

Report by Nick Kenton, Director of Finance

The Board is asked to:

 Note the approach to benefits realisation.

1 Background and Summary

The overall strategic direction for NHS Highland is based around a Quality & Efficiency Framework. As part of this ethos, there has been a change in emphasis regarding the delivering of efficiency improvements. This has seen an increasing focus on realising the financial benefits of quality improvements as opposed to more traditional methods of reducing costs. There is considerable international evidence of the value of this approach. However, it is recognised that the change in emphasis to a benefits realisation approach does take time to embed within an organisation. The purpose of this paper is to present a brief resume of the savings delivered in 2011/12 in the context of this approach and to present a summary of the progress to date in 2012/13.

2(i) Benefits Realisation 2011/12

As noted above, it is recognised that the change in emphasis away from ‘traditional’ cost improvements to a benefits realisation approach takes time to embed. The intention was to use a benefits realisation approach in 2011/12. This met with some success. However, there was evidence of instances where a quality improvement was achieved but there was a failure to close the loop and realise the financial benefits. As a result of this, it was necessary to utilise a mixed approach which included a range of traditional cost improvement measures – particularly in relation to non-recurring savings.

The table in the next section summarises across 12 broad categories the benefits realised on a recurring basis, which totalled just over £8m. Specific examples include Mental Health and Tele consultation below. However the majority of recurring savings were achieved across the operational units as a result of redesigning staffing provision and bed capacity. Specific Examples of Benefits Realisation Mental • Single point of access – releasing 90 clinical hours per week Health • Generic assessment tool • 75% reduction in Cognitive Behavioural Therapy waiting list • 85% reduction in waiting list for psychology • 50% reduction in did not attends (DNAs) • Additional 22 hours per week clinical care Tele • Development of toolkit for the use of Video conferencing in clinics consultation • Successful trial for both patients and staff giving valuable insight for roll out  Increased patient appointments, reduction in waiting times.  For Diabetes o Reduction in travelling time by 50% o Increase in number of consultations by 30% Belford • Consolidation on one site • Improved quality of care through improved medical cover • Reduce Length of Stay • Rework staffing establishment Invergordon • Use of anticipatory Care plans Virtual Ward • Regular multidisciplinary review of patients • Reduced length of stay in Raigmore • Reduction of 22,000 occupied bed days Corporate • More efficient off-site storage / improved access to patient records Services • Staff travel / lease car processes • More focussed and effective induction process However, over £10.9m of savings were achieved non-recurrently and these were primarily opportunistic rather than as a result of redesign. Clearly there is a requirement for an increase in recurring benefits realised and a reduction in non-recurrent savings from 2012/13 onwards. Benefits Realised in 2011/12 – by Category

Cat Service Redesign Plan No £000's WTE 1 Workforce 2,930 88.63 2 Primary Care 385 0.00 3 Out Of Hours 8 4 Pathway Management 73 5 Property 473 6 Corporate Services 618 6.27 7 Business Processes 113 8 Technology 77 9 Procurement 141 10 Tertiary 2,168 11 Prescribing 852 0.05 12 Income 0 Sub Total 7,837 94.95 Other Other not specified above 171 TOTAL RECURRENT 8,009 94.95 NON RECURRENT £000's WTE Achieved Non Recurrently 10,909 29.71 GRAND TOTAL 18,917 124.66

2 2(ii) Benefits Realisation 2012/13

The Board is absolutely committed to a benefits realisation approach to efficiencies for 2012/13. This approach was formally endorsed by the Board when it approved the Five Year Financial Plan in April 2012. The Board will recall that it approved a financial plan that allocated financial targets across the key themes of reducing harm, waste and variation. The next stage was to translate these into targets for individual units in order for units to be held to account for delivering the targets. After some negotiation, targets have now been allocated to units and these have received the sign-up of all the Directors of Operations and Executive Directors who have responsibility for delivering efficiencies. As part of these negotiations, it was mutually agreed to allocate the targets afresh as from 2012/13 and in effect to write off any targets not met from previous years. The result is a set of financial targets that should be achievable for each unit, as well as a system-wide target that will require co-operation between units. The targets can be broadly summarised as follows:

Argyll & Bute CHP – 2.2% North & West Highland – 2% plus share of adult social care savings South & Mid Highland - 2% plus share of adult social care savings Raigmore – 3% Corporate services – 5% Pharmacy, facilities - 3%

In addition to the above, for Northern Highland there is a target of £9m for system-wide benefits realisation arising from quality initiatives. It is anticipated that these will take time to deliver financial benefits and it is assumed that around £4.5m will be delivered in the current financial year, with the balance delivered in next financial year.

Good progress is being made in identifying efficiencies through tackling waste, harm and variation and this will be reported throughout the year. It is recognised that a balanced budget will require some ‘housekeeping’ efficiencies (however it is generally still possible to frame these in the context of reducing harm, waste and variation) in addition to more strategic initiatives. It is imperative that quality is at the heart of strategic initiatives and equally important that the resulting opportunities for financial efficiencies are realised. Crucially, it is vital that a system-wide approach is adopted in respect of benefits that require co-operation across management units. A group has been established that includes all Directors of Operations and is chaired by the Director of Finance to take this forward.

3 Contribution to Board Objectives

Ensuring that the benefits opportunities arising from a quality approach are realised will make a crucial contribution to the aim of Better Value.

4 Governance Implications

The approach to benefits realisation described in this paper will have a positive impact on financial governance by contributing to delivering financial targets. This approach requires engagement with staff, patients, the public and clinicians and this will ensure that all aspects of governance are considered.

3 5 Risk Assessment

Financial risks, including the potential failure to deliver the necessary Financial Targets are included on the Corporate Risk register and managed accordingly.

6 Planning for Fairness

A robust system of financial control is crucial to ensuring a planned approach to benefits realisation – this allows time for impact assessments of key proposals impacting on any changes to services.

7 Engagement and Communication

The majority of the Board’s revenue budgets are devolved to operational units, each of which has a governance committee that includes staff-side, patient and public forum members in addition to local authority members, voluntary sector representatives and non-executive directors. These meetings are open to the public. The overall financial position is considered at the full Board meeting on a regular basis. All these meetings are also open to the public. The overall financial position was described in “Health Check” which was sent to every household in Highland.

Nick Kenton Director of Finance

25 May 2012

4 Highland NHS Board 5 June 2012 Item 4.6

HOSPITAL SCORECARD – JUNE 2011 AND SEPTEMBER 2011

Report by Lesley Anne Smith, Head of Quality on behalf of Elaine Mead, Chief Executive

The Board is asked to:

 Note the publication of the Hospital Scorecards for June 2011 and September 2011 together with the management and assurance actions being taken in response to the data.

1 Background and Summary

1.1 NHS Board Chief Executives agreed in November 2011 that it was important to establish a core set of measures which could be used, alongside a range of other intelligence, to track a number of key areas of healthcare quality across Scotland, providing alerts where there are potential areas of concern which required more detailed investigation. As a result, colleagues across Scottish Government, NHS:QIS (and latterly HIS), NSS:ISD and across Territorial Boards have explored a range of potential measures, and considered the role of this national ‘scorecard’ alongside the local systems which individual NHS Boards have developed or are developing. The result of this work is the attached ‘Hospital Scorecard’.

1.2 The Scottish Government Health and Social Care Management Board (HSCMB) examines the scorecard on a quarterly basis to gain assurance and identify areas of potential concern about the quality of healthcare services in acute hospitals across NHSScotland based on their assessment of the full range of indicators. This exercise is carried out alongside, but aligned with, and informed by, a range of specific improvement programmes such as Scottish Patient Safety Programme (SPSP) where HIS and ISD are in regular contact with Boards about the detail which underpins measures such as the Hospital Standardised Mortality ration (HSMR). It also complements the assessment of progress towards HEAT targets and financial performance, considered regularly by HSCMB.

1.3 HSCMB considers the Scorecard following each new update and any relevant ongoing SG/HIS improvement and performance support work with NHS Boards. The next discussion will relate to the June 2012 Scorecard and will take place at their meeting in June 2012. They will also continue to invite Boards to use the Scorecard locally for quality assurance and benchmarking, as appropriate.

1.4 ISD plan to undertake development work in the next few months with a view to being able to make case-mix adjustments to the readmissions and average length of stay indicators in the Scorecard from June 2012 onwards.

2. Position in NHS Highland

2.1 The Hospital Scorecards for June 2011 (July 2010 - June 2011) and September 2011 (October 2010 – September 2011) were issued in May 2012. The details of the position in relation to NHS Highland overall, and each of the hospitals is attached at Appendix 1. 2.2 The majority of the indicators are monitored through our existing management and governance structures, and the reporting lines are indicated on the table.

2.3 The outliers in relation to readmission rates for Belford Hospital have been investigated by the management team. This is a data inputting issue and has arisen since the redesign of the Belford Hospital in 2010 to a Combined Assessment Unit. Following discussions with the Principle Information Analyst, National Services Scotland, it has been confirmed that elective activity i.e. day attenders for blood transfusion on a fortnightly basis have been coded as emergency admissions and have therefore been collated as readmissions. The correction of this error will show that the Belford in reality is not a true outlier. This issue has now been corrected at a local level.

2.4 In February 2012, the Clinical Governance Committee agreed that a Clinical Governance/Quality Committee Dashboard be developed with the following measures included in the first instance:

Dimension Measure Frequency Person-centered Complaints measure Quarterly Better Together results Annual Local Inpatient Survey results Quarterly Safe Hospital Standardised Mortality Rate (HSMR) Quarterly Raw Mortality Quarterly Adverse events using Global Trigger Tool Quarterly Falls Measure Quarterly Pressure Ulcer Measure Quarterly Nutrition Clinical Quality Indicator (CQI) Quarterly Effective Emergency Admission Rate/Bed Days Quarterly Percentage of time in the last 6 months of life Quarterly spent at home or in a community setting

The first dashboard is due to be presented to the August 2012 meeting of the Clinical Governance Committee.

2.5 Work is ongoing to develop measures and a reporting format in relation to the Care Capacity Workstream of the Quality & Efficiency Plan and this will include length of stay indicators.

2.6 A number of other measures are reported in other Fora within NHS Highland including the Balanced Scorecard and the Infection Control Report. Work will continue to ensure appropriate alignment throughout the organisation.

3 Contribution to Board Objectives

NHS Highland is committed to ensuring systems are in place which support the organisation to meet the following objectives:  Monitor responses to patient specific focused interventions  Evaluate the impact of specific care processes  Improve processes on a continuous basis  Manage organisational imperatives  Report performance both internally and externally.

2 4 Governance Implications

Clinical Governance Delivery of a high quality, safe and effective service is fundamental to the Highland Quality Approach and can continued scrutiny of the Hospital Dashboard provides assurance to the Board that systems are in place to allow quality to be measured, monitored, managed and improved.

5 Risk Assessment

The purpose of the Hospital Dashboard is to ensure a system is in place to alert the organisation to where there are potential areas of concern which require more detailed investigation. Early intervention ensures that risks are managed as necessary. Any areas of significant concern will be subject to risk assessment and consideration given as to whether escalation to the risk register is required.

6 Planning for Fairness

This paper does not require to be assessed in relation to Planning for Fairness.

7 Engagement and Communication

This is an update paper as part of the Highland Quality Approach. The Engagement and Communication Plan relating to the Highland Quality Approach is the subject of a separate Board paper.

Dr Lesley Anne Smith Head of Quality NHS Highland

25 May 2012

3 HOSPITAL SCORECARD ISSUED MAY 2012 October 2010 - September 2011 June 2010 - July 2011 Indicator Definition Reporting Scotland Highland Belford Caithness L&I Raigmore Scotland Highland Belford Caithness L&I Raigmore Hospital Standardised Observed/Expected SPSP/ Clinical Mortality Ratios deaths Governance Committee - - 0.92 0.91 0.78 0.84 - - 1.11 0.82 0.67 0.73 Surgical Readmissions within Standardised* Rate per 7 Days 1,000 admissions 19.87 23.62 100.82 27.52 30.49 16.80 19.57 23.43 93.62 22.97 24.75 17.61 Surgical Readmissions within Standardised* Rate per Surgical Profiles/ 28 Days 1,000 admissions Clinical Governance Committee 37.90 40.44 133.62 52.33 49.08 32.12 37.41 40.80 123.28 49.06 42.20 33.80 Medical Readmissions within Standardised* Rate per Medical Profiles/ 7 Days 1,000 admissions Clinical Governance Committee 46.42 55.44 152.18 41.74 64.60 41.00 45.83 55.54 157.43 40.14 57.56 41.78 Medical Readmissions within Standardised* Rate per Medical Profiles/ 28 Days 1,000 admissions Clinical Governance Committee 104.27 113.28 207.54 82.63 109.23 99.66 103.34 112.25 214.92 80.62 103.90 97.42 Average Surgical Length of Calendar days Surgical Profiles/ Stay (Unadjusted) Clinical Governance Committee 5.56 5.77 3.68 6.75 4.80 6.01 5.57 5.70 3.35 6.38 4.73 6.02 Average Medical Length of Calendar days Medical Profiles/ Stay (Unadjusted) Clinical Governance Committee 8.17 8.13 4.26 8.23 6.51 7.24 8.19 8.22 4.10 8.46 7.06 7.30 Surgical Crude Rate Complications (per 1,000 admissions) ------2.11 - 0.00 0.00 1.28 1.46 A&E Waiting Times A&E attendances Balanced Scorecard/ waiting more than 4 hr, Improvement % Committee - 1.17 2.34 0.82 1.03 1.78 - 1.36 1.61 0.93 0.95 2.03 C.Difficile Infections (Over Crude Rate per 1,000 Balanced Scorecard/ 65) acute occupied bed Improvement days Committee 0.58 0.33 0.78 0.00 0.00 0.12 0.56 0.34 0.71 0.00 0.41 0.16 SAB Infections (All MSSA/ Crude Rate per 1,000 Balanced Scorecard/ MRSA) acute occupied bed Improvement days Committee 0.38 0.16 0.00 0.00 0.00 0.10 0.39 0.19 0.00 0.51 0.00 0.13 Scottish Inpatient Patient Scottish Inpatient Annual Survey/ Experience Survey 2011 Patient Experience Clinical Governance Survey 2011 Committee -- 86.67 83.78 86.11 80.30 78.10 82.80 86.67 83.80 86.10 80.30

Key: Outlier

Above average/greater than target Below average/less than target Highland NHS Board 5 June 2012 Item 4.8

INFECTION PREVENTION & CONTROL REPORT

Report by Liz McClurg, Infection Control Manager and Dr Emma Watson Infection Control Doctor on behalf of Heidi May, Board Nurse Director & Executive Lead for Infection Control

The Board is asked to:

 Note the contents of the report.

1 Aim

The purpose of this paper is to update Board members of the current status of Healthcare Associated Infections (HAI) and infection control measures in NHS Highland.

2 Background

In line with the NHS Scotland HAI Action Plan 2008, there is a requirement for a HAI report to be presented to the Board on a two monthly basis.

3 Summary

This report provides an overview for the Board of Infection Prevention and Control with particular reference to the incidence of Healthcare Associated Infections (HAI) against Scottish Government HEAT targets, together with results from cleanliness monitoring, hand hygiene audit results and surgical site infections.

Staphylococcus aureus Target of 0.26 cases per 1000 acute occupied bed days bacteraemia (SAB) met and exceeded.

NHS Highland rate April –March 2012 is 0.18.

Clostridium difficile Target of 0.39 per 1000 total occupied bed days in patients aged 65 and over met and exceeded.

NHS Highland rate April –March 2012 is 0.26.

Significant Event Review on the Clostridium difficile outbreak in Raigmore Hospital in January 2012 completed.

Hand Hygiene Compliance with hand hygiene 97% in March and April 2012.

Work on how to achieve consistent compliance with all staff groups ongoing.

Cleaning and the Healthcare Cleaning Compliance 93% in March and 95% in April Environment 2012.

Estates Monitoring Compliance 95% in March and 96% in April 2012. Maintaining the fabric of patient areas in older buildings to enable effective cleaning is a challenge. The effectiveness and application of existing monitoring tool is being reviewed

Significant HAI incidents / Clostridium difficile infection outbreak in Ward 2C outbreaks, emerging threats Raigmore Hospital April 2012. An incident debrief has been held. A Significant Event Review is not planned, as the recommendations from the one undertaken following the outbreak in January will apply

Nationally norovirus outbreaks are continuing to arise despite the time of year. Wards in Caithness General and Raigmore hospitals have been closed to admissions.

Antimicrobial Prescribing Continuing compliance above 95% with antibiotic choice in medicine and choice and duration of prophylaxis in colorectal elective surgery. Working with general surgery to improve compliance above median of 91%.

Surgical site infections Orthopaedic and caesarean section surgical site infections rates remain low, and within anticipated levels. Work is ongoing with the colorectal surgeons to reduce the SSI rate in elective patients.

Decontamination Risks identified and detailed in the main report regarding washer disinfectors, local decontamination units in Argyll & Bute, decontamination of instrument compliance in Independent Dental Practitioner practices.

4 Contribution to Board Objectives

Our key objective is “to reduce to an absolute minimum the chance of acquiring an infection whilst receiving healthcare and to ensure our hospitals are clean”. This report presents a comprehensive view of HAI data and activities for scrutiny and feedback from the Board.

5 Governance Implications

5.1 Staff Governance

As additional information is distributed more widely it should ensure staff are better informed in respect of current issues relating to Infection Prevention & Control and the management of HAI in our healthcare premises - “Infection Prevention is Everybody’s Business”.

5.2 Patient and Public Involvement

The distribution of regular information to the patient/public sector should increase awareness and facilitate increased participation of patient/public representatives in the Infection Prevention & Control agenda.

5.3 Clinical Governance

By improving infection control practices, we will endeavour to provide a healthcare environment for patients that minimises the risk of HAI. 2 5.4 Financial Impact

By reducing the incidence of HAI in our healthcare premises, financial savings can be achieved through lower rates of infection.

5.5 Better Health, Better Care, Better Value

By improving infection control practices, we will endeavour to provide a healthcare environment for patients that minimises the risk of HAI.

6 Risk Assessment

By risk assessing infection control practices, we will endeavour to minimise the risk of HAI.

7 Planning for Fairness

As Infection Control policies are updated they are impact-assessed for equality and diversity.

8 Communications and Engagement

Work is ongoing around raising awareness with staff to make sure they consistently apply the principles of Standard Infection Control Precautions. Hand hygiene is the single most important procedure for preventing cross infection, as hands are of special significance in the transmission of infections. All health board are required to demonstrate every two months, a minimum of 95% compliance with the five moments and technique for hand hygiene. A Hand hygiene module is now available online and is in the process of being launched. The module is mandatory for all staff. A section on Infection Control has been included in new Staff Handbook which is out for consultation. A range of briefing materials on infection control has been prepared.

There is a public representative on NHS Highland Control of Infection Committee. Further recruitment of patient and public representatives would be welcome to support work programme and identify best ways to raise awareness with patients, visitors and wide public. A high level summary is attached (Appendix 1).

Liz McClurg Emma Watson Infection Control Manager Infection Control Doctor

25 May 2012

3 NHS Highland Healthcare Associated Infection Report – May 2012 Section 1 – NHS Highland Board Wide Issues

Key Healthcare Associated Infection Headlines .  NHS Highland continues to achieve the HEAT Targets.  CDI outbreak in Raigmore Hospital  Norovirus prevalent in Highland May 2012 Hospital wards closed

Staphylococcus aureus (including MRSA)

Staphylococcus aureus is an organism which is responsible for a large number of healthcare associated infections, although it can also cause infections in people who have not had any recent contact with the healthcare system. The most common form of this is Meticillin Sensitive Staphylococcus Aureus (MSSA), but the more well known is MRSA (Meticillin Resistant Staphylococcus Aureus), which is a specific type of the organism which is resistant to certain antibiotics and is therefore more difficult to treat. More information on these organisms can be found at: Staphylococcus aureus : http://www.nhs24.com/content/default.asp?page=s5_4&articleID=346 MRSA: http://www.nhs24.com/content/default.asp?page=s5_4&articleID=252 NHS Boards carry out surveillance of Staphylococcus aureus blood stream infections, known as bacteraemias. These are a serious form of infection and there is a national target to reduce them. The number of patients with MSSA and MRSA bacteraemias for the Board can be found at the end of Section 1 and for each hospital in Section 2. Information on the national surveillance programme for Staphylococcus aureus bacteraemias can be found at: http://www.hps.scot.nhs.uk/haiic/sshaip/publicationsdetail.aspx?id=30248

Current HEAT status With effect from April 2011, all Boards are expected to achieve a rate of 0.26 Staphylococcus aureus bacteraemia (SAB) cases per 1000 acute occupied bed days or lower by year ending March 2013. For NHS Highland that means no more than 73 cases.

April – March 2012, NHS Highland Staphylococcus aureus bacteraemia rate is 0.18 per 1000 acute occupied bed days, 51 cases (for the same period 2010, the rate was 0.21 per 1000 acute occupied bed days, 59 cases)

4 Figure 1 Funnel plots of Staphylococcus aureus bacteraemia rates per 1000 AOBDs by NHS Board for the year 2011

HG = NHS Highland

During March and April there were 4 Staphylococcus aureus bacteraemias cases (3 x MSSA and 1 x MRSA).

Appendix 2 (attached) gives the analysis of Staphylococcus aureus bacteraemias in NHS Highland from April 2011 – March 2012.

Figure 2 shows year on year Cumulative SAB numbers in NHS Highland

80

70

60

50

40 s e d

30o s i p

20E e v i

10t a l u 0 m u C 2008-09 2009-10 20105 -11 2011-12 Initiatives to reduce SAB Infections

Each SAB is reviewed in microbiology and, if it is felt that the SAB could have been avoided or prevented, then a clinical review meeting is held with the relevant clinical team who are responsible for ensuring that learning outcomes are disseminated to staff and that processes are in place to monitor practice.

MRSA Screening

The roll out process across acute hospitals is complete. The roll-out process in the majority of community hospitals throughout Highland is almost complete; the 4 outstanding will be complete by end of June 2012. NHS Boards are required to ensure MRSA screening becomes part of their local integrated approach to improving the quality of person centred, safe and effective patient care. The allocation from SGHD that will allow Boards to fully embed the policy and ensure it is sustainable will be known by end May 2012.

Clostridium difficile

Clostridium difficile is an organism which is responsible for a large number of healthcare associated infections, although it can also cause infections in people who have not had any recent contact with the healthcare system. More information can be found at: http://www.nhs.uk/conditions/Clostridium-difficile/Pages/Introduction.aspx NHS Boards carry out surveillance of Clostridium difficile infections (CDI), and there is a national target to reduce these. The number of patients with CDI for the Board can be found at the end of Section 1 and for each hospital and community hospitals within each CHP in Section 2. Information on the national surveillance programme for Clostridium difficile infections can be found at: http://www.hps.scot.nhs.uk/haiic/sshaip/ssdetail.aspx?id=277

Clostridium difficile Infection (CDI)

With effect from April 2011, all Boards are expected to achieve a rate of 0.39 cases of Clostridium difficile per 1000 total occupied bed days (OCBDs) or lower among patients aged 65 and over by year ending March 2013. For NHS Highland that means no more than 86 cases.

April 2011 – March 2012, NHS Highland Clostridium difficile rate was 0.26 per total occupied 1000 bed days (59 cases) in patients age 65 and over (for the same period 2010, the rate was 0.299 per total occupied 1000 bed days, 66 cases)

April 2011 – March 2012, NHS Highland Clostridium difficile rate was 0.39 per 1000 total occupied bed days (22 cases) in patients aged 15 – 64 years ( for the same period 2010, the rate was 0.53 per total occupied 1000 bed days, 30 cases).There is no national HEAT target for this age group.

6 Figure 3 Funnel plot of incidence rates of CDI for all NHS Boards in Scotland in patients aged 65 and over against occupied bed days (total) for the year 2011

HG = NHS Highland

Figure 4 Funnel plot of rates of incidence CDI for all NHS Boards in Scotland in patients aged 15 – 64 years against occupied bed days (acute) for the year 2011.

HG = NHS Highland 7 Figure 5 shows Clostridium difficile toxin positive episodes in NHS Highland in patients aged 65 and over.

70

60

50 s e d o s i

40p e

e v i t a l

30u m u C 20

10

0

2010-2011 2011/2012 2012/2013

Figure 6 shows NHS Highland cumulative Clostridium difficile Toxin Positive Episodes All ages

250

200

150

100s e d o is p 50e e v ti la0 u m u C 2008-2009 2009-2010 2010-2011 2011/2012

8 Initiatives to reduce CDI Cases

 Promoting prudent antimicrobial prescribing message to all prescribers in NHS Highland.  A plan to reduce PPI prescribing  Continued promotion of good hand hygiene across all staff groups and general public.  Attention to environmental cleanliness.  Developing an environment that is easy to clean and promotes single rooms.  Review of the diagnostic methodology used in the laboratory and availability of 7 day testing.

Enhanced surveillance is carried out on every CDI case with immediate feedback to staff concerned. Surveillance includes 30-day follow up from diagnosis for Clostridium difficile.

The Infection Prevention & Control Team, Antimicrobial Pharmacist and CHP Pharmacists continue to work with clinical staff to ensure best practice and appropriate antibiotic prescribing is embedded at every opportunity.

Anti Microbial Prescribing

Table 1 shows NHS Highland progress against the 3 national indicators

Antimicrobial Indicator NHS Highland progress Hospital-based empirical prescribing Non-compliant In acute admission areas, antibiotic Two areas are monitored, as required, in prescriptions are compliant with the local Raigmore Hospital. Median compliance with antimicrobial policy and the rationale for antibiotic prescribing guidelines, based on treatment is recorded in the clinical case note data from April 2011 to March 2012, remains in above 95% of sampled cases. at 96% for the Acute Medical Admissions Unit and 91% for Surgical Admissions Ward From April 2011, learning points from cases (4A). of non-compliance are shared throughout the clinical teams to improve practice.

Surgical antibiotic prophylaxis Compliant. Duration of surgical antibiotic prophylaxis is Data to the end of March 2012 shows less than 24 hours and compliant with local continuing compliance above 95% with antimicrobial prescribing policy in above 95% antibiotic choice and duration of prophylaxis. of sampled elective colorectal surgical cases.

Primary care empirical prescribing Compliant. Seasonal variation in quinolone use (summer No further data available until June 2012. months vs. winter months) is less than 5%.

Antimicrobial Prescribing Guidance (Management of Infection Guidance)

The Antimicrobial Management Team continues to review current antibiotic guidelines to ensure the most up-to-date evidence is reflected. New guidance from Scottish Antimicrobial Prescribing Group (SAPG) on the content of local antimicrobial prescribing guidelines will be incorporated in the NHS Highland Management of Infection Guidance in due course. The section on prescribing and monitoring advice for gentamicin is currently under review. A draft algorithm on the management of urinary tract infection in elderly patients and care home residents has been developed by SAPG with comments from NHS Highland AMT

9 members. It is hoped to pilot the algorithm with a group of interested GPs within the board area prior to national roll out across Scotland.

Antibiotic Point Prevalence Audits An audit of antibiotic prescribing in Paediatrics and SCBU has highlighted issues around antibiotic choice for skin and soft tissue infections and documentation of duration of therapy. The clinical teams involved have agreed to discuss how this can be improved at ward level.

Hand Hygiene

Good hand hygiene by staff, patients and visitors is a key way to prevent the spread of infections. More information on the importance of good hand hygiene can be found at: http://www.washyourhandsofthem.com/ NHS Boards monitor hand hygiene and ensure a zero tolerance approach to non compliance. The hand hygiene compliance score for the Board can be found at the end of section 1 and for each hospital and community hospitals within each CHP in section 2. Information on national hand hygiene monitoring can be found at: http://www.hps.scot.nhs.uk/haiic/ic/nationalhandhygienecampaign.aspx

NHS Highland Hand Hygiene Rolling Monthly Audit Programme continues across all clinical areas sustaining an average of 96% compliance. NHS Highland continues to participate in the bi-monthly National Hand Hygiene audits.

Audible signage (Speechpods) were purchased and distributed across Highland; however given the volume of the signage they are unsuitable for ward areas, as repeated messages are disturbing for patients - therefore they have limited value and are not used as extensively as first envisaged. Work is ongoing to ensure the message given to staff and patients supports the WHO 5 moments for hand hygiene.

Hand Hygiene training Hand hygiene training is now available via E-learning on LearnPro NHS. The module is mandatory for all staff with a revalidation/refresher period of 3 years. In addition to undertaking the module, staff will be required to demonstrate in their work place that they are able to carry out the procedure to a high standard .The aim of the module is to provide an understanding of when and how to clean hands and care for skin. The AT-Learning (Learning Management System) will monitor who has undertaken the module and provide reports.

Cleaning and the Healthcare Environment

Keeping the healthcare environment clean is essential to prevent the spread of infections. NHS Boards monitor the cleanliness of hospitals and there is a national target to maintain compliance with standards above 90%. The cleaning compliance score for the Board can be found at the end of Section 1 and for each hospital and community hospitals within each CHP in Section 2. Information on national cleanliness compliance monitoring can be found at: http://www.hfs.scot.nhs.uk/online-services/publications/hai/ Healthcare environment standards are also independently inspected by the Healthcare Environment Inspectorate. More details can be found at: http://www.nhshealthquality.org/nhsqis/6710.140.1366.html 10 Domestic Service teams continue to carry out monthly cleaning and estates audits. Compliance with cleaning across NHS Highland was 93% in March and 95% in April 2012. Compliance with estates monitoring across NHS Highland was 95% in March and 96% in April 2012.

Following the January 2012 outbreak in Raigmore Hospital, an HAI task force was established and HEI-type inspections were carried out across Raigmore. The findings raised significant concern about the fabric of the environment in Raigmore. There are challenges around maintaining the fabric of patient areas in older buildings to enable effective cleaning which have not been picked up using the national monitoring tool. The effectiveness of the existing monitoring tool and how it is applied is under review by the Infection Prevention and Control Lead Doctor.

Outbreaks/Incidents

Significant Event Review on the Clostridium difficile outbreak in Raigmore Hospital in January 2012 has been completed. An action plan, developed following the outbreak, is well underway to address the recommendations made around policy, practice, staffing and structural issues. See Appendix 3 for full Significant Event Review report.

On 17th April 2012 the second outbreak of Clostridium difficile was confirmed in Ward 2C (Oncology) Raigmore Hospital. The ward reopened on Monday 23rd April 2012 once deep cleaning completed. During the period of the outbreak a total of 3 patients were confirmed as having Clostridium difficile.

A debrief meeting was held on 9th May 2012. The findings highlighted 1. Commode replacement programme underway but not fully completed. 2. The location of hand washing sinks for staff and visitors is being considered. 3. A bed management system is being trialled which will enable better tracking patients. 4. Communication with the Estates Department and Domestic Services was good. 5. Having the Senior Charge Nurse with clear guidelines worked well.

A Significant Event Review is not planned, as the recommendations from the one undertaken following the outbreak in January will apply.

Nationally norovirus outbreaks are continuing to arise despite the time of year. Norovirus has been prevalent in the community setting. Several care homes were closed throughout Highland. Some hospitals saw admissions of patients with Norovirus symptoms from the community with ward closures in Raigmore Hospital, Ward 2A Care of the Elderly, Ward 6C and Ward 7C Medical, Rosebank Ward (Medical) in Caithness General Hospital and Glenaray Ward, Mid Argyll Hospital, Lochgilphead

HAI Related Death One patient died within 30 days following diagnosis of Clostridium difficile infection in April 2012; it was recorded as a contributory factor on the death certificate. The Scottish Government Health Directorate and Health Protection Scotland were informed at the time.

11 Other HAI Related Activity

Planning for Integration – Care Homes

The first of a series of workshops will be held at the end of May 2012 to explore implications of integration for infection prevention and control. Operational issues will also be reviewed, with a view, for example, to streamlining supplies and waste disposal arrangements with current NHS Highland practice

HEI Inspections

The Health Care Environment Inspectorate made an announced inspection to Lorn & Islands Hospital on 18th April 2012. They found evidence that Lorn and Islands General Hospital is complying well with the NHS QIS HAI standards to protect patients, staff and visitors from the risk of acquiring an infection. The draft report has indicated that there is one requirement and four recommendations. The final report will be published Wednesday 30 May 2012.

The HEI made an unannounced inspection to Belford Hospital on 8th May 2012. The draft report is expected 30/05/2012 and will be published 18th June 2012.

The HEI made an unannounced inspection to the MacKinnon Memorial Hospital on 10th May 2012. The draft report is expected 30/05/2012 and will be published 20th June 2012

Infection Prevention & Control Governance Structure NHS Highland Control of Infection Committee has approved, in principle, a change to the infection prevention & control committee structure which will strengthen lines of accountability.

Annual Work Programme 2012 - 2013

NHS Highland Control of Infection Committee have accepted in principle the 2012-13 annual work programme which will be submitted to the Board in August 2012 for ratification.

NHS Highland Water Safety Group

A Water Safety Group has been set up to ensure that there are robust and consistent arrangements in place to ensure the safety of water systems in NHS Highland. It will report to the Infection Control Improvement Group.

Surgical Site Infections (SSI)

The Infection Control Surveillance team continue to monitor Caesarean Section and Orthopaedic Surgical Site infections. There is no substantial change in prevalence in either since the last Board report.

Colorectal Surgical Site Infection

Colorectal surveillance commenced February 2011. Areas for improvement have identified and the Infection Prevention & Control and Colorectal teams are working together to implement changes.

12 Figure 7 shows colorectal surgical site infections February 2011 – January 2012

Colorectal SSI Feb 2011 - January 2012

80 limited data range, Development of SSI Commencement of interpret with caution surveillance system 90 day Feb 2011 - June 2011 3 emergency ops, improvement 70 2infections Aug

60 4 emergency ops 2 2 emergency ops 1 infections Nov 50 infection Jan s n o i t

c Elective e

f 40 n

i Emergency

f o

% 30

20

10

0 Feb-11 Mar-11 Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Month

Decontamination

The Central Decontamination Unit is CE Certificated with the Medicines and Healthcare products Regulatory Agency (MHRA) which is subject to the successful application of ISO 13485:2003, Quality Management System – Medical Devices and satisfactory surveillance auditing. The next surveillance audit is due in May 2012. The unit is however vulnerable as the washer disinfectors are reaching the end of their life span. The Decontamination Manager has submitted a paper to the Asset Management Group that has been noted and prioritised amongst the other capital requirements for the Board. The planned preventative maintenance programme for the washer disinfectors continues to ensure their safe functioning capabilities.

All of the completed NHS Highland Local Decontamination Units comply with the Glennie Technical requirements; work is ongoing to provide suitable units or contingency arrangements for locations within Argyll & Bute which as yet do not comply.

Compliance within the Independent Dental Practitioner setting is challenging as the development of decontamination units is undertaken by the individual sites. CDO (2009)01 notified GDP independent contractors that they were required by December 2011 to provide LDU facilities within their practices for the decontamination of instruments which were compliant with SHPN 13 Part 2. Based on GDPs self assessment, as of 31 March 2012: 82% (40) practices assess themselves as compliant, 14% (7) state that they have plans in place to extend or relocate their practice to achieve compliance by December 2012 and 4% (2) practices have no plans in place and are intending to sell their practice. NHS Highland Control of Infection Committee to seek advice from Chief Dental Officer on compliance issues.

A working group has been established to look at what needs to be done to enable all local decontamination in theatres to be halted by the end of 2014.

An option appraisal paper on delivering compliant endoscope decontamination facilities for NHS Highland will be submitted to the Senior Management Team for consideration.

13 Healthcare Associated Infection Reporting Template (HAIRT) Section 2 – Healthcare Associated Infection Report Cards

The following section is a series of ‘Report Cards’ which provide information for each acute hospital (Raigmore, Caithness General, Belford and Lorn & Islands), and the community hospitals within each CHP. The information includes the number of cases of Staphylococcus aureus blood stream infections (also broken down into MSSA and MRSA) and Clostridium difficile infections as well as hand hygiene and cleaning and estates compliance. With effect from April 2012, there are two additional report cards to reflect the community hospitals in the North & West Highland and South & Mid Highland Divisions.

The out-of-hospital infections report card identifies infections as having been contracted from outwith hospital.

The information in the report cards is provisional local data, and may differ from the national surveillance reports carried out by Health Protection Scotland and Health Facilities Scotland. The national reports are official statistics which undergo rigorous validation, which means final national figures may differ from those reported here. However, these reports aim to provide more detailed and up-to-date information on HAI activities at local level than is possible to provide through the national statistics.

Understanding the Report Cards – Infection Case Numbers

Clostridium difficile infections (CDI) and Staphylococcus aureus bacteraemia (SAB) cases are presented for each hospital and the community hospitals within each CHP broken down by month. Staphylococcus aureus bacteraemia (SAB) cases are further broken down into Meticillin Sensitive Staphylococcus aureus (MSSA) and Meticillin Resistant Staphylococcus aureus (MRSA). Data is presented as both a graph and a table giving case numbers. More information on these organisms can be found on the NHS24 website:

Clostridium difficile : http://www.nhs24.com/content/default.asp?page=s5_4&articleID=2139§ionID=1

Staphylococcus aureus : http://www.nhs24.com/content/default.asp?page=s5_4&articleID=346

MRSA: http://www.nhs24.com/content/default.asp?page=s5_4&articleID=252§ionID=1

For each acute hospital and community hospitals in each CHP, the total cases for each month are those which have been reported as positive from a laboratory report on samples taken more than 48 hours after admission. For the purposes of these reports, positive samples taken from patients within 48 hours of admission will be considered to be confirmation that the infection was contracted prior to hospital admission and will be shown in the “out-of-hospital” report card.

Understanding the Report Cards – Hand Hygiene Compliance

Good hand hygiene is crucial for infection prevention and control. More information can be found from the Health Protection Scotland’s national hand hygiene campaign website: http://www.washyourhandsofthem.com/

Hospitals carry out regular audits of how well their staff are complying with hand hygiene. The first page of each hospital/CHP report card presents the percentage of hand hygiene compliance for all staff in table form.

Understanding the Report Cards – Cleaning Compliance

14 Hospitals strive to keep the care environment as clean as possible. This is monitored through cleaning and estates compliance audits. More information on how hospitals carry out these audits can be found on the Health Facilities Scotland website: http://www.hfs.scot.nhs.uk/online-services/publications/hai/

The Report Cards show the hospitals’ cleaning compliance percentage in table form.

Understanding the Report Cards – ‘Out of Hospital Infections’

Clostridium difficile infections and Staphylococcus aureus (including MRSA) bacteraemia cases are all associated with being treated in hospitals. However, this is not the only place a patient may contract an infection. This total will also include infection from community sources such as GP surgeries, care homes and the community itself. The final Report Card report in this section covers ‘Out of Hospital Infections’ and reports on SAB and CDI cases reported to a Health Board which are not attributable to a hospital. Given the complex variety of sources for these infections it is not possible to break this data down in any more detail.

15 Abbreviations

AMT Antimicrobial Prescribing Team

AMAU Acute Medical Admissions Unit

CHP Community Health Partnership

CDI Clostridium difficile Infection

CNO Chief Nursing Officer

CVC Central Venous Catheter

GDP General Dental Practitioner

HAI Healthcare Associated Infection

HAIRT Healthcare Associated Infection Reporting Template

HEAT Health Improvement, Efficiency, Access, Treatment

ICU Intensive Care Unit

JAG Joint Advisory Group

MSSA Meticillin Sensitive Staphylococcus Aureus

MRSA Meticillin Resistant Staphylococcus Aureus

PICC Peripherally Inserted Central Catheter

PVC Peripheral Venous Catheter

QUAD Quality Assurance Document

SAB Staphylococcus aureus Bacteraemia

SHPN Scottish Health Planning note

SPC Statistical Process Chart

SAPG Scottish Antimicrobial Prescribing Group

SICPs Standard Infection Control Precautions

SPSP Scottish Patient Safety Programme

VAP Ventilator Associated Pneumonia

16 Quarterly rolling year Clostridium difficile Infection Cases per 1000 total occupied bed days for HEAT Target Measurement

0.45

0.40

0.35

0.30

0.25

0.20

0.15

0.10

0.05

0.00 Apr 10 - Jul 10 - Oct 10 - Jan 11 - Apr 11 - Jul 11 - Oct 11 - Jan 12 - Apr 12 - Mar 11 Jun 11 Sept 11 Dec 11 Mar 12 Jun 12 Sept 12 Dec 12 Mar 13

Apr 10 - Jul 10 - Oct 10 - Jan 11 - Apr 11 - Jul 11 - Oct 11 - Jan 12 - Apr 12 - Mar 11 Jun 11 Sept 11 Dec 11 Mar 12 Jun 12 Sept 12 Dec 12 Mar 13 Actual Performance 0.34 0.26 0.26 0.22 Target 0.39 0.39 0.39 0.39 0.39 0.39 0.39 0.39 0.39

Quarterly rolling year Staphylococcus aureus Bacteraemia Rates per 1000 Acute Occupied Bed Days for HEAT Target Measurement

0.30

0.25

0.20

0.15

0.10

0.05

0.00 Apr 10 - Jul 10 - Oct 10 - Jan 11 - Apr 11 - Jul 11 - Oct 11 - Jan 12 - Apr 12 - Mar 11 Jun 11 Sept 11 Dec 11 Mar 12 Jun 12 Sept 12 Dec 12 Mar 13

Apr 10 - Jul 10 - Oct 10 - Jan 11 - Apr 11 - Jul 11 - Oct 11 - Jan 12 - Apr 12 - Mar 11 Jun 11 Sept 11 Dec 11 Mar 12 Jun 12 Sept 12 Dec 12 Mar 13 Actual Performance 0.21 0.21 0.21 0.21 Target 0.26 0.26 0.26 0.26 0.26 0.26 0.26 0.26 0.26 Pan Highland Total Staphylococcus aureus Bacteraemia Cases (all ages)

12

10

8

Data on Estates Monitoring Compliance available only from April 2011 6

4

2

0 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12

May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 Hand Hygiene Monitoring Compliance (%) 3 2 2 6 2 5 4 6 7 3 4 4 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar 12 Apr 12 Apr-12 95 96 94 94 96 96 97 97 97 97 97 97 MRSA Bacteraemia Cases (all ages)

12

Cleaning Compliance (%) 10 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 8

93 92 92 93 93 94 94 94 94 94 93 95 6

4

2 Estates Monitoring Compliance (%) 0 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 95 93 94 95 96 96 95 96 95 96 95 96

May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 0 0 0 1 0 1 1 0 3 1 1 0

Clostridium difficile Cases (ages 15 and over) MSSA Bacteraemia Cases (all ages)

18 10012 16 10 14 80 12 8 60 10 6 8 40 6 4

4 20 2 2 0 00 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-11May-11 Jun-11 Jun-11 Jul-11 Jul-11 Aug-11 Aug-11 Sep-11 Sep-11 Oct-11 Nov-11 Oct-11 Dec-11 Nov-11 Jan-12 Dec-11 Feb-12 Jan-12 Mar-12 Feb-12 Apr-12

May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 5 7 8 8 4 3 5 5 15 8 5 13 3 2 2 5 2 4 3 6 4 2 3 4 Raigmore Hospital Total Staphylococcus aureus Bacteraemia Cases (all ages)

12

10

8

6

4

2

0 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12

May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 Hand Hygiene Monitoring Compliance (%) 1 1 1 2 1 3 2 4 1 2 1 0 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 93 94 94 94 95 97 96 93 96 95 96 96 MRSA Bacteraemia Cases - (All Ages)

12

10 Cleaning Compliance (%) 8 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 93 82 94 95 91 94 93 93 93 93 93 95 6

4

2 Estates Monitoring Compliance (%) 0 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 98 85 98 98 99 97 97 95 95 95 97 96

May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 0 0 0 1 0 1 1 0 0 0 0 0

Clostridium difficile Cases (ages 15 and over) MSSA Bacteraemia Cases (all ages)

18 10012 16 10 14 80 12 8 60 10 6 8 40 6 4

4 20 2 2 0 00 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-11May-11 Jun-11 Jun-11 Jul-11 Jul-11 Aug-11 Aug-11 Sep-11 Sep-11 Oct-11 Nov-11 Oct-11 Dec-11 Nov-11 Jan-12 Dec-11 Feb-12 Jan-12 Mar-12 Feb-12 Apr-12

May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 0 2 1 2 0 1 1 2 0 2 1 2 1 1 1 1 1 2 1 4 1 2 1 0 Caithness General Hospital Total Staphylococcus aureus Bacteraemia Cases (all ages)

12

10

8

6

4

2

0 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12

May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 Hand Hygiene Monitoring Compliance (%) 0 0 1 0 0 0 0 0 0 0 0 0 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 95 96 94 95 97 99 98 98 99 98 98 99 MRSA Bacteraemia Cases (all ages)

12

Cleaning Compliance (%) 10 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 8

93 92 93 93 97 97 95 94 95 95 90 95 6

4

2 Estates Monitoring Compliance (%) 0 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 98 97 98 95 99 98 96 98 97 98 98 96

May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 0 0 0 0 0 0 0 0 0 0 0 0

Clostridium difficile Cases (ages 15 and over)

18 10012 16 10 14 80 12 8 60 10 6 8 40 6 4

4 20 2 2 0 00 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-11May-11 Jun-11 Jun-11 Jul-11 Jul-11 Aug-11 Aug-11 Sep-11 Sep-11 Oct-11 Oct-11 Nov-11 Nov-11 Dec-11 Dec-11 Jan-12 Jan-12 Feb-12 Feb-12 Mar-12 Mar-12 Apr-12

May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 0 0 1 0 0 0 1 0 0 1 1 1 0 0 1 0 0 0 0 0 0 0 0 0 Belford Hospital Total Staphylococcus aureus Bacteraemia Cases (all ages)

12

10

8

6

4

2

0 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12

May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 Hand Hygiene Monitoring Compliance (%) 0 0 0 0 0 0 0 0 1 0 0 0 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 97 94 90 95 97 95 98 99 97 92 99 100 MRSA Bacteraemia Cases - (All Ages)

12

Cleaning Compliance (%) 10 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 8

90 96 93 95 91 90 92 94 90 96 93 95 6

4

2 Estates Monitoring Compliance (%) 0 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 97 96 99 99 99 97 96 98 99 99 97 98

May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 0 0 0 0 0 0 0 0 0 0 0 0

Clostridium difficile Cases (ages 15 and over) MSSA Bacteraemia Cases (all ages)

18 10012 16 10 14 80 12 8 60 10 6 8 40 6 4

4 20 2 2 0 00 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-11May-11 Jun-11 Jun-11 Jul-11 Jul-11 Aug-11 Aug-11 Sep-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Feb-12 Mar-12 Mar-12 Apr-12 Apr-12

May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 0 1 1 0 0 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0 1 0 0 0 Lorn & Islands Hospital Total Staphylococcus aureus Bacteraemia Cases (all ages)

12

10

8

6

4

2

0 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12

May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 Hand Hygiene Monitoring Compliance (%) 0 0 0 0 0 0 0 0 0 0 0 0 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 95 97 91 95 98 95 96 98 96 100 99 99 MRSA Bacteraemia Cases (all ages)

12

Cleaning Compliance (%) 10 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 8

96 95 95 92 94 96 97 96 97 97 96 95 6

4

2 Estates Monitoring Compliance (%) 0 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 93 93 95 96 93 95 93 95 94 95 94 93

May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 0 0 0 0 0 0 0 0 0 0 0 0

Clostridium difficile Cases (ages 15 and over) MSSA Bacteraemia Cases (all ages)

18 10012 16 10 14 80 12 8 60 10 6 8 40 6 4

4 20 2 2 0 00 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-11May-11 Jun-11 Jun-11 Jul-11 Jul-11 Aug-11 Aug-11 Sep-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Feb-12 Mar-12 Mar-12 Apr-12 Apr-12

May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Mid CHP Community Hospitals Total Staphylococcus aureus Bacteraemia Cases (all ages)

12

10

8 Mid CHP Community Hospitals include Ross Memorial Hospital Dingwall, County Community Hospital Invergordon, MacKinnon memorial Hospital, 6

Broadford & Portree Hospital Isle of Skye. 4

2

0 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12

May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Hand Hygiene Monitoring Compliance (%) 0 0 0 0 0 0 0 0 0 0 0 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 95 95 91 90 95 96 91 97 96 99 95 MRSA Bacteraemia Cases (all ages)

12

Cleaning Compliance (%) 10 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 8

97 89 95 92 91 94 94 92 93 93 93 6

4

2 Estates Monitoring Compliance (%) 0 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 91 91 85 92 90 93 90 94 94 96 94

May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 0 0 0 0 0 0 0 0 0 0 0

Clostridium difficile Cases (ages 15 and over) MSSA Bacteraemia Cases (all ages)

18 10012 16 10 14 80 12 8 60 10 6 8 40 6 4

4 20 2 2 0 00 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 May-11May-11 Jun-11 Jun-11 Jul-11 Jul-11 Aug-11 Aug-11 Sep-11 Sep-11 Oct-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Mar-12

May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 South East CHP Community Hospitals Total Staphylococcus aureus Bacteraemia Cases (all ages)

12

10

For the purposes of monitoring New Craigs Psychiatric Hospital is included 8 in this report card. Other hospitals included are RNI Community Hospital 6 Inverness, Town & County Hospital Nairn, Ian Charles Community Hospital Grantown on Spey, St. Vincents Hospital Kingussie 4 2

0 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12

May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Hand Hygiene Monitoring Compliance (%) 0 0 0 0 0 0 0 0 0 0 0 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 94 98 97 93 94 93 97 95 96 99 98 MRSA Bacteraemia Cases (all ages)

12

Cleaning Compliance (%) 10 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 8

94 93 91 92 94 95 95 96 95 93 94 6

4

2 Estates Monitoring Compliance (%) 0 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 94 92 95 92 96 96 95 97 95 95 94

May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 0 0 0 0 0 0 0 0 0 0 0

Clostridium difficile Cases (ages 15 and over) MSSA Bacteraemia Cases (all ages)

18 10012 16 10 14 80 12 8 60 10 6 8 40 6 4

4 20 2 2 0 00 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 May-11May-11 Jun-11 Jun-11 Jul-11 Jul-11 Aug-11 Aug-11 Sep-11 Sep-11 Oct-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Mar-12

May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 0 1 1 0 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Argyll & Bute CHP Community Hospitals Total Staphylococcus aureus Bacteraemia Cases (all ages)

12

10

Argyll & Bute Community Hospitals include Argyll & Bute Hospital, Lochgilphead, 8 Campbeltown Hospital, Cowal Community Hospital Dunoon, Dunaros Community 6 Hospital, Isle of Mull, Islay Hospital, Mid Argyll Community Hospital & Integrated Care Centre Lochgilphead, Victoria Hospital & Annex Rothesay 4 2

0 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12

May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 Hand Hygiene Monitoring Compliance (%) 0 0 0 0 0 0 0 0 0 0 0 0 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 95 96 97 97 98 93 97 97 97 94 95 95 MRSA Bacteraemia Cases (all ages)

12

Cleaning Compliance (%) 10 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 8

94 94 94 94 95 95 94 95 94 95 95 95 6

4

2 Estates Monitoring Compliance (%) 0 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 94 94 95 96 94 95 96 97 95 96 94 97

May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 0 0 0 0 0 0 0 0 0 0 0 0

Clostridium difficile Cases (ages 15 and over) MSSA Bacteraemia Cases (all ages)

18 10012 16 10 14 80 12 8 60 10 6 8 40 6 4

4 20 2 2 0 00 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-11May-11 Jun-11 Jun-11 Jul-11 Jul-11 Aug-11 Aug-11 Sep-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Feb-12 Mar-12 Mar-12 Apr-12 Apr-12

May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 0 0 0 1 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 North CHP Total Staphylococcus aureus Bacteraemia Cases (all ages)

12

10

8 North CHP Community Hospitals include Dunbar Hospital, Thurso; Town & County Wick; Lawson Memorial Hospital, Golspie; Migdale Hospital, Bonar 6

Bridge. 4

2

0 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12

May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Hand Hygiene Monitoring Compliance (%) 0 0 0 0 0 0 0 0 0 0 0 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 99 98 99 100 98 100 100 100 97 98 99 MRSA Bacteraemia Cases (all ages)

12

Cleaning Compliance (%) 10 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 8

93 93 90 93 95 95 94 94 93 94 93 6

4

2 Estates Monitoring Compliance (%) 0 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 99 95 97 96 96 96 96 96 94 94 96

May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 0 0 0 0 0 0 0 0 0 0 0

Clostridium difficile Cases (ages 15 and over) MSSA Bacteraemia Cases (all ages)

18 10012 16 10 14 80 12 8 60 10 6 8 40 6 4

4 20 2 2 0 00 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 May-11May-11 Jun-11 Jun-11 Jul-11 Jul-11 Aug-11 Aug-11 Sep-11 Sep-11 Oct-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Mar-12

May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Out of Hospital Infections Clostridium difficile Infection Cases

12

10

8

6 .

4

2

0 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12

May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 5 2 4 4 3 2 3 1 6 4 2 8

MSSA Bacteraemia Cases MRSA Bacteraemia Cases

12 12

10 10

8 8

6 6

4 4

2 2

0 0 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12

May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 2 1 0 4 1 2 2 2 2 0 2 4 0 0 0 0 0 0 0 0 3 1 1 0 NW Operational Unit Total Staphylococcus aureus Bacteraemia Cases (all ages)

12

10

The North West Operational Unit comprises Dunbar Hospital, Thurso; Town & 8 County Wick; Lawson Memorial Hospital, Golspie; Migdale Hospital, Bonar Bridge, Ross Memorial Hospital Dingwall, County Community Hospital Invergordon, 6 MacKinnon memorial Hospital, Broadford & Portree Hospital Isle of Skye. 4

2

0 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13

Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Hand Hygiene Monitoring Compliance (%) 0 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 97 MRSA Bacteraemia Cases (all ages)

12

Cleaning Compliance (%) 10

Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 8 97 6

4

Estates Monitoring Compliance (%) 2

Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 0 98 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13

Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 0

Clostridium difficile Cases (ages 15 and over) MSSA Bacteraemia Cases (all ages)

12 12100

10 10 80

8 8 60 6 6 40 4 4

2 220

0 00 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Apr-12May-11 May-12 Jun-11 Jun-12 Jul-11 Jul-12 Aug-11 Aug-12 Sep-11 Sep-12 Oct-11 Oct-12 Nov-11 Nov-12 Dec-11 Dec-12 Jan-12 Jan-13 Feb-12 Feb-13 Mar-12 Mar-13

Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 0 0 South Mid Operational Unit Total Staphylococcus aureus Bacteraemia Cases (all ages)

12

10 The South Mid Operational Unit comprises Ross Memorial Hospital Dingwall, County Community Hospital Invergordon, RNI Community Hospital Inverness, 8

Town & County Hospital Nairn, Ian Charles Community Hospital Grantown on 6 Spey, St. Vincents Hospital Kingussie. For the purposes of monitoring New Craigs 4 Psychiatric Hospital is included in this report card. 2

0 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13

Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Hand Hygiene Monitoring Compliance (%) 0 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 97 MRSA Bacteraemia Cases (all ages)

12 Cleaning Compliance (%) 10 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 8 96 6 d 4

Estates Monitoring Compliance (%) 2

Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 0 97 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13

Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 0

Clostridium difficile Cases (ages 15 and over) MSSA Bacteraemia Cases (all ages)

12 12100

10 1080

8 8 60 6 6 40 4 4

2 220

0 00 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Apr-12May-11 May-12 Jun-11 Jun-12 Jul-11 Jul-12 Aug-11 Aug-12 Sep-11 Sep-12 Oct-11 Oct-12 Nov-11 Nov-12 Dec-11 Dec-12 Jan-12 Jan-13 Feb-12 Feb-13 Mar-12 Mar-13

Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 1 0 APPENDIX 1 High Level Communications and Engagement Plan

Workstream: Infection Prevention & Lead: Liz McClurg Infection Control Manager May 2012 Control

Planning for success Summary

1. Strategic Aim . To make sure patients do not come to harm while in hospital

2. Supporting Principles . Successful implementation of evidence-based infection prevention and control policies and procedures will reduce hospital acquired infections

3. Key Measurable Outcomes . Reduction in infection rates including Clostridium difficile and Staphylococcus aureus bacteraemia (SAB)

4. Key Messages . Poor infection control can cause harm to patients . Infection prevention and control measures must be followed at all times . Hand hygiene is the single most important procedure for preventing cross infection

5. Key Assumptions . If policies and procedures are followed infection rates will be minimised . There are systems in place for monitoring compliance . There are systems in place for feed-back compliance

6. Issues . Consistent implementation of policies across a large number of sites . Policy applies to everyone . Communication challenge around risks of coming into hospital balancing confidence in our ability to provide safe care with why there are some risks with the length of time people are in hospital

7. Risks . Staff now aware of policies or don’t follow them . Failure to follow policy . Need to ensure appropriate staffing levels, shift by shift, specialty by specialty

8. Monitoring and Escalation . Monitoring by site and ward . Bi Monthly Report to Board . Infection Control Committee . Improvement Committee

9.Communications and Engagement . Develop key messages and include in key communications  Prepare Briefing Note on issues and performance for MSPs and others . Raise awareness of Standard infection control precautions policy  Promote e-learning hand hygiene module  Patient representatives on Infection Control Committee  Ongoing awareness for Patient Councils . Recruit more patient and public members including to support with hand hygiene audits

10. Education and Training . Develop, launch and monitor E-learning hand hygiene module

2 APPENDIX 2 Staph aureus Bacteraemia NHS Highland

APRIL 2011 – MARCH 2012 SAB April 2011 - March 2012 (N=52)

MRSA 15%

MSSA 85%

SAB April 2011 - March 2012 (N=52)

True community 19%

Hospital 29%

Contaminated Blood Culture 8%

Community onset - HAI 44% RAIGMORE SAB April 2011 - March 2012 (N=42)

True community 14%

Hospital 33%

Contaminated Blood Culture 5% Community onset - HAI 48%

SABS by CHP April 2011 –March2012

0% 0% 10%

10%

Raigmore North CHP Mid-Highland CHP South East Highland CHP Argyll & Bute CHP

80% SABs (MSSA) by Age Group April 11 - March 12 (n=44)

7% below 30

18% 5%

5% 31 years to 40 years

41 years to 50 years

51 years to 60 years

18%

61 years to 70 years

71 years to 80 years 31%

81 years to 90 years

16%

NHS Highland SAB April 11- March 12 by Primary Source (N=52)

Unknown Contamination 8% 8%

Peipheralvenouscatheter infection (Venf lon) 7%

Ot her Centrallineinfections 6% 8%

Vascular Fist ula 4%

Nephrost omies Chest inf ect ion 0% 8%

UTI 4%

Vascular / Endocarditis 6%

Bone & Joint 9%

Ulcer / Cellulitis/ Soft Tissue 32% Staph aureus bacteraemias NHS Highland April 11 - March 12

12

10

8 s e d o s i 6 p E o N

4

2

0 C S R 1 I 2 2 3 3 4 S 4 5 5 6 M 6 7 8 1 1 A C A B B G H M P C A T A A C A C A C A C A C C 0 1 C H d e r o W e C o G S P M U & & o B m l r n s B D f / C U a t H o H A a E p r B U A i U d U s r e l c i d c M f s e o u e i / A o r t

e d B n U s e l h L a o v u e n n g e Ward / Clinical Area

MSSA MRSA

SAB OUTCOME April 11 - March 2012 (N=52)

Unknown 8% DEAD (SAB on Death Cert) 6% ALIVE (before 30 days) 0% DEAD (SAB not on Death Cert) 15%

ALIVE (after 30 days) 71% Highland NHS Board 5 June 2012 Item 4.7

APPENDIX 3

SIGNIFICANT EVENT REPORT – FINAL REPORT AND RECOMMENDATIONS FOLLOWING THE C DIFFICILE OUTBREAK AT RAIGMORE HOSPITAL

Report by Heidi May, Board Nurse Director, Infection Control Executive Lead

The Board is asked to:

 Note the content of the significant event review;  Endorse the recommendations made by the Raigmore Quality and Patient Safety Management Team;  Note the actions already implemented or being progressed (pp 383-385);  Note that a follow up report will be brought back to the Board within six months.

Introduction

Following the C difficile outbreak at Raigmore Hospital in January 2012 on wards 4C and 3A, a significant event review (SER) was undertaken to understand what happened and with the intention of reducing the risk of further outbreaks occurring in the future.

Outbreaks of Clostridium difficile in hospitals are fortunately rare and NHS Highland has one of the lowest rates in mainland Scotland. When outbreaks do occur, however, they are very serious and require to be examined in forensic detail, as has been carried out in this instance by the Raigmore Management Team.

Purpose of Review

The review group sought to understand why the outbreak occurred and considered a number of contributory factors including:

 Standards of cleanliness  Capacity issues within domestic services  Capacity issues within nursing in the two wards  The quality of the building infrastructure  Vulnerable patient population

Recommendations and Actions

Sixteen recommendations (pp381-382) were made by the Raigmore Management Team and an action plan with nominated leads and time lines has been produced (pp383-385). Conclusion

The C difficile outbreak at Raigmore Hospital was a serious incident which has been thoroughly investigated. Some of the recommendations identified have already been actioned. The remaining actions are due to be completed by the end August 2012.

NHS Highland remains vigilant to the cause and implications of C difficile and will continue to work closely with the infection control team to learn from this outbreak. This will include taking actions to minimise any further chance of patients acquiring an infection whilst receiving health care, and ensuring that our hospitals are clean.

Heidi May Board Nurse Director Infection Control Executive Lead

28 May 2012

NHS HIGHLAND

Significant Event Report

Final Report to Quality & Patient Safety Raigmore Management Team of Findings from Significant Event Review Meeting – 07/03/12 QPS 056

In Attendance Dr R Harvey, Associate Medical Director (Chair) Mr C Lyons, General Manager Mrs S Cascarino, General Manager, Surgical Specialties Division Mr R Coggins, Head of Service, General Surgery Dr D Parrat, Consultant Microbiologist Dr E Watson, Consultant Microbiologist Mrs A Chalmers, Infection Prevention & Control Nurse Team Leader Mrs A MacDonald, Antimicrobial Pharmacist Ms C Dow, Nurse Manager, Surgical Specialties Division Mr W Gaynor, Charge Nurse, Ward 4C Ms L Galbraith, Staff Nurse, Ward 3A Ms P Cameron, Staff Nurse, Ward 3A Mr D Mackay, Domestic Services Manager Ms E Grieg, Press Officer Mr L Gaffney, Quality & Patient Safety Facilitator

Apologies None

This note is a factual summary of a significant event review meeting. Whilst not a verbatim account of the meeting, it is an accurate representation of the information presented at the meeting, and the overall views of those present as to the management of the case.

1.0 Outline of Significant Event Dr Harvey opened the meeting to explain that it had been called as a significant adverse event had occurred in that an outbreak of Clostridium Difficile infection (CDI) involving 8 patients had occurred in the Surgical Division, Raigmore Hospital in January 2012.

The impact and rarity of this event was in itself sufficient to warrant scrutiny through a significant event analysis.

He added that he hoped those present would find the meeting valuable as a learning experience for future care. He also emphasised that the meeting was not to apportion blame.

Rather, the purpose of the meeting was:

To understand what happened and why To acknowledge and commend what was done well To identify what could have been done better To make recommendations for changes to practice in accord with this learning

1

2.0 Background 04/01/12 In Ward 4C a patient with acute pancreatitis tested positive to CD toxin. He was asymptomatic, so was not placed in isolation.

In Ward 3A an 85yr old patient with a fractured neck of femur also tested positive to CD toxin. He was symptomatic and was placed in isolation the following day.

12/01/12 The above patient in Ward 4C became symptomatic and so was placed in isolation.

14/01/12 A patient who had been transferred from Ward 4C to Invergordon Hospital the previous day tested positive to CD toxin. He had been placed in isolation on admission to Invergordon on account of his continuing symptoms of diarrhoea. He had been admitted to Ward 4C on the 19th December 2011 and subsequently developed symptoms of diarrhoea. A stool sample submitted on the 27th December 2011 tested negative for CD Toxin and other pathogenic organisms. He remained symptomatic for the remainder of his admission to Raigmore Hospital, but was not isolated all of this time (two and a half weeks). No further stool samples were sent during his admission to Raigmore Hospital.

14/01/12 (Continued) In Ward 3A, a 91yr old patient with repair of a fractured femur tested positive to CD toxin, was symptomatic, and was placed in isolation.

17/01/12 A fifth patient, this time within Ward 4C, became symptomatic. The situation that was developing was discussed with the Surgical Nurse Manager and the Infection Prevention & Control Nurse (IPCN).

The Infection Control Doctor and IPC Nurse met with staff from both Ward 4C and Ward 3A, and highlighted deficiencies in cleanliness that they had observed in both ward areas.

18/01/12 The fifth patient tested positive to CD toxin, and was placed in isolation the following day.

A planning meeting took place involving the Lead Nurse, Surgical Nurse Manager, Infection Control Doctor and IPCN Nurse, followed by an update meeting that afternoon.

A sixth patient, recently discharged from Ward 4C, became symptomatic at home.

19/01/12 A CDI meeting was held, a CDI outbreak was confirmed, and declared as per NHS Highland Outbreak/Incident of Communicable Infection & Ward Closure Policy 2010.

Accordingly, Ward 4C was closed to all new admissions.

A further CDI update meeting took place, with daily meetings thereafter for the duration of the CDI outbreak.

20/01/12 The sixth patient was readmitted to hospital, tested positive to CD toxin, and was placed in isolation.

21/01/12 A seventh patient, within Ward 4C, who was symptomatic, tested positive to CD toxin and was placed in isolation the following day.

2

25/01/12 An eighth patient, within Ward 4C, became symptomatic.

A meeting took place between the Associate Medical Director, Lead Nurse and Infection Control Doctor and the family of one of these patients, following a formal complaint relating to standards of care in Ward 4C. The family applauded the work of the nurses in this ward, and recognised that they were ‘stretched’, with many patients to care for. However they highlighted several instances in relation to the care of their relative where the standard of cleanliness and hygiene were seriously deficient.

A written summary of this meeting which had been prepared in consultation with the complainants was read out to the attendees of the SER meeting. Dr Harvey stressed that having been party to the meeting he had no reason to doubt the veracity of the issues that were described.

The family questioned whether there was a clear delineation of duties between nursing and domestic staff. The patient’s son also made reference to a ‘Don’t Walk By’ policy that existed in his organisation, whereby everyone had a responsibility to address a matter of concern once it was apparent irrespective of their job role.

The family also stated that they did not raise these matters at the time as they were very aware of the enormous pressure that Ward 4C nursing staff were under. The family had been reassured that a quality improvement plan would be produced for Ward 4C, as part of the formal response to their complaint.

26/01/12 The eighth patient tested positive to CD toxin and was placed in isolation the following day.

01/02/12 Ward 4C was reopened to new admissions.

03/02/12 A CDI debrief meeting was held involving key staff.

In summary, the CDI outbreak had involved a total of eight patients in two surgical wards. Six of these patients had been in Ward 4C, and 2 patients in Ward 3A. Although not known at the time the outbreak had involved 3 different strains of CDI – Ribotype 002 in Ward 3A, and 014 and 020 in Ward 4C.

3.0 Findings of the review group The review group addressed several questions.

1. Why did the CDI outbreak occur?

It was acknowledged that sporadic episodes of CDI cannot be prevented completely in susceptible, ill patients. Therefore, the focus must be both on reducing the risk of individual cases occurring but also importantly on preventing transmission of CDI between patients and eliminating any environmental sources of infection.

The review group considered the following issues as potential contributory factors in the cause and spread of the outbreak;

(i) Standards of cleanliness There was consensus that standards of cleanliness, both environmental and of equipment, were sub-optimal in both affected ward areas. It was considered that this was likely to have contributed to the outbreak, since the clustering of C Diff subtypes within the individual wards suggested that 3

there had been transmission between patients or a common environmental source. The issue of environmental cleanliness was identified to have several strands.

Capacity issues within Domestic Services. Whilst domestic staffing levels met the national specification, it was argued that this did not allow for a uniformly first class standard of cleaning. That is, there was necessarily some shortcomings in the service provided, requiring prioritisation of tasks performed.

Capacity issues within Nursing in the two Wards. It was acknowledged that there had been isolated cases of CDI in other ward areas that had not led to a CDI outbreak. Therefore, there were circumstances specific to these two wards that may have led to the outbreak. There had been high levels of patient occupancy but also of patient acuity within both wards at the time of the outbreak. This had been coupled with a mismatch of nurse staffing levels which were inadequate. These staffing levels had been compounded by staff sickness but also staff vacancies. These vacancies had not been immediately filled since a proposed bed reconfiguration within the Hospital would have possibly enabled the permanent re-deployment of staff from other areas of the Hospital. It was observed that over a 20yr period in Ward 4C a relatively far more complex and dependant case mix had developed and that the nursing establishment in this ward had not been revised to reflect this. It was noted that a Serious Untoward Incident Review in 2008, which had been referred to the Procurator Fiscal, had recommended an increase in the nursing establishment for Ward 4C but this had not happened. A workforce study in 2010 had recommended that the nursing establishment in Ward 4C should be increased by 1.58 whole time equivalent staff but this had not taken place. A more recent workforce review of nursing within all of Raigmore Hospital was conducted in December 2011, which has confirmed that Ward 4C is understaffed. The findings of this workforce study are currently being considered by the Senior Management Team for Raigmore Hospital, who will agree and implement its recommendations.

Infrastructure not fit for purpose (toilets etc). It was identified that some of the apparatus within the hospital that is being cleaned is not fit for purpose as it is very difficult and in some cases impossible to achieve adequate cleaning by the nature of the design; for example the patients’ toilets are not compliant with disability standards. It was observed that there had been a failure to progressively invest in the infrastructure of the hospital over many years, and that some clinical developments had probably taken place at the expense of investment in the infrastructure.

(ii) Infrastructure not fit for purpose (lack of single rooms) It was noted that Raigmore Hospital has fewer single rooms than most Scottish hospitals. There is a National directive that hospitals should aim for 100% single rooms, which should be a priority in any building development. As a minimum hospitals should achieve 50% single rooms. Raigmore Hospital currently has about 20% single rooms, with no clear plan for achieving the 50% target. This places staff under significant pressure as they try and match competing demands, for example from palliative care patients, for an inadequate, finite resource. It was stated that this has huge implications for the hospital in containing any outbreak of infectious disease.

Current infection control policy requires isolation of patients with suspected infective diarrhoea within 24 hours of the onset of symptoms or on admission (whichever is the later). Four of the 8 patients with CDI who were symptomatic and subsequently found to be positive to CD toxin were not immediately placed in isolation, due to a lack of available single rooms. These patients would however have been placing other patients at risk of CDI.

(iii) Vulnerable patient population It was identified that the patient population of both Ward 4C and Ward 3A comprised frail, often elderly patients with significant co-morbidities, requiring complex and difficult surgery. These patients frequently had complications of treatment, necessitating long-term antibiotics, and long- term hospital admissions. These were all risk factors for the development of CDI.

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(iv) Injudicious use of proton pump inhibitors (PPI) It was highlighted that all 8 patients had been receiving some form of medicine to reduce gastric acid secretion, thereby increasing the risk of colonisation of the gut with harmful bacteria. It was stated that there is strong evidence to support a correlation between PPI drugs and CDI. It was also highlighted that this patient group were receiving high levels of antibiotics, but that these drugs were appropriate as many of the patients had some form of sepsis. The use of PPI drugs must reflect a risk-benefit analysis. That is, the risk of a stress ulcer in a vulnerable patient if not used versus the risk of CDI if inappropriately used. It had proved possible to stop the PPI drugs in some of the 8 patients, supporting the hypothesis that there might have been injudicious use of these drugs with some patients.

2. Could the CD outbreak have been identified earlier? The review group considered whether the outbreak could have been identified at an earlier stage. It was explained that a highly specific test (low false positive rate) is used to detect CD toxin but that it lacks sensitivity (significant false negative rate) and there is therefore some risk of truly positive patients being undetected. In addition this test is unable to detect asymptomatic carriers who are colonoised with the bacterium and who pose an infective threat to others. It was emphasised that these colonised patients pose a real risk of transmission of CD to other patients by the release of CD spores into the environment. There was consensus that the outbreak could not have been identified earlier with the testing regime available, but that it would have been possible if a more sensitive primary screening test had been used together with one which could also identify colonisation. This is important as in this outbreak there is evidence that an initial false negative report enabled an infected patient to continue to contaminate the environment for up to eighteen days.

3. Should the management of patients with suspected CDI change? It was highlighted that the first patient, who had tested positive to CD toxin, was not isolated for another 8 days until he became symptomatic. This was in accord with the current NHS Highland guidance on infection control & prevention. There was consensus that current guidance should be revised so that all patients with a positive stool test for CD should be placed in isolation even if asymptomatic.

It was acknowledged that the patient with symptomatic diarrhoea with an eventual positive test for C Diff in Invergordon following an initial negative result in Raigmore, was probably infective for a substantial part of his stay in Raigmore Hospital. The group considered that patients with ongoing symptomatic diarrhoea without a confirmed cause should remain in isolation irrespective of a negative stool culture result and that further samples should be sent at regular intervals should symptoms persist.

4. Should Ward 3A have declared a CDI outbreak and also closed? It was noted that there had been 3 different strains of CDI. The type found in the two patients in Ward 3A was rare, and so likely to have been connected by transmission or a common environmental source. However this information was not available at the time that decisions on closure had to be taken as the turn around time for the sub type test is in excess of a week. The nursing staff involved reported that the decision to remain open had proved a burden in trying to provide a near normal service whilst deep cleaning the ward environment. It was also acknowledged that the decision to remain open and accept new admissions potentially placed other patients at greater risk of acquiring CDI. Consideration was also given to the likely impact of the loss of two acute surgical wards from a main service provider. It was observed that practice varies widely in other centres as to what constitutes a CDI outbreak, with some centres declaring an outbreak at 2 patients but others stipulating a much higher number. The validity of the arguments for both closure and remaining open were recognised. It was observed that lack of timely information posed the greatest risk in the management of a potential CDI outbreak. The availability of a more sensitive testing system capable of identifying colonisation might have identified additional patients in Ward 3A with CD. In the future such a system would be able to guide an escalation policy for dealing with a potential CDI outbreak. 5

The Chair summarised the findings of the group as to the likely reasons that the CDI outbreak had happened: I. Sub-optimal standards of cleanliness relating to capacity issues with domestic services and nursing. II. Infrastructure not fit for purpose (lack of side rooms, inadequate provision of appropriate toilets, wash basins and taps, equipment difficult to adequately clean) III. The vulnerable patient population IV. Possible injudicious use of PPI drugs

5. What should be done to address these issues?

(i) Standards of cleanliness

Capacity issues within Domestic Services The General Manager stated that there was no additional expenditure available for staffing next financial year but current levels of domestic staffing would be maintained. It was identified that domestic services was undergoing a period of transition, with new management, and that there had been focussed training on ‘training the trainers’ – the domestic supervisors. These managers were key to the delivery of an excellent service. It was also identified that there was some ambiguity around service delivery between nursing and domestic services, as had been identified by the family of one of the patients. It was noted that in both Ward 4C and Ward 3A nursing staff had introduced an excellent initiative of 2hrly cleanliness checks of toilets with confirmation signatures. The nursing staff were keen to take complete ownership of toilet cleanliness and remove the current ambiguity. It was also noted that many disciplines would have encountered the sub-optimal standards of cleanliness previously described and done nothing about these. The review group was attracted to the ‘Don’t Walk By’ principle already described. There was consensus that the Domestic Services Manager, Surgical and Medical Nurse Managers plus Charge Nurse, Ward 4C, should produce and disseminate hospital-wide a short policy describing clear responsibility for cleanliness. This policy should include nursing ownership of 2hry toilet checks. The policy should also include a ‘Don’t Walk By’ statement that every member of staff has a duty to highlight substandard cleanliness.

Capacity issues within Nursing The group was informed that vacant positions within the two wards were to be addressed on a permanent basis in accord with the findings and recommendations of the recent workforce study. Meanwhile, the nursing establishment in Ward 4C had been temporarily increased with supplementary staffing to reflect the findings of the recent workforce analysis. It was agreed that nurse staffing levels should be monitored at an individual ward level, in order to avoid ‘hot spots’ being masked by overall staffing levels, and that mechanisms should be put in place to identify and address any mismatch between patient activity/acuity and nurse staffing.

Infrastructure not fit for purpose (toilets etc) It was reiterated that there had been a failure to invest in the infrastructure of the Hospital over time. It was agreed that there was a need to actively implement improvements over time. The General Manager confirmed that there were no as yet identified additional capital monies available for the new financial year. It was agreed that the Infection Control & Prevention team and the Domestic Services Manager should identify and develop a prioritised inventory of improvements required to the infrastructure, including toilets that are disability compliant, for the attention of the General Manager.

(ii) Infrastructure not fit for purpose (lack of single rooms) It was observed that the structural lack of single rooms within the hospital had been compounded over time by the reconfiguration of single rooms and treatment rooms to become offices. It was emphasised that CDI was only one of several outbreaks of infectious diseases that the Hospital may have to contain, including MRSA, Influenza and Vancomycin Resistant Staph Aureus. The previous discussion had identified that there were competing demands for the finite resource of 6

single rooms but not a clear picture of overall current usage. It was agreed as an initial measure that there should be an audit undertaken of single room usage throughout the Hospital to provide these data. It was also observed that the Hospital has a ‘state of the art’ isolation facility within Ward 11 for the control of infectious diseases, but that these beds are largely used for other purposes as they form part of the respiratory ward. It was noted that the fire upgrade work will necessitate temporary reconfiguration of wards in the Hospital. This would present an opportunity to alter the status of Ward 11. It was recommended that the isolation facility in Ward 11 should be reviewed for the specific use of infectious patients.

It was highlighted that the current square metres per patient bed area in the 6 bedded bays in the Hospital is contrary to National guidance for the control of and prevention of infection. Compliance with this guidance would require an increase in the size of bed areas which could be achieved by the reconfiguration of 6 bedded bays to become 4 bedded bays, which would also improve the ratio of beds to toilet, hand washing and showering facilities. It was felt that the ongoing pressure to reduce beds within Raigmore Hospital was in potential conflict with the need to limit the risk of future outbreaks of infectious diseases. The strategy of reducing beds by closing whole wards had led to an increased population of vulnerable patients in existing wards, with insufficient area by current standards between bed spaces. There was consensus that any proposed review of bed profiling at Raigmore Hospital should be accompanied by a formal risk assessment of its implications by the Infection Prevention & Control Team. It was also suggested that any future reduction of beds should be on the basis of addressing the structural issues of adequate space between patients by reducing 6 bedded bays to become 4 bedded bays, by increasing the number of single rooms and by reinstating patient treatment rooms wherever possible. It was also agreed that the final report of this Significant Event Review and its recommendations should be shared with the Senior Management Team of NHS Highland.

It was acknowledged that the Hospital does not have a robust bed management policy for addressing issues of patient flow and placement, and especially relating to issues of competing demands for the finite resource of single rooms. It was agreed that a bed policy should be developed for the Hospital to determine which patients go into which beds, and who is responsible for making that decision.

(iv) Injudicious use of PPI drugs The discussion acknowledged a habit had developed of routinely prescribing PPI drugs for post- operative patients receiving analgesic drugs short-term. It was also acknowledged that some patients who had been receiving PPI drugs in the community long-term would require these, and that there were risks in being too prescriptive about usage. It was felt that a solution to this issue was beyond the scope and remit of this review. It was agreed that a short life working group, to include representation from the Acute Pain Team, should produce guidance for the appropriate use of PPI drugs in hospital and prior to hospital admission.

4.0 Recommendations for action 1. Current NHS Highland guidance on infection control & prevention should be revised to ensure that all patients with a positive stool test for Clostridium Difficile are placed in isolation irrespective of their symptoms.

2. Patients with ongoing symptomatic diarrhoea without a confirmed cause should remain in isolation irrespective of a negative stool culture result and further samples should be sent at regular intervals should symptoms persist. Current NHS Highland guidance on infection control & prevention should be revised if required to make this policy explicit.

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3. A new regime of stool testing for Clostridium Difficile infection should be introduced that utilises a reliable initial test with a high sensitivity, and which is capable of delivering a result within a short period of time on a 24x7 basis when required.

4. The Domestic Services Manager, Surgical and Medical Nurse Managers, and Charge Nurse, Ward 4C, should produce and disseminate a Hospital-wide short policy describing clear lines of responsibility for cleanliness. This policy should include nursing ownership of 2hrly toilet checks. The policy should also include a ‘Don’t Walk By’ statement that every member of staff has a duty to highlight substandard cleanliness.

5. Nurse staffing levels should be monitored at an individual ward level in order to ensure that inadequate levels are not masked by overall staffing levels across the hospital, and mechanisms should be put in place for identifying and addressing any mismatch between patient acuity/activity and nurse staffing.

6. The Infection Prevention & Control Team and the Domestic Services Manager should identify and develop a prioritised inventory of improvements required to the infrastructure of the hospital for the attention of the General Manager to take to the Infection Control Committee of the Health Board for further consideration.

7. An audit should be undertaken of single room usage throughout the Hospital to identify current patterns of usage and the consequent implications for infection control.

8. Future use of the isolation facility in Ward 11 for patients with contagious infectious diseases should be considered as part of the overall bed utilisation policy (see recommendation 13).

9. Any proposed review of bed numbers and profiling at Raigmore Hospital should be accompanied by a formal risk assessment of its implications by the Infection Prevention & Control Team.

10. Any future reduction of beds in Raigmore Hospital should be implemented in a way that addresses the structural issue of inadequate bed spacing and supporting facilities (by for example reducing 6 bedded bays to 4 bedded bays).

11. Single rooms and patient treatment rooms that have been converted for other uses should be reinstated wherever possible

12. The final report of the Significant Event Review and its recommendations should be shared with the Senior Management Team of NHS Highland.

13. A bed policy should be developed for the Hospital to determine which patients go into which beds, and who is responsible for making that decision.

14. Through the Formulary sub group of the Area Drug and Therapeutics Committee a short life working group, including representation from the Acute Pain Team, should produce guidance for the appropriate use of PPI drugs in hospital and pre-admission.

Compiled by - Liam Gaffney Date 19/04/12. Revised 08/05/12, 11/05/12, 16/05/12

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5.0 Recommendations Following QPS RMT Review & Approval Ratified 1. Current NHS Highland guidance on infection control & prevention Yes, as modified should be revised to recommend that all patients with a positive stool test for Clostridium Difficile should be placed in isolation irrespective of their symptoms.

2. Patients with ongoing symptomatic diarrhoea without a confirmed Yes, as modified cause should remain in isolation irrespective of a negative stool result. Further samples should be sent at least weekly should symptoms persist. Current NHS Highland guidance on infection control & prevention should be revised if required to make this policy explicit.

3. A new regimen of stool testing for Clostridium Difficile infection Yes, with correction of should be introduced that utilises a reliable initial test with a high typographical error sensitivity, and which is capable of delivering a result within a short period of time on a 24x7 basis when required.

4. The Domestic Services Manager, Surgical and Medical Nurse Yes, as modified Managers, and Charge Nurse, Ward 4C, should produce and disseminate a Hospital-wide short policy describing clear lines of responsibility for cleanliness. This policy should include nursing ownership of 2hrly toilet checks. The policy should also include a ‘Don’t Walk By’ statement that every member of staff has a duty to highlight substandard cleanliness. This policy should be shared with the Infection Control Improvement Group via its Chair.

5. Nurse staffing levels should be monitored at an individual ward Yes, as modified. See level in order to ensure that inadequate levels are not masked by also additional overall staffing levels across the hospital. The Senior recommendation 15 Management Team should identify and rectify any mismatch between patient acuity/activity and nurse staffing.

6. The Infection Prevention & Control Team, the Domestic Services Yes, as modified Manager and Estates should identify and develop a prioritised inventory of improvements required to the infrastructure of the Hospital (microbiology clean) for the attention of the Director of Operations to action.

7. An audit should be undertaken of single room usage throughout No, merged with no.13 the Hospital to identify current patterns of usage and the as new consequent implications for infection control. recommendation 16

8. Future use of the isolation facility in Ward 11 for patients with Yes, as modified contagious infectious diseases should be considered as part of the reconfiguration of the Hospital, given it is a purpose-designed control of infection ward.

9. Any proposed review of bed numbers and profiling at Raigmore Yes Hospital should be accompanied by a formal risk assessment of its implications by the Infection Prevention & Control Team. 10. The future reconfiguration of beds in Raigmore Hospital should be Yes, as modified implemented in a way that addresses the structural issue of inadequate bed spacing and supporting facilities (by for example reducing 6 bedded bays to 4 bedded bays).

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11. Single rooms and patient treatment rooms that have been Yes converted for other uses should be reinstated wherever possible

12. The final report of the Significant Event Review and its Yes recommendations should be shared with the Senior Management Team of NHS Highland.

13. A bed policy should be developed for the Hospital to determine No, merged with no 7 which patients go into which beds, and who is responsible for as new making that decision. recommendation 16

14. Through the Formulary sub group of the Area Drug and Yes Therapeutics Committee a short life working group, including representation from the Acute Pain Team, should produce guidance for the appropriate use of PPI drugs in hospital and pre- admission.

15. The identified mismatch between patient acuity/activity and nurse Yes - new staffing in Ward 4C should be immediately rectified and a permanent solution introduced.

16. A review should be undertaken of single room usage throughout Yes - new the Hospital to identify current patterns of usage and demand, and consequent implications for the control of infection. Subsequently, a bed policy should be developed for the effective utilisation of all beds.

Compiled by - Liam Gaffney Date 17/05/12 Date 17/05/12

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ACTION PLAN

Recommendation Action Action Completion SER No Action Division Status Comments No No Owner Target Date Current NHS Highland guidance on infection control & prevention to be revised to recommend that all patients with a Dr E Watson, Medical & QPS056 1 1 positive stool test for Clostridium Difficile Consultant 14/06/12 Diagnostics should be placed in isolation irrespective of Microbiologist their symptoms

Patients with ongoing symptomatic diarrhoea without a confirmed cause should remain in isolation irrespective of a negative stool result. Further samples are to be sent Dr E Watson, at least weekly should symptoms persist. Consultant Medical & QPS056 2 2 14/06/12 Current NHS Highland guidance on Microbiologist Diagnostics infection control & prevention to be revised if required to make this policy explicit

A new regimen of stool testing for Clostridium Difficile infection to be introduced that utilises a reliable initial test Dr E Watson, with a high sensitivity, and which is capable Medical & Completed QPS056 3 3 Consultant 14/06/12 of delivering a result within a short period of Diagnostics 17/05/12 Microbiologist time on a 24x7 basis when required

A Hospital-wide short policy describing Ms C Dow, clear lines of responsibility for cleanliness to Nurse be produced and disseminated. This policy Manager, to include nursing ownership of 2hrly toilet Surgical checks. The policy to also include a ‘Don’t Surgical Specialties/M QPS056 4 4 Walk By’ statement that every member of Specialties/H 12/07/12 r D Mackay, staff has a duty to highlight substandard otel Services Domestic cleanliness. This policy to be shared with Services the Infection Control Improvement Group Manager via its Chair

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Nurse staffing levels to be monitored at an individual ward level in order to ensure that inadequate levels are not masked by Quality & overall staffing levels across the Hospital. Mrs U Lyon, QPS056 5 5 Patient 09/08/12 The Senior Management Team to identify Lead Nurse Safety and rectify any mismatch between patient acuity/activity and nurse staffing

The identified mismatch between patient (1)Ms C Dow, acuity/activity and nurse staffing in Ward 4C Nurse Surgical to be immediately rectified (1) and a Manager, (1) 14/06 Specialties/Q permanent solution introduced (2) Surgical /12 QPS056 15 6 uality & Specialites (2) 09/08 Patient (2) Mrs U /12 Safety Lyon, Lead Nurse The Infection Prevention & Control Team, Mrs E the Domestic Services Manager and Watson, Estates to identify and develop a prioritised Consultant inventory of improvements required to the Microbiologist infrastructure of the hospital (microbiology /Mr D Medical & clean) for the attention of the Director of Mackay, Diagnostics/ 6 7 Operations to action Domestic 14/06/12 QPS056 Hotel Services Services Manager/ Mr J Scott, Estates Operational Manager Future use of the isolation facility in Ward 11 for patients with contagious infectious Mr C Lyons, diseases to be considered as part of the QPS056 8 8 Director of All 17/05/13 reconfiguration of the Hospital, given it is a Operations purpose-designed control of infection ward

Any proposed review of bed numbers and profiling at Raigmore Hospital should be Mr C Lyons, accompanied by a formal risk assessment Director of of its implications by the Infection Operations/D Completed QPS056 9 9 All 14/06/12 Prevention & Control Team r E Watson, 17/05/12 Consultant Microbiologist

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The future reconfiguration of beds in Raigmore Hospital to be implemented in a way that addresses the structural issue of Mr C Lyons, Completed QPS056 10 10 inadequate bed spacing and supporting Director of All 14/06/12 17/05/12 facilities (by for example reducing 6 bedded Operations bays to 4 bedded bays)

Review to be conducted of single rooms and treatment rooms that have been Mrs U Lyon, Quality & converted for non-clinical use to identify QPS056 11 11 Lead Patient 09/08/12 those that can be reinstated as clinical Nurse Safety areas

The final report of the Significant Event Dr R Harvey, Review and its recommendations to be Quality & Associate Completed QPS056 12 12 shared with the Senior Management Team Patient 24/05/12 Medical 17/05/12 of NHS Highland Safety Director

A review to be undertaken of single room usage throughout the Hospital to identify current patterns of usage and demand, and Mrs S consequent implications for the control of Medical & QPS056 16 13 Lamont, Bed 09/08/12 infection. Subsequently, a bed policy to be Diagnostics Manager developed for the effective utilisation of all beds

Through the Formulary sub group of the Area Drug and Therapeutics Committee a short life working group, including Mrs A representation from the Acute Pain Team, MacDonald, Medical & QPS056 14 14 09/08/12 to develop a protocol to guide the Antimicrobial Diagnostics appropriate use of PPI drugs in hospital and Pharmacist pre-admission.

- - Action identified but not yet progressed - Action plan being progressed

- Action completed and verified - Action Abandoned

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Highland NHS Board 5 June 2012 Item 4.8

REPORT TO THE BOARD ON RAIGMORE HOSPITAL QUALITY APPROACH TO IMPROVEMENT IN 2012/2013, 2013/14 AND 2014/15

Report by Chris Lyons, General Manager, Raigmore Hospital

The Board is asked to:

 Note the approach to quality improvement in 2012/2013 by Raigmore Hospital Management Team.  Note the details of the quality improvement initiatives and the expected benefits of the improvements planned and underway.  Note the Initial work to identify quality improvement in 2013/14 and 2014/15.

1. Background and Summary

1.1 The overall strategic direction for NHS Highland is based around a Quality & Efficiency Framework. This framework is designed to bring together the requirements of the Healthcare Quality Strategy and the Productivity & Efficiency Framework in a way that is meaningful to staff and also delivers the organisational requirements to maintain financial balance year on year.

1.2 NHS Highland has taken a whole system approach to quality improvement initiatives focusing on reducing HARM, WASTE and VARIATION in the delivery of services. This is the approach that Raigmore Hospital intends to use.

1.3 In addition NHS Highland has assumed responsibility for delivery of adult social care for the Highland Council Area as from 1 April 2012 which will present further opportunities for whole system working.

1.4 This report to the Board sets out to summarise the approach to quality improvement adopted by the Raigmore Management Team and the anticipated benefits to be realised from these initiatives, both in 2012/13 and over the subsequent 2 years.

1.5 The Board will be aware that Raigmore under-achieved its recurring savings target for 2011/12 by £5.7m. Since the previous Board meeting (at which the Board agreed the overall savings target of £24m and the broad themes) considerable discussion has taken place regarding the way in which this target should be allocated by individual unit. The key goal was that each unit should face targets that are challenging yet realistic. Based on this approach, mutual agreement has been reached between units that the £24m target should be allocated ‘afresh’ with no carry forwards from previous years. This is described in more detail in a separate paper on this agenda. For Raigmore, the target is 3% (which is in line with the Scottish Government’s Efficient Government target for all parts of NHSScotland) which equates to £4.1m on a budget of £135m. In addition, Raigmore will also contribute to the £4.5m quality savings which will be identified to the whole system initiatives pump primed by change money initiatives. 1.6 Whilst the schedule of quality improvement initiatives are detailed in Appendix 3 and costed in Appendix 5, it is noted that the benefits will be realised over more than one financial year. Therefore, the programme of work for subsequent years has less detail, but will follow the same approach.

1.7 The approach adopted is in line with the Highland Quality Approach and seeks to cover specifically the 6 dimensions of quality set out in The Healthcare Quality Strategy for NHS Scotland published in May 2010. These 6 internationally recognised dimensions of healthcare quality are that services should be:

 Person-centred;  Safe;  Effective;  Efficient;  Equitable; and  Timely.

1.8 In identifying quality improvement initiatives, projects and proposals the management team had to confirm that each improved upon at least one of the six dimensions mentioned above and the waste, harm and variation themes, and that the initiative did not significantly impact upon any of the remaining dimensions.

1.9 Whilst it was accepted that the dimensions were relative concepts and a degree of trade-off between the dimensions could be expected, this did not apply to “safety”, where no trade off was acceptable which would have a negative impact on safety.

2. Approach Adopted

2.1 Three broad methods have been used in identifying quality improvement initiatives:

a) The structure promoted by the Institute of Health Improvement for identifying where “waste” might be identified within any healthcare organisation. This approach sets out to identify potential initiatives which will lead to a quality improvement by focusing in on a number of areas including supply chain issues and staffing structures

b) Focusing on the utilisation of quality improvement techniques to address the reduction in harm and waste, and the management of variation

c) A comprehensive review of the current clinical service provision by Raigmore Hospital including outreach services has been initiated. This review aims to identify the potential for reconfiguration of services, both within NHS Highland and in collaboration with other Boards, and the effect of any such changes on the key dimensions of quality. This exercise is being coordinated by Dr Rod Harvey, Associate Medical Director.

2.2 On the basis of the methods described above, a template with associated explanatory notes has been developed to facilitate the collecting of all proposed quality initiatives for 2012/13. These documents are attached as Appendix 1 and 2 respectively.

Completion of the template has allowed for the identification of quality improvement initiatives and resultant benefits including efficiencies which are within the ability of Raigmore Management team to secure independently from other parts of the health and social care system. Additional savings requiring support and input from Executive team members and capital/revenue investment are also identified. This allows for clarity on the required actions to realise the benefits anticipated. 2 3 Quality Improvement Proposals

3.1 A number of initiatives are already underway. These constitute the current Quality Improvement & Efficiency Plan for Raigmore in 2012/2013 (Appendix 3). It is important to note that these are the initial proposals. Examples of completed templates in relation to this are contained in Appendices 4 a, b, and c. Work is ongoing to develop further initiatives by all relevant teams which will be added to the plan in due course.

3.2 The financial implications of the proposals within the Quality Improvement & Efficiency Plan are being analysed in detail in order to identify the anticipated impact on expenditure. Whilst this work is still ongoing, the current version of this document is appended as Appendix 5.

An indication of the breadth of the proposals is summarised below under the work stream headings reducing harm, reducing waste and reducing variation, although some straddle 2 or more of these.

3.3 Reducing Harm

This work stream is focusing on initiatives which improve quality of care and as a result reduced length of stay or cost per patient episode including:

 Roll out of Scottish Patient Safety Programme across all ward areas. In addition to reducing harm and mortality it is anticipated that this will release resource by reducing length of stay and expenditure on consumables.

 A 90 day Improvement Programme has been implemented in one ward area using an approach developed by the Institute of Health Improvement (IHI). It was designed to produce innovation in a reliable and efficient manner, bringing new ideas to action. The aim was to reduce falls, pressure ulcers, colorectal surgical site infections (SSIs) Central Venous Catheter associated infections (CVCs), and Catheter Associated Urinary Tract Infections. The results have been extremely encouraging. For example the number of falls was reduced by 50% in one pilot area as a direct result of this work This work is the subject of several poster presentations at the NHS Conference in June 2012

Based on the success in the pilot area the program is now being rolled out across the hospital. It is estimated that this will mean that 120 fewer patients will come to harm as a result of a fall in hospital with a consequent reduction in avoidable bed occupancy.

 Reducing sepsis mortality in the Acute Medicine Unit. As a result of the development of 6 step management of sepsis, 102 lives have been saved over the past year as well as a significant reduction in length of stay for a number of patients. Work is underway to roll this approach out over the hospital. This work is also the subject of a poster which will be shown at the NHS Conference in June 2102

 Raigmore clinicians are involved with the poly pharmacy initiative. Together with the virtual ward initiative this has contributed to a reduction in occupied bed days within the target population of older people.

3  Implementing a single Board wide cross-specialty Venous Thromboembolism (VTE) Risk assessment protocol. This work is being led by the Raigmore Associate Medical Director. It is anticipated that reliable implementation will reduce morbidity, mortality and hospital admissions. This work is the subject of a poster which will be shown at the NHS Conference in June 2102

3.4 Reducing Variation

A number of workstreams to reduce variation in referrals and hospital admissions and length of stay are underway within Raigmore Hospital and the community. These are detailed below

 Reduction of patients admitted over age 65 as an emergency as well as a reduction in LOS for those who are admitted. This will require joint working with community colleagues to

. Identify and address issues with outlying admitting practices . Increase the percentage of patients with anticipatory care plans

 Focus on referral management to reduce variation by

. Development of care pathways and clinical guidelines . Community based triage where appropriate e.g. orthopaedics

 Reduce variation in length of stay for all age groups by specialty and clinician, for example by maximising the use of day surgery

 Outpatient utilisation and innovation - A number of initiatives are underway within the outpatient department in line with the National Efficiency and Productivity work stream. These include centralised reception cover ensuring that every patient is met by a receptionist who can ensure they are appropriately seen by the clinician and the clinic runs smoothly and the development of note viewing area which will ensure that the clinician can view the notes in advance of the clinic, order them appropriately and order any tests required prior to the appointment thus saving the patients return visits and making it more possible to have one stop clinics

3.5 Reducing Waste

 Service managers will work closely with the Clinical Procurement Manager to ensure that best value in contracts is obtained for the departments they manage. For example, savings of £160k full year effect on theatre supplies will be possible if the national contracts are fully utilized for drapes, procedure packs and orthopaedic trauma.

 Ensure compliance with drug formulary.

 Fully implement patient focused booking to maximize use of available capacity with the aim of reducing DNA rates to below 5%. There is a potential to avoid the loss of the equivalent of 169 outpatient clinics per year which will allow the hospital to reduce spend on the premium payments that are needed to pay waiting times

 The use of community hospital capacity by developing capability

4  Manage patients closer to home by increasing number of patients managed with tele- care facilities. Current initiatives include

. Diabetes tele consultation . Renal tele-med . Cardiac initiative . Telephone consultations

Already there has been excellent progress made with almost 50% of the diabetes peripheral clinics now being undertaken using tele health technology. There are plans to explore the feasibility of this approach across a number of other specialties. With over 5000 hours spent by Raigmore clinicians in travelling to peripheral clinics, the opportunities for providing additional patient services through this type of redesign is significant.

This work is a the subject of a poster which will be shown at the NHS Conference in June 2102

 Provide condition support in primary care e.g. Dermatology services also allow patients to be managed closer to home. Raigmore clinicians have been instrumental in creating innovative patient pathways to ensure that much of the dermatology procedures are undertaken in the patients GP practice. This programme has evaluated very well with high patient satisfaction and a corresponding reduction in waiting times for specialist services. We believe that extension of this approach to other specialties may allow avoidance of admission or outpatient referral whilst maintaining quality of care.

 Maximise use of all current employment contracts

. The teleconsultation rollout mentioned above will provide more patient services by reducing consultant travel. . The improvement of clinic utilisation will ensure that patients are seen in a timely manner by reducing waiting lists. Work is underway in cardiology using a bespoke report which provides real time information to the management team on the clinic utilisation. This is being piloted and it is planned to roll out to other specialties as soon as practicable. This should reduce the need for additional clinics and therefore the need for enhanced payments . Reduce overtime in ward areas and laboratories through the development of shift rotas rather than on call arrangements. This will ensure that resources are maximized for patient care and services . Utilise administrative staff to release clinical staff i.e. in outpatients the creation of a band 1 role ensures that clinical time is allocated appropriately to clinical tasks

3.6 Summary

These are examples of a number of Quality Improvement workstreams underway in Raigmore Hospital which are designed to improve the quality of care for patients and deliver a more cost effective service. The approach will require appropriate engagement to ensure that all aspects of governance are considered.

5 It is anticipated that Raigmore Hospital will be in a position to deliver financial break even in 2012/13, providing the anticipated benefits from these initiatives are realised through whole system working, and that no further unexpected cost pressures are experienced.

4 Contribution to Board Objectives

The Raigmore Hospital Quality Approach to Improvement contributes to Better Health, Better Care and Better Value by providing a comprehensive review and redesign of service provision, maximising the use of the facilities and resources currently available. Working closely in conjunction with partners in primary and social care, Raigmore Hospital will continue to protect and develop specialist services to the highest quality.

5 Governance implications

 Staff Governance

The proposals described in this paper will be subject to further detailed work in conjunction with staff members and partnership representatives and in line with PIN guidance.

 Financial Governance

The proposals outlined in this paper are anticipated to have a positive impact on financial governance by contributing to the financial break even of Raigmore Hospital and the wider Highland Health and Social Care Partnership.

 Clinical Governance

Specific consideration has been given to the clinical governance implications of all proposals, as described in the templates. This approach to maintaining quality and assuring safety is fundamental to the delivery of the proposals within this, and future financial years.

6 Risk Assessment

Raigmore Hospital maintains a risk register with actions in place to mitigate against any outstanding risk. The risk of inability to deliver financial break even is mitigated through the actions contained within this paper.

7 Planning for Fairness

Specific redesign initiatives that have potential implications for patients will be subject to full equality and diversity impact assessment.

6 8 Engagement and Communication

Raigmore Hospital has in place an effective and engaged Patient Council, and Staff governance group. In addition, it is anticipated that staff, partnership representatives and patient or public representatives will continue to be fully engaged in redesign work at the earliest possible stages.

Communication with staff will be through the cascade from senior management, staff briefings and the joint staff governance paper along with the NHS Highland communications. Engagement and communication with the public will be in conjunction with the communications team for NHS Highland but with every intention to be open about proposals as they are developed.

Chris Lyons Director of Operations Raigmore Hospital

25 May 2012

7 APPENDIX 1

Template to be completed for each Quality Cost Saving Initiative Proposal 2012/2013

Completed by / Lead Officer: ______

Date: ______

1. Title and Description of Proposal

2. Quality basis of Proposal – Tick Relevant Boxes

Positive Neutral Negative Impact Impact Impact Patient Centred Safe Effective and Cost Effectiveness Efficient Equitable Timely Local Delivery Plan Objective

Yes No Planning for Fairness

Provide commentary which quality dimensions are addressed by proposal and how these dimensions will be improved…

3. Realisable Savings/Additional Income

These should be based on current employment policies/practices, the requirement to meet all HEAT targets, be aligned with the Local Delivery Plan, workforce study recommendations, health and safety requirements, etc. and be within the ability of Raigmore Management Team to achieve

Saving/Additional 2012/13 2013/14 Recurrent (2014/15 Income Onwards) £000s £000s £000s

Please provide a summary indicating how savings or additional income will be realised. If investment is needed to achieve these savings please specify what this is and provide explanation

8 4. Potential for Additional Savings/Income

Some measures will require input from the NHSH Executive team members and/or changes to NHSH practices and policies. Outlined below is a number of categories. Please indicate the appropriate category and provide explanation. Complete table with estimates of potential savings and any costs of implementing proposal

 Requires NHSH Executive level input to determine appropriate access/threshold levels for treatment, e.g. access to drugs and diagnostics

 Requires changes to CHP Operational Practices

 Requires negotiation with third party to NHSH Board

 Requires capital Investment required to realise savings

 Requires revenue investment required in one year to realise savings in a future year

 Implications for health & safety of staff, patients, visitors, e.g. infection control which needs to be addressed

 Requires agreement to changes to internal work practices on Raigmore Site including redesign of services

 Expected increase in demand on service will absorb any financial benefit of the proposal in 2012/13

 Requires HR issues to be resolved

o Need to restructure a team o Need to change type of business TUPE in/out o Need to implement skill mix changes o Need to implement change of working patterns e.g. out of hours review / changes of shift systems o Need to reduce staff numbers o Need to change management arrangements

Also include likely HR constraints impacting on savings if applicable:

 Whether there is a pay protection requirement  Whether redeployment is required  Whether there are statutory requirements to consult and staff governance requirement to inform and involve staff in decisions that affect them  Whether there is an increased need for FTCs and  Will there be Training and Development

Explanation (include details of any costs, e.g. investment in equipment, pay protection and explanation of HR issues)

9 Saving/Additional 2012/13 2013/14 Recurrent (2014/15 Income Onwards) £000s £000s £000s

10 APPENDIX 2

Explanatory Notes for the Completion of the Quality Cost Saving Initiative Proposal Template

There is a requirement to provide information in the following format namely:

1. Title and description of proposal

A title and description of each proposal is required. This description should include information on how the proposal is to be implemented and the proposed benefits in non-financial terms associated with this proposal

2. Quality basis of Proposal

Each proposal should have a basis underpinned by quality dimension(s). As quality has a number of different dimensions it is important to be explicit as to the dimensions of quality which underpin the specific proposal. I would ask each of you to be aware of the quality ambitions set out in the Healthcare Quality Strategy for Scotland which are as follows:

 Person centred – Proposal allows for care to be delivered on the basis of meeting patient concerns and priorities  Safe – Proposal reduces risk of harm to patients  Effective and Cost Effectiveness – proposal allows for a treatment / intervention which results in an appropriate clinical outcome e.g. reduction of pain, increased mobility, increase in life expectancy etc. Also to be considered is the cost effectiveness of each proposal / intervention i.e. how do both the costs and outcomes compare before the proposal is implemented compared to current service provision  Efficient – proposal results in an improvement in use of resources e.g. theatre use, nursing time, CT Scanning time by speeding up processes and reduce downtime. Efficiency is the relationship between inputs (resources) and outputs e.g. number of operations preformed per theatre session.  Equitable – does the proposal enhance equality of access by reducing limitations on access due to age, sex, disability, race and sexual orientation?  Timely – does the proposal enhance / reduce time which patients want to access a service.

The Scottish Patient Safety Programme focuses on ensuring that services are safe and effective. Programs underpinned by LEAN thinking attempt to ensure that the services provided are efficient and timely. It is important to note that there is not an absolutely clear delineation between the SPSP programme and the LEAN methodology adopted by the Board and there is at times cross over between the different dimensions depending on the program or initiative being implemented.

It is also useful to note the framework suggested by Lesley-Anne Smith as a useful starting point for identifying initiatives or proposals which result in reducing the overall cost to the organisation. This is as follows:

 Supply Chain Issues i.e. ensuring that the purchasing arrangements which will provide the best value for money are in place in relation to clinical and non clinical supplies. This includes improving stock control, limiting purchasing authority and limiting stock lines.  Quality Agenda i.e. ensuring that initiatives which are primarily focussed on enhancing patient safety, reducing risk and enhancing clinical outcomes generate a reduction in expenditure and that this reduction in expenditure is realised in terms of staff reduction/re-profiling and reduction in bed use. 11  Flow Issues i.e. ensuring that the most efficient arrangements are in place in terms of inputs and outputs across the organisation.  Staffing Structures i.e. looking at opportunities for band re-profiling to ensure that the appropriate group mix of staff is available to provide services.  Mismatched Services i.e. ensuring that only appropriate treatments and diagnostic tests are provided to defined patient groups.

3. Potential Savings

In this section there is a need to identify the level of savings in cash terms that will be realised as a result of this implementation of the proposal. It is important that this is the actual amount of cash savings to be released as opposed to a value given to the enhanced level of efficiency associated with the implementation of a proposal. If expenditure is not to be reduced then this should be clearly stated. Many proposals will give a greater level of efficiency but will not necessarily take costs out of the system. It is important that this distinction is made.

4. Are the Savings Achievable by the Raigmore Management Team or is External Executive Team Input Required

In this section clear statements should be made as to whether or not the savings are achievable by the Raigmore Management Team in isolation from the wider input from the Executive Management Team or community colleagues. If external assistance and input is required then this should be clearly described. For example reduction in medical beds which are dependent on the change fund reducing the number of medical emergency admissions and presentations to Raigmore Hospital.

12 APPENDIX 3

Raigmore Hospital

Quality Improvement and Efficiency Plan 2012/2013

Proposals are categorised in Levels of 1 - 3

Level 1

Internal Operational Unit Quality and Efficiency Proposals. These proposals do not need the input from the other departments etc from within the wider NHS Highland Organisation. Furthermore they do not require negotiations with any other 3rd party to ensure implementation.

Level 2

Unit based proposals which require broader NHS Highland input\support and or negotiations with external 3rd parties to NHS Highland. Examples of this type of [proposals might be reviewing the clinical threshold for Endoscopy which will require the input of the Department of Public Health and our own review of Microbiology Services which will require us to negotiate an extension of the Seamen’s Direct Managed Service Contract.

Level 3

Proposal’s which are essentially strategic in nature i.e. they require a significant shift in how we provide our services which cuts across a number of the operational units. An example of such a proposal would be in relation to Rheumatology Services which would require the buy in of a number of the operational units.

General / Hospital Wide Proposals Level Template Complete 1. Introduce system to track patient location in real-time and to 2 facilitate electronic transmission of laboratory results and hence replace paper reports ACTION: Rod Harvey, Chris Lyons & Donna Smith

2. Endoscopy Services – Combine waiting lists expenditure from 1 medical and surgical divisions budget / expenditure profile to create a whole-time clinical post ACTION: Carl Hope & Jo Veasey

3. Relocate lumps and bumps work and urology work to Nairn 1 Hospital to create 3 additional endoscopy sessions per week on Raigmore site ACTION: Carl Hope & Donna Janssens

4. Management of return patients to meet planned review dates 1 ACTION: Donna Smith

5. Review of Clinical threshold for access to Endoscopy (refer to 2 Pan Highland Surgical Group) ACTION: Carl Hope, Jo Veasey, Morag Macleay & Donna Janssens

13 6. Review drug usage for top 10 drugs (by cost) for Raigmore to 2 ensure drugs are being used as per SMC guidance. ACTION: Chris Lyons, Rod Harvey & Ian Rudd

7. Investigate use of telemedicine across all specialties. 1 ACTION: Jo Veasey/Carl Hope/Donna Smith

ACTION: Carl Hope to provide overall information for Hospital. To be obtained for discussion and analysis at future clinics. (09/05/12)

8. Aim to ensure uniformity on payment for waiting list work. 1 ACTION: Carl Hope & Jo Veasey

9. Review feasibility and potential benefits of expansion of ward 1 Pharmacy services. ACTION: Una Lyon/Ian Rudd

10. Review use of technology both current and future e.g. 2

 Printing  Self service check-in  Pharmacy robots  Ordercoms

ACTION: Donna Smith, Linda Kirkland

11. Review availability and use of facilities on Friday afternoons in 1 order to optimise use of resources. ACTION: Carl Hope/Donna Smith/Jo Veasey

ACTION: Donna Smith to bring information on which specialties hold Saturday clinics. (09/05/12)

12. Review of triage and GP referral across all specialties as part 1 of comprehensive review of clinical services. ACTION: Rod Harvey/Jo Veasey/Carl Hope

13. Review benefits and savings associated with “Releasing time 1 to care” ACTION: Una Lyon

14. Comprehensive review of specialist services 2 ACTION: Rod Harvey

14 Beds Reduction / Reconfiguration Proposals 1. Reduction of beds associated with adherence to daycase 1 policy ACTION: Carl Hope/Andrew Ward

2. Development of a OMFS sedation service 1 ACTION: Carl Hope/Andrew Ward

3. Impact of change fund investment to facilitate a reduction in 2 required hospital medical beds

3.1 Aim to close 4 beds on 7C by reducing OBDs (Occupied Bed Days) associated with delayed discharges based on: a) Reducing average number of daily delayed discharges b) Reducing average length of time taken to move a delayed discharge (i.e. speeding up discharge) ACTION: Jo Veasey/Iona McGauran

3.2 Reduce LOS and improve speed of discharge as a result 2 of change fund Aim to close beds by reducing OBDs Hospital to Hospital Transfers based on: a) Reducing average number of delayed daily hospital transfers b) Reducing average length of time taken to move a hospital to hospital transfer (i.e. speeding up discharge) c) Encouraging a reduction in number of medical 2 emergency admissions to Raigmore and/or d) Contributing to an ongoing and significant reduction in the length of stay associated with these patients ACTION: Jo Veasey/Shona Lamont/Emma Mackinnon

4. Combine Gynae ward activity with other female surgical activity 1 in order to fully utilise Ward 8 area or another surgical ward area in Raigmore. ACTION: Derick MacRae

5. Reconfiguration of Oncology beds across the hospital to allow 1 for an increase of 4 additional beds on ward 2C and corresponding decrease in surgical beds. (i.e. not increase in beds of zero). ACTION: Jo Veasey

6. Reduce surgical beds as a result of re-routing of GP surgical 2 referrals to Belford and Caithness. (note expected minimal impact on beds and theatre usage at Raigmore – however further work to be developed).

15 ACTION: Carl Hope

7. Ongoing weekend and holiday closures of beds based on 1 predicted activity. ACTION: Iona McGauran/Carolyn Dow/Shona Lamont

8. Roll out of 90 day Improvement Programme in relation to Falls 1 prevention, Pressure Ulcer prevention, Acquired Catheter Infections and Surgical Site Infections. ACTION: Una Lyon

9. Relocate young adult rehab service to Invergordon 1 ACTION: Jo Veasey

10. Develop and implement pathway for Management of COPD 1 patients ACTION: Rod Harvey

Surgical Services Proposals 1. Orthodontic/Dental Nurse Proposal to reduce dependency on 1 consultant staff proposal ACTION: Carl Hope/Andrew Ward

2. IVAC Pump Purchase Proposal 1 ACTION: Carolyn Dow/Ally Cattanach

3. a)Substitute use of Avastin for Lucentis in the treatment of Wet 2/3 Macular Degeneration ACTION: Carl Hope/Andrew Ward

b) Income generation from Novatis Ophthalmology trial. 2/3 ACTION: Carl Hope/Andrew Ward

4. Review patients on waiting lists for appropriateness of 1 treatment (Cleaning) ACTION: Carl Hope

5. Investigate possibility of extending use of Nairn facility for 2 surgical work. (note – knock-on impact on Endoscopy) ACTION: Carl Hope

6. Roll out/further extend use of enhanced recovery 1 ACTION: Carl Hope/Carolyn Dow

16 7. Review benefits and savings associated with “Productive 1 Theatre Project” ACTION: Carl Hope

Medical and Diagnostics Services Proposals 1. Diabetic Services Repatriation Proposal to Raigmore 2 ACTION: Jo Veasey & Linda Kirkland

2. a) Rationalisation of Radiological Services across Sites 2 Proposal ACTION: Katherine Sutton

b) Review of Radiology Equipment and Maintenance Contract 2 Proposal ACTION: Katherine Sutton

3. Microbiology Service redesign and restructure (including 1/2 possible purchase of Molecular Testing Equipment and Microbiology Serology Equipment. ACTION: Jo Veasey

4. Review of use of unscheduled care practitioners (UCPs) 1 workforce in the A&E Department ACTION: Jo Veasey & Brendan Foreman

5. Review waiting list expenditure on Neurology work to assess 1 feasibility of re-profiling expenditure ACTION: Jo Veasey & Stuart Caldwell

6. Review provision of Cardiology Services (proposal to have a 3 cardiology summit to identify key service and cost pressures associated with this service) ACTION: Jo Veasey

7. Implementation of rotational shift system in Blood Sciences 1 ACTION: Jo Veasey/Dave Smith

8. Continued redesign of Wheelchair Services 1 ACTION: Jo Veasey/Stuart Caldwell

9. Medical Physics Redesign Project 1 ACTION: Fraser Brunton

10. Review benefits and costs associated with COPD pathway 2 work. ACTION: Jo Veasey & Morag MacLeay

17 11. Establishment of point of care testing service 1 ACTION: Jo Veasey & Dave Smith

12. Out of hours Drivers Service Review 1

Patient Services Proposals 1. Review of Outpatient Department Staffing Profiles (note this 1 links to CEL 11: 2012) ACTION: Donna Smith

2. Central Records LEAN Project 1 ACTION: Donna Smith

3. Achieve 4% DNA rate across all specialties in Raigmore 1 Project (note this links to CEL 11: 2012) ACTION: Donna Smith

4. Review delivery of external mail 2 ACTION: Donna Smith

5. Establish a PAS users group to reduce ISOFT system errors 1 ACTION: Donna Smith

6. a) Roll out of Customer Care Project (utilising SPSP 1 methodology) to reduce risk and enhance patient experience (note this links to CEL 11: 2012) ACTION: Donna Smith 1 b) Roll out of Core – set of values and behaviour policies for all outpatient staff (note this links to CEL 11: 2012) ACTION: Donna Smith

7. Establishment of Audit Trail including introduction of Electronic 1/2 Triage Project ACTION: Donna Smith

8. Implementation of findings of administration and Clerical 1 review in 2012/2013 ACTION: Donna Smith

9. Establish consistent pricing policy of provision of notes to 1 solicitors etc. ACTION: Donna Smith

10. Rationalise fax usage across hospital site 1 ACTION: Donna Smith

18 Hotel Services Proposals

1. Aim to improve Catering Income 1 ACTION: Chris Lyons

2. Review order process for patient meals 1 ACTION: Chris Lyons & Crawford Howat

3. Review benefits of changing to air dryers in toilets 1 ACTION: Chris Lyons & Crawford Howat

19 APPENDIX 4a

Template to be completed for each Quality Cost Saving Initiative Proposal 2012/2013

Completed by / Lead Officer: Dr David Ashburn

Date: 28th March 2012

1. Title and Description of Proposal Implementation of the Microbiology service redesign and departmental restructure (including equipment replacement and introduction of new equipment).

Historically the Microbiology department comprised three separately managed sections: Bacteriology, Virology/Parasitology and Immunology. Although each has its own operating budget Virology/Parasitology and Immunology have been amalgamated for administrative purposes since July 2007. The core Quality Management System is shared across the whole department and both Microbiology (incorporating Bacteriology and Virology/Parasitology) and Immunology currently have full CPA (UK) accreditation. The department houses the Scottish Toxoplasma Reference Laboratory (funded by Health Protection Scotland) and a Specialist Service for Lyme borreliosis which is funded through direct charging to other Scottish Health Boards.

An external review of July 2011 (Duerden review) recommended combining Bacteriology and Virology/Parasitology (to include Toxoplasma and Lyme borreliosis testing); the Immunology section was not included in the proposals due to the reviewer’s lack of experience in this discipline but the section is fragile because of the small staffing complement and so will be included in this proposal to ensure continuity of service.

Since March 2011 the department has lost 12 staff including 2 consultants and 7 Biomedical Scientists (BMS) and Clinical Scientist staff at band 6 or above; a one year secondment within the department means that losses have been spread across all sections of the department. These staff have been replaced by one full time consultant, two long term locum consultants, two band 4 Medical Technical Officers (MTO) and 3.5 band 3 Medical Laboratory Assistants (MLA) on two year fixed term contracts. Staff changes since March 2011 have already resulted in recurring savings of £199,292.

The aim of the Microbiology department is to provide a patient centred service by producing clinically appropriate results in a timely manner. This will be achieved through redesign the service to include review of the repertoire offered and method of delivery, which will include modernisation of several aspects; review of department opening hours, out-of-hours provision and turnaround times.

Several initiatives are required to enable effective change:

a) Change the skill mix: The current ratio of BMS to MTO/MLA is approximately 70:30; through review of skill mix our proposal will be to change the ratio to approximately 56:44. It is anticipated that this could release an additional £300,000 recurring savings in staff costs (appendix 1). b) Replace the current (obsolete) manual system for Chlamydia trachomatis/ Neisseria gonorrhoea with an automated system. Automated equipment will be less labour intensive and will be used by lower banded staff than at present so releasing staff for use elsewhere in the department. If authorisation to proceed is given before the end of April 2012 will result in additional savings (see later). c) Replace the current (obsolete) Abbott Axsym analyser with an Abbott Architect. It would be intended that all antenatal serology testing would be done by using this 20 analyser instead of the current system where screening is done by a combination of automated, semi-automated and manual methods. This equipment also is less labour intensive and will be used by lower banded staff than at present. d) Replace current Viral culture methodology and introduce bacterial confirmation with molecular techniques: This will require investment for equipment and consumables but some of this will be offset against existing non-pay spend.

Although investment is required, capital purchase is not necessary because all equipment can be obtained through the Siemens Managed Service Contract.

2. Quality basis of Proposal – Tick Relevant Boxes

Positive Neutral Negative Impact Impact Impact Patient Centred Safe Effective and Cost Effectiveness Efficient Equitable Timely Local Delivery Plan Objective

Yes No Planning for Fairness

Provide commentary which quality dimensions are addressed by proposal and how these dimensions will be improved…

1. Patient centred The department’s aim is to provide a more patient focused service by reducing turn around times and offering tests which could provide an earlier diagnosis. Bacterial culture (approximately 150,000 samples per year) and viral culture (approximately 2000 samples per year) is time consuming (2 – 14 days) and consequently may delay effective treatment. Use of molecular tests to confirm positive bacterial culture results and to replace viral culture techniques will not only allow more rapid diagnosis, so having potential to reduce in-patient stay, but will also allow more appropriate antibiotic treatment. 2. Safe All laboratories should be accredited by CPA (UK) Ltd. In order to achieve this status an effective Quality Management System must be maintained. The process ensures that a department operates under standard reproducible conditions (often using National Standard Methods) but also that assays used are CE marked. Integral to any laboratory structure is a Consultant capable of satisfying CPA standard B1 (Professional Direction). Due to staff changes we no longer conform to this standard for Immunology and will fail the next inspection (2013). 3. Effective and cost effectiveness The Microbiology department has run as three separate units (Bacteriology, Immunology and Virology/Parasitology, incorporating Toxoplasma and Lyme borreliosis testing) each with its own staff. In the proposed structure the department will run with three sections (Culture, Molecular and Serology) with a single pool of staff which and is being designed to include optimal numbers of staff at appropriate grades. Externally funded services will be integrated into ‘mainstream’ testing thereby making better use of staff and resources. Through cross training staff in a single pool the department will provide an effective and cost effective service and be more 21 resilient.

Virology serological tests are available from several suppliers but the quality, including sensitivity and specificity, is variable from different suppliers and therefore it is necessary to perform a tender exercise against clearly defined specifications and it is important to realise that the cheapest solution may not be the best. Clinical Governance issues should play a large part in selection of the most appropriate platform. 4. Efficient In the Keele benchmarking exercise the department is one of the more expensive ones. Through the redesign and restructure we will review processes making better use of automated equipment available to us, replace aging equipment and introduce new equipment necessary to deliver a sustainable quality service. 5. Equitable The Microbiology service is demand led but through consultation with our users, as well as through expertise available within the department, the repertoire is being reviewed with the aim of delivering a service appropriate to the needs of the patients with our users. 6. Timely Service redesign is time consuming and investment is necessary to realise our vision. Each discipline listed in (3) above is recognised by the Institute of Biomedical Sciences through specialist training and as such staff training is a key issue. It is anticipated that MLA and MTO staff (band 3 & 4) will be fully rotational within two years. BMS staff (currently bands 6 - 8A) will be trained during this period but implementation of a full rotation system will take up to 5 years. 7. Local delivery plan objective The department is involved in several surveillance and improvement plans e.g. antenatal screening, Sexual Health strategy and Blood Borne Virus (BBV) action plan. Testing in these areas, as well as in others, will increase and have a requirement for a wider repertoire as they are rolled out. The replacement and new equipment is essential to provide the service required by our users.

3. Realisable Savings/Additional Income

These should be based on current employment policies/practices, the requirement to meet all HEAT targets, be aligned with the Local Delivery Plan, workforce study recommendations, health and safety requirements, etc. and be within the ability of Raigmore Management Team to achieve

Saving/Additional 2012/13 2013/14 Recurrent (2014/15 Income Onwards) £000s £5000s £250,000s

Please provide a summary indicating how savings or additional income will be realised. If investment is needed to achieve these savings please specify what this is and provide explanation

Departmental structure Departmental restructure will take place over at least 5 years as existing staff leave and could realise approximately £300,000 savings in addition to £199,292 already achieved in 2011/12. Changes to the departmental structure have already started through recent appointment of MTO (band 4) and MLA (posts) posts and further changes will be made as staff leave. Future changes will be made according to the needs of the department and not necessarily to

22 the lowest proposed post. This will result in additional spending compared to the previous year in 2014/15 and 2015/16

Chlamydia trachomatis/ Neisseria gonorrhoea The current equipment used for the molecular detection of Chlamydia trachomatis has been in use for approximately 8 years. Although the same equipment is now used to test Neisseria gonorrhoea on samples from Highland Sexual Health and Highland Brook clinic that capacity for the dual nucleic acid amplification test (NATT) is 25% less than for Chlamydia alone. Therefore as dual NATT is rolled out to other users (Sexual Health strategy) there will be significant pressures on our ability to deliver this part of the service.

The current instrument (now supplied through the Siemens Managed service contract) will be due replacement. Becton Dickinson, the supplier of the instrument, is planning to launch a new analyser in 2012/12 and have offered a discounted deal to existing customers that opt to act as pilot sites. Methodology is similar to existing ones and so it is not anticipated that there is a risk to quality through being a pilot site. In addition to Chlamydia trachomatis and Neisseria gonorrhoea, the new equipment also has methodology for Herpes simplex virus (types 1 & 2) and Human Papilloma Virus (HPV) should this testing be required. The new equipment is fully automated and would therefore sit well in the restructured department as it would be operated by lower band staff than currently perform this testing thereby realising the savings described in the Service redesign and department restructure proposal.

As part of the upgrade (which can be done through the Siemens MSC), Becton Dickinson have agreed to hold prices for the first 5 years. Predicted savings using a model supplied by Becton Dickinson will be approximately £11,500 although it is probable that increased test activity will reduce this amount. However in order to benefit from this offer, the company wants a confirmed order by 30th April 2012.

Replace the current (obsolete) Abbott Axsym analyser with an Abbott Architect The Microbiology department, Raigmore Hospital currently performs Blood Borne Virus (BBV) testing on the Abbott Axsym analyser. This platform is reliable but obsolete and we are one of the few laboratories in the country still using this equipment; spares are increasingly difficult to obtain and the clinical risk in the event of a breakdown is significant. The Axsym is supplied under a reagent rental agreement and although Abbott have offered to replace the Axsym with their current platform, the Architect, we are no longer in contract.

The majority of the test repertoire currently performed on the Axsym comprises Hepatitis B virus (HBV) tests, Hepatitis C virus (HCV) tests, Human Immunodeficiency Virus (HIV) antigen/ antibody. In addition the analyser is used for Cytomegalovirus (CMV) IgG, Rubella IgG and Toxoplasma IgM as confirmatory tests for routine screening tests.

Introduction of a replacement platform will provide the opportunity to review how we offer our current repertoire for example:

a) Mandatory antenatal screening tests are currently done using the Abbott Axsym (HBV and HIV), a semi automated ELISA (Rubella IgG) and manual tests for syphilis serology. The methods used are all validated for use but there is a clinical governance risk in use of three different techniques because of the possibility of specimen mix up. It would be preferable and less labour intensive to do all tests on one platform. b) The BBV action plan has resulted in increased testing for HBV, HCV and HIV and as a consequence more confirmatory tests being referred to other Health Boards. Hepatitis C virus antibody positive specimens are referred to the West of Scotland Specialist Virology Centre (WoSVC) in Glasgow for confirmation using a sensitive molecular test. It would be highly desirable for the Microbiology Laboratory at Raigmore to be able to offer Hepatitis C antigen testing; this would offer a 23 sensitive confirmation with significantly shorter turn-around-time (TAT) than referring samples to Glasgow. Abbott Diagnostics are the only supplier currently to include Hepatitis C antigen in their repertoire, which is performed on the Architect platform. c) There are concerns about the quality and consistency of results from the Vancomycin assay currently done in Blood Sciences. This test was previously done on the Abbott Axsym platform in Microbiology and in seeking an alternative assay it is possible that this assay will be repatriated to Microbiology.

Replacement could be done through the Siemens Managed Service Contract thereby avoiding large capital outlay. Alternatively an reagent rental directly from Abbott could be done but due to the value of the contract would need to be done through full tender. As described above, our currently mandatory antenatal surveillance testing is done by a series of manual, semi-automated and fully automated methods. Incorporating all testing on a single platform may result in additional reagent and consumable costs but will be performed by lower grades of staff than currently and is consistent with the proposal for Service redesign and department restructure.

Replace current Viral culture methodology and introduce bacterial confirmation with molecular techniques The molecular testing equipment currently in the department is ageing and inadequate to provide the required service: our extraction equipment has limited capacity (maximum of six specimens per run) and is not suitable for all specimen types (notably faeces) and it is not safe to rely on a single Real Time PCR analyser. To match equivalent labs a nucleic acid extractor and real time PCR analyser (or a combined platform) is needed at a cost of approximately £68,000. In addition an ‘on demand’ stand alone platform is necessary to provide rapid confirmation (1hour) of for example Staph aureus in blood cultures, MRSA, TB and Clostridium difficile. The cost of this will be up to approximately £60,000.

Savings generated will not be realised in the Microbiology department but will be reflected in the patents’ experience, length of in-patient stay and ability of clinical colleagues to provide more appropriate treatment

1. Outbreaks - Norovirus and C.difficile outbreaks for example have a significant impact on the hospital. Molecular methods to diagnose these could reduce the turn-around- time by up to 24 hours (Norovirus); similarly for ‘difficult’ cases where our current methods for C.difficile are not conclusive molecular methods would be confirmatory and indicate when it is safe to move patients. 2. In-patient stay – confirmation of Staph. aureus bacteraemia will be achieved 24 hours earlier than using current culture methods. 3. Antibiotics – Earlier diagnosis will lead to reduction in potentially damaging side effects and more efficient use of antibiotics by: a. Allowing switch to a more appropriate antibiotic b. Stopping ineffective treatment

Service Level Agreements At present most of our molecular tests are referred elsewhere for testing. Although we are not charged directly for some of these tests, savings may be available through redundant SLAs or by reduction in ‘top slice’ charges.

24 4. Potential for Additional Savings/Income

Some measures will require input from the NHSH Executive team members and/or changes to NHSH practices and policies. Outlined below is a number of categories. Please indicate the appropriate category and provide explanation. Complete table with estimates of potential savings and any costs of implementing proposal

 Requires NHSH Executive level input to determine appropriate access/threshold levels for treatment, e.g. access to drugs and diagnostics

 Requires changes to CHP Operational Practices

 Requires negotiation with third party to NHSH Board

 Requires capital Investment required to realise savings

 Requires revenue investment required in one year to realise savings in a future year

 Implications for health & safety of staff, patients, visitors, e.g. infection control which needs to be addressed

 Requires agreement to changes to internal work practices on Raigmore Site including redesign of services

 Expected increase in demand on service will absorb any financial benefit of the proposal in 2012/13

 Requires HR issues to be resolved

o Need to restructure a team o Need to change type of business TUPE in/out o Need to implement skill mix changes o Need to implement change of working patterns e.g. out of hours review / changes of shift systems o Need to reduce staff numbers o Need to change management arrangements

Also include likely HR constraints impacting on savings if applicable:

 Whether there is a pay protection requirement  Whether redeployment is required  Whether there are statutory requirements to consult and staff governance requirement to inform and involve staff in decisions that affect them  Whether there is an increased need for FTCs and  Will there be Training and Development

Explanation (include details of any costs, e.g. investment in equipment, pay protection and explanation of HR issues)

Negotiations: Siemens - Provision for service change is built in to the Siemens Managed Service Contract.

25 Immunology consultant - discussion with Grampian Health board over shared post. Microbiology consultant - discussion with Argyle & Bute and Western Isles Health boards re: funding. Investment: Investment is integral to being able to redesign the service and restructure department. As described above, the current equipment from Becton Dickinson for Chlamydia and gonorrhoea testing is included in the Siemens Managed Service contract and the current Abbott Axsym is also under reagent rental. Both of these items are essential for continuity of service. If all of the necessary equipment was replaced through capital purchase then the likely outlay would be in excess of £300,000 however any/all of it can be incorporated into the Siemens MSC thereby avoiding large outlay. Health & Safety: Reduced turn around times will benefit patients and have potential to identify outbreaks (e.g. C.difficile and Norovirus) earlier thereby improving the response time of the Infection Control Team. Increase in demand: NHS Highland has the lowest screening rate for Chlamydia in Scotland and in addition is the only Scottish Health Board that does not offer dual NAAT testing to samples sent from GPs. To comply with the current Sexual Health strategy targets both of these issues could be addressed through introduction of the new analyser. It is expected that additional testing demand would be paid for through savings made by introduction of the new analyser.

As part of the BBV action plan increased screening is possible thereby increasing workload.

HR issues A proposed departmental structure was offered at the Microbiology Modernisation group meeting of 27th March 2012. Discussions between the HR department and staff representatives are being initiated.

HR constraints Also discussed at the Microbiology Modernisation group meeting of 27th March 2012.

Saving/Additional 2012/13 2013/14 Recurrent (2014/15 Income Onwards) £000s £000s £000s

Dr David Ashburn Service Manager Microbiology Department

26 APPENDIX 4b

Template to be completed for each Quality Cost Saving Initiative Proposal 2012/2013

Completed by / Lead Officer: ______Iona/McGauran______

Date: ______23/03/12______

1. Title and Description of Proposal

Closure of 4 medical Beds on Ward 7C from 1.4.12. The proposal is possible because the number of occupied bed days lost as a result of delayed discharges has reduced in the last year from 710 to 294 in medical for the period January to March.

Note – Whilst this proposal is to be considered it should be noted that within the medical and diagnostic division there is also a requirement to increase the number of beds required on the oncology ward by 4 between Monday to Friday and before this proposal is accepted that needs to be fully discussed.

2. Quality basis of Proposal – Tick Relevant Boxes

Positive Neutral Negative Impact Impact Impact Patient Centred x Safe x Effective and Cost Effectiveness x Efficient x Equitable x Timely x Local Delivery Plan Objective x

Yes No Planning for Fairness x

Provide commentary which quality dimensions are addressed by proposal and how these dimensions will be improved…

Ward 7C is the largest of the Medical wards with 34 beds currently. In accordance with meeting infection control requirements and the HEI agenda the closure of 4 beds will reduce each of the 6 bedded bays to 5 beds creating more space for patients.

3. Realisable Savings/Additional Income

These should be based on current employment policies/practices, the requirement to meet all HEAT targets, be aligned with the Local Delivery Plan, workforce study recommendations, health and safety requirements, etc. and be within the ability of Raigmore Management Team to achieve

27 Saving/Additional 2012/13 2013/14 Recurrent (2014/15 Income Onwards) £53,824 £53,824 £53,825

Please provide a summary indicating how savings or additional income will be realised. If investment is needed to achieve these savings please specify what this is and provide explanation

The savings will be realised from a reduction in staffing levels.

4. Potential for Additional Savings/Income Some measures will require input from the NHSH Executive team members and/or changes to NHSH practices and policies. Outlined below is a number of categories. Please indicate the appropriate category and provide explanation. Complete table with estimates of potential savings and any costs of implementing proposal

 Requires NHSH Executive level input to determine appropriate access/threshold levels for treatment, e.g. access to drugs and diagnostics

 Requires changes to CHP Operational Practices X

 Requires negotiation with third party to NHSH Board

 Requires capital Investment required to realise savings

 Requires revenue investment required in one year to realise savings in a future year

 Implications for health & safety of staff, patients, visitors, e.g. infection control which needs to be addressed

 Requires agreement to changes to internal work practices on Raigmore Site including redesign of services

 Expected increase in demand on service will absorb any financial benefit of the proposal in 2012/13

 Requires HR issues to be resolved X

o Need to restructure a team o Need to change type of business TUPE in/out o Need to implement skill mix changes o Need to implement change of working patterns e.g. out of hours review / changes of shift systems o Need to reduce staff numbers x o Need to change management arrangements

Also include likely HR constraints impacting on savings if applicable:

 Whether there is a pay protection requirement  Whether redeployment is required 28  Whether there are statutory requirements to consult and staff governance requirement to inform and involve staff in decisions that affect them  Whether there is an increased need for FTCs and  Will there be Training and Development

Explanation (include details of any costs, e.g. investment in equipment, pay protection and explanation of HR issues)

Saving/Additional 2012/13 2013/14 Recurrent (2014/15 Income Onwards) £000s £000s £000s

Iona McGauran Divisional Nurse Manager Medical & Diagnostics Division

29 APPENDIX 4c

Template to be completed for each Quality Cost Saving Initiative Proposal 2012/2013

Completed by / Lead Officer: ___Jo Veasey______

Date: ______22nd March 2012______

1. Title and Description of Proposal Impact of Change Fund investment to facilitate a reduction in Raigmore Hospital Medical Beds.

The Change Fund in Highland sits within the policy context of Reshaping Care for Older People and represents an indicative investment over time of £3.4 m for the Highland Council/NHS Highland Partnership. The aim of this programme is to promote independence and wellbeing for older people at home or in a homely setting

In the 1st phase is comprised of significant direct NHSH/THC investment, action and impact with a 2nd phase of ongoing investment planned for NHS H Community infrastructure/THC and the Voluntary Sector.

To allow for the reduction in Medical beds by 10+, as indicated in CHP proposals a decrease in emergency medical admissions and/or a reduction in the medical length of stay must be seen.

Increase in Medical Admissions:

Within the Medical & Diagnostics Division it must be noted that there continues to be an increase in the number of emergency inpatient admissions through the Acute Medical Assessment Unit (AMAU) on a month by month basis. Fig. 1 details this trend and shows that during the period September 2010 to September 2011 the average number of emergency inpatient admissions has increased from approximately 650 per month to just over 700. This is an 8% increase from 2010 which was 3% higher than 2009.

Figure 1: NHS Highland | Raigmore Hospital | Monthly Admissions No of Elective & Emergency admissions to Raigmore hospital to Medical Specialties January 09 - September 11

30 NHS Highland | Raigmore Hospital | Monthly Admissions No of Elective & Emergency admissions to Raigmore hospital to Medical Specialties January 09 - September 11

Medical Emergency Medical Elective 800

700

600

s 500 n o i s s i

m 400 d A

f o

o

N 300

200

100

0

9 9 9 9 9 9 9 9 9 9 9 9 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 1 1 1 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 ------l- - - t------l- - - t------l- - - n b r r y n u g p c v c n b r r y n u g p c v c n b r r y n u g p a e a p a u J u e o e a e a p a u J u e o e a e a p a u J u e J F M A M J A S O N D J F M A M J A S O N D J F M A M J A S Month

Medical Length of Stay:

Length of stay has been steadily reducing over the last two years (Fig. 2), with the most significant reduction since July 2011. During July to September 2011 the average length of stay was 6.7 days, compared with 7.6 days for the previous 12 months. The corresponding reduction in the medical length of stay has allowed the Medical & Diagnostics Division to cope with this increased emergency activity.

Figure 2: NHS Highland | Raigmore Hospital | Mean Length of Stay Mean length of stay (untrimmed) for Emergency and Elective Medical patients January 09 to September 11

NHS Highland | Raigmore Hospital | Mean Length of Stay Mean length of stay (untrimmed) for Emergency and Elective Medical patients January 09 to September 11

MED Emerg ALOS Med Elect ALOS 10.0

9.0

8.0

7.0 ) s y a 6.0 d (

y a t S

5.0 f o

h t

g 4.0 n e L 3.0

2.0

1.0

0.0

9 9 9 9 9 9 9 9 9 9 9 9 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 1 1 1 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 ------l- - - t------l- - - t------l- - - n b r r y n u g p c v c n b r r y n u g p c v c n b r r y n u g p a e a p a u J u e o e a e a p a u J u e o e a e a p a u J u e J F M A M J A S O N D J F M A M J A S O N D J F M A M J A S Month

31 2. Quality Basis of Proposal:

Positive Neutral Negative Impact Impact Impact Patient Centred Y Safe Y Effective and Cost Effectiveness Y Efficient Y Equitable Y Timely Y Local Delivery Plan Objective Y

Yes No Planning for Fairness Y

Person-Centred Mutually beneficial partnerships between patients, their families and those delivering healthcare services will be developed, which respect individual needs and values and which demonstrate compassion, continuity, clear communication and shared decision-making.

Safe By keeping patients in their own home the number of avoidable injuries or harm to people from healthcare they receive and an appropriate, clean and safe environment will be provided for the delivery of healthcare services at all times.

Effective & Cost Effectiveness The most appropriate treatments, interventions, support and services will be provided at the right time to everyone who will benefit, and wasteful or harmful variation will be eradicated.

The patient will be cared for in their own home environment r as close to home as possible in a community hospital. Acute hospital admissions will be kept to an essential minimum and therefore the likelihood of HAI and/or morbidity associated with hospital in patient stay will be minimised.

3. Realisable Savings/Additional Income

These should be based on current employment policies/practices, the requirement to meet all HEAT targets, be aligned with the Local Delivery Plan, workforce study recommendations, health and safety requirements, etc. and be within the ability of Raigmore Management Team to achieve

Saving/Additional 2012/13 2013/14 Recurrent (2014/15 Income Onwards) £000s £000s £000s

Recurring budget will be released following the closure of medical beds related to reduced hospital admissions and/or length of stay. 32 Table 1: Indicative recurring savings from closing beds within one 34 bedded ward

No of Beds Closed 1 3 6 12 18 24 30 34

Pay Savings (£000s) 0* 0* 100 250 500 900 1,100 1,390

Non Pay Savings (£000s) 5 15 31 62 93 124 154 190

Total Indicative Savings 5 15 131 312 593 1,024 1,254 1,580

*Minor savings if nursing shifts can be changed

4. Potential for Additional Savings/Income Some measures will require input from the NHSH Executive team members and/or changes to NHSH practices and policies. Outlined below are a number of categories. Please indicate the appropriate category and provide explanation. Complete table with estimates of potential savings and any costs of implementing proposal

 Requires NHSH Executive level input to determine appropriate N access/threshold levels for treatment, e.g. access to drugs and diagnostics

 Requires changes to CHP Operational Practices Y

 Requires negotiation with third party to NHSH Board N

 Requires capital Investment required to realise savings N

 Requires revenue investment required in one year to realise savings in a Y future year

 Implications for health & safety of staff, patients, visitors, e.g. infection N control which needs to be addressed

 Requires agreement to changes to internal work practices on Raigmore Y Site including redesign of services

 Expected increase in demand on service will absorb any financial benefit N of the proposal in 2012/13

 Requires HR issues to be resolved Y

o Need to restructure a team Y o Need to change type of business TUPE in/out N o Need to implement skill mix changes P o Need to implement change of working patterns e.g. out of hours P review / changes of shift systems o Need to reduce staff numbers Y o Need to change management arrangements Y 33 Also include likely HR constraints impacting on savings if applicable:

 Whether there is a pay protection requirement P  Whether redeployment is required Y  Whether there are statutory requirements to consult and staff Y governance requirement to inform and involve staff in decisions that affect them  Whether there is an increased need for Fixed Term Contracts and P  Will there be Training and Development Y

Any reduction in beds of this magnitude, i.e. 10 + beds, would result in a reduction in the required nursing and ancillary staff. With planning it may be possible to do this through natural wastage however there would be considerable upheaval and churn in the system to facilitate the closure of 10 + beds in one ward area to maximise the highest possible saving.

Saving/Additional 2012/13 2013/14 Recurrent (2014/15 Income Onwards) £000s £000s £000s

Jo Veasey Divisional General Manager Medical & Diagnostics Division

34 Quality and Cost Improvement Plan Version 9 APPENDIX 5 n o

i

t Recurrent Savings t c n u e

d d r s c n 3 m e e e e t g 1 o r

/ i r R i l b s n

i 2 s e u e

i Total n d m v 1 v q v v e o a 0 i u e e Leadn 2012/132013/142014/15 (FYE)

Quality Improvement Proposal B I r N s 2 D N L

General/Hospital

G 1 Patient tracking & Electronic Results (DAS) 2 RH,DS&CL 50 0 20 80 0 100

G 2 Endoscopy Services - Flow Proposal 1 JV & GH 10 10 0 20

3RelocatelumpsandbumpsandurologyworktoNairn 1 CH/CH TBC 10 10

G 4ManagementofReturnPatients 1 DS 0 0 0 0

G 5 Clinical Thresholds - Endoscopy (DAS) 2 JV, MM DJ 0

G 6 Ensure drug usage in line with SMC guidance (DAS) 2 CL,RH, IR 400 400

G 7 Investigate use of telemedicine across all specialties 1 JV/CH/DS TBC 50 50

G 8ReviewallWLpaymentstoensurepaidatNHSHagreedrates 1 CH 20 100 100

G 9 Review feasibility/benefits of ward pharmacy service 1 UL/IR 0 G 10 Review use of technology: 0

G 10a Printing (DAS) 2 DS/LK 0 20 TBC 20

G 10b Self service checking (DAS) 2 DS/LK TBC 0

G 10c Pharmacy robot - to release pharmacist to work on ward (DAS) 2 DS/LK TBC 0

G 10d Order comms (DAS) 2 DS/LK TBC 0 0

G 11 Review availability and use of facilities on Friday pm to optimise resource use 1 JV/CH/DS 10 0 0 10

G 12 Review triage and GP referral across all specialties 1 JV/CH/DS 20 0 0 20

G 13 Review benefits & savings associated with "Releasing time to care" 1 UL 0 0 G 14 Comprehensive review of specialist services (DAS) 2 RH 0

Bed Reduction/Reconfiguration

B 1 Adherence to Daycase Policy 1 CH/AW

B 2 Development of OMFS Sedation Service 1 CH/AW 0 B 3 Impact of Change Fund:

B 3a Close 4 beds on 7C (DAS) 2 JV/IM -4 Reduction in LOS/Admissions/discharges (change fund) - savings assume 12 beds close in one ward*. Improve speed of hospital B 3b transfers. (DAS) 2 JV/SL/EM -12

B 4 Combine Gynae activity with other female surgical activity 1 DM TBC

B 5 Reconfigure oncology & surgical beds 1 JV 0

B 6 GP Surgical Referrals to RGHs. (DAS) 2 CH -2

B 7WeekendandHolidayBedClosures 1 IM/SL/CD TBC 50

B 8 Roll out 90 day Improvement Programme - savings assume beds close in one ward* 1 UL -6 TotalSavingsfromBeds 750 750 1500

Surgical Specialties

S 1OrthodonticsRedesign 1 AW 0 0 0 0

S 2 IVAC pump purchase 1 CD 20 0 0 20 S 3a Substiture Avastin for Lucentis for treating WMD OR (DAS) 2/3 CH/AW 0 0

S 3b NovartisOpthalmology Trial- Income generation (DAS) 2/3 CH/AW 0 0

S 4Reviewpatientsonwaitinglistforappropriatenessoftreatment 1 CH/DS 100 100

S 5 Investigate use of Nairn facility for surgical work (DAS) 2 CH 0

S 6 Roll-out Enhanced Recovery 1 CH/CD 0

S 7 Review benefits associated with productive theatre project 1 CH 200 200

25/05/2012 1 50/022 25/05/2012 S8IpeetA&CRve 1 1 1 1/2 1 1 1 2 1 1 etc. site Solicitors hospital to across notes 1 usage of fax provision Rationalise of policy 10 pricing consistent Establish 9 Review PS C & A Implement 8 PS Trail Project/Audit Triage 1 Electronic 7 PS Policy Behaviour and Values Core PS 6b Project 1 Care gp) Customer user PS 6a (PAS errors ISOFT Reduce Mail ext 5 for PS Contract National to Transfer 4 OPD 1 PS in rates 1 DNA 1 Reducing 3 PS 1 PS PS 1 PS 1 PS PS Project: Lean Records Central ** 2 PS Staffing Outpatient of Review 1 PS PS unit medical acute the in sepsis Reducing 13 review drivers Hours of service Out testing 12 care M of point of Establishment 11 M 10 Project M Redesign Physics Medical 9 Redesign M Wheelchair Continue 8 shifts rotational - M Sciences Blood 7 M 6 Expenditure list M Waiting Neurology 5 workforce M UCP of Review 4 M 3 M 2.2 M 2.1 M 2 M 1 M M S2Rve re rcs o ain el 1 1 1 toilets in dryers air to changing of benefits Review meals 3 patient for process order Review 2 income HS catering increase to Measures 1 HS HS TOTAL above the including costed be to initiatives - Targets Department above) included (not initiatives Procurement Services Hotel Services Patient Diagnostics & Medical Division 2e 2d 2b 2a 2c Number eta eeto 1 00010 0 0 10 10 1 3 1 2 Reception Central areas admission to Bank notes and of OT Provision reduce to posts) (flexible Team Disciplinary Multi Records Medical of Culling Records Health iof prep and tracking Movement, Pathway. COPD with Associated Costs and benefits Review Services. Cardiology of Review Redesign Service Microbiology Contracts. Maintenance Eqt Radiology sites. NHSH over Rationalisation Radiology Radiology: Care. Secondary to Repatriation Services Diabetic ult mrvmn Proposal Improvement Quality Y o ul elsdutl21/7 (DAS) 2016/17. until realised fully not FYE rpslt aesummit. have to Proposal (DAS) (DAS) (DAS) (DAS) (DAS) 1/2

2 3 2 2 2 Level DS DS DS DS DS DS DS DS DS JV/MM JV/DS JV/DS JV/MM FB JV/SC JV/DS JV JV/SC JV JV KS KS JV CL/CH CL/CH CL DS DS DS DS DS DS ed21/321/42014/15 2013/14 2012/13 Lead

Bed Reduction B 0 50 0 TBC 25 0 25 TBC 0 TBC TBC 250 TBC 50 0 25 TBC 175 TBC TBC TBC TBC B 00010 0 0 10 0 0 TBC TBC TBC TBC TBC Investment 001 10 0 0 10 0 50 0 0 12 0 0 0 0 12 0 12 0 0 6 6 0 0 01 20 50 0 0 5 5 10 0 0 20 0 10 0 50 0 0 0 0 0 0 0 5 0 0 5 0 0 20 0 0 0 0 0 0 0 0 0 required

Non rec savings 52 20 20 55 546 265 5749 50 1226 4063 75 2012/13 752235 1765 00040 0 0 40 20 10 0 20 0 20 250 20 0 200 50 010160 100 60 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 eurn Savings Recurrent (FYE) Total 0 0 0 Highland NHS Board 5 June 2012 Item 4.9

CHIEF EXECUTIVE’S AND DIRECTORS’ REPORT EMERGING ISSUES AND UPDATES

1 DALLAS – DELIVERING ASSISTED LIVING LIFESTYLES AT SCALE

DALLAS is a national programme aiming to establish ‘communities’ of 10,000 plus people across the UK to show how assisted living technologies and services can be used to promote wellbeing and independence. In Scotland the initiative is supported by Scottish Government, Scottish Enterprise and Highlands & Islands enterprise with funding totalling £10.3 million having been awarded to the Scottish Community. The amount of funding for each of the five areas involved in Scotland is still being finalised and will be communicated week commencing 28th May.

The Scottish Community Initiative “Living it Up” is being led by NHS 24 and in Highland includes, NHS Highland, Highland Council and Argyll and Bute Council. The other areas in Scotland involved are Lothian, Forth Valley, Moray and Western Isles.

In Highland the target population for Living it Up will be approximately 13, 200 people aged 50 year or over. The initiative will deliver new technologies for self management of health and wellbeing. Between June and December 2012 work will be undertaken, led by a Highland Project Manger, to scope user needs and develop technical and service specifications for what will begin to be provided to users from January 2013. The products to be delivered will include; a digital service available by internet, TV and mobile phone/SMART phone, which will provide personalised information, community communication services (video and messaging), on line booking for some services and Telehealthcare linked to and building on existing Telehealthcare provision.

2 DIABETES CARE ACROSS THE NORTHERN NHS HIGHLAND AREA

For a number of years, NHS Highland has been working towards a shift of diabetes care from Hospital based services into primary care. This relates to both non-insulin and insulin dependant patients, although it is recognised more complex cases will continue to require specialist or shared clinical input.

Funding has been provided to Primary Care via a Service Level Agreement with GP Practices. This SLA formally ended on the 31 March 2012. It has been extended until the end of June whilst negotiations take place with the LMC and Practices around the future delivery and funding of the service. Negotiations are ongoing and are based on the premise that Primary Care is the most appropriate place for care delivery and that this service should be delivered within available recurrent resources.

Patient involvement has been via Diabetes UK with the local lead being kept up-to-date and consulted throughout the process.

For historical and geographical reasons, Argyll and Bute CHP has a different type of SLA to northern NHS Highland. 3 FIRE SAFETY – INVERGORDON COMMUNITY HOSPITAL – NOTIFICATION OF UNSATISFACTORY STANDARD

On 2 May 2012 Highland and Islands Fire & Rescue Service undertook an audit of fire safety standards at Invergordon Community Hospital. During this audit a number of issues were identified in relation to the fire doors in the Sutor Ward and access from the building outside the Fyrish Ward which were deemed unsatisfactory and require resolution as a matter of urgency. Colleagues in the Estates Department are working with Robertson Dawn Healthcare who own the building to resolve these issues and are keeping Highland & Islands Fire & Rescue Service up to date with progress.

4 HIGHLAND EATING DISORDER OUT PATIENT SERVICE AND THE EDEN UNIT SPECIALIST IN-PATIENT FACILITIES

Highland Eating Disorder Services were established 10 years ago to provide out patient treatment for adult mental health patients with an eating disorder from across Highland. Currently, on average, 100 referrals a year are made to the service, with around a third of these patients having anorexia nervosa and a half having bulimia nervosa. Patients are managed by a multi-disciplinary team of two nurse therapists, part time staff grade and consultant psychiatrists, part time dietician and part time clinical psychologist. A range of psychotherapies are offered including CBT, IPT, DBT, EMDR, CRT and nutritional support. Treatment plans are agreed on an individual basis, with input from each discipline as appropriate, to accommodate the often complex needs of this patient group. It is only for a small minority of our patients ( 2-6 per year) for whom in-patient treatment is considered necessary.

Should patients require specialist in-patient treatment they are referred to the Eden Unit which has 10 in-patient beds for patients from across the North of Scotland including Highland, Tayside and Grampian. These patients sometimes require to be admitted to Raigmore Hospital for medical stabilisation first to ensure that they are physically well enough to be transferred to Aberdeen.

Since the Eden Unit opened three years ago, close links have developed between staff across the services which helps to ease patients' transition through out and in-patient care. Monthly clinical liaison meetings are held between staff from Highland ED Services and the Eden Unit. Staff from both services meet with in-patients to discuss assessment, treatment planning, progress reviews and discharge planning as appropriate. Quarterly Eden Unit review business meetings are also attended by members of the North of Scotland Managed Clinical Network for Eating disorders.

Access to NHS beds in the North of Scotland provides for high quality specialist in-patient care when indicated. Although the ten beds are in constant use, there has rarely been a delay of more than a few days for a bed to become available, once the need for one has been identified. Recent development of a "three week only assessment bed" appears to have helped to ease pressure on bed use. In line with recent national RCollPsych MARSIPAN guidelines, there has been some work with one of the consultant physicians in Raigmore to develop local guidelines for the management of physically unwell eating disorder patients in medical wards. This closer liaison between psychiatric and medical services is again contributing to improved standards of care for Highland Eating Disorder patients.

2 Close liaison across the services is essential and this is facilitated by frequent joint meetings which are carried out via videoconferencing. This allows for regular contact with both staff and patients without the additional burden of frequent travel. Joint staff training events organised in both Grampian and Highland have been well attended, allowing for face to face contact and to occur. Highland ED Service benefits from being part of the North Scotland Managed Clinical Network for Eating Disorders and staff participate fully in many varied aspects of the work of the Network including quality assurance, the setting of standards and training and service developments.

Issues identified for further consideration in Highland are:

1. Transition from adolescent to adult mental health services 2. Local Day Care Facilities 3. Primary Care Management

In summary, there is a close working alliance between Highland Eating Disorder Services, The Eden Unit and the North of Scotland Managed Clinical Network for Eating Disorder Services. Services have been developed at secondary and tertiary levels, but there are still gaps in service provision at primary care level, for patients in transition from CAMHS to adult services and for day care, or an equivalent intensity level of care in the community.

5 INVESTIGATION INTO THE MANAGEMENT CULTURE IN NHS LOTHIAN

As a result of the findings of the PricewaterhouseCoopers (PWC) Report into Waiting Time Management in NHS Lothian, Nicola Sturgeon MSP, the Cabinet Secretary, for Health and Well- Being, met with the Chair of NHS Lothian in March 2012 and required him to commission an investigation into the culture in NHS Lothian. As a result, a Report by David Bowles and Associates Limited, entitled ‘Investigation into the Management Culture in NHS Lothian’, was issued in May 2012.

As well as specific issues relating to waiting times the Report included a number of findings on culture as follows;

“It is important that individuals are held to account for their performance; however the style and nature of this within NHS Lothian has been at the expense of developing strong team working, allegedly breached the Board’s Dignity at Work Policy and as a consequence created a blame culture. Taken together they have combined to create an organisational culture where bad news is not passed up the line, a gloss is put on reports and staff are told to ‘fix it’ without support. The organisational problems have been exacerbated, as the culture has lasted a long time, some staff allegedly emulated inappropriate management styles and staff have not used the Board’s whistle-blowing and other procedures to raise concerns, apparently for a number of reasons including a lack of confidence in their application at senior level and concerns about reprisal. The review has concluded that is difficult to see how such a culture was consistent with delivering the benefits of single system working.”

The Report made a number of recommendations, including:

“We recommend that the change programme should be overseen by a Steering Group, reporting to the Board, which should work in a manner which engages staff and that any change programme should be implemented in a way that delivers sustainable change whilst recognising that the Board has, in common with all other NHS Boards, considerable challenges against which it needs to deliver.”

3 “Changes of leadership style, values, culture and organisational culture, re-establishing trust and confidence, performance management, targets and accountability, embedding polices, risk and reputation, mapping the future.”

Local Context Through our work on the 18 Weeks Referral to Treatment Programme, NHS Highland has been making ongoing progress on the delivery of waiting times. This has included various external reviews into how we manage our waiting times.

We do have some ongoing pressures in some specialities and these have previously been reported to the Board and our Improvement Committee.

Having received the Lothian Report, however, the Chair of NHS Highland has asked for a Short-Life Working Group to be set up to consider in more detail the findings of the Report . The purpose of the Group is to take the opportunity to look at our own culture and ways of working and determine whether our approach is commensurate with delivering the provision of high quality services and a positive staff experience; while at the same time meeting various Targets. This will build on work which is already ongoing around the Highland Quality Approach, customer care, communications and engagement and the findings will provide a solid foundation to bring in the Patient Rights (Scotland) Act.

The Short-Life Working Group will comprise of the Chair, the Vice Chair /Chair of Clinical Governance Committee, the Chair of the Staff Governance Committee, the Employee Director, the Chief Executive, the Director of Human Resources and the Head of Public Relations and Engagement, in the first instance. The first meeting with be held in June 2012, with the intention of providing a Report to the NHS Highland Board in August.

6 MAGNETIC RESONANCE IMAGING (MRI) SCANNER REPLACEMENT – RAIGMORE HOSPITAL

6.1 Background

The MRI Scanning service located on site at Raigmore Hospital was initiated as a result of a government funded initiative, the funding allowed for start up costs for the initial NHS Highland MRI scanning service to be established by providing both capital and revenue costs for procurement of an MRI scanner and supporting staffing and consumables costs.

The first scanner was installed in 2001, commissioned in 2002 and the first Highland MRI patients were scanned in January 2003. The scanner was sold to a leasing company in 2004 and a five year lease arrangement was initiated which was extended for a further three years in 2009. The scanner was purchased from the leasing company in March 2012 and is now an NHS Highland owned asset.

With a view to improving efficiency the scanner software was upgraded to a newer release in 2006 to help reduce the time it took to perform each MRI scan as a part of the Diagnostics Collaborative Programme. A second MRI scanner was installed within the MRI scanning suite to help accommodate the burgeoning requirement for access to MRI scanning for patients in June 2010, to allow contingency arrangements in the event of technical failure of the equipment and to provide access to higher quality MRI scanning as the first scanner was becoming technically obsolete.

4 The Raigmore based NHS Highland MRI service has been a resounding success Table 2 shows the year on year activity the service has provided for since its initiation in 2003.

(Table 2)

MRI Exams performed s n o i

t 7000 a n

i 6000

m 5000 a x

E 4000

I Exams performed

R 3000 M

f 2000 o

r 1000 e b 0 m u

N 3 4 5 6 7 8 9 0 1 2 0 0 0 0 0 0 0 1 1 1 0 0 0 0 0 0 0 0 0 0 /2 /2 /2 /2 /2 /2 /2 /2 /2 /2 2 3 4 5 6 7 8 9 0 1 0 0 0 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 0 2 2 2 2 2 2 2 2 2 2 Year

The service is now heavily relied upon by local clinicians to provide a range of MRI examinations to NHS Highland patients including neurology, paediatrics, musculoskeletal, oncology, vascular, breast, ENT, cardiac, gynaecology, urology, gastro-intestinal and Radiotherapy planning scans.

Activity and demand for MRI services is expected to continue to increase into the future due to the continually expanding range of diagnostic pathways MRI is useful in supporting. The Detect Cancer Early Programme will generate additional workload for MRI services in relation to suspected breast and gastro-intestinal cancers plus follow-up cancer surveillance.

Further developments that will add to the demands on the MRI service in the very near future are development of the cardiac MRI service; cardiac MRI has been shown to be gold standard for assessing myocardial perfusion, ischaemia as well as less common cardiac pathologies. MRI spectroscopy is an emerging development to aid diagnosis of neurological conditions, paediatrics and some cancers e.g. prostate. Diffusion techniques, already in common use will also expand to aid in diagnosis and staging of cancers.

6.2 Requirement to replace the oldest MRI Scanner

The MRI Scanner commissioned in 2002 now requires replacement due to its age.

In addition there are now significant issues in relation to technical obsolescence with the current machine; a very limited range of examinations can be provided by this MRI scanner, as a result issues are beginning to surface relating to service delivery in terms of bottlenecks and inefficient working practices.

The scanner is becoming increasingly unreliable with significant periods of unplanned down time within the past twelve to eighteen months which not only is affecting waiting times maintenance but is also causing significant disruption to patients with the equipment technically failing without warning and patients having to be cancelled at the last minute when already in the MRI department. This is increasing hospital spend as a result of having to programme in additional lists to replace lost scanning down time.

5 As a result of the issues stated above the Radiology department requires to replace the older, unreliable and technically obsolete MRI Scanner as soon as possible.

6.3 Summary

Due to financial constraints NHS Highland is facing significant challenges in securing adequate resource to support a conventional replacement exercise for the MRI scanner based in the Raigmore Radiology Department.

A recent tendering exercise has revealed that a potential solution to this problem would be to enter into an agreement with the original manufacturer of the MRI scanner to upgrade the existing scanner to an equivalent specification to that of the newer MRI scanner installed in 2010. Following this course of action will substantially improve the availability of reliable and sufficiently high quality scanning capacity to the NHS Highland MRI scanning service based at Raigmore Hospital Inverness and will provide service sustainability for the foreseeable future. In addition this option is financially viable within existing funding streams.

An economic appraisal of the options indicates that an operating lease is the preferred option. The revenue cost of this can be financed using the existing funding stream.

Alternative service models have been considered to provide assurance that upgrading the local scanning technology is the best option to be progressed to meet the needs of local NHS Highland patients.

The NHS Highland Asset Management Group have reviewed the issues, risks and options available to provide solutions to these problems and support the decision to upgrade the scanner on site at Raigmore Hospital and move to lease the equipment via a five year operating lease arrangement.

The proposed timescale for implementing the updated scanning technology is the beginning of September 2012.

7 REFORM OF POLICE AND FIRE SERVICES

Since 2005 the statutory duty placed on Category 1 & 2 Responders to work together to plan, prepare for and respond to emergencies has been delivered through the mechanism of the eight Strategic Co-ordinating Groups (SCGs), which are based on the footprint of the eight Scottish constabularies. NHS Highland, as a Category 1 Responder, participates fully in the business of the Highlands and Islands Strategic Co-ordinating Group (HISCG).

As of 1 April 2013 there will be a single National Fire and Rescue Service and a single National Police Force in Scotland. Changes to these organisations will undoubtedly impact upon the structures and governance of the SCGs.

While the process of reform for both these organisations continues, what is emerging is the likelihood of a new North of Scotland Police Division which would be an amalgamation of the existing Northern Constabulary and Grampian Police boundaries. This new Division would be led by one territorial Assistant Chief Constable, probably based in Aberdeen, with a Chief Superintendent responsible for policing the current Northern Constabulary area.

6 We are fully engaged through our health protection team in ensuring that any proposed changes to the role and configuration of the HISCG are not to the detriment of the current close and effective working relationships. We will keep the Board updated on the implications and propose bringing a more detailed paper to the next Board meeting.

8 REGIONAL PLANNING – NORTH OF SCOTLAND PLANNING GROUP AND WEST OF SCOTLAND PLANNING GROUP

A copy of the Briefing from the North of Scotland Planning Group for April 2012 is circulated as Supplementary Paper 1 to this update. A copy of the Briefing from the West of Scotland Planning Group for May 2012 is circulated as Supplementary Paper 2 to this update.

9 RISE IN CASES OF WHOOPING COUGH (PERTUSSIS)

In 2012 Health Protection Scotland has seen a marked increase in both the number of clinical notifications and laboratory confirmed cases of pertussis. This is consistent with a rise in pertussis across England and Wales. Cases of whooping cough tend to increase cyclically every three or four years, although the number of laboratory confirmed cases in Scotland this year now exceeds the number reported in all of the last peak year in 2008.

Pertussis can affect individuals of all ages but infants under 1 year old (especially those who have not started or finished their primary immunisation course) are at highest risk of severe complications, hospitalisation and death. Although adolescents and adults tend to display milder symptoms, they can be an important source of infection for very young infants.

Locally, the health protection team are working closely with GP practices in north Argyll to manage an increase in community cases of whooping cough. So far there are 66 confirmed cases and a further 168 clinically suspected cases. The cases are mainly in and around north Argyll including Dalmally, Taynuilt, Connel, and Oban. There have also been 11 confirmed cases in the rest of Highland. Cases are in all age groups but primarily those aged 5 years to 17 years. Waning immunity in teenagers, even among those who are fully vaccinated, is thought to be a significant contributory factor. There has been no serious illness in any NHS Highland cases.

All our efforts are focussed on trying to prevent illness in the most vulnerable group who are young infants – especially those pre-vaccination. The aim is to try and avoid infection entering the households/families of those children.

The measures involved in controlling pertussis infection are: - Vaccination; - Detection and surveillance of confirmed and suspected cases; - Treating cases and excluding them from situations or activities where further spread may occur; - Defining close asymptomatic contacts and when appropriate, providing them with antibiotic prophylaxis and vaccination to stop the infection developing in them and reducing the possibility of transmission; - Managing outbreaks especially in at-risk settings (e.g. schools, care institutions)

Vaccination is the most effective way to prevent spread of the disease. Children are offered pertussis vaccine as part of the “5 in 1” vaccine at two, three and four months of age as part of the routine childhood vaccination programme and a booster at around three years and four months.

7 Health professionals have been asked to continue working to maintain the high vaccine coverage of the childhood immunisation programme (over 95% uptake) and take the opportunity to offer vaccination to those who have missed doses and are not appropriately fully vaccinated for their age. In a further effort to minimise spread information letters were sent in April to all parents of pupils at Oban High school plus several local primary schools and pupils who stay in the school hostel accommodation in Oban were all offered vaccination.

As the increase in cases is affecting Scotland as a whole, a national group has been convened to co-ordinate the steps being put in place locally to reduce the probability of transmission. It is liaising closely with a similar group in England.

Chief Executive’s Office Assynt House

25 May 2012

8

NORTH OF SCOTLAND PLANNING GROUP

NHS Board Briefing April 2012

A meeting of the NoSPG Executive was held on 18 April 2012. The following briefing has been prepared to update the North NHS Boards on the outcome of the meeting.

NoSPG Projects

NoS Weight Management Implementation Group

A revised pricing structure for bariatric surgery is in place as from 1 April 2012. Discussions to be held at the National Planning Forum (NPF) for assurances that Boards are prepared and there are no expected breaches, for patients who have been clinically identified for surgery after going through the pathway.

Paediatric Secondary Care Sustainability Review

The NoS Paediatric Secondary Care Sustainability Review report, which had been carried out by Dr Zoe Dunhill, Independent Child Health Consultant has been circulated more widely and Boards have been formally requested for feedback and commitment against the report’s recommendations. A deadline of 31 st May 2012 had been set for this.

CAMHS Financial Risk Share

The CAMHS Financial Risk Share had been subject to discussion during the process of the OBC being presented to Boards and was subsequently circulated around IPG members for their feedback on the preferred option. Members confirmed their support of the preferred option, which was Option 1 and the principles around the risk share were contained in the OBC.

National Work Streams

National Update

A paper regarding the NPF review of National Services Advisory Group (NSAG) and efficiency of specialised services and Service Reviews of existing national services was noted.

NoSPG Business Management

NoSPG – Interim Management Arrangements

Mr Peter Gent has been appointed to the role of Interim Director Regional Planning & Workforce Development following Dr Ingram’s move to NHS Grampian.

Workplan 2012/13

North of Scotland Planning Group is a collaboration between NHS Grampian, NHS Highland, NHS Orkney, NHS Shetland, NHS Tayside and NHS Western Isles

The 2012/13 workplan was noted. Some structural changes have been recommended to help measure projects more visually.

Clinical Lead – Child Protection

Members noted the interim arrangements to establish expert tertiary child protection advice for the region; and noted the intention to develop a proposal for the NoS specialist child protection network to be further discussed at NoSPG in the following months.

Date and time of next meeting

The next meeting will be a virtual meeting to be held on 13 June 2012 at 10:30 am.

Mr Peter Gent Interim Director of Regional Planning & Workforce Development North of Scotland Planning Group

27 April 2012

North of Scotland Planning Group is a collaboration between NHS Grampian, NHS Highland, NHS Orkney, NHS Shetland, NHS Tayside and NHS Western Isles

SUPPLEMENTARY PAPER 2

WEST OF SCOTLAND REGIONAL PLANNING GROUP

Briefing Paper

The following is a resume of the key points from the West of Scotland Regional Planning Group Meeting held on the 4th May 2012.

1 Radiotherapy Capacity Planning in the Central Belt - Update on Progress

The site options had now been assessed and the following ranking had been identified:

Rank Location Total Score Clinical Benefit Patient Access Strategic Fit 1 Monklands DGH 338 114 116 108 2 Forth Valley RH 325 118 102 105 3 St. John’s Hospital 214 89 67 58

It has been determined that a single site for the West and East is not viable, therefore not withstanding the need to continue the overall planning piece, the capacity problems within the west are pressing. The West RCAG should now move to assess the options for a west satellite facility serving the west Boards populations. The full business case for this development will need to be complete by mid 2012/13 with a view to capital allocation in 2015/16 and the WoS RPG recommends that the National Programme Board should approve the findings and support the OA and business case development.

2 Regional Vascular Services

The Regional Vascular Services Review aim was to complete a high level WoS review which would focus on:

• FeasibleoptionsforaTier3centre • Development of Tier 2 services locally • Coherent clinical pathways for vascular services

NHS GG&C currently provided a service at the Western Infirmary (to be relocated to the Southern General site in 2015) NHS Ayrshire and Arran, NHS Lanarkshire and NHS Forth Valley had expressed an interest in hosting a second centre. NHS Dumfries and Galloway continued to have discussions with Cumbria but also wished to link into the west discussion. NHS Forth Valley was in discussion with SEAT regarding the Lothian position. It was acknowledged that issues remain in the north of Scotland and that the Western Isles wish to be included in any solution for the West of Scotland. It was noted that only 3% of west service would requires to be relocated to different centre and discussions with Cabinet Secretary was needed as to whether this could proceed to implementation without full consultation as this was substantially a quality issue.

3 Workforce – Implications of Medical Workforce Numbers on Service Reduction:

The WoS RPG update on the current position with trainee reductions from August 2012 was noted and the detailed risk assessment across Boards re service implications was ongoing. Karen McGhee risk manager liaising with each Board to look at by specialty & site and by Sept/Oct- will be presented to CE and Medical Directors. 4 Scottish Ambulance Service – Provision of Transport for Renal Dialysis Patients

The RPG had received a response from SAS re delays in progressing renal services redesign to improve service provision and providing a cost saving. SAS confirmed commitment to this within their scheduled service programme and agreed to look to accelerate this and a meeting was to be held in 6th June with relevant leads across the WoS to examine current issues and look forward to the future e.g. development of more dispersed units.

5 Neonatal Service Implications - Neonatal Care in Scotland: A Quality Framework (QF)

The RPG received a preliminary report on:

 An assessment of each Board against the indicators within Neonatal Care in Scotland: A Quality Framework (QF) including some commentary around implications and risks

 A ‘Table Top’ assessment of each Board’s neonatal workforce and the high level costs to achieve the workforce commitments within the framework including reconfiguration options.

Overall, west Boards are achieving the majority of the quality indicators within the framework. There are costs associated with achieving the framework. In particular, two Boards i.e. NHS Forth Valley and NHS Ayrshire and Arran have identified that there would be significant workforce costs associated with maintaining their current Level 3 status. It was noted that NHS GG&C had already changed the status of the RAH to level 2.

Further work to be done on refining the options for maintaining or changing the status of the service to meet the new national framework and this to be brought back to Boards and submitted to the National planning forum for consideration.

6 NHS Greater Glasgow & Clyde Children’s Diabetes Service Insulin Pump Therapy

WoS Boards were asked for their views on the introduction of insulin pumps for the paediatric patients from other Board areas including those looked after by the diabetes team at Yorkhill

Our current service delivers care in RHSC, RAH and Inverclyde. Via an obligate network, we also provide care to 20 patients in the Western Isles. The service also provides ‘outreach’ clinics to support Highland patients in Oban and Lochgilphead.

Delivering on the Directive to have 25% of children with Type 1 Diabetes on Insulin Pumps by March 2013 Implementation for NHSGGC residents requires 91 pump starts in 2012-13 allowing for the expected 65 new patients (16 pumps) and the fact that we already have 50 patients on pumps.

Implementation equally across all NHS Boards for the patients we currently support would require an additional 36 pump starts to be funded by other NHS Boards. Boards were asked to confirm their wish for NHSGG&C to provide the service and support it with appropriate funding. NHS Highland (Argyll and Bute) confirmed wish NHS GG&C to initiate pumps and establish a resource of local Dietetic and specialist nurse support to provide local service. An action plan with costs etc will be submitted accordingly to SGHD.

7 WoSCAN Cancer Work Plans for approval:

The RPG received and approved the WoSCAN work plan 2011/12 end year position and WoSCAN work plan 2012/13- the major themes for this year are:

2 1 Detect Cancer Early o Referral & Access –Bowel and Breast Cancer o Cancer Genetics And Molecular Testing o Diagnostics- examine feasibility and cost effectiveness of open access for Primary Care

2 Cancer Modernisation o Surgical Oncology o Radiotherapy o Systemic Anti Cancer Therapy (Sact) o Acute Oncology

3 Transforming Care After Treatment o Follow up o Patient experience o Patient involvement o Information

4 Quality- Audi review of regional and national guidelines 5 Delivery- Workforce, E-Health, Regional & National working enhance service

Stephen Whiston Head of Planning, Contracting and Performance Argyll & Bute CHP

14 May 2012

3

Highland NHS Board 5 June 2012 Item 5.1(a)

DEVELOPING A QUALITY APPROACH TO ENGAGEMENT AND COMMUNICATIONS: SETTING UP FOR SUCCESS – NEXT STEPS 2012/13

Report by Maimie Thompson, Head of Public Relations and Engagement on behalf of Elaine Mead, Chief Executive

The Board is asked to:

 Note the ongoing work to develop more robust strategic communications and engagement to support delivery of NHS Highland’s aims and objectives.  Discuss and agree the framework including considering the identified assumptions and risks.  Discuss and agree the outline forward plan.  Provide direction in terms of what is expected from the Board to provide assurance that progress is being made and how this will be measured.

1 Background – Where are we now?

1.1 A paper was presented to Board of NHS Highland in February 2012 which set out the scope of work required to develop strategic communication and engagement.

1.2 The importance of CEL(2010)04 “Informing, Engaging, and Consulting people in Developing Health and Community Care Services” was particularly highlighted, including that:

“Public consultation about service change should grow naturally out of a Board’s everyday communication and dialogue with people it serves.”

1.3 The Board endorsed the paper tabled in February 2012 including the recommendation that engagement and communications is fundamental to the successful delivery of NHS Highland’s aims and objectives.

1.4 It was recognised that improving strategic engagement and communications will take time and further focussed work will be required to develop the strategy, priorities as well as capacity and capability. This was further discussed at the Board Development day held on 6 March 2012.

1.5 This paper summarises the communications and engagement strategic framework, and the high-level action which will support prioritisation and tracking of management actions during 2012/13. The detailed high-level action plan has not been circulated but will be reviewed by the Senior Management Team in May 2012.

2 Strategic Framework and Action Plan – What are we trying to do

Our strategic aims are general statements which set out the overall goals of what NHS Highland is responsible for delivering. Our objectives identify some of the individual stages which will help us to reach our goals. 2.1 Strategic Aims of NHS Highland

2.1.1 to deliver Better Health for our communities through population wide and individually focused initiatives to maximise health and well being and prevent illness.

2.1.2 to deliver Better Care through quick access to modern services, in the most appropriate settings, and in clean and infection free facilities by well trained and professional staff. 2.1.3 to deliver Better Value for the use of the public money we spend. This is by ensuring there is no waste and inefficiency; and where money is spent only on what is needed and has evident therapeutic benefits.

2.2 Strategic Objectives of NHS Highland

2.2.1 promote good health, self care and independence

2.2.2 deliver services that are fair and affordable based on need and clinical evidence

2.2.3 deliver more community-based services using hospitals for those needing specialist care

2.2.4 use modern facilities and technology to best effect

2.2.5 re-design services to remove waste and inefficiency

2.2.6 work jointly with local authorities, voluntary and independent sector

2.2.7 ensure that services are run by well-trained and flexible staff working to the best of their skills and abilities.

2.3 Strategic Engagement and Communications Principles to Support delivery

2.3.1 Focus on person-centred care and improving experience of care.

2.3.2 Develop appropriate infrastructure to foster positive involvement and engagement with people including patients, carers, staff, partners and wider public.

2.3.3 Widen access to communications and engagement recognising equality and diversity using a wide range of approaches and methods.

2.3.4 Improve and support more face to face communication, and in particular clinical leaders leading clinical changes to services.

2.3.5 Demonstrate effective systems and leadership in place to facilitate regular feed-back and evaluation which is focussed on improving care, services and understanding the range of views.

2.4 Assumptions

2.4.1 There will be support, in principle from staff, patients, public as well as politically to achieve our strategic aim of Better Health, Better Care, Better Value.

2.4.2 Improving effective communications and engagement will build trust and support and, in doing so improve decision making at all levels.

2.4.3 There are people with skills and influence who can and will lead positive changes to improve communications and engagement in Highland.

2 2.4.4 It will be possible to evidence improvements in communications and engagement leading to people feeling more informed and involved.

2.4.5 Improving communications and engagement will support delivery of organisational aims and objectives.

3 Framework and Action Plan – How are we going to get there?

3.1.1 A logic model (also known as a logical framework) has been drafted to summarise how the programme of work which has been identified is intended to produce particular results.

3.1.2 It sets out how resources that are currently invested (or potentially available), the activities that tare planned, some of the outputs and, finally the benefits or changes that are expected, if the sequence of events are followed through.

Resources/ Activities/ Inputs Task Outputs Outcomes Impacts/ So what?

A supporting logic model and high-level action plan for 2012/13 has been prepared. It has been divided into six work streams, as follows:

3.2 Carry out an ongoing review of the strategic and operational approach to PR & engagement to ensure priorities are appropriately resourced.

. This will be an iterative process and the scope will need to extend to overlapping functions and will link with wider relevant reviews

3.2.1 Implement a strategic approach to developing more effective “Patient” and Public involvement and engagement.

3.2.2 Implement a strategic approach to developing more effective communications and public relations.

3.2.3 Take effective actions to further build internal communications, engagement capacity and capability.

3.2.4 Management of issues and other business requirements.

3.2.5 Develop and co-ordinate a strategic programme of evaluation.

The medium (2013/14) and longer term (2014/15) outcomes as well as the impacts will be developed as the year one programme progresses.

3.3 Forward Plan – Prioritising Next Steps

3.3.1 In order to manage the work load as well as taking a co-ordinated, phased and planned approach, it is recognised that further detailed work is required to develop elements of the plan. This will require Board and Senior Management input and support as well as wider engagement.

3 3.3.2 Developing each of the work streams is a significant undertaking and not to be under-estimated. Further focussed work and expertise is required on:

. Work Stream 1: widening involvement and engagement including current infrastructure and approaches for developing groups and people on groups (Appendix 1)

. Work Stream 2: building capacity and capability to support effective communications (internal, external, media and political) at both strategic and tactical levels. This must include developing our key messages

. Work Stream 3: training and support to promote and deliver the outcomes from CEL(2010)04, including options appraisal

. Work Stream 4: develop and implement Social Media and Social Marketing Strategy

. Work Stream 5: re-design of internet (Public facing website) and intranet (internal website for NHS staff)

3.3.3 It is proposed that short-life working groups be established which would draw on appropriate skills and experience, including leadership support from Non Executive and Executive colleagues.

4 Risks – What do we anticipate might get in the way of success?

4.1 Organisational Risks

4.1.1 The impact of poor strategic day to day engagement and communications has been identified as a very high risk for the Board.

4.2 Communication and Engagement Risks

4.2.1 Not able to agree simple key messages with enough skilled people in the right positions to enable and deliver at both the strategic and tactical CHP levels

4.2.2 Not able to move from basic communications and engagement (reactive media, communications as an after-thought, corporate publications, people on groups) to a more pro-active and engaging approach.

4.2.3 Not able to build sufficient capacity and capability to effect positive change within required time-scale

4.2.4 There are specific challenges to ensure we are able to engage and communicate well with harder to reach populations

4.2.5 Not able to address existing issues with respect to website, intranet, and not everyone using email

4.2.6 Lack of knowledge and expertise on social networking sites and potential influence on engagement and reputation

4.2.7 Not able to effectively co-ordinate, manage and link wide ranging re-design of services across NHS Highland

4.2.8 Not willing to be innovative, take risks or invest in communications and engagement

4 4.2.9 Not able to demonstrate positive impact of communication and engagement activities on achieving outcomes and therefore not able to effectively target resources and effort

4.2.10 More generally, if the assumptions (outlined above) are not valid then the approach and actions will not be effective

5 Evaluation and Assurance – So What? How will we know if we have been successful (or otherwise) and why?

5.1.1 There are recognised challenges around evaluating the effectiveness of communications and engagement strategies and how these might be directly or indirectly related to delivery of organisational outcomes and impacts.

5.1.2 Some of the approaches (National Standards for Engagement, VOiCE, CEL(2010)04 look to assess how well we have engaged or communicated. One of our assumptions (Section 2.4) is that this will support delivery of organisational objectives. Evaluation will need to look at both process measures as well outcomes

5.1.3 It might be helpful to consider what, over the next three years, NHS Highland wants a reputation for.

5.1.4 There will need to be systems in place to provide evidence of:

. having key messages developed and used . greater awareness of staff, patients and public understanding about our key messages . greater consensus about the need for change and what should change . more effective ongoing engagement with people . collecting feed-back including actions taken as a result

6 Governance Implications

6.1 Staff Governance

6.1.1 Having strategic and operational plans in place for engagement and communications will support meeting the staff governance standard. It should be noted that the approach highlights the importance that all staff have to play and that further consideration is required to how best to achieve greater awareness of key messages and the need for change.

6.1.2 The work programme will be further informed by the short-life working groups and other work streams, including customer care, values, dignity at work.

6.2 Patient Focus and Public Involvement

6.2.1 The principles as set out in this paper is fundamental to promoting an inclusive approach to local service provision, as well as taking a patient-centred approach. The work programme will be further developed in line with National Person-Centred Health and Care Programme.

5 6.3 Clinical Governance

6.3.1 Effective engagement and communications will support the organisation with the commitment to working with staff, patients, carers and members of the public. It will help to highlight real clinical concerns as opposed to miscommunication or lack of understanding in clinical services or care.

6.3.2 Detailed plans need to be developed to support specific work programmes. Plans will be further informed by recommendations from National Standards and Guidelines, NHS Highlands work on Pathways, Clinical Advisory Group and Highland Quality Approach.

6.4 Financial Impact

6.4.1 A financial impact assessment has yet to be carried out.

6.5 Planning for Fairness

6.5.1 This report outlines the approach and actions to be taken to develop a Highland Quality Approach to Communications and Engagement. This specific report does not require a planning for fairness assessment. However, impact assessment is already underway to support key work streams.

6.6 Communications and Engagement

6.6.1 This paper and supporting action plan sets out the approach to developing effective communications and engagement with people. Colleagues are being encouraged and supported to make sure specific communication and engagements plans are being developed, and a section is now included as part of Board Papers.

6.6.2 It will be important for the Board to seek assurances that plans are being fully developed and implemented to support consistency in rigour and maximise impacts.

6.6.3 The additional work streams identified will further support colleagues to deliver communications and engagement as well as assessing the impacts.

Elaine Mead Maimie Thompson Chief Executive Head of Public Relations and Engagement

25 May 2012

6 Appendix 1

Further develop public involvement and engagement including current infrastructure and approaches for developing groups and recruiting people to groups

Recommendation

As part of the forward plan one of the next immediate priorities is to further develop strategic and operational involvement and engagement.

Some issues for discussion, review and action

. Meeting statutory requirements and support development of Strategic Groups . When we are seeking representation how could this be supported and assured . Structures and process for recruitment of members on to groups or to support specific bits of work . Developing effective links and networks between District Partnerships and Highland Health and Social Care Partnerships . Developing effective links and networks between services and partnerships . Developing strategic approach to person centred approach including collecting feed- back and linking to improvement work. . Ensuring compliance with relevant CELs

Summary of some supporting Background Information

Public Involvement - Statutory requirements

NHS Highland is required by the Scottish Government to have Public Member(s) as part of Community Health Partnership Governance Committees (Highland Health and Social Care Partnership and Argyll and Bute Community Health Partnership). The process stipulates that the Public Member should be drawn from a Public Partnership Forum (see below). There are requirements to have representation from the voluntary sector and there has been recent guidance CEL 6 (2011) which outlines expectations with regards to carers. Refer also to Board Paper Item 4.2

Item 4.2 of the June 2012 Board Papers provides an update on the establishment of Highland Health and Social Care Partnership, including recruitment.

An outline diagram of the structures to support the Highland Health and Social Care Partnership is summarised (Figure 1).

Public Partnership Forums (PPFs)

Community Health Partnership are required to have Public Partnership Forums though the detail of how they look and operate is not stipulated:

. Highland Health Voices Network (HHVN)

This is a virtual Network with members from across all of the area covered by NHS Highland. Members have been recruited onto the Network and participate as individuals with an interest in health or social care.

When the Network was set up it was designed as a conduit for informing people about what’s going on across NHS Highland services, and offering opportunities for involvement in a wide

7 range of activities. Supporting infrastructure includes an information leaflet with an application form to join. There is also a working agreement which outlines the role and function. Members receive regular information as well as contacted over specific issues.

. Argyll and Bute Public Partnership Forum and Locality Forums

This is set firmly within the local CHP structures. The members elect a chair and vice chair whose role includes fulfilling the statutory requirement to have PPF members on the CHP Governance Committee. In addition, the chair is also a member of the CHP Management Team. There are also various Locality PPFs at different stages of development. Not all the members of the Argyll and Bute Public Partnership Forums are members of Highland Health Voices Network.

Other NHS Highland Board Committees

Last year the Board recommended that public members should be recruited onto various committees. It was agreed that a similar process to recruiting to the Governance Committee should be followed but members could be drawn from a wider audience (i.e not just existing Public Partnership Forum Members.

Groups and Committees

Patient and Public Members sit on a range of Groups and Committees. So far it has not been possible to pull together a comprehensive list.

District Partnership Forums

As part of the structures to support the Highland Health and Social Care partnership a series of District Partnerships will be established (Figure 1). These will be action focussed and will provide a clear two-way link between strategic direction and local solutions. They will involve Councillors, relevant managers, community representatives and representatives of professional groups (Social Work, Nursing, GPs and so on). Guidance on District Partnership was produced in January 2012. Work is underway in Lochaber to set up the first District Partnership.

Patient Participation Groups

Patient Participation Groups are set up around General Practices. These are made up of interested people drawn from the practice population and cover a wide variety of different things. Scottish Health Council has produced guidance to support the development of these Groups. Mid and south operational unit have also developed a toolkit and guidance to assist the formation, development and support for Patient Participation Groups across their area. Some groups are supported by practice managers while others operate quite independently.

Work is ongoing to confirm where groups are established and the chairs and membership of these groups.

Regular Networks: Area or Topic Specific

There are a range of existing arrangements in place to try and ensure regular two-way conversations about local service provision, such as (i) Skye and Lochalsh Reference Group, (iii) Skye and Lochalsh Health and Social care forum, (iv) South East Patient Participation Groups.

Service users themselves also set up groups around particular topics. These will usually be supported by NHS staff in some way.

8 Work is ongoing to confirm where groups are established and the chairs and membership of these groups.

Public and Patient members are also recruited to various clinical networks (eg Diabetic Clinical Network, Stroke Network.

Over and above this staff have their own networks, meetings and conversations in place as part of their day to day working. This is wide-ranging.

Short-Life Groups

There are constantly groups being pulled together to discuss particular issues, topics or service review.

Specific Pieces of Work

There are a wide range of individuals across Highland who become involved in specific pieces of work within individual services. This might be commenting on information, feed- back on a particular service or issues (eg Raigmore Hospitals signs and letters project, dementia services, personality disorder). People can be drawn from all areas (including any of the above) or may involve discussions and input from existing service users. The arrangements for inviting/ recruiting people is variable.

Often other organisations facilitate wider discussions on specific services or issues

Patient Councils

These groups are based round hospitals and consist of interested individuals who aim to provide external advice and support for staff and patients. The Groups are supported by local management. Anyone can join a patient council. Work is being progressed in Raigmore to develop a terms of reference and looking at ways to recruit more members.

Work is ongoing to confirm where groups are established and the chairs and membership of these groups.

League of Friends

These are groups of people who have a specific fund raising role and are also set up around hospitals and community hospitals. They could potentially be an overlap in the work of patient councils though the patient council would not normally have any kind of fund raising remit.

Work is ongoing to confirm where groups are established and the chairs and membership of these groups.

Feedback, comments, complaints and conversations

Another important source of intelligence is from the comments that have been received around services. This is multi-faceted and includes both formal and informal routes. Ranging from findings from Ombudsman and complaints to day to day feed-back. A wide range of tools are in place to support this work. It has been recognised that further work is required to take a more strategic approach to understanding experience and facilitating feed- back. It’s important that each bit of work is not considered in isolation but that we look for patterns and trends. A review of existing feed-back and research should also be inform any re-design of services.

9 Figure 1 Highland Health and Social Care Partnership – Supporting Infrastructure

Highland Health & Social Care Partnership

South and Mid Raigmore North and West

Inverness Inverness Nairn, Ardersier Patient Skye, Lohalsh East Ross Mid Ross Caithness Sutherland Lochaber West East B&S Council & Wester Ross

Public Partnership Forum

Dingwall Caithness General Skye Reference Belford PPG Patient Council Group Patient Council #X 8 Patient Participation Group

Person Centred Patient/public involvement (patients/carers/ (individuals and groups) staff)

Informing and listening (population and staff)

10 Highland NHS Board 5 June 2012 Item 5.1(b)

A QUALITY APPROACH TO STAFF HEALTH AND WELLBEING

Report by Cathy Steer, Head of Health Improvement, Pamela Cremin, Workforce Planning & Development Manager, Linda Rawlinson, Occupational Health Strategy and Development Manager and Bob Summers, Head of Health and Safety; on behalf of Anne Gent, Director of Human Resources and Dr Margaret Somerville, Director of Public Health

The Board is asked to:

 Note the position in developing a quality approach to staff health and wellbeing.  Endorse the approach and support the ‘next steps’ section of the report.

1 Background and Summary

1.1 This paper aims to alert the Board to the approach we are developing to promote staff health and wellbeing that responds to national policy and supports the Boards strategic vision to provide Better Health, Better Care and Better Value through placing quality and innovation at the heart of what we do to support staff health and well- being.

1.2 A number of recent national policies set out the background and context to improving the health of our workforce: Safe and Well at Work2, NHS Health and Wellbeing3 and the new Health Promoting Health Service guidance (CEL (1) 2012)4, highlight not only the duty that we have as employers to promote safe and healthy working but also the importance of staff health and wellbeing to improving quality and efficiency. While there has been a lot of work to implement these individual policies, it is recognized that we need a more efficient approach to promoting the health and well- being of our staff through bringing together a number of strands of existing work and building on this through development of more creative and innovative approach.

1.3 NHS Highland Board is committed to improve the health of the Highland population and develop high quality healthcare services that deliver Better Health, Better Care, and Better Value to the people of Highland. The Boards Quality and Efficiency Framework aims to improve the patients experience and outcome of care whilst identifying and removing waste. There is considerable evidence to show that better quality and safer care is more efficient and delivers financial benefits. In order to deliver the requirements set out by the government in Better Health, Better Care: Action Plan1, and the Boards Quality and Efficiency Framework, the Board must ensure it has a committed, well prepared, dedicated and healthy workforce, working in a safe environment to respond to and deliver health care services now and in the future.

1.4 The development of NHS Highland Strategic Framework is based on the premise that the three components of Better Health, Better Care and Better Value are fundamentally linked, and that to ignore one at the expense of the others, or to only focus on one aspect will lead to failure. So, continued focus on health improvement and preventative measures will reduce the demand on health care services.

1 Scottish Government, 2007. Better Health, Better Care: Action Plan. Edinburgh: SGHD 1.5 Implementing the Strategic Framework is supported by a Board Vision that will require changes to working practices for all staff as consistent systems and pathways are developed, evolved and adopted. Ultimately it must mean that health needs continue to be met as the balance of need and resource becomes tighter. It will mean that the characteristics of service delivery in NHS Highland over the next five years will quickly evolve to be ones of:

1. promoting good health, self care and independence 2. high quality, integrated, equitable, needs and evidence-based, and cost effective 3. increasingly community based with hospital beds preserved for the most acutely ill and those with specialist needs 4. anticipatory care 5. run by healthy, flexible, well-motivated and well-trained staff working to their maximum potential and capability 6. using modern, flexible, efficient, green assets to maximum effect 7. with zero wastage and inefficiency across all services and no unnecessary overheads

2 What do we know about our staff?

Age Profile and Analysis:

NHS Highland Age Profile (Headcount)

1667 20.00

1600 1533 HC Percentage Grand Total 18.00

1400 1324 16.00

1200 14.00 1096

12.00 1000 947

10.00 800 708 8.00 600 553 499 6.00

400 4.00 239

200 112 2.00 36 0.41 2.74 6.35 8.12 10.87 15.19 19.13 17.59 12.58 5.73 1.29 0 0.00 <20 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65+ NHS Highland’s workforce age profile reveals an ageing workforce with the majority of staff in the 45-49 age group, closely followed by 50-54 age group and 40-44 age group. This will have significant impact for NHS Highland in the coming years in terms of an ageing workforce.

37.19% (3,240 HC) of NHS Highland’s workforce are over 50 years of age.

Using the average retirement age projections, the percentages of our workforce that will still be with us in 5 years is 93%; in 10 years is 81%; and in 15 years is 69%. A third of NHS Highland’s workforce will be eligible for retirement and can leave over the next 15 years; and in 20 years, 50% of the workforce will have reached retirement age.

In the current economic climate, retirement rates may be unpredictable, with people choosing to work after retirement age, which will require a focus on the health of the ageing workforce.

2 NHS Highland Gender Profile

Gender

Transgender Male , , 0.08% 18.94%

Male Female Transgender

Female , 80.98%

81% of NHS Highland’s workforce are female; of these 55% are working work part time.

NHS Highland Staff Absence Profile

In terms of staff sickness absence almost 350 whole time equivalents are lost to NHS Highland daily (Apr2010-Mar 2011), with 15% of this being due to absence associated with anxiety, depression and stress. However in absence reporting information reasons for absence reported as ‘other’ forms the single most significant category. Detailed exploration of the ‘other’ category will be required to provide us with a clear picture of what is happening with sickness absence. Our annual average sickness absence is showing promising signs of following a downward trend. Our annual average sickness absence for 2011-12 was 4.19%, a decrease from the previous year when it was 4.40%. The decrease is mainly due to long term sickness absence.

Breakdown of Staff sickness by Approx WTE lost due to a reason by Op Unit 35.00

30.00Sickness Absence •348.85 WTE lost

between Apr 10 to daily Unknown 25.00 Mar 11 Anxiety/stress/depression/other psychiatric illnesses 20.00 Respiratory (colds / influenza) 17.60

GI (D&V) 15.00 12.72 Sickness Absence 11.64 MSD's 10.00 •51.75 WTE (15% of associated with Asthma 5.10 Skin 5.00 1.81total) Anxiety, Depression1.20 1.68

0.00 & Stress Argyll and Corporate Mid Highland North Operational Raigmore South East Bute CHP Services CHP Highland Support Hospital Highland CHP Services CHP

3 The main presenting issues to Occupational Health are for stress/ mild to moderate depression and musculoskeletal disorders. From October 2011 to March 2012 Occupational Health has had 574 management referrals and 418 self referrals. Management referrals are predominately associated with sickness absence and self referrals are related to individuals who are at work but struggling.

3 What are we currently doing to support staff health and wellbeing?

The good news is that there is currently a lot of activity to support staff health and wellbeing across NHS Highland. A range of services, initiatives and projects are available, but while there is evidence of good practice, there are concerns about the spread of such activity. The following section describes some of the work currently undertaken to promote health and wellbeing with our staff.

3.1 Healthy Working Lives – NHS Highland is working towards achievement of the Healthy Working Lives award for all workplaces. This programme supports workplaces to complete a health needs assessment for staff, development of health promotion and safety initiatives and provides a framework for recording and assessing success.

Currently 24 workplaces are registered with the HWL award scheme, covering 87% of our workforce. Although activity tends to vary over time, 11 of these workplaces have achieved the HWL Bronze award, 5 the Silver award and 4 the Gold award. The others are still working towards achieving the Bronze award.

3.2 Occupational Health Service (OHS) – Occupational Health deliver a range of services to staff, including help with mild to moderate depression and anxiety disorders including trauma on four levels according to the needs of the employee. It is the only Health Board in Scotland to offer this service. In order of increasing intensity and specialisation these levels are:

1. Information and signposting to self help websites and resources. . 2. Educational Courses; CBT skills for stress and Compassionate Mind Training. 12 courses a year. 3. One to one Cognitive Behavioural Therapy (CBT) 4. One to one Eye Movement Desensitisation and reprocessing (EMDR)

OHS provides both management and self referral access to physiotherapy via case management process to support musculoskeletal conditions. Employees are contacted by telephone within 48 hours where the physiotherapist will triage appropriately:

1. Directed to self help materials or discharged 2. Seen in OH given exercises 3. Seen in physiotherapy outpatients.

In relation to managing sickness absence OHS provides regular case review meetings with managers and employees are continuously being offered effective and appropriate intervention as outlined above

OHS is responsible for co-ordinating the annual Highland wide staff influenza programme. In 2011 Nurse leads assisted the delivery of the programme within CHP areas which resulted in a significant increase in uptake and the roll out of skin health surveillance programme has been undertaken as part of COSHH programme. OHS offers lifestyle support and advice for alcohol brief interventions, smoking cessation and weight management.

4 3.3 Health and Safety – Among other things, the Health and Safety team within NHS Highland support several programmes of work that promote staff health and wellbeing, including training and support for dealing with violence and aggression in the workplace, support for preventing and dealing with incidents including slips, trips and falls, and supporting work in relation to recognising and managing work related stress. A recent workshop delivered to a group of NHS Highland managers introduced the recent Health and Safety Executive (HSE) “Management Standards”, which provide preventative guidance on best practice for employers in managing work-related stress.

3.4 Using an assets based approach to staff health and wellbeing – an asset based approach is one which seeks to positively identify and mobilise the assets, capabilities and resources available to individuals and communities which could enable them to gain more control over their lives and circumstances. In this context the ‘community’ can be defined as the workplace or team. The more familiar deficit approach to health and wellbeing focuses on the problems, needs and deficiencies in a community such as illness or health damaging behaviours.

A recent review of asset based approaches grouped relevant assets into three levels:

Individual assets e.g. resilience, commitment to learning, self esteem, sense of purpose. Community assets e.g. networks, social capital, community cohesion.

Organisational assets e.g. environment, opportunities for volunteering and participation. The following table summarises the kind of shift in focus required to successfully implement this approach.

Deficit Asset Start with deficiencies and needs Start with strengths Respond to problems Identify opportunities Provide services Invest in people See staff as consumers See staff as co-producers with something to offer Treat staff as passive Help staff to take an active part in their own and their workplaces wellbeing ‘Fix’ staff Support staff to develop their potential Implement programmes See staff as the answer

There are a number of ‘off the shelf’ programmes that purport to take this approach such as the staffWEL project that is currently being piloted in some areas of NHS Highland.

3.5 Health Promoting Health Service – the recent guidance on developing a health promoting health service was issued in January of 2012. This guidance provides a framework that supports the NHS to be health promoting organisations through a number of key priority programmes of work. This framework is as applicable to staff as it is to patients and visitors to our premises and services and as such provides a platform for taking forward work to support our overall approach to staff health and well-being including:

 Achieving the Healthy Working Lives award (see above)  Developing health promoting environments through provision of healthy food and taking a whole hospital approach to healthy eating through catering strategies and support for the national Healthy Living Award.  Providing support for healthy lifestyle through delivering alcohol brief interventions and smoking cessation support 5 3.6 Management of sickness absence – Efforts have been made in recent years to put in place a number of mechanisms to manage sickness absence. Implementation of our ‘Managing Sickness Absence’ policy and proactive work with Occupational Health to support staff is making a difference in relation to reducing long term sickness absence.

4 Next Steps

It is recognised that the current activity to promote health and wellbeing with our staff is appropriate and valuable, but requires additional focus and drive to bring together the various strands of work in a way that will allow us to better build capacity and capability to realise the vision described above. In order to progress this, there are a number of issues that require further work and it is proposed that a small steering group of senior staff will provide strong leadership and visible support to this issue, taking forward a programme of work in partnership with staff side that will include:

 Development of information/data recording and reporting to provide a more accurate picture in relation to the health and wellbeing of our staff  Activity mapping to understand the spread/reach of services/initiatives to support staff health and wellbeing  Communicating the vision and benefits to operational units  Ensuring that staff side representation and staff themselves are involved in shaping the development of our approach to staff health and well-being  Build upon the activity already underway to create and support healthy environments for our staff including work in relation to violence and aggression, healthy eating through development of our Catering strategy etc  Identifying clear routes of reporting and accountability and gain local ownership of this agenda  Developing a dashboard of indicators to monitor and report on progress to very local levels.

5 Contribution to Board Objectives

The Board Vision described through the triple aim of Better Health, Better Care and Better Value and the seven characteristics described under the Strategic Framework requires translation in to specific service strategies to support application and implementation. The Highland Quality Approach to Staff Health and Well Being aims to ensure that we promote good health and self care to our workforce, which will in turn ensure that the organisation is run by healthy, flexible, well-motivated and well-trained staff who are fit to work to their maximum potential and capability.

This quality approach to staff health and well-being supports the Boards Quality and Efficiency Framework by:

 promoting a person centred approach to staff health  ensuring a safe working environment  providing effective support through consistent ways of working  ensuring equity by applying this approach to all staff  promoting efficiency by ensuring a healthy well-motivated workforce with reduced sickness absence  providing support and interventions in a timely manner

6 6 Governance Implications

 Staff Governance

One of the key standards of the NHS Scotland Staff Governance Standard requires NHS Boards to demonstrate that staff are “provided with an improved and safe working environment, promoting the health and wellbeing of staff, patients and the wider community”. The development of a Highland Quality Approach to Staff Health and Well Being is a key underpinning approach to the staff governance standard.

 Patient and Public Involvement

The issue of employee wellbeing has become increasingly important to patients and the public in the last decade due to a number of factors. One of these is the high cost to the public purse of employee absence. In delivery of the Triple Aim, the Board ensures Better Health (of its staff), which in turn supports Better Care (for patients), the outcome of both are Better Value in terms of patient experience and efficient public expenditure.

 Clinical Governance

An educated, trained and developed workforce is an integral part of clinical governance. Valuing the contribution that staff make to quality health care and continuing improvement, and the provision in workplaces of a culture of employee wellbeing practices are important to achieving better patient care.

 Financial Impact

The Board recognises that they have a direct interest in creating an environment that helps people make healthy choices: because of corporate social responsibility and because a healthier, more engaged workforce makes good business sense. A motivated, healthy workforce is more likely to perform well. Employers and employees benefit through improved morale, reduced absenteeism, increased retention and improved productivity.

7 Risk Assessment

Risk assessments have not formally been taken in line with this piece of work. However, it is evidenced above that whilst there is currently a lot of activity to support staff health and wellbeing across NHS Highland, there are concerns about the spread of such activity – the development of a Highland Quality Approach to Staff Health and Well Being will minimise the risk that the work stream is not being implemented consistently across the Board.

The Highland Quality Approach to Staff Health and Well-being will ensure that any implementation plans are prioritised using the agreed risk management assessment process.

8 Planning for Fairness

This report outlines the approach to be taken to develop a Highland Quality Approach to Staff Health and Well-being and as such, does not require planning for fairness assessment at this stage. However, as the approach and any programs of work are developed and embedded, planning for fairness assessment will be undertaken.

7 9 Engagement and Communication

The development of Highland Quality Approach to Staff Health is being developed through engagement with staff and with key individuals across various fora including the health and safety committee, and the staff governance committee. The approach has been discussed at the Boards Partnership forum where it was enthusiastically received by both management and staff side. As a result the Board partnership forum endorsed the approach and staff side is keen to get more engaged. A staff side representative has been put forward to be involved in progressing this work and will fully involved in taking this forward. A joined up approach in corporate services – across human resources and public health functions is key to ensuring that stakeholders are engaged and supported to interact with the development of the approach.

Cathy Steer Pamela Cremin Head of Health Improvement Workforce Planning & Development Manager

Bob Summers Linda Rawlinson Head of Health and Safety Occupational Health Strategy & Development Manager

Corporate Services

25 May 2012

8 Highland NHS Board 5 June 2012 Item 5.1(c)

THE HIGHLAND QUALITY APPROACH TO STRATEGIC COMMISSIONING

Report by Linda Kirkland, Business Transformation Manager & Simon Steer, Head of Community Care on behalf of Elaine Mead, Chief Executive

The Board is asked to:

 Discuss and Agree the definition of a Highland Quality Approach to Strategic Commissioning as described.  Agree that work is undertaken to develop awareness, understanding, capability and capacity to progress the Highland Quality Approach to Strategic Commissioning across all sectors.

1 Background and Summary

“Commissioning” is a phrase which has entered into common usage within the Highlands; however there is limited consistency in terms of its meaning. This paper aims to provide an understanding of definitions, purpose and process; and reflects on Highland’s capability and capacity to progress a commissioning approach within the wider context of the Highland Quality Approach, and the Lead Agency model for the provision of integrated Health and Social Care.

2 A Highland Quality Approach to Strategic Commissioning

Why Are We Talking About Commissioning? In 2006, the Cabinet Office stated that “Commissioning is the cycle of assessing the needs of the people in an area, designing and then securing the appropriate service”, the idea being that the process of commissioning allows the best use of resources to develop capacity and achieve the best outcomes”. The development of Commissioning Practice in the Highlands is therefore based on the idea that we can achieve better outcomes through a change (for the better) in the way that we plan our investment of resources (Fig.1).

Figure 1 Efficiency Better outcomes for Smarter gains individuals & Commissioning & communities (more innovative community & effective use of benefits resource)

What Exactly Is Commissioning? Traditional service and investment planning could be described as “The same as before, plus a bit more to meet demographic and other pressures”.

“Commissioning” is defined by the NHS Improvement Service as “the process of securing and managing appropriate healthcare services for relevant populations at value for money for taxpayers”.

SWIA defines Strategic Commissioning as “the term used for all the activities involved in assessing and forecasting needs, agreeing desired outcomes, considering options, planning the nature, range and quality of future services and working in partnership to put these in place”. The PSSRU suggests, “commissioning forms a multi-dimensional link between purchasers and providers; planning and activity; the identification and deployment of resources; and those resources and the achievement of outcomes”.

There is therefore some consensus that Commissioning is the planning of (all types of) investment to achieve agreed outcomes for defined populations.

Are Commissioning, Procurement and Purchasing the Same Thing? Figures 2 & 3 aim to describe the “Commissioning Cycle” in slightly different ways; however the following descriptions appear to be have consensus.

Commissioning focuses on the identification of need. It is fundamentally about specifying the services/outcomes desired. That means that assessments of need, community engagement and strategic delivery plans all come under the Commissioning umbrella.

Procurement is the process by which public bodies purchase goods and services from others, although this is not the only way that services are obtained, as other methods (e.g. Investment in in-house services) are also used. It is fundamentally about ensuring that those services/outcomes are delivered.

Purchasing represents the technical contracting and compliance aspects of procurement.

It is important to see commissioning hospital activity as following a journey from understanding need, through planning capacity, to disinvestment in some areas for reinvestment in others. The process covers both strategic commissioning analysis, and technical purchasing issues such as tariff.

Simply put, commissioning asks “what do we want?” and procurement “how do we get it?”. Commissioning and procurement can amount to the same thing if “procurement is defined as the process from identification of need through to disposal of asset or decommissioning of service” (IDALG). Figure 2: The Commissioning and Purchasing Cycles, and Procurement

Strategic needs assessment

Monitor Decide priorities and review and outcomes The Commissioning Cycle Plan and Delivery design services

Optional Determine the need Sourcing appraisal

Follow-up/ The Supplier selection evaluation Purchasing Cycle Procurement Expediting Contracting

Ordering

2 The outline above is high level whilst the diagram developed by SWIA provides more detail to describe the same process (Figure 3) Figure 3

What is Good Commissioning?

Good Commissioning practice displays the following

1. Understands the population needs by engaging with communities and representatives 2. Engages provider organisations when setting priorities 3. Outcomes are the heart of the process 4. Maps and engages the fullest practical range of providers 5. Considers investing in the provider base 6. Ensures contract processes are transparent and fair 7. Ensures long-term contracts and risk-sharing 8. Seeks feedback to review effectiveness of the commissioning process

3 Good commissioning practice is therefore about growing involvement, capacity and capability across all sectors.

For the NHS, this means moving from a “provider” focus (i.e. commissioning from ourselves) to strategically commissioning and leading the development of an equitable, evidence based, transparent and engaged model for planning investment (and disinvestment)

For other provider sectors, (such as voluntary and independent), this means a move from bidding and design in isolation; to a collaboration with the statutory sectors.

For communities and representative groups, this means finding new ways to engage proportionately, so that the community’s voice is present throughout, but the process is not disabled by consultations.

Good Commissioning means that all sectors have to behave differently, with the focus shifting from “consultation” to “engagement and innovation in line with agreed community priorities”.

Good commissioning also means making explicit links with existing, complementary initiatives. There is a good fit with:

 Co-production frameworks – Governance International suggest that “Co-production of public services means professionals and citizens making use of each other’s assets, resources and contributions to achieve better outcomes and efficiencies”. Good commissioning means understanding all available assets, not just public sector finance. The Highland 3rd Sector Interface describes the biggest issue in this approach as being “that we commission for jointly agreed needs”. To achieve this, the “biggest change in co- production is in agreeing with partners what wants we should be meeting, and not what needs we think service users have; so that ‘the help they get is right for them”. This represents “a change in the way care is commissioned, with the benefit that listening to users about their health issues is much more likely to ensure that they ‘engage in the co- production of their health outcomes”.  Small tests of change – (PDSA) provide evidence of efficiency and effectiveness of resource allocation and return.  The LEAN framework – provides whole system analysis and rapid improvement methodologies.  Integrated Resource Frameworks –(IRF, PBMA) provide resource mapping methodologies and investment option appraisal methodologies.  Self Directed Support which effectively makes the person in receipt of the service the commissioner, but which also places a responsibility on agencies to disinvest in services that people choose not to use.

Commissioning For Outcomes “Commissioning for Outcomes” takes us to a different, more challenging level. Commissioning for Outcomes means we understand the differences between inputs; outputs and outcomes, with the defined outcomes being sought dominating the business of commissioning. That means a move from “numbers of people seen”, to more difficult returns about the quality of experience and the level of personal benefit.

Commissioning for outcomes means a collaborative approach towards planning, which involves all sectors and the population as active, equal partners in both decisions to invest and assessing whether the return on investment meets the commitments given by providers.

Where Are We Now? In 2008, the King’s Fund noted “...serious doubts about the analytical power of [partnerships] and the level of resources they have available for the analytical task. It will require sophisticated economic, epidemiological, activity and cost modelling to be able to determine with sufficient certainty what services need to be commissioned over which periods of time and in which settings.

4 It needs sophisticated programme and project management skills and well-developed procurement and evaluation capacity. Without this, services will change only incrementally – if at all – and any imagined benefits for patients or costs will not be realised.”

Similarly, the Audit Scotland report on the Commissioning of Social Care (2012) noted “Councils and NHS Boards do not have sufficient information to make informed decisions about how they allocate their combined resources…..they do not have a full understanding of how much (social care) services cost and their value for money”, and further that the Strategic Commissioning Strategies examined lacked analysis of the “type, quality, cost, capacity and accessibility of all services in the area, including council’s in house services”

What Do We Need To Do? All Partners in the Highlands need to reflect on their current capability, capacity and approach and their readiness to engage in strategically commissioning for outcomes, specifically in terms of:

Management Capabilities and Capacity – The skill sets required for commissioning are extensive but traditional, target-orientated planning has limited the development of such skills to date. Are the capability of commissioners and of the resources available to them be effective?

Information Systems – Do these systematically provide the individual and population level data on costs or outcomes required for commissioning?

The External Environment and Provider Base – Is there an awareness that investment by one partner may impact on another? Effective joint strategic commissioning requires a mutual understanding of interdependency across organisational boundaries, and the capacity and commitment to switch funding from one organisation to another.

Leadership and Culture – Is critical. Do the relationships and behaviours express equity and mutual respect, and is there a sense of trust between partners?.

An initial reflection on the above would suggest that we need to develop in all of these areas.

Where Do We Want To Get To? Points 1 to 5 below suggest the components of the Commissioning agenda that we need to pursue:

1. A Shared Understanding of what we mean by “Commissioning” is required. All collaborating organisations need to understand what commissioning is, and what it is not, and what we are commissioning (i.e. what outcomes).

2. Capacity and Capability needs to be developed to enable all organisations to contribute. This means establishing a programme with the aim of developing and sharing analytical skills and information, understanding what the information is telling us, understanding the implications for planning investment etc.

3. A Spectrum of Proportionate Engagement needs to be understood. Major engagement exercises, such as the development of the Community Care Plan give a mandate for action, however some initiatives, such as those impacting significantly on hospitals may require formal consultation measures. The key point is that a major redesign, such as implementing Reablement, may require less engagement at a local level than the development of a day service in a village hall.

4. Planning Investment over the next 3 to 5years is required to build stability and breadth in the provider base.

5 5. Provider Base; User Engagement and Community Development. All of the above need to take place with the full and equal engagement of all sectors to ensure that the provider base and community capacity is developed to full potential.

3 Contribution to Board Objectives

As indicated above, a Highland Quality Approach towards Strategic Commissioning will impact on all board objectives by promoting optimal use of all available assets in the pursuit of optimal quality and outcomes, as per Board Objectives.

4 Governance Implications

 Staff Governance  Patient and Public Involvement  Clinical Governance As described above, Staff; Patient; Public; Clinical and other Sector engagement is a key component of the Highland Quality Approach to Strategic Commissioning. The implications for all of these areas are an increased engagement in the planning of investment and review of impact.

 Financial Impact Strategic commissioning is expected to have a positive financial impact, by providing a comprehensive framework for planning investment and use of assets, across all sectors, with a view to optimising outcomes.

5 Risk Assessment

A commissioning approach will assist in reducing existing risks, but does not constitute a risk of itself.

6 Impact Assessment

The details of structures and processes for implementing Strategic Commissioning will be risk assessed as development takes place.

Linda Kirkland Simon Steer Business Transformation Manager Head of Community Care

25 May 2012

6 Highland NHS Board 5 June 2012 Item 5.2

HIGHLAND QUALITY APPROACH TO OLDER ADULT MENTAL HEALTH SERVICES: UPDATE ON IMPLMENTATION OF NATIONAL STANDARDS ACROSS HIGHLAND HEALTH AND SOCIAL CARE PARTERNSHIP AREA

Report by Nigel Small & Gill McVicar, Directors of Operations on behalf of Dr Ken Proctor Associate Medical Director and Heidi May, Board Nurse Director

The Board is asked to:

 Note the range of initiatives to improve care in Older Adult Mental Health Community Services.  Note the proposals to re-design in-patient care for dementia patients in the Highland Health and Social Care Partnership area.  Note that Directors of Operations are developing action plans to implement the recommendations around appropriate requirements for hospital beds.  Note the requirements for re-investment into community and specialist acute services.  Note the introduction of the patient care system “The Butterfly Scheme” for patients with dementia in acute hospitals in NHS Highland.  Note the work already carried out and future proposal to support communications and engagement.

1 Background and Summary

The Scottish Government published the National Dementia Care Strategy and Dementia Care Standards in 2011. The National Dementia Strategy has placed a series of requirements on NHS areas, including the implementation of an Integrated Care Pathway (ICP), provision of post-diagnostic support, and a series of Care Standards. In addition there are clear requirements to improve the care of older people in Acute Care settings.

NHS Highland has to meet these national standards, and accommodate the expected increase in dementia sufferers, within a set budget and at the same time deliver services in the most cost effective way.

The Northern Highland Older Adult Mental Health Services Redesign Steering Group has been assessing NHS Highland’s compliance with the delivery of the standards. As the Argyll and Bute CHP review has been reported previously, this paper focuses on services in the Highland Council area.

2 Update on Older Adult Mental Health Services in Northern Highland

At February 2012 the Eurocode prevalence formula estimates Northern Highland (=Highland Health and Social Care Partnership area) to have 3800 adults with dementia. 1848 (49%) are on the GP Registers. Projected population increases, including the largest being in the very oldest age groups, are likely to result in substantial increases in the number of people with dementia.

NHS Highland has benefited from valued expert partnerships including with Alzheimer’s Scotland, Knowledge Transfer Partnership with Dementia Services Development Centre at the University of Stirling), and the Community Care Plan. In addition feed-back from various consultation exercises identified similar themes which were the need for enhanced community care, clear routes of support and advice, and availability of specialist care when required. The Butterfly Scheme One of the National Standards is that ‘People with dementia and their carers will receive good quality care if admitted to a general hospital, accident and emergency department, or attend an Outpatient Department’.

NHS Highland Senior Management Team has agreed to address this by introducing the Butterfly Scheme to Raigmore Hospital in 2012 and subsequently roll out across NHS Highland area. The Butterfly Scheme is an opt-in programme in general hospitals scheme which allows patients and carers to choose to request this specific care response by using the scheme's symbol - a discreet Butterfly.

It teaches hospital staff a simple, targeted five-point response to people using that symbol and includes the integral use of a carer sheet, chosen by the hospital. It provides ongoing support and teaching to member hospitals. It includes a simple adaptation to allow people with confusion but no dementia diagnosis to use the scheme without running the risk of a false diagnosis going on record and offers that same response to people with delirium, again without risking false recording.

Recruitment of Nurse Consultant for Dementia for Highland This role will provide professional nursing leadership, strategic direction and expert consultancy on all aspects of clinical nursing practice and care of people with Dementia across the patient pathway. It will cover all of NHS Highland but with a specific remit to develop practice and services in the Acute Care and Community Hospitals. This will involve working across professional and organisational boundaries, in partnership and in collaboration with others including service users, carers, health professionals, social work, voluntary sector staff, and local education providers.

This post is funded by Alzheimer’s Scotland for the first two years with NHS Highland continuing support thereafter. The post is currently out to advert. The post holder will initially work out of Raigmore but will progress to covering all relevant hospital settings.

The National Dementia Champion Programme 15 staff in NHS Highland are undertaking training. This is part of a national initiative to train 300 staff. The programme is designed to create inspirational leaders to support people with dementia in their own homes, primary care settings or acute hospital settings. One of the key aims is to enhance the skills of Champions to ‘infect’ those around them positively and to capture the learning needs of their colleagues.

The dementia champions will have the necessary skills, and freedom to enhance current dementia care practice with the aim of creating capability and capacity. In doing so they will be able to build upon the creation of a whole new culture of dementia care.

Promoting Excellence The Education and training programme to support development of the Health and Social Services Workforce is being implemented in NHS Highland via the Educational Sub- Group chaired by Mr Stephen Loch, Senior Nurse – Education and Training. All clinical and care staff who provide services to those with dementia require some training relevant to the level of interventions they provide. A training plan has been developed in conjunction with colleagues from Social Work and is being implemented.

Post Diagnostic Support 'No-one should ever have to walk this lonely dementia journey alone ... and with early diagnosis and early carer support a dementia family can learn their lives don’t have to stop or go on hold … they simply have to take a different route.',

Highland Carer May 2012.

2 The Scottish Government announced in March 2012 that patients diagnosed with dementia and their carers would be guaranteed 12 months post diagnostic support. As the recent quote above illustrates, and the Knowledge Transfer Partnership work confirms, this is a key issue for people with dementia and their carers.

NHS Highland has allocated Change Fund resources to commission Alzheimer’s Scotland to recruit Dementia Link workers to be based alongside Community Mental Health Services to provide this 12 month post diagnostic support. Each area of Northern Highland will have access to the link workers.

Other Supporting Activities As part of the Quality Outcomes Framework in 2012/13, GPs will be encouraged to use the dementia Integrated Care Pathway. This will require all areas to clearly describe the access routes for GPs, but mental health services are confident that this can be done.

Anticipatory Care Plans and polypharmacy review work is being targeted on care homes and patients with dementia, including detailed review visits by Care of the Elderly Physician. Telehealth methods are also being trialled to support care homes, with work underway in Lochaber.

In an earlier paper to the Senior Management Team it was reported that the redesign steering group had compared the current level of service provision to mentally ill adults over 65 against the best practice recommendations in the document ‘Raising the Standard’. This work was undertaken within the context of improving services within existing resource.

This comparison identified NHS Highland had significant shortfalls in specialist community services but more in patient beds than that recommended for the population (20) – currently operating with 68 beds across six sites. To meet the recommended level of specialist Community Mental Health Team and liaison services for older adults will require the redistribution of £632K from in-patients services. Since making these recommendations operational matters have led to the temporary closure of Fyrish Ward (12 beds), Invergordon Community Hospital. The Nursing establishment is currently placed in temporary positions across the service.

In addition due to HEI non compliance of Clava Ward (20 beds) in New Craigs Hospital there has also been a reduction in beds and the ward is currently operating with 14 beds.

The effect of this has been to reduce the available dementia beds to the recommended 48 across the Northern Highland area. In practice, there has been an average of 40 patients in these beds on any one day, which gives reassurance that the proposed number is appropriate for current needs.

There has also been a decrease in the number of in-patient admissions since 2000 (Figure 1). This reduction was largely related to the cessation of respite care in NHS services. There are substantial projected increases in dementia numbers, and while services have coped well with increases in the last few years, the additional investment in community services will help to support people in the community and allow NHS Highland to meet the dementia standards.

Outline Proposals A stake holder’s workshop held on 10th April 2012 considered all these matters and proposed the following:

 Raising the Standard will continue to be the service planning template  The Dementia Standards and best practice clinical guidelines are non negotiable  The Dementia bed base should be at the level recommended in Raising the Standard (48) and resources be released for investment in the community services

3  The Dementia ICP is to be implemented  Investment is required to implement liaison Psychiatry Service for Older Adults for Raigmore (Appendix 1)  Ongoing engagement and awareness raising with users, carers, staff, third sector and wider public is necessary and should build on the work already undertaken including via the Dementia Strategy, Knowledge Transfer Partnership and Integrated Care Pathway development consultations. All of the work to date confirms people with dementia want to remain at home as long as possible.

Whilst a great deal of work has taken place further work is required to fully meet the Dementia Care Standards. In addition, NHS resources are not being spent as efficiently and effectively as possible. A minority of individuals require specialist in-patient care and receive this when required. Further investment for people with dementia living at home, in care homes or admitted to general hospitals would deliver better outcomes.

The pattern of bed use over the last four years has demonstrated that the evidence that 40 beds is sufficient for current dementia in-patient assessment and treatment and 48 will be sufficient until 2018. The re-allocation of the funds to improve community based services and liaison to general hospitals will improve the prospects of NHS Highland meeting the Dementia Care Standards.

The Senior Management Team has agreed that:  the dementia bed base total will be 48 for Northern Highland  the Older Adult Mental Health Group will be remitted to develop a change plan for hospital and community services, including identifying a preferred option for bed configuration within the new bed resource  the resource released from in-patient services will be used to: o fund investment in specialist community services o Provide a specialist service for older adults with mental illness in acute hospitals  A Communications and Engagement Group will be established

3 Contribution to Board Objectives

Successful implementation of the proposal will improve services, increase accessibility and provide person centred care at home or closer to home where possible.The project will deliver better value from the resource invested and will be consistent with NHS Highland’s Quality Approach.

4 Governance Implications

 Staff Governance

Education, training and development of hospital, community (including Care Homes) staff is a major component of this work stream. (Please see Promoting Excellence section above).

 Patient, Carer and Public Involvement

NHS Highland has benefited from valued expert partnerships including with Alzheimer’s Scotland, Knowledge Transfer Partnership with Dementia Services Development Centre at the University of Stirling), and the Community Care Plan. The feed-back from various consultation exercises identified similar themes: . enhanced community care, . clear routes of support and advice, and . availability of specialist care when required.

4 The Older Adult Mental Health Group includes representatives from Age Concern, Alzheimer’s Scotland and the Scottish Health Council. A communications and engagement group which will initially be led by Head of Public Relations and Engagement is in the process of being established. This will have wide ranging representation including from Alzheimer’s Scotland, Age Concern, the Scottish Health Council, Carers and representatives from third sector. As part of the wider strategic approach being adopted in Highland the approach will move towards a more assets based approach, working with families, carers and communities to further develop dementia friendly approaches.

 Clinical Governance

Implementing consistent standards of care remains a challenge. To address this NHS Highland has developed an Integrated Care Pathway which sets out service expectations and includes reference to relevant standards and guidelines. This will continue to be refined based on experience of implementation including feedback from primary care.

 Financial Impact

The Nurse Consultant for Dementia costs for the initial two years are to be funded by Alzheimer’s Scotland. NHS Highland has agreed to meet the recurring costs thereafter.

Redesign of hospital services will fund the investment to bring community services to the recommended level.

As part of the redesign process the Older Adult Mental Health group will seek to identify areas where costs can be reduced by implementing a quality approach.

5 Risk Assessment

Without the shifting of resources to enhance community services there is a risk NHS Highland will not meet the requirement of the Dementia Care Standards.

Once service reconfiguration options have been clarified by the Operational Units the risk assessments will be conducted.

6 Planning for Fairness

The work is intended to implement the National Dementia standards. Work is ongoing to identify what work on impact assessment has been carried out as part of development of National Standards. It will build on any national work to explore any specific impacts for our population. Individual service reconfigurations will require Planning for Fairness review. and this will be led by the Engagement and Communication sub-group.

7 Engagement and Communication

An engagement and communication sub group is in the process of being established. An outline action plan has been developed which will be further evolved once the sub group is fully established.

Nigel Small, Director of Operations Gill McVicar, Director of Operations South & Mid Highland North & West Highland

25 May

5 Figure 1: Episodes of care rate per 1,000 population: Highland residents aged over 65 years of age discharged from psychiatric inpatient care with a diagnosis associated with dementia from select Highland hospitals

6.0

n 5.0 o i t a l u p

o 4.0 p

0 0 0 1

r 3.0 e p

e t a r

e 2.0 g r a h c s i 1.0 D

0.0 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Year ending 31 March 2001-2011 Data Source: SMR 04 HIKT, NHS Highland All admissions Excluding holiday relief care

Appendix 1 Liaison Psychiatry Service for Older Adults for Raigmore

The development of this service is considered a priority because evidence suggests that on an average day Raigmore will have;-

 303 beds occupied by older people  202 older people will have a mental disorder  94 older people will have dementia  86 older people will have depression  61 older people will have delirium  21 older people will have other diagnosable disorders

There is currently no dedicated specialist service for older adults with mental illness in Raigmore. If left untreated older adults with a physical condition and a mental illness remain in acute beds 11 days longer than those with no mental illness.

Most people coming close to breaching the delayed discharge target are people with dementia, who are awaiting incapacity assessments.

6 Highland NHS Board 5 June 2012 Item 5.3

JOINT HEALTH PROTECTION PLAN 2012 – 2014

Report by Ken Oates, Consultant in Public Health on behalf of Margaret Somerville Director of Public Health

The Board is asked to:

 Discuss and Agree the content of the Joint Health Protection Plan for 2012-14.  Note the Joint Health Protection Plan has already been approved by the relevant committees of Highland Council and Argyll & Bute Council.  Once all agencies have signed it off, Agree to it being placed on the NHS Highland website.

1 Background and Summary

The Public Health etc (Scotland) Act 2008 restates and amends the law on Public Health in Scotland. The last part of the Act to be implemented, namely the requirement to have a Joint Health Protection Plan (JHPP), was put in place in April 2010. Each Health Board was required to prepare such a plan relating to the protection of public health in its area and to prepare these in consultation with the relevant local authorities, with whom there is a statutory duty of co-operation on health protection issues. These plans were required to be formally submitted to the NHS Board and relevant Local Authority Committees for sign-off.

The first JHPP for 2010-12 formalised the working relationships which existed between the 3 bodies and identified priorities for action. It was signed off in April 2010. This original plan was reviewed during 2011 and it was noted that work had progressed well and there had been significant achievements in several areas, including substantial work on joint policies and procedures and development of an overarching public health incident plan. The JHPP has now been updated and amended to produce the second JHPP which covers the period April 2012 - March 2014.

2 Joint Health Protection Plan

The Joint Health Protection Plan for 2012-14 is attached for your consideration and subsequent agreement. This has been produced by NHS Highland with Highland Council and Argyll & Bute Council.

The Plan is the result of close liaison between Environmental Health colleagues in both Local Authorities and the Health Protection Team at NHS Highland. It has been formatted according to a template provided by Scottish Government and is in keeping with plans produced by other NHS Boards.

The key section which outlines the national and local priorities for action is on pages 10 – 15. The national priorities are common to all of NHS Scotland but some of the local issues highlighted are specific to our own area. The plan will continue to be subject to annual review although the formal Act only requires a new plan to be produced every two years.

This Plan has already been approved by the relevant committees within each Local Authority area. (In Argyll and Bute Council by the Planning, Protective Services and Licensing Committee on 18 April 2012 and in Highland Council by the Transport, Environmental and Community Services Committee on 15 March 2012) 3 Contribution to Board Objectives

Health Protection is a core function of the NHS and this plan contributes to local efforts to protect and improve the health of the Highland population.

4 Governance Implications

Agreement of this plan fulfils our legal obligation outlined in the Public Health Scotland Act. No financial impact is anticipated.

5 Risk Assessment

The JHPP clarifies and strengthens governance arrangements between the partners and therefore should mitigate risks of any health protection issue not being adequately managed.

6 Planning for Fairness

This plan and all health protection work are expected to maintain equitable protection for all members of society. Part of the health protection service is to provide information and action in appropriate languages and formats as required and emergency planning arrangements include ensuring that vulnerable groups are given due consideration.

7 Engagement and Communication

All relevant stakeholders have been consulted. The JHPP has been presented to 1 council committee in each local authority.

Dr Ken Oates Consultant in Public Health Public Health Directorate, Assynt House

25 May 2012

2 NHS HIGHLAND AREA JOINT HEALTH PROTECTION PLAN

APRIL 2012 – MARCH 2014

SGÌRE NHS GÀIDHEALTACHD CO-PHLANA DÌON SLÀINTE

GIBLEAN 2012 – MÀRT 2014

20thMarch2012 Version1 CONTENTS

Page Introduction 3

Section 1 – Overview The Joint Health Protection Plan 4 Health Protection Planning 5 Risks and Challenges 5 Capacity and Resilience 6 Supporting information 7

Section 2 – Priorities National Priorities 8 Local Priorities 13

Section 3 – Review Review of Joint Health Protection Plan 2010-2012 16 Review of Health Protection Standard Operating 16 Procedures, Protocols and Plans

Appendices: Appendix 1 - List of Joint NHS/Council Plans 17 Appendix 2 – Maps 18 Appendix 3 – Designated local Competent Persons 19 Appendix 4 – Supporting Information 20

20thMarch20122 Version1 Introduction

The Public Health etc. (Scotland) Act 2008 requires NHS Boards, in consultation with Local Authorities, to produce a Joint Health Protection Plan which provides an overview of health protection (communicable disease and environmental health) priorities, provision and preparedness for the NHS Board area. Guidance on the content of joint health protection plans has been published by the Scottish Government.1

This is the second Highland Joint Health Protection Plan and covers the period from 1 April 2012 to 31 March 2014.

It is a public document and is available to members of the public on the NHS Highland website (www.nhshighland.co.uk) and on request. We hope that you will find this plan to be of interest, and of value, and that its production will contribute to protecting the health of the people who visit, work and live in the Highlands and Argyll & Bute.

Signed

Ken Oates Consultant in Public Health Medicine (Health Protection) NHS Highland Assynt House Beechwood Park Inverness IV2 3BW

Alan Yates Acting Head of Environmental Health Highland Council 38 Harbour Road Inverness IV1 1UP

Alan Morrison Regulatory Service Manager Argyll & Bute Council Kilmory Lochgilphead PA31 8RT

1 www.scotland.gov.uk/Resource/Doc/924/0079967.doc

20thMarch20123 Version1 SECTION 1 – OVERVIEW

1. The Joint Health Protection Plan 1.1 This plan has been created following the requirements set out in the Public Health etc (Scotland) Act 2008. NHS Highland has prepared this plan in collaboration and consultation with its two local authorities; Argyll and Bute Council and Highland Council. This plan is herewith referred to as the Joint Health Protection Plan.

1.2 The plan relates to the period 1st April 2012 to the 31st March 2014.

1.3 The plan requires to be formally approved by the NHS Highland Board and the Executive Councils of the local authorities.

1.4 The format of the plan meets the details of Annex D of the Scottish Government Guidance “Joint Health Protection Plans”.

1.5 The purposes of the plan are:- i. To provide an overview of health protection priorities, provision and preparedness for NHS Highland, Highland Council and Argyll & Bute Council.

ii. To outline the joint arrangements which Argyll and Bute Council, Highland Council and NHS Highland, have in place for the protection of public health.

iii. To improve the level of “preparedness” to respond effectively to a health protection incident and emergency.

iv. To clarify the priorities for the period of the plan 2012 – 2014.

v. To identify and subsequently secure the resources which are required to meet the plan.

vi. To detail the liaison arrangements between NHS Highland, the 2 Local Authorities and other Agencies (e.g. Scottish Water, SEPA etc).

vii. To develop “learning” across the agencies.

viii. To provide a mechanism for reviewing and recording outcomes and achievements.

1.6 The plan will be reviewed annually by the multi-agency Environmental Health Liaison Committee and any necessary changes made. However the plan will only be formally changed and updated in accordance with the legislation which requires this every 2 years.

20thMarch20124 Version1 2. Health Protection Planning

2.1 The prevention, investigation and control of communicable diseases and environmental hazards require specialist knowledge and skills. These include risk assessment, risk management and risk communication amongst others. These specialist skills and knowledge are applicable to a wide range of potential incidents or scenarios and are often facilitated by the existence of agreed plans and procedures for specific disease or situations. There are many such national and local plans.

2.2 Effective working arrangement are in place to support partnership working between NHS Highland and the environmental health services within Argyll and Bute Council and Highland Council. This is evidenced through the work undertaken to develop common plans to ensure a systematic and consistent approach to tackling common pubic health issues, learning from best practice in both local authority areas.

2.3 A list of the plans which are common to all 3 agencies are in Appendix 1.

3. Risks and Challenges

3.1 The geographical profile of the area presents several challenges to effective and timely management of a health protection incident. This poses a significant risk to the delivery of the service. The area covered by the health board is vast; travelling arrangements must be factored into the planning of a response to an incident. This is especially the case for island communities where access is dependent on ferries. Many communities, within the NHS Highland area, are remote and can be isolated, particularly during periods of adverse weather. Maps of the areas are provided in Appendix 2.

3.2 All three agencies are heavily dependent on effective telecommunications systems. Lack of mobile telephone networks is a common problem in remote areas and some island communities. The response to a public health incident would be compromised in the event of a significant failure of the telecommunications system.

3.3 Staff from all three agencies may be required to travel to the site of a public health incident. This may necessitate several hours of journey time, increased by the need for specific transport or adverse weather conditions. As such the duration of deployment is increased. It is accepted that any reduction in staffing for either agency would impact even further on capacity to respond appropriately and timeously to health protection incidents.

3.4 Collection and analysis of samples forms the first step in the management of a disease outbreak. The specimens are delivered to the regional laboratories by road. There may be a longer turnaround time from submitting the sample to

20thMarch20125 Version1 receiving a result depending on the analysis required. A recommendation from reviews of several previous outbreaks is that couriers and specialist transport should be used in order to reduce sample transit time.

3.5 NHS Highland collates the surveillance data and information relating to disease outbreaks and environmental incidents. Local Authorities have systems in place for the recording of investigative and monitoring work associated with health protection. These systems include in-house systems and also include the use of the national Food Surveillance System, supported by Health Protection Scotland. These systems may also utilise Geographical Information Management Systems (GIS). Argyll and Bute Council found GIS technology useful at the Radionuclide exercises associated with HMNB Faslane. However, there is still no recognised and widely used national outbreak management system.

3.6 Both Highland Council and Argyll and Bute Council have published local risk registers. These highlight specific high risk facilities, events or scenarios within each area and are available through the regional Strategic Coordinating Groups – Strathclyde Emergency Coordinating Group and Highlands and Islands Strategic Coordinating Group.:

4. Capacity and Resilience

4.1 Review of capacity and resilience is on-going, particularly in response to the current pressure on all services to reduce expenditure.

4.2 Human resource capacity of specialist health protection skills in NHSH, Argyll and Bute Council and Highland Council is limited. Appendix 3 lists designated competent persons in terms of the Act. NHSH services are located in Inverness. The local authorities deliver their services from a number of geographical centres. This approach is an efficient use of limited human resources. However this also creates small teams where the absence of an individual staff member stretches the resources available to respond to an incident. The occurrence of two or more simultaneous incidents in different parts of the board area would present significant challenges. Capacity has been stretched further for the past 3-4 years as NHS Highland public health staff have provided cover for NHS Western Isles through a very long period of sick leave absence and job vacancies.

4.3 As a consequence of small team size, individuals may be required to take on both strategic and operational roles during a large incident. Regular multi agency training exercises and debriefs give strategic leads flexibility in the roles taken during an outbreak.

4.4 Staff from the wider department of public health will be utilised as required on a large incident and beyond that staff from other teams/departments in NHS

20thMarch20126 Version1 Highland. Formal arrangements for mutual aid with other NHS Boards are recorded and reviewed through the emergency planning procedures. Informal arrangements for mutual aid exist within the local authorities and act to support the provision of the service in remote and isolated areas.

5. Supporting information

5.1 Appendix 4 provides the following background information in support of the plan: 1. Health Protection definitions 2. Overview of NHS Highland and its local authority partners 3. Resources and operational arrangements for Health Protection 4. Information and Communication Technology 5. Emergency Planning and Business Continuity 6. Inter-organisation collaboration 7. Mutual Aid 8. Out-of Hours arrangements 9. Maintenance of competencies for Health Protection staff 10.Public Feedback

20thMarch20127 Version1 SECTION 2 - HEALTH PROTECTION: NATIONAL AND LOCAL PRIORITIES

6. National Priorities

6.1 The Chief Medical Officer and the Scottish Health Protection Advisory Group have previously identified various national priorities (see table 1 below). NHS Highland commits to meeting these in the term of this plan.

6.2 Further national priorities may arise out of the work of the Scottish Government Health Protection Stocktake Group whose final report is due to be published around Easter 2012..

6.3 Developing areas that will require further work in future years includes: - improving health in early years (especially in reducing respiratory infections); - ensuring the effective implementation of the Sexual Health and Blood Borne Virus Framework; and the Scottish TB Action Plan; - enhancing the prevention and management of life threatening or life long conditions (as is already occurring with HPV (vaccine for cervical cancer) and the Hepatitis C Action Plan); - further developing a coherent, measurable strategy to reduce the risks to health from environmental risk factors; - improving food and environmental safety; - protecting vulnerable groups, especially older people in health and social care, against exposure to hazards and their adverse effects.

7. Local Priorities

7.1 Health Protection is core to the services delivered by NHS Highland, and Argyll & Bute Council and Highland Council, particularly through protective services remits (environmental health, trading standards and animal health and welfare). The plan recognises that work is undertaken on a daily basis relating to areas of responsibility and service delivery:

 Preventing the spread of communicable diseases in the community  Improving standards of food safety  Ensuring safe and potable drinking water supplies  Improving standards of workplace health and safety standards  Ensuring adequate plans are in place to respond to incidents and emergencies.

7.2 In addition, a number of local health protection priorities requiring joint action have been identified through a variety of mechanisms including regular review of surveillance data, and joint meetings.

20thMarch20128 Version1 7.3 Highland Council and NHS Highland are entering a new period of joint working through the integration of social services. This has an impact on arrangements for the welfare of the public during or after a major incident such as flooding or fire and how national guidance such as “Care for People” is implemented. Existing plans are being reviewed and future arrangements have been outlined in the partnership agreement agreed for specific types of response such as establishing emergency centres or rest centres and these will be further clarified and exercised in the near future.

7.4 These local priorities which each Local Authority and the NHS is seeking to deliver either using their own resources or through joint working in accordance with this plan are detailed in table 2 below:

20thMarch20129 Version1 TABLE 1 - NATIONAL PRIORITIES How they are being addressed National priorities Current Arrangements Examples of Joint Working Agencies involved Intended Actions 2012- 2014 The NHSH pandemic Joint working with Argyll and Audit and evaluation to influenza plan informed the Bute Council and Highland identify further opportunities management of the H1N1 Council in the control of the to improve preparedness epidemic. pandemic and learn lessons for other health protection issues A potential pandemic of Resources have been Joint working with Argyll and ABC/ HC/ NHSH influenza developed and systems Bute Council and Highland evolved as a result of the Council implementing the Revise pandemic flu plans experience of the H1N1 vaccination campaign for future emergent strains. swine flu situation and the subsequent vaccination campaign Guidance for the Promoting effective management of viral infection control practices in Healthcare associated outbreaks in care homes. care homes infections and For more detail on the HAI ABC/ HC/ NHSH antimicrobial resistance agenda see workplan of NHSH Infection Control Committee Continuation of routine vaccination programs Embedding annual HPV (Childhood, seasonal vaccination of S2 pupils in Vaccine Preventable influenza) routine service. Diseases and the impact Collaboration with both local Introduce measles of them on current and ABC/ HC/ NHSH authorities to ensure effective vaccination into school planned immunisation delivery of the HPV vaccine leaving booster programme programs Continuation of HPV vaccination program in schools, in addition to provision of dT/IPV and measles boosters

20thMarch201210 Version1 TABLE 1 – NATIONAL PRIORITIES continued How they are being addressed National priorities Current Arrangements Examples of Joint Working Agencies involved Intended Actions 2012- 2014 NHSH is working with both ABC and HC in relation to contaminated land strategies To consider and prevent The local air quality reports for specific environmental each area and general work exposures associated relating to radon. with public and private Major incident planning, training water supplies, and exercising for the nuclear ABC/ HC/ NHSH contaminated land, air establishments at Dounreay and quality and radioactive Faslane materials. Collaboration between all 3 agencies and Scottish Water in Environmental exposures the monitoring and improvement which have an adverse of public and private water impact on health supplies Tackling the effects of antisocial The investigation and or excessive noise in the resolution of noise communities related complaints Ensuring that noise attenuation measures are integrated into new ABC/HC developments Increase awareness in the community and promotion of a good neighbourhood noise guide

20thMarch201211 Version1 How they are being addressed National priorities Current Arrangements Examples of Joint Working Agencies involved Intended Actions 2012- 2014 Joint working to ensure the Review of relevant joint Joint protocols are control of instances of infection plans and procedures Gastrointestinal and available for the through proactive risk ABC/ HC/ NHSH Zoonotic Infections management of specified management and the infections investigation of suspected or confirmed infections Scottish Hepatitis C and More of an NHS issue. Local Implementation of the HIV Action Plans and authorities represented on BBV NHSH plans and HIS Sexual Health and BBV Steering Group. Standards Framework Information leaflets Joint training in Improving available for all major Common leaflets have been managing communications with the ABC/ HC/ NHSH infectious diseases and developed incidents/outbreaks and public on risks to health on website. chairing these meetings

20thMarch201212 Version1 TABLE 2 - LOCAL PRIORITIES Outcome Proposed actions Agencies involved Timescale to be achieved by

Resilience to response to 1. Review pandemic flu plans ABC/ HC/ NHSH 1. 31 October a Pandemic Flu outbreak 2. Liaison to ensure effective multi-agency response 2012. through effective 2. Ongoing multi-agency response throughout 2012- 2014 Effective sea and airport 1. Review existing sea and airport health plans across ABC/ HC/ NHSH 1. 31 October health plans to provide Argyll and Bute Council and Highland Council 2012. adequate disease control measures 2. Develop a generic approach to sea and airport 2. 31 March 2014 plans to ensure compliance with International Health Regulations

Enhance recovery planning 1. Further develop a generic Recovery Plan outlining ABC/ HC/ NHSH 1. 31 March 2013 for a major incident multi-agency responses 2. Review and update specific incident plans relating 2. 31 March 2014 to the recovery of an incident 3 Review and update procedures on rest/reception 3. 31 March 2013 centres 4. Review and update procedures for radiation 4. 31 March 2013 monitoring units To minimise the risk to the 1. Further develop a local E.coli O157 strategy and ABC/ HC/ NHSH 1. 30 September public from E.coli action plan based on the national VTEC action plan 2012 contamination and to provide a holistic approach for reducing the risks protect public health of E.coli 0157 cases in the community 2. Implement the action plan across food safety, environmental health, public health and through 2. 31 March 2014 enhanced public and professional education 1. Ensure that the public in radon affected areas are HC/ NHSH 1. Ongoing Minimise impact of Radon provided with adequate information relating to the throughout 2012- on affected areas risks of radon and the mitigation measures which 2014 can be taken to reduce the risk

20th March201213 Version1 TABLE 2 - LOCAL PRIORITIES continued Outcome Details Agencies involved Timescale to be achieved by

1. Through food safety enforcement and ABC/ HC 1-4. Ongoing Control of Norovirus and regulation, ensure that adequate steps are throughout 2012-2014 biotoxins in the shellfish industry taken to minimise risks from norovirus 2. Working with the FSAS and the industry to develop standards and controls to minimise norovirus risks 3. Investigate suspected or confirmed cases, taking appropriate controls 4. Liaison with Scottish Water regarding wastewater treatment processes and their investment programme for public sewer systems adjacent to shellfish harvesting sites and SEPA for private sewage schemes

Effective and proportionate 1. Review and update joint local plans and ABC/ HC/ NHSH 1. Ongoing as per arrangements in place procedures review dates to protect public health 2. Exercise emergency incident plans in 2. One per year accordance with programme 3. Joint training exercise on foodborne 3. 31 March 2013 outbreak 4 Review service arrangements following 4. 31 March 2013 publication of the Health Protection Stocktake Report from the Scottish Government 5. 5.Ongoing throughout Develop key performance standards for the 2012-2014 response, investigation and actions for public health incidents

20th March201214 Version1 TABLE 2 - LOCAL PRIORITIES continued Outcome Details Agencies Timescale to be involved achieved by

To minimise the risk to the public 1. To assist with on-going research and reviews ABC/ HC/ NHSH 1. 31 March 2014 from Lyme Disease 2. To consider joint work to minimise risks 2. 31 March 2014

Protecting the vulnerable 1. Under-age sales regulation relating to alcohol, ABC/ HC 1. Ongoing in our community tobacco, sunbeds and regulation of throughout 2012- tattooing/skin piercing 2014

Protecting the vulnerable 1. Implement Care for People – welfare and ABC/ HC/ NHSH 1 and 2. Ongoing in our community guidance including recovery planning for throughout 2012- 2. major incidents 2014 Facilitate good infection prevention practice in the community and care homes and work to prevent and manage C. Difficile infection

Education and advice programme 1. Reducing teenage pregnancy and improving NHSH 1, 2 and 3. standards of sexual health Ongoing 2 Raising awareness of communicable disease ABC/ HC/ NHSH throughout 2012 - and controls through improved public 2014 information 3. Extend use of Food Hygiene Information ABC/ HC System and EatSafe awards in the food sector 1. Investigation of suspected and confirmed 1. Ongoing Preventing and minimising the cases of communicable disease and ABC/ HC/ NHSH throughout 2012- spread of infection implementation of appropriate controls 2014 2. Implement the Scottish Public Health 2. Within 3 months Information Management System when it NHSH of it becoming becomes available available 3. Monitoring trends by surveillance and NHSH 3. Ongoing reporting Delivering vaccination programmes 4. NHSH 4. Ongoing

20th March201215 Version1 SECTION 3 – REVIEW

8. Review of Joint Health Protection Plan 2010-2012

8.1 A review document of the 2010-2012 plan will be produced later in 2012. The review will cover: - Progress against national and local priorities - Significant Incidents that occurred in 2010-12 and any identified learning outcomes.

9. Review of Health Protection Standard Operating Procedures, Protocols and Plans

9.1 NHS Highland and its two local authorities have a number of standard operating procedures and policies. These concern a variety of health protection issues including food safety.

9.2 Each policy held by NHS Highland has a scheduled date of review.

9.3 The Environmental Health Liaison Group provides an opportunity for members to highlight policies that may require revision in light of new evidence or legislation.

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20th March201216 Version1 APPENDIX 1

List of joint NHS/Council Plans

Title Protocol / Procedures / Plans

1 Investigation of enteric disease Local 2 Investigation of foodborne and waterborne Local diseases 3 Protocol for failures of prescribed concentrations and serious or gross contamination of Private Local Water Supplies 4 Lead in Water Supplies Local 5 Blue Green Algae in Inland and Inshore Waters: Local Assessment and Control of Risk 6 Care Homes (Outbreaks of Illness) Local 7 Protocol for the investigation and management of Local viral outbreaks in the Tourist and leisure Industry 8 Pre-School – Infection Control National 9 Procedure for cases of illness arriving at a port / Local airport 10 Legionella National

11 VTEC (inc E coli O157) Local 12 Highlands & Western Isles Notifiable (Animal) Regional Disease Plan 13 Argyll & Bute Council Generic Animal Disease Plan Local

14 Protocol for notifications of Psittacosis Local

15 Pandemic Influenza Local 16 Rabies Contingency Plan National Guidance and Local procedures 17 Smallpox National

18 Scottish Waterborne Hazard Plan National

19 Scottish Water Wastewater Pollution Incidents Plan National

20th March201217 Version1 Appendix 2 NHS Highland Area Map

Argyll and Bute Council Area Map Highland Council Area Map

20th March201218 Version1 Appendix 3

Designated Competent Persons under the Public Health etc. (Scotland) Act 2008

NHS Highland Dr Margaret Somerville Dr Ken Oates Dr Cameron Stark Dr Rob Henderson Abhayadevi Tissington Lorraine McKee

Highland Council EH Archie Lang John Lee Chris Ratter Alan Yates Angus Hogg Helen Gordon Andy Hurst Clifford Smith Robin Fraser Fiona Yates Carol Rattenbury Gregor MacCormick Zoe Skinner Patricia Sheldon Karen Johnstone Robert Murdoch David Proudfoot Stephen Cox Mark Phillips Sharon Mitchell Coila Hunter Graeme Corner

Argyll & Bute Council EH Lead Local authority competent person: Alan Morrison, Depute Local authority competent persons: Iain MacKinnon, Depute Local authority competent persons: Jo Rains

The Council policy is that professional staff are authorised by the Regulatory Services Manager according to competency, and experience

20th March201219 Version1 Appendix 4 Supporting information

1. Health Protection - Definitions

1.1 Health Protection is the branch of public health which seeks to protect the public from being exposed to hazards which damage their health and to limit any impact on health when such exposures cannot be avoided. The hazards are categorised as biological (bacteria, viruses), chemical and radiological.

Health Protection historically was known as Communicable Disease and Environmental Health (CD&EH)

Health Protection services carry out a range of functions as indicated in the figure below.

Surveillance Alert and Response Investigation

Co- Communication ordination Assessment

Prevention & Control

1.2 Environmental Health is the branch of Public Health that is concerned with all aspects of the natural and built environment that may affect human health. This remit is delivered within local authorities.

The Environmental Health Service has a lead role in Health Protection through its regulatory core functions of Food Safety, Health and Safety at Work, Communicable Disease control, Public and Private Water Supplies, Monitoring bathing water quality, Contaminated Land, Air Quality, Noise control, Nuisance abatement, Smoking Enforcement, and prevention and control of Zoonotic diseases.

1.3 The Trading Standards Service performs the Council’s Consumer protection function, which includes tobacco controls; product and consumer safety; licensing of persons, explosive and petroleum; feeding stuffs and fertilisers; age related sales and weights and measures.

2. Overview of NHS Highland and its Local Authority partners NHS Highland’s territorial area is shared between two local authorities, Highland Council and Argyll and Bute Council. The resident population is estimated to be 304,000. The population is ageing, this profile is increased by the large number of young people leaving to continue education or seek employment in other urban settlements.

20thMarch201220 Version1 Immigration, from outside of and within the European Union has increased in recent years, but remains lower than other parts of Scotland.

The territorial area covers 32,518 km² (12,507 square miles), which represents approximately 41% of the Scottish land surface. It extends across the most northerly and westerly fringes of the Scottish mainland and includes 29 inhabited islands. A large proportion of the population lives in remote rural towns and settlements.

Transport infrastructure across much of the Highlands and Argyll and Bute consists of single road or rail networks. Island communities are reliant on ferries with few inter island connections.

Due to the geographical profile of the region, a higher than average proportion of people have a private water supply.

A large number of tourists visit the area throughout the year pursuing a variety of activities. This influx, particularly to remote and rural areas increases demands on both health and local authority services. In order to facilitate trade and tourism, the area contains several air and sea ports providing local and international connections.

3. Resources and Operational Arrangements for Health Protection

The human resources available for delivering health protection services are outlined in the table below.

3.1 NHS Highland – Health Protection Team Job Title Role and Responsibility WTE

Director of Public Strategic and Operational Lead for Public Health activities in NHS 1 Health Highland.

Consultant in Public Provide leadership for health protection development and 1 Health Medicine implementation in NHS Highland. To co-ordinate the provision of an effective service for the control of communicable disease, and environmental health hazards 24/7. Health Protection Coordinate, lead and support activities surrounding the 2 Nurse Specialist prevention, investigation and control of communicable disease and immunisation programmes. TB Liaison Nurse Co-ordinate the contact tracing for TB cases/contacts 0.2

Public Health Responsible for disease surveillance records and reports. 0.2 Surveillance Officer

Emergency Ensuring NHS Highland is prepared for a major incident. 1 Planning Officer Administration Provision of administrative support. 1.4

20thMarch201221 Version1 3.2 Argyll and Bute Council Job Title Role and Responsibility WTE Regulatory Services Strategic and operational management of environmental health, 1 Manager animal health and trading standards, including debt counselling within the Council. Delivery of effective health protection interventions. Lead and support the development of staff. Effective management of resources. Council’s Head of Food Safety. Environmental Health Management and delivery of the environmental health service 2 Managers within a geographical area of Argyll and Bute – east and west regions Environmental Health Provide specialist food safety advice and expertise within Argyll 1 Officer (Food Control and Bute Council. Provides specific advice and supports the and Service Support) development of protocols, service plans and ensure that they are in line with current legislation.

The inspection of high risk and EC approved food premises. Environmental Health Provide specialist health and safety advice and expertise within 1 Officer Health and Argyll and Bute Council. Provides specific advice and supports the Safety and Service development of protocols, service plans and ensure that they are Support) in line with current legislation.

Environmental Health Full range of environmental health duties including public health, 10 Officers food safety, environmental protection and health and safety. Environmental Carrying out the Council’s statutory duty to identify contaminated 1 Protection Officer land and local air quality. To deal with historic contamination under the planning process and by programmed inspection; to carry out risk assessments in accordance with legislation, statutory guidance and the Council’s published Strategy. Regulatory Services To undertake a specific range of environmental health duties 4.6 Officers principally in food safety. Technical To support the environmental health service and undertake 5.2 Assistants/Sampling environmental sampling and monitoring programmes. Officers Senior Animal Health To supervise the delivery of animal health and welfare service. To 1 and Welfare undertake programmed visits relating to animal heath and welfare and primary food production. Investigate all cases of notifiable animal disease including zoonotic diseases. Animal Health and To undertake programmed visits relating to animal health, welfare 1 Welfare and primary food production. Investigate all cases of notifiable animal disease including zoonotic diseases Civil Contingencies Ensuring Argyll & Bute Council is prepared for a major incident. 1 Manager Civil Contingencies Ensuring Argyll & Bute Council is prepared for a major incident. 1 Officer Manage, co-ordinate, lead and support activities surrounding Trading Standards Trading Standards. Develop protocols, service plans in line with 1 Manager current legislation. Trading Standards Carry out Trading Standards interventions in accordance with 7.6 Officers and current plans, protocols and legislation Regulatory Services Officers

20thMarch201222 Version1 3.3 Highland Council

Job Title Role and Responsibility WTE Environmental Health Strategic and Operational Lead for Environmental Health 1 Manager and Public Health activities in Highland Council. Area Environmental Operational Lead in respective areas for Environmental 3 Health Managers Health and Public Health activities. Principal Coordinate, lead and support activities surrounding 1 Environmental Health Environmental Health and Public Health. Officer (Food) Principal Coordinate, lead and support activities surrounding 1 Environmental Health Environmental Health and Public Health. Officer Environmental Health Carry out Environmental Health and Public Health 17.6 Officers interventions and inspections in accordance with current plans, protocols and legislation. Environmental Health To undertake a specific range of environmental health 7.6 Technical Officers duties principally in food safety and Health & Safety. Environmental Health To support the environmental health service and 7.7 Technical Officers – undertake environmental sampling and monitoring sampling programmes. Principal Officer Management of the Council’s statutory duty to identify 1 (Contaminated Land) contaminated land. Scientific Officer Carrying out the Council’s statutory duty to identify 4.6 (Contaminated Land) contaminated land. Information Maintenance of the Council’s contaminated land 1 Technician information records. . (Contaminated Land) Senior Animal Health Management of Council’s statutory duties in relation to 1 & Welfare Officer Animal Health & Welfare including management of Animal Health & Welfare Officers. Animal Health & Carry out Council’s statutory duty in relation to Animal 3 Welfare Officer Health and Welfare. Emergency Planning Strategic and Operational Lead for Emergency Planning 1 and Business and Business Continuity Continuity Manager Emergency Planning Ensuring Highland Council is prepared for a major 2 Officer incident. Administration Provision of administrative support. Trading Standards Strategic and Operational Lead for Trading Standards. 1 Manager Trading Standards Coordinate, lead and support activities surrounding 2 Team Leader Trading Standards. Trading Standards Carry out Trading Standards interventions in accordance 16 Officers & Assistant with current plans, protocols and legislation. Trading Standards Officers

20thMarch201223 Version1 3.4 Laboratory Services

Arrangements to access laboratory facilities vary across the two local authorities. Argyll and Bute services tend to be provided by laboratories located in Central Scotland for logistical and practical convenience. Further details on laboratory services are detailed below.

Sample type Argyll and Bute Highland Council NHS Highland Council Public Analyst services Glasgow Scientific Edinburgh Scientific n/a including food examination Services Services

Environmental monitoring Glasgow Scientific Scottish Water, n/a including drinking water Services Inverness analysis

Faeces and blood samples Royal Alexandra Raigmore Hospital, Raigmore Hospital, etc Hospital Paisley Inverness Inverness

Inverclyde Royal National reference laboratories Shellfish Biotoxin analysis Weymouth Weymouth n/a

Chemical and Biological Porton Down Toxins e.g. anthrax

4. Information, Communication Technology  NHS Highland and its local authority partners have access to a wide range of ICT hardware. In the event of an emergency, the agencies have demonstrated the capacity to source extra equipment.

 Interagency collaboration encourages pooling of some ICT resources and tasks in order to achieve a ‘best fit’ solution.

 The majority of incidents are remotely managed due to the geographical constraints of the area. Reliable network coverage is essential to remote management.

 Video conferencing and tele-conferencing is widely used for communication across the health board and within the local authorities. A number of VC points exist that can bridge into the NHS Highland system.

 NHSH is responsible for disease surveillance. Information collected is entered into a database to allow for further analysis of trends. Routinely collected data and reports are fed back to the local authority. Databases can be adapted to suit the needs of individual outbreaks. The software required is widely available and there are a number of staff across the agencies with data entry skills. The limitation on this service is the few individuals available who can create or manipulate databases as information requirements change. This limitation could significantly delay the collection and dissemination of essential data during a large outbreak.

20thMarch201224 Version1  Adequate arrangements are in place for the reporting and recording of work electronically within local authorities. However, these systems, with the exception of the Food Surveillance system, are not compatible with the NHS systems or between local authorities.

5. Emergency Planning and Service Continuity

The NHS Highland Emergency Planning & Business Continuity Group (EPBCG) convenes as a strategic forum to shape and inform the emergency planning and business continuity agenda. The Group meets on a quarterly basis and the work programme consists of reviewing and updating all Major Incident Plans and Business Continuity Plans for operational units, overseeing a programme of training and exercising, and ensuring arrangements are in place to warn and inform the public.

The Group links with the work carried out by the Emergency Planning Groups located within each of the Community Health Partnerships and Raigmore Hospital, ensuring a co- ordinated and integrated response to any emergency or crisis that might arise.

6. Inter-organisational collaboration

 Feedback on disease surveillance collected as part of routine and statutory monitoring is given from NHSH to both Highland Council and Argyll and Bute Council.

 The Environmental Health Liaison Group which meets twice per year provides an opportunity to evaluate the management of significant incidents. Lessons learnt can be shared and disseminated within each partner agency.

Meeting / Group Membership Frequency Environmental Health NHSH, ABC, HC, Scottish 6 monthly Liaison Group Water, SEPA, Animal Health, SAC, FSA, HPS Scottish Water Liaison Scottish Water, NHSH ABC, Group HC 6 monthly

 Following a significant incident, debriefing is organised routinely for the involved agencies. This provides an opportunity for those involved operationally and strategically to evaluate the management of the incident and provides a forum for critical reflection. A final incident report should be produced within 6 weeks of the debrief.

NHS Highland is fully committed to the principles of co-operation for planning and preparing for emergencies. Much of this work is carried out under the auspices of the Highlands & Islands Strategic Co-ordinating Group, and the Strathclyde Emergencies Co- ordinating Group in respect of Argyll & Bute CHP. NHS Highland has appropriate representation at strategic and tactical levels within both Co-ordinating Groups, ensuring the obligations as a Category 1 responder under the Civil Contingencies Act are met. This work has led to the creation of a number of multi-agency contingency plans, many of them site specific, detailing NHS Highland’s role during the response and recovery phases of an incident or emergency.

20thMarch201225 Version1 7. Mutual Aid

Due to the vast geography of NHS Highland, it has been necessary to develop arrangements with NHS Greater Glasgow and Clyde in relation to the initial response to major incidents occurring within Argyll and Bute. In particular, there are specific arrangements written into the HM Naval Base, Clyde, Off Site Contingency Plan, which is designed to cover radiation emergencies at HM Naval Base, Clyde and the Faslane, Coulport and Lochgoil berths. While NHS Highland retains overall responsibility for the NHS response, they would be assisted, particularly in the initial stages, by personnel from NHS Greater Glasgow and Clyde, with staff from both boards being deployed to manage the incident from the Clyde Off-Site Centre. Additionally, depending on the extent and volume of casualties, designated receiving hospitals would be nominated within NHS Greater Glasgow and Clyde for the reception of casualties.

Across the North of Scotland Public Health Network all 5 participating public health departments have signed a mutual aid agreement which states that each Board will assist any of the others which has pressures it cannot meet on its own. For example, in a large outbreak or incident.

There is also an informal mutual local authority support arrangement in place with neighbouring authorities.

8. Out-of-hours arrangements

NHS Highland A senior member of public health staff is available 24 hours a day 7 days a week. Outside of office hours, this service is provided by health board competent persons which comprise medical public health consultants, health protection nurses, public health specialists, as well as training grade public health doctors. The service can be accessed through the Raigmore hospital switchboard on 01463 704000. Raigmore laboratory provides a limited bacteriology service out of hours; virology and parasitology services are significantly restricted. Urgent sample requests can be performed following discussion with the on call microbiology team. National Reference laboratories will perform analysis of urgent specimens following discussion of their appropriateness.

Highland Council No on-call service is provided by the Council, however there are out-of-hours arrangements in place to access the service in case of emergency. This can accessed through the following number: 01349 886690 Arrangements are in place to access laboratory services outwith normal hours.

Argyll and Bute Council No on-call service is provided by the council, however there are out-of-hours arrangements in place to access the service in case of emergency. This can be done through the Regulatory Services Manager or the Civil Contingencies Manager (Telephone no 01389 753667 or 01436 676018). Similar arrangements are in place to access laboratory services outwith normal hours.

9. Maintenance of Competencies for Health Protection Staff

NHS Highland NHS Highland staff undergo an annual appraisal to ensure that their knowledge and skills remain up to date. Staff are encouraged to identify their own learning needs and attend external conferences and meetings as part of continuing professional development (CPD) activities. Nursing staff meet the requirements of the Knowledge and Skills Framework. The internal procedures for continuous professional development require further

20thMarch201226 Version1 development in order to comply with recommendations made in the Framework for Workforce Education Development for Health Protection in Scotland.

Highland Council Highland Council has a corporate performance and development review process. Actions and competencies are identified periodically and objectives set for CPD. Details of this are held centrally on a register which managers review at regular intervals and as part of the employee appraisal process. The individual learning needs of each member of staff can be identified and targeted through this mechanism.

Argyll and Bute Council Argyll and Bute Council has a corporate performance and development review process with its entire staff. Appraisals are carried out on an annual basis. Details of this are held centrally on a register which managers review at regular intervals and as part of the employee appraisal process. The individual learning needs of each member of staff can be identified and targeted through this mechanism. Within Regulatory Services, professional and technical officers are required to meet the continued development requirements in the Royal Environmental Health Institute of Scotland’s CPD scheme.

10. Public Feedback

NHS Highland Information is provided to the public through the use of local media and the NHS Highland website along with written information where required. NHS Highland Health Protection Team does not have any formal processes for obtaining feedback from the public.

Argyll and Bute Council Customer and business surveys are regularly undertaken as part of the customer engagement strategy. Whilst not specific to health protection, these surveys provide useful information about the service provided and are used to inform improvements and developments. Recent surveys have indicated that on average 94% of customers are satisfied with the service provided to them

Highland Council Information is provided to the public through the use of local media and the Highland Council website along with written information where required. Business surveys are regularly undertaken.

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20thMarch201227 Version1

Highland NHS Board 5 June 2012 Item 5.4

PROCUREMENT STRATEGY

Report by Malcolm Iredale, Head of Procurement on behalf of Nick Kenton, Director of Finance

The Board is asked to:

 Note the role of Procurement within overall Board activities.  Agree the procurement principles detailed in section 3 of the Procurement Strategy.  Approve the Procurement Strategy.  Note that a Procurement Workplan will be agreed by the Senior Management Team.

1 BACKGROUND

In delivering Patient Services, NHS Highland buys a huge variety and volume of goods and services – with a “Trade Spend” of almost £100m. This activity occurs widely throughout the Board, and involves many employees – most of whom undertake procurement, (buying), as only part of their operational duties. It is important that all procurement is undertaken to the highest standards, and that consistent practices and systems are applied throughout the area.

At the same time, many other organisations, including other Scottish Health Boards, also undertake such procurement activities, and the linking and co-ordination with others may generate additional benefits. This has been recognised within NHS Scotland and the wider Public Sector over the last few years, and NHS Highland should plan and deliver its Procurement activities to address local needs, but while operating within this wider environment.

2 DETAIL

A Draft Procurement Strategy for NHS Highland is attached, and this identifies the Procurement Principles, and a process for meeting them. This draft Strategy was approved by the Senior Management Team (SMT) in April, recognising the wide organisational involvement in procurement activity at local level, and the significant work underway at regional and national level. SMT recognised it would impact on a range of Board staff throughout the organisation if appropriate, professional procurement is to be delivered on all occasions – regardless of specific service or geographic location.

The Senior Management Team noted that a Procurement Workplan would be produced to provide both specific and short term objectives, and a method to measure progress in this area – which will be independently verified through the annual Procurement Capability Assessment (PCA) carried out by NHS National Services Scotland.

3 CONCLUSION

The Board is asked to approve the attached Procurement Strategy which provides for both monitoring to ensure delivery, and annual review to maintain relevance. 4 CONTRIBUTION TO BOARD OBJECTIVES

 Staff Governance A Procurement Strategy ensures a professional methodology for the purchase of all items required by the NHS Board, and provides not only a framework for buying, but an audit trail on which staff can rely if subsequently challenged on decisions taken.

 Patient and Public Involvement The Procurement Strategy is based on best professional practice which includes the patient and public input into relevant contracts.

 Clinical Governance The Procurement Strategy will help to deliver clinical consistency through the procurement of appropriate quality clinical goods

 Financial Impact The Procurement Strategy will help deliver best value in the procurement of non pay items.

5 RISK ASSESSMENT

The Procurement risks, including the potential failure to deliver the necessary Financial Targets or obtain the necessary items required to maintain service delivery are included in Operational Risk registers and managed accordingly.

Malcolm Iredale Head of Procurement

25 May 2012 Procurement Strategy

Lead Manager: Malcolm Iredale, Head of Procurement Executive Sponsor Nick Kenton, Director of Finance Approved By: Senior Management Team + NHS Board Date Approved: SMT April 2012 + NHS Board June 2012 Expiry Date: March 2015 Review Date: March 2013 Replaces Previous Version: September 2010 Procurement Strategy

1. Why are we doing it?

NHS Highland has the overall triple aims of :

 Better Health  Better Care  Better Value

This approach fully integrates quality and efficiency, recognising that Efficiency without Quality is Unthinkable, but Quality without Efficiency is Unsustainable.

The overall NHS Highland objective must be fully supported by the appropriate clinical and business strategies – including a Procurement Strategy. This Procurement Strategy sets down the key principles, objectives and processes in NHS Highland for the years 2012 to 2015, and provides a clear statement on the focus, and importance of, Procurement. It addresses both the national drive to improve procurement performance - aiming for the highest professional standards - while helping to deliver local NHS Highland objectives.

The NHS Highland 2011/12 revenue spend is some £650m, of which it is estimated that “Trade Spend” accounts for approximately £100m. It is essential to maximize the impact of this expenditure in order that the necessary quantity of goods and services are available when required to support the delivery of patient services. This premise forms the basis of the principles behind the Procurement Strategy which seek to provide:

 Appropriate product  Appropriate and sufficient quantity  When required  Where required  Purchased at the right price to provide Best Value

The Procurement Strategy sets out how we can do this in NHS Highland, recognising:

 The unique challenge of delivering this in an area that covers over 40% of the Scottish landmass and includes over 24 Inhabited Islands  That this is a time of unprecedented change  The significant financial constraint and organisational change  The internal re-alignment of Operational Divisions  The nationally unique work of lead agency arrangements for the delivery of Adult and Children’s Services – Planning for Integration, or P4I.

- 2 - Procurement Strategy

2. What are we doing?

Improving Procurement has been underway nationally for some years, with the establishment of National Procurement in 2005, and the publication of the McClelland Report – covering the wider Scottish Public Sector - in 2006. Part of this work involves a Procurement Capability Assessment, (PCA), for all public sector bodies to measure progress against 8 key performance areas – thus providing a focus for the development and delivery of Procurement, and an independent means of measuring progress – detailed further in Section 6 below. The principles of this process have been reinforced with the issue of CEL 05 (2012) in March 2012, copy at Appendix 1.

The Procurement Reforms recognise that while progress within individual organisations is essential, success cannot be delivered without effective joint working. This is reflected in the Procurement Strategy which includes not only work within NHS Highland, (including the P4I Project highlighted above), but also with Partner Agencies at Local, Regional and National level.

Within NHS Scotland, the overall procurement lead is provided by National Procurement, (NP), an operational unit of National Services Scotland (NSS) who:

 Provide the strategic procurement lead  Manage national NHS contracts  Operate the National Distribution Centre (NDC) as the national NHSS warehouse  Undertake Procurement Capability Assessments (PCA’s) for NHSS organisations

The NHS Highland Procurement Strategy recognises this national dimension to ensure that appropriate use is made of this Centre of Expertise, and that maximum benefit is derived from the purchasing power and national distribution network within Scotland. While recognition of the national dimension is important, it is appropriate to work closely with National Procurement to ensure that the application of a national strategy is able to meet the unique geography of NHS Highland, as noted above. In addition to this NHS resource, there are also wider Scottish Government initiatives – such as the Public Contracts Portal, and in common with other NHS Boards, NHS Highland seeks to use these where possible.

As well as working at National level with National Procurement, NHS Highland is part of the East of Scotland Procurement Consortium, (ESPC). This Consortium, formed in 2011, consists of 7 territorial Mainland NHS Boards – Borders, Lothian, Fife, Forth Valley, Tayside, Grampian and Highland – and it seeks to improve procurement capacity and performance within the 7 Boards, linking with National Procurement as appropriate. Work has evolved from an initial reactive model to one with a more proactive approach, and work is also underway with the three Island Boards to explore potential participation.

- 3 - Procurement Strategy

Increased Joint working will also be undertaken with the two Local Authorities within Highland. This accords with other national developments, such as the Clyde Valley work following the Arbuthnott Report, the local work through the Highland Partnership, and the specific detailed work with Highland Council as part of the Planning for Integration Project (P4I). It must however be recognised that the ability to work jointly on the procurement agenda with Local Authorities is relatively restricted given the specialist nature of much of the purchasing (eg the clinical bias), and the progress being made in other linked areas – such as the development of a single instance NHS Scotland finance ledger, the potential single instance PECOS within NHS Scotland, the increased working at regional NHS level through ESPC.

3. How will we do it?

NHS Highland has bought goods and services for many years to support the delivery of high quality patient care services, and it is appropriate to review, and potentially confirm, the underlying procurement principles in the light of both experience, and the “drivers for change” highlighted above. Rather than detail the methodology for reviewing each principle, the paragraphs below detail the major procurement principles before moving on to identify the implications for both users and procurement.

Although procurement activities have been devolved in some areas, such as Estates, Pharmacy, Labs, and Catering, the principles apply throughout all activities and geographical areas of the Board .

Clinical Effectiveness NHS Highland will seek to buy the most clinically effective products which also provide best value for money, recognising that this can only be delivered with appropriate user input.

Best Value NHS Highland will seek to deliver best value in the ordering, purchasing, use and storage of appropriate and effective goods and services, supported by the provision of the necessary procurement Management Information (MI).

- 4 - Procurement Strategy

National Contracts and Frameworks National contracts and frameworks are available for a wide variety of goods and services within Scottish Government and NHS Scotland, and where relevant, these must be used unless otherwise authorised by the Director of Finance or Head of Procurement as prescribed in CEL 05 (2012).

Procurement Workplan NHS Highland will produce a Workplan as part of the Board’s Annual Local Delivery Plan to set out the key areas of focus each year. It will help ensure that procurement activity meets the operational requirements of the Board while reflecting the plans and priorities of operational partners such as National Procurement and ESPC.

Standardisation & Co-ordination NHS Highland will try where possible to co-ordinate and standardise its purchasing throughout the different geographic, functional and operational areas of the Board.

Official Orders Official Orders must be used for all goods or services at the point of ordering, and NHS Highland will not pay any invoice for goods or services supplied without such an order.

Electronic Ordering The maximum use will be made of electronic ordering through PECOS – the Board’s preferred ordering system, or MAXIMO for Estates orders and electronic Pharmacy orders.

Use of the National Distribution Centre (NDC) NHS Highland will work with national and local colleagues to maximise its use of the NHS National Distribution Centre (NDC), on the basis that it meets local needs.

Stores and Stockholding Within operational requirements, NHS Highland will seek to minimise the number of stores locations, and to minimise stockholdings within these locations, recognising the need for ongoing review to maintain this position in the light of service changes and developments.

Geography and Logistics NHS Highland will seek to ensure maximum availability of appropriate goods and services throughout the Board area, recognising that it represents over 40% of the Scottish landmass

East of Scotland Purchasing Consortium NHS Highland will work with regional and national colleagues to develop, use and benefit from the East of Scotland Purchasing Consortium

- 5 - Procurement Strategy

Partnership Working NHS Highland will work with local operational partners, particularly Local Authorities to identify and secure any local procurement benefits that can be delivered jointly. This includes work with Highland Council on Planning for Integration.

Sustainable Procurement NHS Highland will source goods and services which are economically and environmentally sustainable, and which are the result of Fair Trade and Fair Wage agreements, and which support the local economy where possible.

Supplier Management NHS Highland will work with suppliers to manage contracts and seek any relevant developments for the benefit of patients and service users.

Financial Regulations Procurement activity will continue to be included within the Board’s Standing Financial Instructions (SFI’s), and Standing Financial Procedures (SFP’s), with review and update as appropriate..

Procurement Competencies Staff undertaking procurement activity, in whatever department, should be trained in the necessary competencies, and if unsure of the necessary actions to take should contact the Procurement section.

Engagement and Participation The successful delivery of the Procurement Strategy, and full implementation of all Procurement Principles, requires the engagement of all relevant members of staff throughout NHS Highland.

4 What it means to Users

The purchasing of goods and services is undertaken by many staff throughout the organisation, working in a variety of locations over many Departments. However, all staff work towards securing the NHS Board objectives of Better Health, Better Care, Better Value and adoption of the Procurement Principles detailed above will help this process. Although this is already happening in many Departments, it is important that the agreed Procurement Principles are universally applied – including geographically and functionally.

- 6 - Procurement Strategy

To help deliver this it is important that we use the resources available within the Board, including the current expertise within Procurement and Pharmacy, with ready reference by users to access this help. This is shown diagrammatically at Appendix 2 which gives some examples of the need to contact Procurement or Pharmacy; these are posed as a series of questions to users:

 Do you need to engage in financial discussions with companies?

 Are company representatives cold calling?

 Do you have to change an existing product, service or piece of equipment or use a new one?

 Do you require a quote for a product, service or equipment?

 What do you do if product samples have been provided by companies for evaluation?

 Do you have any issues with a product, service or equipment?

If the answer to any of these questions is yes, or maybe, then users are advised to contact Procurement, or Pharmacy in the case of drug related items.

The annual Procurement Workplan will identify specific deliverables and a timescale for these, and will be able to reflect user requirements and priorities, as well as linking with work already planned within National Procurement and ESPC.

An integral part of this work is for users to be fully involved in any specification and evaluation work – such as participation in National Commodity Advisory Panels (CAP’s) or in local Technical User Groups (TUG’s). These allow the user needs and views to be included and reflected in national contracting – including any aspects or factors which may be unique to Highland. In recognition of the importance of these Groups, invitations for membership will be issued by the Chief Executive. It also allows users to be fully involved in the implementation of agreed contracts and frameworks to ensure that they are able to meet the requirements of NHS Highland.

5 What it means to Procurement Procurement will work in partnership with users to help deliver the above agenda acting as both a link with national and regional procurement work, and a source of specialist help and expertise in Procurement and contracting.

- 7 - Procurement Strategy

It is important within the whole Procurement Journey to recognise the role of appropriate Management Information (MI) – that is to say data relating to the purchase of goods and services. This allows users and management to compare and review items bought, with follow up work as necessary relating to respective quality, quantity and value for money. Although much of this follow up and review work needs to be undertaken within Operational Units, the development, provision and oversight of this information rests with the Procurement Section.

There are ongoing Procurement developments – both within the Public Sector, and also the wider professional procurement community – and it is important that such developments are reflected in the work of NHS Highland. It is the role of Procurement to maintain an oversight of the wider procurement agenda and to highlight any key emerging issues for local attention and implementation.

6 How will we know if it Works?

As noted in section 1, procurement activity covers a wide area and it is important to ensure that progress is made in line with expectations to help in the delivery of overall NHS Board objectives. Given the involvement of a significant number of staff throughout the Board area, and the links to external organisations, such as National Procurement and partner agencies it is likely that a range of indicators will be best suited to monitor delivery over time and these are described below.

The agreement of an annual Procurement Workplan will provide an immediate focus on the deliverables expected in the forthcoming year, not only in terms of particular tasks or projects, but also timescale and accountability as both target dates and staff responsible are also detailed. The Plan will be agreed by the Senior Management Team who will be able to monitor progress in year, in addition to more formal review during preparation of the next year’s plan – which would need to include any non delivered items which need to be carried forward.

To monitor the local uptake of national contracts, including the delivery of associated savings, National Procurement operates a National Tracker to record the progress in the local implementation of such contracts. This document is completed on a monthly basis and provides an audit trail of implementation, including any assumptions with regard to timescales, risk, etc. Although completed locally for each Board it is aggregated at national level and so provides the opportunity for comparators with other Boards, etc. It can also be augmented to include local contracts which can be monitored in the same format. The Tracker provides an auditable record of savings delivered, and this can be used to measure the success of achievement against the overall savings target set by the Board

- 8 - Procurement Strategy

As previously noted, a Procurement Capability Assessment is undertaken on the Board each year by National Procurement using an independent standard methodology which produces an overall score. This covers a wide range of Procurement capabilities, and with the independent nature of the assessment process, provides a measure of progress – both against previous performance and other public sector organisations.

There are specific national KPI’s covering some areas of procurement activity, such as those around the use of the NDC. These are produced on a monthly basis and record progress against given targets, and also against previous performance.

Procurement is an area of audit activity – both internal and external – and the resultant audit reports can be used to measure progress – either overall, or against specific objectives. This work links with financial regulations, including tendering limits, uptake of national contracts, etc and is a further independent way of monitoring the progress being made in the implementation of the Procurement Strategy.

7 Timescale and Objectives

Following final approval of the Strategy, a Procurement Plan Table will be added to both identify some overall high level objectives, and to detail specific objectives and contract activity within the short to medium term.

This Table will include key dates, deliverables and those responsible – thus providing a source of organisational knowledge, departmental objectives and links with wider procurement activity in operational partners. In this format, it will provide a ready measure for delivery within the organisation and as a statement which can be assessed through the audit function (internal and external), and the Procurement Capability Assessment (PCA).

Malcolm Iredale Head of Procurement

March 2012.

- 9 -

Directorate for Health Finance and Information Health Finance

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CEL 05 (2012) Dear Colleague 1 March 2012

KEY PROCUREMENT PRINCIPLES

Purpose Addresses

1. The purpose of this CEL is to: For action

a) Refresh the guidance issued within HDL(2006)39 in order to Chief Executives and Directors of Finance, NHS clearly mandate the use of national, regional and local Boards contracts where such contracts exist; and For information b) Provide a series of supporting principles which should be adopted by all Health and Special Boards in Scotland in order Director, NHS National to support the aim of achieving best value from procurement Services Scotland National activity. Procurement

NHSScotland National Background Procurement Steering Group 2. The Accelerated Procurement initiative was established by the NHS Chief Executive Officers’ Group in August 2010. The group Auditor General recognised the essential nature of the engagement between procurement professionals and the wider Health Board teams to maximise the delivery of benefits for NHSScotland, and to Enquiries to: ensure that appropriate professional input from across the Directorate for Health service is provided to assist in Best Value outcomes for Finance and Information procurement activity. St Andrew’s House Regent Road 3. This work was developed further and is now controlled within the Edinburgh EH1 3DG NHSScotland Procurement Steering Group. This CEL sets out the key principles of this engagement to be adopted by all Health Tel: 0131-244 2422 Fax: 0131-244 2371 Boards and Special Boards in Scotland with regards to Point of contact procurement activity. [email protected]. gov.uk http://www.scotland.gov.uk

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Key Principles a) National, regional & local contracts: Where national, regional or local contracts exist (including framework arrangements) the overriding principle is that use of these contracts is mandatory. Only in exceptional circumstances and only with the authority of the Board’s lead Procurement Manager or the Director of Finance, based on existing schemes of delegation, shall goods or services be ordered out-with such contracts. Procurement leads will work with National Procurement and other national contracting organisations to ensure best value decisions are made, and that a record of exceptions is maintained for review. b) Engagement: Technical User Groups (TUGs) should be established by each Health Board for key projects with decision making powers from their Executive Board through a scheme of delegation. Each TUG will be responsible for supplier award and product selection decision making within their Board for local contracts and will provide representation to national CAP (Clinical/Commodity Advisory Group) panels for national contract activity. The decision of the TUG will be mandatory across the Board and will be made prior to development of national contract tendering activities. c) CAP Panel Membership: CAP panels will have a membership consistent with the principle of decision making based on the consensus of the majority of informed users. Boards should ensure that appropriate representation, based upon the clinical or commodity area concerned is released to and provided with the appropriate authority to input on behalf of a Board and/or clinical specialism. d) Commitment Contracts: The CAP and TUG groups will work to the principle of seeking to award Commitment based contracts. This means where possible a supplier(s) will be selected for an agreed volume of business by each Board and such volumes aggregated to provide a national commitment level. Where commitment cannot be provided, CAP and TUG groups will support the principles of reduced variation and increased consistency, commensurate with clinical and operational requirements. e) eCommerce Systems: In support of governance and transparency each Board should adopt the Scottish Government national eCommerce solutions and associated business processes for all procurement activity. These solutions will include Public Contracts Scotland, Public Tenders Scotland, Collaborative Content Management and Pecos. Use of alternative or local systems for procurement activity must be approved by the Board’s lead Procurement Manager or the Director of Finance, based on existing schemes of delegation. Procurement leads will work with National Procurement and any other relevant bodies to ensure appropriate decisions are made. f) Transparency: All awards whether from existing framework contracts or local tender processes will be established following the principles of openness and transparency. This requires clear specifications of need and award criteria against which competing offers can be assessed. All members of evaluation panels must confirm that they have no conflict of interest in relation to the specific procurement activity. Any individual wishing to challenge an award decision must also confirm likewise. Any member of staff who confirms a conflict of interest will not be able to be involved in such panels or challenges. g) No Purchase Order / No Payment: Each Board must implement a policy where no payment shall be made to any supplier where there is no pre-let purchase order. Only if a separately agreed payment mechanism has been pre-arranged should direct payments be made. Each supplier should be formally notified of this and the limit of the Board’s liability if they proceed with supply without such order cover. St Andrew’s House, Regent Road, Edinburgh EH1 3DG www.scotland.gov.uk abcde abc a

Action

4. NHS Board and Special Health Board Chief Executives should ensure that:

a) Staff work with National Procurement and the NHSScotland Procurement Steering Group to ensure full adoption of and compliance with these principles, by means of evidence presented as part of the Procurement Capability Assessment (PCA) cycle; and

b) The Standing Financial Instructions of each Health Board and Special Board are amended to include the principles set out in this paper.

Yours sincerely

JOHN MATHESON Director for Health Finance and Information

St Andrew’s House, Regent Road, Edinburgh EH1 3DG www.scotland.gov.uk abcde abc a

Highland NHS Board 5 June 2012 Item 5.5(a)

ASSET MANAGEMENT GROUP – TERMS OF REFERENCE

Report by Nick Kenton, Director of Finance

The Board is asked to:

 Approve the attached Asset Management Group Terms of Reference.

1 Introduction

The Asset Management Group (AMG) was established to provide a robust process for managing the Board’s capital investment programme. In the light of the significant constraints on capital expenditure in recent times, it has become increasingly clear that the Terms of Reference of the AMG required revisiting and that there needed to be a focus on managing the entire asset base (including assets that are below the capital threshold) rather than just new capital developments. There have also been issues around the difficulty in securing clinical engagement and this meant that the membership of the AMG requires revisiting at the same time. In addition, a recent internal audit report noted the fact that the AMG does not formally report into a ‘parent’ committee and recommended that the AMG should report to one of the standing committees of the Board.

2 Process

Initial revised Terms of Reference were discussed at the AMG meeting in March 2012, after which some revisions were made. The issue of the ‘parent’ committee was discussed at the Board development session in April 2012. The general view was that there was no obvious standing committee of the Board that would be a natural ‘parent’ for the AMG and given the degree of interest from Board members in the work of the AMG it was suggested that the AMG should report directly into the Board itself. This would require an amendment to the Board’s Standing Orders. In the light of this, revised draft Terms of Reference (attached at Appendix A) were discussed and agreed by the AMG at its April meeting – these were subsequently discussed at the SMT and some amendments (shown as tracked changes in the attached) were suggested.

This paper has been prepared on the presumption that such an amendment will be made and that the AMG will be formally constituted as a standing committee of the Board (and therefore be chaired by a non-executive Board member) and will report directly to the Board. The intention is that the draft Terms of Reference will be put to the Board in June and (if approved) the Standing Orders will be amended by the Board in August as part of the annual cycle for reviewing committees. Although the Board would be the ‘parent’ of the AMG, the intention is that the Senior Management Team (SMT) will receive regular updates on the work of the AMG.

3 Conclusion

The Board is asked to approve the attached Terms of Reference. 4 Contribution to Board Objectives

The revised terms of reference and membership of the Asset Management Group should facilitate more pro-active management of the Board’s asset base thereby contributing to all three aims of Better Health, Better Care, Better Value.

5 Governance Implications

 Staff Governance – Inclusion of a staff side member on the AMG should help ensure the Group considers Staff Governance  Patient and Public Involvement – Inclusion of two public members on the AMG should help ensure the Group considers Patient and Public Involvement  Clinical Governance – Inclusion of two clinical director members on the AMG should help ensure the Group considers Clinical Governance  Financial Impact – by considering the whole asset base rather than capital investment it is anticipated that the Group will have a positive impact on maximising the resources available

6 Risk Assessment

The scarcity of capital resources is recorded on the corporate risk register.

7 Planning for Fairness

Not directly applicable to the AMG’s terms of reference but we would expect fairness to be considered in respect of any major decisions relating to assets. Each significant proposal would be subject to specific Planning for Fairness assessment

8 Engagement and Communication

The specific issue of Terms of Reference has been discussed twice at the AMG and considered at Senior Management Team. The principles have been discussed at Board development session. A high-level communications and engagement plan is being developed to support the work of the group. The specific implications will be subject to local communications and engagement plans.

Nick Kenton Director of Finance

25 May 2012

2 Appendix A

NHS Highland Asset Management Group: Terms of Reference

The Asset Management Group will formally report directly to the Board of NHS Highland on all asset investment/disinvestment decisions funded through either Capital or Revenue

Role of the Asset Management Group: The Asset Management Group (AMG) has been established in NHS Highland, to:

 Support the process of all Asset Management and investment/disinvestment decisions now and in the future on behalf of NHS Highland.

 Ensure consistency with all policies and the strategic direction of NHS Highland and taking account of the requirement to remain within the Capital Resource Limit (CRL) and Revenue Resource Limit (RRL).

 The AMG must take into account all relevant statutory guidance and legislation as well as guidance issued by the Scottish and UK governments.

 The AMG has responsibility to

o produce a draft 5 year capital programme for consideration by the Board with the first year based on firm SG allocations and subsequent years on indicative allocations

o Monitor the in year programme against budget and allocate contingency funds as necessary.

o Develop a priority-based, rolling Five Year Asset Management Plan.

 Develop an infrastructure investment matrix to ensure that the appropriate level of limited funds is invested in the areas of highest organisational risk.

 Oversight and monitoring of all Non-profit distributing, hub and PFI type contracts

The AMG will be directly accountable to the Board of NHS Highland and will also report regularly to the Senior Management Team (SMT). The AMG has a responsibility to follow Scottish Government guidance and policies and lead on the following:

 Strategic Property and Asset Management Guidance for NHS Highland.

 Follow Health Facilities Scotland (HFS) Frameworks advice for the traditional capital build route or Scottish Futures Trust (SFT) guidance for the alternative revenue models of hub or Non-Profit Distributing (NPD).

 Follow Capital Investment guidance as described in the Scottish Capital Investment Manual (“SCIM”), for any proposed development. Currently that process requires: An Initial Agreement, Outline Business Case and Full Business Case, to be completed for all investment decisions for projects costing more than

3 £1.5M. A Standard Business Case is required for smaller projects (between £50,000 and £1,500,000).

 Develop an Asset Management Strategy for NHS Highland (AMS).

 In developing the Plan, the AMG must have regard to:

o The needs of NHS Highland identified in the AMS, The Highland Council Social Care Adult services and other providers of infrastructure.

o Provide guidance to NHS Highland Board on strategies to address matters included in the AMS.

o Determine a process and approach for monitoring the achievement of the Outcomes, Objectives and Actions included in the AMS.

o Have regard to and build upon the range of activities being undertaken in Councils

Membership: The AMG will comprise the following representatives: o Two Non Executive Board Member (one will chair the AMG)

o Executive Member

o Clinical Directors – (one from Highland Health & Social Care Partnership and one from Argyll & Bute)

o Chair of Area Clinical Forum

o Operational Directors – (one from Highland Health & Social Care Partnership and one from Argyll & Bute)

o Head of Estates

o Head of Procurement

o Finance Manager

o Staff side Representative

o eHealth, Radiology and Medical Equipment Leads

o Head of Capital and Property Planning

o Head of Social Care – on ad hoc basis

o Head of Business Transformation

o Two public representatives

o Others as required, determined by the AMG

Note that Infection Control experts will not be standing members of the AMG but there is a requirement that the inclusion of such representatives will be considered for meetings or governance structures regarding specific issues or projects.

4 Note that the leads for eHealth, Medical Equipment and Radiology will be expected to engage with relevant clinicians regarding these areas and for this engagement to be reflected in their input to the AMG. Clinicians may be co-opted on to the AMG to assist with the discussion around specific issues.

Note that the AMG may require to set up short-life sub-groups to consider specific asset- related issues.

Desirable attributes for Membership: The following attributes are sought for members of the AMG:

Essential:  A Sound understanding of the concept of asset management  An understanding of the role of NHS Highland  Ability to represent the views and opinions of NHS Highland, Community care, Primary Care and Acute Services and The Highland Council Adult Social Care Services as well as service users

Desirable:  An understanding of the role of The Highland Council, Local Government and Adult Social Care Services in the community.  Awareness of issues facing NHS Highland and Social Care services following Integration  Formal qualifications or significant experience in either Engineering, Financial  Management or similar discipline essential for the management of infrastructure assets.

Term of Appointment: A review of the AMG will be undertaken annually to determine its future roles. Membership of the AMG will therefore be subject to change.

Changes to membership and roles are to be proposed by the chair of the AMG subject to ratification by the Board.

Resourcing: The AMG is to be supported by administrative staff from within Capital Planning/Finance

Version 8 – approved by AMG 20/4/12

5

Highland NHS Board 5 June 2012 Item 5.5(b)

PROPERTY AND ASSET MANAGEMENT STRATEGY

Report by Eric Green, Head of Estates on behalf of Nick Kenton, Director of Finance

The Board is asked to:

 Approve the Property Asset Management Strategy.  Note the progress on improving performance.  Note the issues around backlog maintenance and the plans to tackle this problem.

1 Background and Summary

CEL(2010)35 required all Boards to provide a Property Asset Management Strategy to Scottish Government and provided guidance as to how this was to be achieved.

The strategy is intended to provide a comprehensive review of property performance, highlight areas for improvement and provide clear guidance as to how NHS Highland’s clinical strategy is being used to drive the property strategy.

This report will be produced annually and discussion is ongoing nationally as to how the report will be developed.

It is intended that next year this report will be entitled Asset Management Strategy and include more detail on Transport, IT and Medical Equipment.

2 Property Asset Management Strategy.

The strategy produced meets all the Scottish Government's requirements and follows the guidance they have set out.

There are a number of areas where we need to do further work on strategy in particular transport is lacking in detail and work is underway to collect this data and provide a way forward.

This strategy is then used to compile a “State of the Estate” report which compares the performance of boards across NHS Scotland. This report is scheduled to be published in October.

This document is aligned to our Local Delivery Plan, our Capital Plan and our cost book submission to ensure we have a fully integrated strategy.

3 Proposed Way Forward

Over the last year NHS Highland has worked at improving performance in all areas covered by the property strategy and a lot of good work has been done and is on-going to improve performance in this area. In particular it worth noting the excellent work being undertaken in Belford Hospital where innovative clinical strategy led by the Hospital management team and supported by Estates has allowed services to be redesigned to improve quality for patients, improve space utilisation and efficiency, lower operating costs while freeing a building for either disposal or other uses.

There are similar projects highlighted in the report in all other operational areas and this has allowed us to improve our performance with regard to space utilisation.

Although this work will assist in reducing backlog maintenance, this still remains a significant issue. Work is underway to deal with many of the issues and the plans laid out within this strategy represent a significant improvement on the current situation. However this level of effort must be sustained and developed.

4 Contribution to Board Objectives

This strategy contributes to the board achieving it objectives in the following ways:

 To deliver better health of our communities through population wide and individually focused initiatives to maximise health and well-being and prevent illness.

This strategy ensures that we spend money wisely on all our assets. This will ensure that the only required resources are spent on our assets ensuring efficiency and the maximum amount of money released for front line services.

 To deliver better care of our patients through quick access to modern services, in the most appropriate settings and in clean and infection free facilities by well trained professional staff

This strategy enables NHS Highland to improve its estate and ensure that our facilities are suitable for the services we deliver from them. This strategy will ensure that our investment in our estate will provide maximum benefit.

 To deliver better value for the use of the public money we spend. This is by ensuring there is no waste and inefficiency, where money is spent only on what is needed and has evident therapeutic benefits.

This strategy will ensure that the investment we make in our estate is targeted and provides value for money. By adopting this strategy we will be able to demonstrate increased efficiency.

5 Governance Implications

This strategy will be monitored through the Asset Management Group. This is consistent with Scottish Government guidance.

6 Risk Assessment

The risks associated with this strategy are clearly explained within the strategy.

2 7 Planning for Fairness

This strategy ensures NHS Highland retains and delivers its commitment to ensure equitable access to treatment across Highland.

8 Engagement and Communication

Most of the service redesign and development have clinical and public engagement at the heart of the process. This strategy has also had clinical engagement in its production.

The masterplan exercise currently underway will also include extensive clinical, staff and public engagement. This will further develop this strategy.

9 Conclusion

The Property Asset Management Strategy highlights many areas of good practice and improvement, it also highlights areas where further work and investment is required.

The issue of backlog maintenance remains a high risk area and needs further sustained investment to deal with the historical issues. While progress is being made on tackling backlog, much more remains to be done.

The strategy proposed will lead NHS Highland firmly towards the performance standards required by Scottish Government.

Eric Green Head of Estates NHS Highland

25 May 2012

3

2012-2017

NHS Highland Property Asset Management Strategy (PAMS)

NHS Highland 2012-2017 NHS Highland Property Asset Management Strategy (PAMS)

Contents

1. Executive Summary 2

2. Introduction 6

3. The Property Asset Management Process 10

4. Where are we now? 14

5. Where do we want to be? 32

6. How do we get there? 35

7. Roles and Responsibilities 41

8. Performance Monitoring 42

9. IM&T 46

10. Transport 47

11. Medical Equipment 48

12 Case Study Broadford Health Centre 49

13 Case Study EAMS 51 Appendices

Appendix A Scart Improvement Programme

Appendix B Property Re-Survey Programme

Appendix C Property Investment Programme

Appendix D IM&T data

Appendix E Transport Data

Appendix F Medical Equipment Data

Appendix G Estate Data

NHSH PAMS March 2012 Page 1 NHS Highland Property Asset Management Strategy (PAMS)

Executive Summary

NHS Highland is firmly committed to providing high quality, safe care to the population of the Highlands in an efficient manner and recognises the need to underpin clinical strategy with assets that fit a model of patient centred health care.

NHS Highland is leading the way in transforming the way care is delivered in the Highlands by undertaking a project with Highland Council to integrate the services that we deliver. From the 1st of April 2012 all adult community care services in Highland will be delivered by NHS Highland and all Children’s community services will be delivered by the Highland Council. This ambitious project is about transforming the delivery of care to our patients and is in line with Government Policy.

This will have a marked effect on our estate and on our property strategy. The first impact is that this will increase the size of the estate, although NHSH is firmly committed to ensuring that every opportunity is taken to rationalise the estate as part of this process.

NHS Highland has worked hard in many areas over the last year to improve data collection and improve the deficiencies identified in our original strategy as well as delivering improvements in our performance and governance structures.

In order to achieve this, NHSH recognise the vital role that Asset Management plays in delivering health care, this strategy underpins our vision for delivering our key objectives in the next 5 years. NHS Highland will use its Property and Asset Management Strategy to:

 Ensure developments in our estate are driven by “needs not wants”.  Further develop the Highland Public Sector Property Group and work with Scottish Futures Trust to develop best practice.  Deliver the NHS Highland Strategic Framework which is about delivering better health to the population of the Highlands, better care to those who need it and better value across our business.  Delivering the Integration agenda while reducing overall property costs, freeing money for the delivery of front line services.  Ensure Asset objectives underpin and fully align with corporate objectives, Strategic Plans and Clinical objectives.  Challenge the status quo and provide a basis for Structured and innovative forward thinking.  Tackle the problems of backlog maintenance and reduce the risks to continued operations by setting a five year investment programme.  Install a culture of driving improved performance from our estate, by setting demanding improvement targets in our KPI’s  Improve data quality of our estate; use the 3i system to push forward with an agenda of continuous improvement.

NHSH PAMS March 2012 Page 2 NHS Highland Property Asset Management Strategy (PAMS)

The Scottish Government Health Directorate’s Capital Planning and Asset Management Division Policy CEL 35 (2010) requires that all NHS Boards have a Corporate Asset Management Strategy and Plan that reflect the following policy aims:

• To ensure that NHS Scotland Assets are used efficiently, coherently and strategically to support Scottish Governments plans and priorities and identified clinical strategies and models of care.

 To provide, maintain and develop a high quality sustainable asset base that supports and facilitates the provision of high quality health care and better health outcomes.

• To ensure that the operational performance of assets is appropriately recorded, monitored, reported and reviewed, and where appropriate improved.

• To ensure an effective asset management approach to risk management and service continuity.

• To support and facilitate joint asset planning and management with other public sector organisations.

NHS Highland is committed to using this strategy to underpin all development in its estate and will regularly review this document at its Asset Management Group, led by the Director of Finance. In addition the strategy will be reviewed and sent to the NHS Highland Board annually for discussion and approval. All transactions surrounding our estate are completed in accordance with the Property Transactions Handbook and systems are in place to ensure that the governance of projects and operations are properly in place.

This PAMS covers the period 2012 to 2017 and is NHS Highland property strategy for that period. As mentioned above this will be reviewed each year and work is on-going to improve and upgrade the strategy in accordance with our PAMS development plan, so we can ensure that all aspects of the estate are covered and considered.

The strategy is meant to answer three key questions:

 Where are we now?

 Where do we want to be?

 How do we get there?

Where are we now?

CEL 35 requires boards to complete a six facet survey of all properties, the six facet methodology is well understood inside the NHS, it has been used for a number of years as a method for assessing a building’s condition. The six facets used are as follows:

NHSH PAMS March 2012 Page 3 NHS Highland Property Asset Management Strategy (PAMS)

 Physical Condition Surveys. These are elemental surveys of a facility looking in a highly structured way at each element of the building fabric and the Engineering systems that make the building work. These are ranked from A to D, with A being brand new, B satisfactory requires some work, C unsatisfactory requires work to bring up to an acceptable standard and D is unfit for purpose, major concerns

 Compliance with Statutory Standards this is an assessment of each facility’s level of compliance with statutory standards, Fire Code and all other relevant standards as contained within the Statutory Compliance Audit Reporting Tool (SCART). This is given as a percentage score.  Functional suitability is a measure of how suitable the building is for delivering the services it is now being asked to deliver. This is often quite different from the original use it was designed for. A means perfectly suitable, B means reasonably suitable, C requires work to address issues, D means not suitable.

 Space Utilisation is a measure of how well space is used and how often space is used. E indicates empty, F indicates fully utilised, U indicates a degree of underutilisation and O indicates overcrowded.

 Environmental is an assessment of how well the facility complies with current environmental standards. This section will include an assessment of issues like pollution levels, energy efficiency, fuel storage regulations and others.

 Quality is an assessment of the quality of the environment for both patients and staff. This looks at many of the HAI/HEI issues and also areas like patient dignity, single room availability, comfort, working conditions and signposting among others. The NHS Highland Estate contains buildings of varying ages; an age profile is included in table 1.

Figure 1.

NHSH PAMS March 2012 Page 4 NHS Highland Property Asset Management Strategy (PAMS)

This is of interest because it shows that 69% of the hospital estate was built between 1981 and 2000. Further analysis shows that two hospitals in particular count towards the largest percentage of this, Raigmore Hospital and Caithness General. Both were built in the early 80’s and are now 25 years old and in need of the refurbishment they were designed to have at 25 years. This is evident in the periodic maintenance schedules currently being undertaken which will feed into the next revision of the PAMS. This chart also shows an improvement on last year reflecting the closure of the old Migdale Hospital and the opening of the new facility.

In total 16% of our total Hospital estate predates 1960, In Highland it must also be remembered that Raigmore accounts for half the entire estate by floor area, if Raigmore is excluded a third of our Hospital estate predates 1960.

NHSH PAMS March 2012 Page 5 NHS Highland Property Asset Management Strategy (PAMS)

2 Introduction

NHS Highland is tasked with providing Healthcare to some of the most rural and remote parts of Scotland. The geography of NHS Highland brings unique challenges, the population is small (approx 350000) spread over 43% of the land mass of Scotland. When you add all of the inner islands on the west coast then the complexity becomes clearer.

Ensuring fair and equitable access to the correct services in each of these areas is difficult, travelling times to obtain healthcare are inevitably longer than those enjoyed in the central belt, this also requires NHS Highland to have more buildings than we ideally would have to ensure fair access to the entire population of the Highlands. This is shown clearly in the space utilisation figures; we have many buildings that are used on a part time basis, this is unavoidable in the challenging geography of the Highlands. In turn this puts further pressure on Highland’s capital allocation, we have to provide more buildings and up to date radiography and medical equipment, in truth our operating costs are higher due to the challenging geography and the need to provide equitable access in small remote communities.

A map below shows the area covered by NHS Highland. The red dots indicate our main health centres while the Hospital symbols are shown.

NHSH PAMS March 2012 Page 6 NHS Highland Property Asset Management Strategy (PAMS)

NHS Highland has developed a Property Asset Management Strategy (PAMS) to inform and guide strategic decision making on our estate, to assist in the delivery of the clinical vision of the organisation and to help drive improvement in quality for patients.

The aim of the PAMS is to give the organisation a clear framework for planning our infrastructure investment over the next 5 years and establish progress made in the previous year. The focus is primarily on the next five years with longer term objectives identified and included where it is appropriate to do so.

NHSH has developed this document in conjunction with our Community Health Partnerships, to ensure that the plan for the estate is based on the clinical strategies developed for the populations we serve.

We aim to provide a strategy that challenges the existing estate to become more efficient, to deliver the facilities to underpin the clinical strategies at the lowest possible costs, to challenge clinical views of what estate is required to deliver the services and form a plan that quantifies the investment needed to ensure the estate is maintained to the required standard.

This PAMS is intended to form a framework for improving the quality of patient experience within NHS Highland. The result of this PAMS must be a better quality environment for patients and staff, aligned to lower operating costs for the organisation.

With the fiscal tightening that is being implemented across the public sector NHS Highland must expect a continued reduction of budgets for the period of this plan. Capital investment is required in the NHS Highland estate, even though funding is difficult NHS Highland is making a strong commitment to tackle backlog maintenance out of its current allocation with a five year plan to achieve a reduction in high risk backlog maintenance to under 10% of the total.

The Board of NHS Highland must therefore demonstrate the following:

 It has an accurate picture of the estate, its condition and how it is used.

 It has arrangements in place to maintain the estate efficiently so as to avoid backlog building up in a similar manner again and that maintenance costs represent value for money.

 It has a robust system in place to ensure this data is managed effectively and is regularly updated.

 It has fully implemented the 3i asset management system.

 It has a Property Asset Management Strategy that underpins the clinical strategy, Board strategic aims and direction.

 It has a robust system in development for managing the estate by setting KPI’s and regularly reviewing them.

NHSH PAMS March 2012 Page 7 NHS Highland Property Asset Management Strategy (PAMS)  It has a robust system for prioritising and managing capital investment, embedding strategies for sustainability and whole life cycle costing in its process.

 It has an achievable plan for meeting HEAT targets on energy and carbon reduction.

 It has the correct level of governance around estate matters that ensures the PAMS is an integral part of forward planning of services.

 We achieve maximum value for money when investing in our estate, this will require an innovative approach

This strategy must therefore be developed in conjunction with the plans put forward to manage services in the Community Health Partnerships. It is essential that the estate supports service delivery not the other way round.

Over the last year significant work has been undertaken to develop clinical strategy; NHS Highland has embarked on a substantial piece of innovative work to further develop clinical capacity strategy with GE Healthcare, the first of its kind in Scotland.

The strategic framework and vision set the context for this initiative. To realise the vision of independence, rehabilitation and care closer to home will mean a significant change in the pathways, services and facilities for our patients, which will inevitably lead to changes in our asset base and what it is used for. A significant level of preparatory work has been undertaken over the last few months which requires to be considered in its entirety to ensure that decisions made regarding services, facilities and pathways are informed by as much evidence as possible. To further assist with this work, NHS Highland has commissioned GE Healthcare Performance Solutions. GE have been offering a modelling solution across the USA and the work with NHS Highland is the first in the UK

This work is a vital component in this initiative and will help NHS Highland deal with the issues common across the NHS of

 Lack of real-time, accurate data to make informed decisions

 Integration/collaboration between hospital departments

 Variation in hospital schedules, ED arrival patterns, governance

One of the core challenges of a hospital is to match capacity with demand and operate at high occupancy in such a way that it is both safe (for patients and staff) and sustainable over time. It is clear that asking the staff to do more with less is simply not sustainable. To reduce the strain on the staff and create more time and energy for patient care, the operation must be transformed.

With the variance and influx that NHS Highland hospitals are experiencing, there is a growing need to invest in new, innovative approaches to enable decisions to be made now to help sustain high occupancies for the long-term.

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A number of scenarios have been agreed and are being tested through the model and it is anticipated that an action plan will be drawn up after this work is complete in March 2012 for discussion and agreement and then implementation.

In particular this work has allowed us to understand the future demands likely to be placed on Raigmore and the interdependencies with our other hospitals. This will also allow us to move forward with a master planning exercise in the Inverness area, based on accurate clinical data modelled up until 2020. A suitable contractor has been procured through Frameworks Scotland.

NHS Highland is also moving forward with the social care integration which started on the 1st of April 2012. Work is underway to rationalise the estate used to deliver these services. Work is also starting on how services can be best integrated and what opportunities this may offer for redesign. The principles of this PAMS are being applied to this project

It is important that this process is a two way process in that lessons learned and feedback from the different interactions is into the process at all levels, no one component of this strategy can be delivered in isolation.

The GE Healthcare output then provides a clear strategic direction; this has to be articulated into a broader strategy that allows the development of clinical pathways and then a property strategy to support this work. NHS Highland has appointed Buchan and Associates, healthcare planners to prepare a masterplan for the greater Inverness area.

However, continued development of this PAMS will give NHS Highland a firm platform to deliver an estate that is efficient and focused on delivery of what patients require. The expected benefits of this PAMS are as follows:

 Planning changes in a more structured, holistic way that will allow improvements to be measured.

 Provision of an improved quality environment for staff and patients across Highland.

 The provision of safe, secure high quality healthcare environments with appropriate buildings which aid patient outcomes and satisfaction levels and also increase staff morale and aid staff retention.

 The provision of greener more sustainable assets that do less damage to the environment.

 A framework for decision making on Capital investment that ensures the risks are well understood and funds are targeted where they can best reduce risk.

 Identification of assets no longer required that can be disposed of, thus reducing the backlog maintenance figure.

 A framework for measuring and improving the performance of the estate.

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The Property Asset Management Process

The fundamental building blocks of this strategy are four key questions:

 Where are we now?  Where do we want to be?  How do we get there?  Are we maintaining our estate effectively to ensure we don’t add to the problems.

The starting point has to be the where are we now question. To answer this we used the tried and tested six facet survey that is well understood within the healthcare community. The facets used are as follows:

 Physical Condition: This is a detailed elemental breakdown of the condition of a building and the engineering components required to operate it.  Statutory Standards: This is an assessment of compliance against the statutory standards applicable to the facility.  Space utilisation: This is an assessment of how effectively the space within the building is used and how often it is used.  Environmental management: A measure of compliance and performance against environmental standards.  Functional Suitability: An assessment of how well the building is suited to the functions it is being asked to deliver at present.  Quality: An assessment of how the quality of the environment affects patients and staff.

These six facets have been used to survey the estate as per our implementation plan. The survey results have indicated a clear picture of the estate condition and performance. They also clearly identify where the risks are located within the estate.

NHS Highland has completed the survey of all its owned buildings used to deliver services, in addition we have a commitment to resurvey 20% of the estate every year, a contract is in place to survey Raigmore Site over two years which will amount to 50% of the NHSH estate. A plan for resurvey is shown in appendix B, this plan is funded and included in our budget. A further project is underway to resurvey all GP owned premises and put them into 3i along with other third party providers.

Our current information is now loaded into 3i, we have some more to add yet but this is still going through the validation and checking process internally before being sent to 3i. Our methodology to deliver the surveys has been to use our own estate staff supplemented by an agency Chartered Surveyor, using the toolkit developed by Capita Symonds. This gives consistency of output and has been successful and cost effective. This policy is not suitable for a complex site like Raigmore, where a contract has been placed with consulting Engineers based in Inverness to minimise costs.

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The programme of future work to complete the survey of our estate is shown in Appendix B.

The where do we want to be question is driven by the clinical strategy as set out by the Board of NHS Highland. This section looks at the impact of service changes on the estate. This is also where we set targets and KPI’s to improve the quality of the estate.

How do we get there?

The final part of the strategy is detailing the methodology for how we get to where we need to be. This process involves capital spending, capital investment in projects to deliver the required change and modernisation of the facilities to deliver the level of change required. This also involves reconfiguration of existing facilities, disposals and leases.

It is important that this strategy deals with the key issues facing the Board in a holistic way that offers quality improvements for patients while also delivering an estate that is fit for purpose and manageable.

In order to achieve this the strategy looks at the following key elements:

 Planning – What assets are required and when they are required.  Acquisition – How assets are funded and what partners might be involved  Operation and Maintenance – ensuring assets are maintained and performing adequately • Disposal – What is the best future use for an asset? • Performance management and monitoring– collecting and managing data to inform asset management including KPIs.

This part of the strategy highlights options and challenges for the Board. These options will have to be clearly linked to the strategies developed by the Board and will have to have the continued involvement of local community planning partners, so the solutions offered reflect real need not what is wanted.

NHS Highland are integral members of the Highland Public Sector Property Group, looking at ways of developing and improving the use of the public sector estate with all our partners. This group is working with SFT on a pilot study in Dingwall to look at all public sector property and develop a local joint strategy. The results of this study will inform the next property strategy, if this initiative is successful we intend to develop the expertise to perform these reviews across Highland on a joint basis.

Option appraisals will be done within the framework required by the Scottish Capital Investment Manual and as most of these opportunities are projects that would fit the remit of ALBA as our HUB partners. Discussions have already taken place as to how we may progress these issues with ALBA.

NHS Highland is also involved in extensive public consultation in most areas of Highland about redesigning services and developing clinical strategies that will inform the property strategy. The main improvement we have in this area from last year is we now have projects in progress to deal with all our Category D physical condition survey buildings.

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Maintenance Performance It is also essential that we ensure that the estate is being effectively maintained and that the Board has a strategy to ensure that the facilities it delivers services from are maintained to a level so as not to add to the problems we already have.

Good maintenance regimes support service delivery, it is essential if a facility is to attain the levels of availability that a range of maintenance techniques are deployed to ensure optimum efficiency is derived from the maintenance investment.

In the first instance it is essential that the organisation delivering maintenance is organised to deliver in a consistent manner across the organisation, given that statutory compliance is so essential in the modern regulatory and legal environment the NHS now operates in.

NHSH has organised it’s estate department in accordance with SHTM 00, introducing a compliance team and a maintenance manager to improve focus and delivery in these key areas. Success has already been seen with maintenance performance now averaging 70% from a starting point of 25%.

Statutory compliance has also improved rising from 51% to 71% in a year. This team is beginning to work through the backlog of compliance challenges and a forward work plan is included as an appendix A to this strategy.

NHS Highland has also invested in an Enterprise Asset Management System (Maximo). This enables a much more holistic view to be taken of asset management; this system operates a dynamic link to the Cedar financial system allowing real time information on purchasing and labour transactions.

In addition this system deploys automatic scheduling and electronic work management (Click) by means of handheld devices, either phones or PDA’s. A case study for this is included at the end of the report. This combination of Maximo and Click achieves the top quartile of the Gartner Index, a recognised marker of excellence.

This approach to asset management is based on a maintenance manual, a series of flowcharts that offer an efficient standard way of delivering maintenance based on the LEAN principles of avoiding waste and unnecessary maintenance. NHS Highland has developed this manual and is continually working towards further improvement.

We are also introducing reliability centred maintenance and condition based maintenance both supported by Maximo. This use of EAMS is delivering better maintenance for less input, something we need to maximise.

In addition to completely rewriting the maintenance schedule for all our estate, we have added new maintenance instructions rewritten from SHTM’s and other guidance and incorporated method statements and risk assessments for standard breakdowns.

This system also allows tracking of Service Level Agreements so we can measure response times in order to achieve an acceptable level of performance between planned and reactive maintenance. We now regularly achieve 70% of all our activity as planned, a turnaround from 70% unplanned.

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This changes the performance of the estate department and the introduction of these new technologies automates much of the maintenance tasks and starts to deliver performance that can be benchmarked against private sector maintenance providers.

We recently had an internal audit that produced the idea of furthering this system to become a Healthcare Enterprise Asset Management system (HEAM) covering a much wider range of healthcare assets. This idea is still in its infancy but is widely used in the US which is regarded as leading in this field.

We are also developing asset live plans for our major assets again supported by Maximo. This allows much better forward capital planning, incorporating maintenance results into the forward planning system.

The advantages of EAM or HEAM are summarised in the diagram below.

This is an illustration of how interlinked these functions are, they are all vital to the management of assets. In order to fully understand the cost and efficiently plan assets then the information has to be held in one location and linked to the asset. This allows easy interpretation of the information and good accurate information is the key tool to allow good quality decisions to be made based on actual costs.

NHSH PAMS March 2012 Page 13 NHS Highland Property Asset Management Strategy (PAMS) Where are we now?

NHS Highland delivers healthcare to 43% of the land mass of Scotland including the inner islands of the west coast. This is a challenging diverse population to deliver healthcare for, requiring more facilities to deliver equitable access to services locally. Even with the estate we currently have, “local” can still involve travelling substantial distances for services, it is important that this is recognised along with the additional capital costs associated with providing this estate.

NHS Highland provides a full range of acute services at the main hospital site, Raigmore Hospital in Inverness. This is a large site covering in excess of 100 000 m2. This site has been built in stages from the 1950’s until recently, but the main area was built in 1985. In floor area terms Raigmore accounts for half the NHS Highland estate.

We have three other Rural General Hospitals that perform a limited range of acute services located in Wick, Oban and Fort William. We then have a further 23 community Hospitals around the Highlands.

On the 1st of April 2012 NHS Highland embarked on a ground breaking project to integrate adult social care across the Highland area, initially excluding Argyll and Bute. This will have profound implications for the estate, a further 60 buildings will be added to our estate after year one. This will present opportunities for estate rationalisation and work is already underway to understand these opportunities. This project will also offer new ways of delivering services, these are being explored, it is expected that this will lead to opportunities for estate rationalisation.

The following table shows the age profile of the properties in the NHS Highland portfolio. This shows almost a quarter of our property over 30 years old. All of these properties present considerable challenges in delivering modern healthcare.

Figure 2.

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These charts show that NHS Highland still has 14% of its total hospital estate over 50 years old. Predictably these buildings do not provide a good healthcare environment for patients. The graph also reveals that 69% of our estate was built between 1981 and 2000 and of that most is now past 25 years old and is starting to require significant expenditure as per the original design life for each facility.

This can however present a slightly misleading picture, given that half the NHS Highland estate is based at Raigmore. If the chart above is shown without Raigmore the picture is markedly different. This shows that 30% of the Hospital property we are delivering healthcare from across the Highlands is over 50 years old an Improvement on last year’s figure, by the opening of Migdale Hospital.

Figure 3.

The primary care estate shows a different picture, reflecting a long standing commitment from NHS Highland and its predecessors to invest in Primary Care. More than half the primary care estate is less than 30 years old, with only 15% over 50 years old.

It should be noted though that a building over 50 years old may not present a problem. Some of these are historic buildings and are perfectly fit for purpose. This measure must be viewed alongside the condition ratings, old buildings do not automatically equate to bad buildings.

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Figure 4.

The physical condition of our hospitals is shown in figure 5, below. This chart indicates that 62% of our estate either requires significant work or is in poor condition. While this is accurate it presents a slightly misleading picture in that Raigmore Hospital equates to half the NHSH estate, so when the same chart is shown minus Raigmore in figure 5 below, the picture is markedly different.

Figure 5.

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Figure 6.

This indicates that 64% of the estate outside Raigmore is in either excellent or good condition with a third requiring upgrade. This third is primarily the facilities that are included in our investment plan later in the strategy.

Figure 7.

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This clearly highlights the NHS Highland strategy of increased estate investment is working, the percentage of estate requiring significant investment has reduced from 74% to 67%, based on a much larger survey. The table below highlights some of the work that has contributed to this improvement in performance.

Facility Work Done Cost Belford Hospital, Fort This facility has had an asset life extension £1.1m William programme to ensure it remains fit for purpose for the next 10 years. Work done includes, replacement of the entire electrical system, replacement of the glazing in inpatient areas, replacement of roof coverings, replacement of the lifts, removal of steam supply, recladding of Renal unit, repairs to retaining wall. This work will complete in 2014 Caithness General Hospital, Phase 1 renewal of roofing system, upgrades to £0.5m Wick Hot water system, external road resurfacing Dunbar Hospital, Thurso Renewal of Electrical System, fabric repairs, £0.8m redecoration, Installation of new Biomass Boiler, renewal of Emergency lighting system, resurfacing of roads, upgrade of fire alarm system to L1 Islay Hospital, Islay Installation of L1 fire alarm system, removal of £0.15m Asbestos. New Health Centre Replacement of Sub-standard facility with new £1.2m Broadford, Skye. purpose built facility. See Case Study. Refurbishment of Dingwall Refurbishment of existing building into fit for £2.5m Health Centre purpose building. Phase 1&2 complete, Phase 3 intended for 2013 Rothesay Hospital Fire compartmentation and fabric upgrade, £1.4m Installation of L1 fire alarm system, upgrade of emergency lighting.

Figure 8.

This demonstrates the work that NHS Highland has undertaken to tackle physical condition and backlog maintenance. The policy of prioritising Capital and revenue expenditure on the basis of risk is clearly having a positive effect.

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Statutory Compliance

NHS Highland has restructured its estate department to align with SHTM 00 and to address the statutory compliance issues in a holistic manner. Highland estates has moved from a geographical based structure to develop a discipline based compliance team, based in Inverness with a smaller operational team based on alignment to operational units. This gives clear focus to the agenda of improvement in standards and ensures a pan highland level of compliance. Early signs of success are already being seen with the previous SCART target being exceeded and a new more ambitious target has now been set.

The previously carried out Fire Risk Assessments identified a number of deficiencies in relation to fire. Significant investment has been provided by NHS Highland in the past 5 years towards improving compliance with all inpatient accommodation excluding Argyll and Bute now having full L1 fire alarm systems. The capital investment programme in Appendix B shows significant investment over the next 5 years mostly in Fire Compliance but also covering areas such as Legionella, Water Bylaw compliance, Electrical Safety and Ventilation.

Most hospitals have fire compartmentation defects; there are some that do not comply with travel distances, lack of protection in staircases and hazard rooms not properly protected. A number of ventilation systems have a lack of fire dampers; there are properties that require improved smoke control and most hospitals require Fire door replacement programmes. Steady progress is being maintained and the 5 year Backlog Maintenance plan included in this plan clearly demonstrates a commitment to statutory compliance.

There are a number of Hospitals that require water system upgrades to comply with water bylaws and reduce Legionella risks. Again work has started on a programme to achieve this although a significant amount of work remains to be done.

One of the improvements in this revision of our PAMS is the inclusion of a statutory compliance improvement programme intended to bring our statutory compliance up to 85% in the next year and to achieve the Scottish Government target of 95%by April 2014.

Our improvement plan focuses on three key areas of improvement, Fire Compliance with a programme to complete all risk assessment of buildings in 3i that is resourced and funded. A programme to revise Hospital Legionella risk assessments that is funded and resourced, a programme for implementation of revised control of contractors policy. Further work is intended on confined spaces, abrasive wheels, noise at work and is included in the programme.

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Item Question posed Response Note 1 Percentage of Properties 100% SCART now includes all assessed NHS operated buildings.

2 Percentage compliance for Average compliance figure Target exceed in this year, each property is now 71% progress revised. 3 Topics with least Control of Contractors New policy and procedure compliance currently being implemented. New software bought to address specifically Highland geography issues without having to increase operating costs. 4 High risk items identified Legionella Risk reduced from last year programme in place and resourced to move to 100% compliance. Firecode Risks of compartmentation and emergency lighting across Highland. Capital plan prioritised to deal with this issue

COSHH Work on this almost complete. Final Audit planned for June 2012, more information on this on page 31. Ventilation Theatre ventilation systems need upgrading. 5 Action plans identified for Action plans are underway, Action plans included in High risk items? work is costed but likely to Appendix C. be funding challenges 6 Degree of annual New target set in light of Progress should be compliance improvement improved performance. maintained as NHS Highland is prioritising capital spend on this area. 7 Evidence that current This document is approved status is reported to by the board. board. Figure 9

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Environmental

The assessment of environmental management does not aim to replicate the reporting requirements of each Health Board’s environmental management system (EMS), which requires performance reporting via Corporate GREENCODE and eMART. This section provides an overview of environmental performance taken mainly from the historical reporting of energy and water consumption figures via the electronic data collection system eMART.

Data on eMART for NHS Boards in Scotland are for hospitals only. The information provided in the following tables therefore covers only these property types. Table 1 below outlines the level of energy consumption for all current hospitals over the last 3 yrs. This shows the trend downwards in energy continuing once the seasonal adjustment for the cold winters is applied. An approximate ratio of Hospitals to other sites is approximately 85% to 15%.

Table 1: Total Hospital Consumption Board Hospital Energy PI's' for NHS Highland 2008-09 2009-10 2010-11 In-Yr Diff. %age GJ/100m3 GJ/100m3 GJ/100m3 Site Name (Corrected) (Corrected) (Corrected) GJ/100m3 Diff. Argyll and Bute Hospital 27.25 37.54 28.87 8.67 23.1 Belford Hospital 57.18 58.5 64.78 -6.28 -10.7 Caithness General Hospital 105.63 97.98 93.42 4.56 4.7 Campbeltown Hospital 83.22 86.9 82.25 4.65 5.4 County Hospital 47.97 51.19 48.64 2.55 5.0 Dunbar Hospital 72.9 83.58 76.13 7.45 8.9 Dunoon and District Hospital 39.37 44.94 42.24 2.7 6.0 Ian Charles Hospital 101.52 118.52 119.35 -0.83 -0.7 Islay Hospital 77.72 79.69 72.03 7.66 9.6 Lawson Memorial Hospital 71.76 74.09 108.68 -34.59 -46.7 Lorn and Islands DGH 57.06 61.08 61.21 -0.13 -0.2 Mackinnon Memorial Hospital 82.35 87.18 72.62 14.56 16.7 Mid Argyll Comm. Hospital 34.33 42.28 42.32 -0.04 -0.1 Migdale Hospital 74.26 75.13 76.52 -1.39 -1.9 New Craigs - PFI 66.59 62.49 59.6 2.89 4.6 Portree Hospital 55.47 67.86 42.76 25.1 37.0 Raigmore Hospital 71.14 60.36 57.97 2.39 4.0

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Ross Memorial Hospital 70.89 62.01 62.44 -0.43 -0.7 Royal Northern Infirmary 61.31 61.96 49.76 12.2 19.7 St Vincent’s Hospital 97.13 86.28 65.75 20.53 23.8 T&C - Nairn 76.93 68.33 37.87 30.46 44.6 Town and County Wick 69.14 70.51 130.95 -60.44 -85.7 Victoria Hospital 88.96 94.8 71.32 23.48 24.8 Victoria Hospital Annex 77.86 73.31 52.63 20.68 28.2 TOTALS 1667.94 1706.51 1620.11 86.4 5.1

This provides a slightly different reduction in total energy used for NHS Highland to that stated in the national HEAT target returns. Despite this difference in how the calculations were applied both comparisons show a similar direction of reductions. Overall this means NHS Highland met its phase I HEAT Target for reductions in consumption by approximately double the target level. Some noticeable differences of where there weren’t reductions are easily explained – e.g. Nairn Hospital having completed its expansion and a couple of sites where Biomass was introduced and effectively double energy needs whilst commissioning the new plant. Meeting the HEAT Target reductions was achieved despite minimal investment in efficiency measures. Additionally Raigmore’s management of fuel had a significant impact that otherwise would have meant the Board would have failed to achieve the targets set. Indications are that the efficiencies seen over recent years are likely to be reduced in the 2011-12 consumption figures as a new equilibrium is established and the recent measures bedded in. If a long term reduction is to be gained and sustained then investment in real terms must be secured. NHS Highland has in place a structured approach that follows the Carbon Trust’s Carbon Management Programme. The original Carbon Management Plan has been revised and a great many projects are identified that provides the opportunity for NHS Highland to become almost Fossil fuel free and reduce the overall Carbon footprint by almost half its 2010-11 level. In most cases reducing emissions will reduce total financial costs of meeting the energy needs of the organisation. Thus it is a double gain for NHS Highland to meet/surpass the national targets for efficiency and emissions.

Water costs equate to over 15% of the total utilities costs for NHS Highland. Scottish Water is the largest electricity user in Scotland. Reducing Water usage is both good financially and environmentally. Table 2 outlines the level of water consumption for the hospitals in NHS Highland over the last 3 years:

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Table 2: Water Consumption

2008- 09 2009-10 2010-11 Target Target Actual Actual In-Yr m3/m2 Actual m3/m2 m3/m2 Diff. Site Name /yr m3/m2 /yr /yr /yr m3/m2 Argyll&ButeHosp. 2.31 1.22 1.22 2.04 0.82 BelfordHospital 1.51 1.57 2.18 1.64 -0.54 Caithness Gen.Hosp. 1.31 -0.35 1.79 1.54 -0.25 Campbeltown Hospital 0.6 -0.03 0.32 2.34 2.02 County Hospital 0.38 0.28 0.31 1.91 1.6 DunbarHospital 4.33 3.94 0.74 1.29 0.55 Dunoon & Dist.Hosp 0.65 0.61 0.49 2.09 1.6 IanCharlesHosp. 3.53 4.77 4.77 1.26 -3.51 Islay Hospital 0.69 0.32 1.3 2.53 1.23 Lawson Mem.Hosp. 0.27 0.91 1.18 1.2 0.02 Lorn & Islands Hospital 1.55 1.48 1.42 2.1 0.68 Mackinnon Mem.Hospital 0.66 0.71 0.82 1.82 1 Mid Argyll Comm. Hospital 0.53 0.67 0.67 1.04 0.37 MigdaleHospital 2.72 1.81 2.01 2.73 0.72 NewCraigs-PFI 2.82 3.61 3.4 2.27 -1.13 PortreeHospital 0.12 1 1.19 1.21 0.02 RaigmoreHospital 1.73 0.41 0.3 1.96 1.66 Ross Memorial Hospital 2.61 1.33 0.74 2.16 1.42 Royal North. Infirmary 1.16 1.34 1.23 1.67 0.44 StVincent’sHospital 1.57 1.62 1.19 1.98 0.79 T & C Hospital (Nairn) 1.81 2.05 0.28 2.14 1.86 T&C Hospital (Wick) 1.18 0.49 1.4 2.71 1.31 Victoria Hospital 1.42 1.42 0.55 1.72 1.17 Victoria Hosp.Annex 1.26 1.23 -1.21 2.06 3.27 Totals 36.72 32.41 28.29 45.42 17.13

NHS Highland’s water consumption continues to be considerably less than its benchmark averages. Overall consumption has reduced by 33% over the last 5 yrs.

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There are a number of options that have been identified in reducing water consumption. These include improvements in sanitary fittings and also investigate Rainwater harvesting.

All opportunities are listed within the revised Carbon Management Plan. The intention is to further reduce consumption by 15% (minimum) – and have an annual consumption of around half of what it previously was in 2005-06 levels.

The Energy consumption comparisons above in Table 1 provide only part of the picture. Understanding the Energy Performance of the hospital stock in addition sets the consumption in context with the maintenance and investment needed to make a long term difference. The intention within the Carbon Management Plan is to make good headway in making our buildings more energy efficient and take the organisation towards the government’s objective of Zero Carbon buildings. Table 3 below identifies all the current positions of the hospitals in relation to their EPC grading. It is expected that future years will identify a progressively different position.

EPC Site Name Performance Rating

Caithness General Hospital F

Belford hospital Fort William F

Raigmore Hospital G

Argyll & Bute Hospital G

Campbeltown Hospital F

Islay Hospital G

Dunoon Hospital G

Victoria Hospital G

Victoria Hospital Annexe G

Lorn & Islands Hospital F+

Dunbar Hospital F+

Lawson Memorial Hospital F

Migdale Hospital A

Ross Memorial Hospital F

Royal Northern Infirmary G

Ian Charles Hospital G

NHSH PAMS March 2012 Page 24 NHS Highland Property Asset Management Strategy (PAMS) St. Vincent’s F+

MacKinnon Hospital G

Portree hospital F

Nairn Hospital E+

Figure 10

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Functional Suitability, Space Utilisation and Quality

The final three facets of the appraisal are considered together to establish the suitability and quality of the accommodation as well as how well the space is being used. These three facets are functional suitability, quality and space utilisation.

Last year NHS Highland scored badly compared to all other health boards on the Space utilisation facet. This is explained in the main by the geography of NHS Highland, we have to provide access to small remote communities and many of our buildings will never be utilised on anything other than a part time basis.

However we have significantly improved the metric by looking at the areas where we can make improvement. A good example of this Belford Hospital in Fort William, where improvements in the space utilisation and new working practices have freed up another building adjacent to the hospital for disposal. This work was primarily led by the Hospital Management team supported by estates. We have made similar improvements on a smaller scale elsewhere and this is an excellent example of clinical strategy leading property strategy.

Functional suitability is aimed at determining how well the available accommodation supports the delivery of healthcare and is assessed on the basis of three elements: internal space relationships, support facilities, and location.

The aim of Quality is to determine how well the available accommodation provides a comfortable, modern, pleasing environment in which healthcare services can be provided. It is assessed on the basis of three elements; amenity, comfort engineering, and design.

Space utilisation explores how well available space is being used related to the intensity of use i.e. the number of people using it and the frequency with which they use it.

The information in the tables below identifies the percentage (by floor area) of the estate which is considered to be within each of the defined categories for functional suitability, space utilisation and quality:

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Figure 11

This chart shows that the majority of the estate is suitable for the functions it performs there is 21% of the estate that is not suitable for the services we now deliver from the building. These buildings tend to be the older community Hospitals that score badly on every facet and form the basis of the property investment plan later in this strategy.

The Quality rating of the NHS Highland estate is shown below, which indicates that 67% of our estate is not functionally suitable for the services we are trying to deliver from it. Primarily this is our Hospital estate, in particular Raigmore. The quality of the environment is affecting patient care, the environment, in particular the lack of single rooms in wards is contributing to infection control issues and must therefore rate the facility as a C rating.

Figure 12

NHSH PAMS March 2012 Page 27 NHS Highland Property Asset Management Strategy (PAMS) However if Raigmore is excluded from the figures the picture is again markedly different. The poor quality estate is again that which features in our investment plans. Our primary care estate is generally fit for purpose and offers a reasonable quality environment. There are a few issues in this estate but the significant issues are included in the investment plans.

Figure 13

In the last PAMS NHS Highland had by far the worst space utilisation figures of any board. This can in part be explained by the rural nature of NHS Highland, facilities are required to serve small remote population’s it is inevitable that these will spend periods of time unused. However it should also be noted that the last PAMS did not contain a complete survey of the estate, it concentrated mainly on the Hospitals and main health centres, this document contains all of the primary care estate owned or directly leased by NHS Highland. This still shows that a third of our estate is underutilised, this is definitely a geographical issue, we have to have buildings that are used part time in order to provide equitable access to treatment at centres close to where people live. If we consider space utilisation in our estate, this is shown in figure 14 below

Figure 14

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One third of our estate is underutilised; this is a significant improvement over the figure of last year where 86% of the estate was judged as underutilised. This improvement has been obtained as a result of a series of initiatives that improved space utilisation within the estate, one example the re-organisation of space at Belford Hospital is highlighted as an example. Other work has been carried out at Oban where a new dental access centre is being built in an a part of the Hospital previously underutilised, Cowal Community Hospital and Campbeltown Community Hospital are to have mental health access centres inside previously poorly utilised space, the GP surgery in Bowmore is being relocated into the Islay Hospital, removing a building , Raigmore has carried out a series of minor projects that has improved space utilisation and Migdale Hospital has been replaced with a purpose built building.

This is as a result of a lot of hard work and effort; some more redesign work is included in the “where we want to be” section that will positively impact on these figures further. NHS Highland is also committed to better understanding space utilisation surveys; we intend to work with the Scottish Futures trust to further develop the methodology for space utilisation studies.

While NHS Highland has significantly changed its profile in this area we intend to try to further improve our figures and understanding of the factors affecting this in the near future. It is unlikely that NHS Highland will achieve ratings in the top quartile of NHS Scotland for the access reasons explained elsewhere, however we are committed to achieving the best figure we can.

Significant work is also underway to deal with excess capacity in the community hospital estate, this will have a positive effect as will the investment plans indicated later in this report.

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Backlog Maintenance

Backlog costs arise from a backlog of maintenance that has built up over the last 20 years and is now giving rise to poor condition and poor performance.

The costs for NHS Highland Hospital estate are in the table below, profiled by risk category, using the categories applied in the methodology supplied by SGHD.

This shows a significant cost to bring the facilities back to acceptable condition with a total bill for Hospital estate of some £62.3 million pounds. If the backlog costs of statutory compliance and Environmental issues are included then the costs exceed £75 million. This cost has risen over last year’s figures, due to the increased percentage of the estate now surveyed.

It should be noted no backlog costs have been included for the PFI contracts as cyclical maintenance is covered in the unitary charge we pay to the FM contractor and the building is expected to be maintained at condition B.

It must also be recognised that the works are expressed as work costs, as guidance states they should be. The real cost of doing this work would be much higher when issues like fees, VAT, Decant costs, and specification are included.

When the remainder of the primary care estate is added the costs are £80million pounds. The detailed breakdown by property is included in appendix A.

It must also be noted that this only covers costs for 3 of the 6 facets, Space utilisation, Functional Suitability and Quality issues have not been costed, nor is the cost of energy efficiency improvements likely to be required to meet ever more stringent energy targets.

Risk Profile – Understanding where we are.

It is essential that as well as understanding the amount of backlog maintenance we understand the risks associated with this backlog.

The chart below breaks the figures down into the Low, Medium, Significant and High as prescribed in the guidance entitled “ A Risk Based Methodology for Property Appraisal”.

This involves assessing risks in relation to backlog so the correct work can be prioritised. A full risk assessment has been carried out on the backlog identified as part of the survey and the costs are included.

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Figure 15

This shows that to deal with the most urgent requirements rated as High, which covers things such as Fire maintenance, legionella, ventilation quality, electrical safety and structural building issues, NHS Highland needs to find £13.5million, most of which is likely to require capital funding.

Over the last year NHS Highland has carried out a lot of work to fully understand the makeup of our risk profile.

Primarily we have a big bill for Fire Compliance; all our facilities predating 1990 have fire compartmentation issues, mainly divided into two problems firstly the compartments exist but no longer meet current regulations on size, many of our compartments are way in excess of 750m2. We also lack fire dampers in many ventilation systems; many hazard rooms do not have the required amount of protection, this is reflective of the changed use over the years. In addition many fire doors require replacement and emergency lighting is not up to the required standards.

We now understand how this affects all our hospitals and what is required to deal with this. Constructive discussion with Highland Fire and Rescue Service (HFRS) has taken place in order to gain some degree of regulatory support for the programme of work required to deal with this backlog.

We also have significant water bylaw works to undertake, to date water bylaw inspections have taken place at two sites, Raigmore and Belford in Fort William. The issues uncovered are poor backflow prevention, insufficient check valves, poor condition water storage tanks, cross contamination issues.

Significant parts of the High risk issues at Raigmore have been dealt with or are programmed and funded. The discussion has taken place with the regulator to explain our position.

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NHS Highland is currently undertaking a review of all Legionella Risk assessments; all our community hospitals will be complete by August 2012. These have found issues with dead legs and water storage tanks that need to be addressed. Again some funds have been allocated to this and work is being carried out on the basis of assessed risk.

We also have electrical issues, many of our sites have ageing electrical infrastructure. NHSH Has invested in the last 3 years in this infrastructure, notable projects that have been completed are the HV ring installation at Raigmore, phase one of the LV feeder pillar removal at Raigmore, rewiring Dunbar Hospital Thurso, rewiring Belford Hospital as well as other more minor works. However we are about to embark on a 5 yearly electrical inspection programme that will without doubt highlight further work that needs to be carried out. It is likely that at Raigmore this will mean quite extensive works.

Also during the period we have spent analysing Raigmore we are concerned that the original survey has underestimated the backlog, particularly on the services aspect of the survey. This is the reason for suggesting that Raigmore is resurveyed first, with work already underway.

Other Electrical installations suffer from obsolete systems, where parts are not readily available. Work is on-going to develop solutions for these installations, hopefully without complete replacement.

Our medical gas installations require investment in the medium term with valves requiring replacement amongst other issues. However there are no immediate causes for concern in this area.

Building Fabric tends to rate lower on the risk assessment and only rise in rating as it approaches failure. Again we have widespread issues with roof coverings, doors and windows across much of our estate, most of this is medium term investment, however there are some notable exceptions, we are currently recovering the Caithness General Roof, and flat roof areas of Belford Hospital. This is required to ensure the continued operation of the facilities. They have an added bonus in that they reduce heating costs as we are taking the opportunity to add insulation.

Ventilation systems also feature in our backlog, we are currently working on a programme of repairs and upgrades to our theatre ventilation systems following the national report. We expect to deal with all outstanding issues in the current year. Although it is clear that the Raigmore Theatre Ventilation plant is at a stage in its life where it will require serious investment in the next 5 years.

These are the main issues we are dealing with and they can be found in the five year capital plan that clearly shows we are addressing the issues in a systematic manner.

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Where do we want to be?

Over the last few years NHS Highland has invested significant sums of capital to modernise and improve the Health estate. The Board expects these investments to:

• Enhance patient experience (improved quality of the built environment) • Increase efficient use of space (enabling the disposal of surplus assets) • Improve building estate code performance • Improve productivity (new space designed for modern services) • Increase environmental sustainability • Reduce carbon footprint

The Board have a number of key national policies, Corporate objectives, Strategic aims and an emerging clinical strategy that will shape the proposals within our Property Asset Management Strategy. The Scottish Governments “Better Health, Better Care” Action Plan 2007” requires the Board to focus on the following principles:

• Wealthier and Fairer • Smarter • Healthier • Safer and Stronger • Greener

• Planning for Integration Project. This innovative project is intended to provide a paradigm shift in service delivery by integrating the delivery of Health and Social care. NHS Highland is the first to go live with this in Scotland. • The national Policy “Reshaping Care For Older People” 2010. Reshaping Care supports a more person centred approach to ensuring older people are kept fit and healthy with a range of early intervention and reablement services . • The national policy “Quality Strategy” 2010. The focus of this strategy is that services are person centred, safe and clinically effective. The quality Strategy states “We want confidence for patients that their NHS is amongst the best in the world – safe, effective and responsive to their needs, every time and all of the time” • The national policy “Shifting the Balance of Care” 2008. This strategy is about supporting more of our services being delivered out with the acute environment. • The national policy “Delivering for Remote and Rural Healthcare” 2007

These national policies help to drive and inform our overarching strategy at a local level. As this clinical services strategy emerges the Property Asset Management Strategy will be closely aligned to it.

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Property Strategy – The key principles The Property Asset Management Strategy is a key supporting strategy that underpins the Programme of service improvements and the delivery of the Boards vision for the future. The key principles are:

 To manage the estate effectively and efficiently within the capital and revenue resources that is available to the Board.  To strive for continuous improvements in property performance and to ensure that the Social Integration project is achieved while maximising the efficient use of the estate.  To manage and invest in the estate so as to minimise the risks to health from receiving care and treatment in healthcare facilities(HAI) through the work of NHS Highlands infection Control Committee and the use of the HAI scribe tool and estates/domestic staff walk rounds to identify and prioritise areas for improvements.

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How do we get there?

The analysis of the estate condition is the first part of developing a good Property Asset Management Strategy (PAMS). This shows where the challenges in estate performance lie, a huge backlog maintenance programme requires to be funded, with £18.2m of High Risk backlog that will need to be dealt with.

This can be tackled in several ways but when this is looked at in conjunction with our poor space utilisation performance there are proposals that can improve quality of service, improve space utilisation and reduce backlog maintenance. Over the last year significant improvement has been made in performance and understanding of where we are.

The second part of this is to highlight the changes that the board needs to make to its estate to support changes in service delivery. Some of these are known others are in progress but have needs identified but the solutions are yet to be identified. Simply to invest in the current building stock to take it back to satisfactory condition would not in any way guarantee the right property profile to support the service needs of the future. This is essential as the delivery of services in the future must be supported by the estate, we cannot allow a situation to develop where services improvements are restricted or constrained by the existing estate.

Therefore the board must also ensure this Property Asset Management Strategy achieves the following:

 Investment in current buildings that have a role to play in future service delivery that are described in the Boards Corporate aims, Strategic Objectives and developing Clinical Strategy.

 Investing in new buildings and facilities to enable and facilitate the programme of service improvements required by the operational units.

 Rationalisation of the existing building portfolio to ensure the effective and efficient use of buildings to support services.

 Disposal of properties which can no longer support the current and future models of service delivery and are surplus to requirements.

 Develop this strategy as the Planning for Integration framework progresses to ensure that this transformational project maximises benefits for the estate.

NHS Highland is doing much innovative work in developing clinical strategy in order to meet national strategies and local needs, in particular the social care integration exercise will change the profile of the estate again, this will require swift and frequent changes in this PAMS, this document must be flexible to meet changes in the clinical strategy as it develops. The options that are considered as part of the clinical strategy will require to be costed and be subject to both financial and non-financial benefits analysis and rigorous risk assessment.

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The Property Investment Plan

With cuts to public expenditure now being implemented it is clear that the Boards capital and revenue allocations will be placed under ever increased pressure for the foreseeable future. The announcement of an indicative 3 year funding settlement for capital allows better planning, however this simply highlights the challenge this raises.

It is therefore imperative that the Board has a Property Asset Management Strategy that allows prioritised spending decisions to be made and linked to the Boards Clinical Strategy. The Board will require to revisit its Capital Spending priorities depending on the allocation from Central Government and outcome on Clinical Strategy. These Capital Spending priorities should be assessed against the following criteria and then included within the Local Delivery Plan which will in turn form the basis of the changes within the Property Asset Management Strategy:

• Delivery of patient and clinical benefits, improving the quality of care.

• To be open or at least be live projects within the next five years

• Their impact upon other health services in NHS Highland.

• The need to meet legislative requirements

• The impact upon and extent of contractual commitments

• Affordability within the Financial Plan bearing in mind future financial settlements

• The level of financial expenditure incurred to date

• The level of planning work completed to date

• The amount of spending on projects to date

This PAMS will form the basis of the Boards capital planning for the next five years on all estate and property matters. When bidding for additional capital funding or HUB funding NHS Highland will be able to clearly demonstrate it has well-considered and developed strategies for its Assets linked to its Clinical Strategy going forward. NHS Highland will also show it has an effective asset management approach to risk management and service continuity along with effective review and performance management processes in place regarding assets.

NHS Highland has plans for rationalisation of the estate that will:

• Reduce age profile of estate through rationalisation and investment.

• Improve physical condition of estate through capital investment and improved space utilisation.

• Deal with all properties rated as D on physical condition rating.

NHSH PAMS March 2012 Page 36 NHS Highland Property Asset Management Strategy (PAMS) • Reduce risk adjusted statutory compliance costs

• Reduce risk adjusted backlog maintenance costs

• Generate capital receipts

• Improve space utilisation

• Improve functional suitability

• Reduce Carbon Emissions

• Reduce costs of office accommodation

(costs/m2, costs/WTE, space/m2)

The Boards proposed estate developments for the next five years are as follows:

Funded proposals within 5 year plan:

 Drumnadrochit Health Centre replacement. Needs clearly identified, existing premises cramped, constricting delivery of services locally, patients having to travel 30 and more miles for routine simple treatment due to lack of space. This improves space utilisation and service delivery. Funded by additional Capital allocation in FY14/15 Due to open in April 2015.  Dingwall Health Centre refurbishment. A service development required to provide services in Dingwall; existing building requires extension and upgrade to allow complete range of community services to be offered. Funded by additional capital allocation in FY13/14. Due for completion in April 2014.  Redesign of Mental Health Services Argyll & Bute. Last major mental health redesign in Scotland. This will reduce the hospital estate; improve the condition ratings of the estate as well as improving space utilisation, quality and functional suitability ratings and reducing backlog maintenance. Agreed hub project, work underway expected to be open in FY 14/15.  Oban Dental access centre, to be built in redesign of Lorn and Isles Hospital footprint, funded by additional capital allocation. Opens in January 2013.  Tain Health Centre. New build required to meet the needs of modern health care delivery. This facility will allow the complete range of community services to be offered. Again will improve functional suitability, space utilisation, quality and improve condition ratings as well as reducing backlog maintenance. Agreed hub project expected to open in early 2014.  Mull and Iona Primary Care Centre, replacement for wholly unsatisfactory site on Mull, currently under construction due to open summer 2012. Funded by additional capital allocation.  Raigmore endoscopy and renal capacity improvement. This project is to develop capacity at Raigmore, particularly to deal with the inadequate endoscopy decontamination

NHSH PAMS March 2012 Page 37 NHS Highland Property Asset Management Strategy (PAMS) facilities and procedure rooms. This project is also to look at the establishment of a satellite renal unit in Easter Ross. This is funded by additional capital allocation in FY13/14.  Raigmore biomass, proposal to provide Raigmore Steam production by means of Biomass as opposed to heavy oil. Funding due to be approved by HFS for completion in summer 2013.  Caithness General Biomass conversion, part of SG carbon reduction scheme, due for implementation in summer 2014.  Raigmore Staff accommodation Biomass conversion, again part of SG carbon reduction scheme and due for completion in summer 2014.  Raigmore tower block upgrade project. Project to upgrade fire compliance and other backlog maintenance issues at Raigmore, due for completion in May 2015.

Need identified as part of Service redesign:

 Replacement of existing facilities in Spey Valley - Ian Charles Hospital in Grantown on Spey and St Vincent’s Hospital in Kingussie. A significant public consultation exercise has been carried out with community and clinical stakeholders and agreement has been reached to consider the replacement of both facilities with a purpose built facility located centrally.  Replacement of the Belford Hospital, Fort William this need is included, however this is unlikely to be delivered in the next five years it will be required within the next ten and as such planning and development of the optimal solution needs to start within the timescale of this strategy.  Modernisation of inpatient services on Skye. At present we have two hospitals that deliver services to the community; both have excess capacity and are not functionally suitable. Work is starting on how to best deliver services on Skye, this will require extensive public consultation and this is now beginning.  Lack of theatre capacity at Raigmore. A business case has been put forward for the funding of a Day Services Centre for Raigmore. This need has to be solved. The original business case has been rejected; a review and resubmission will be required.  Lack of Renal capacity Raigmore. The Raigmore renal service is suffering from capacity problems and a solution is required to meet service demand.  Tongue Health Centre is overcrowded and this impedes delivery of services the need however has been identified as part of the clinical strategy development as the existing building cannot support the vision of community care for the future.  Reconfiguration of services at Golspie. This involves shifting wards around in Golspie to improve quality and space utilisation, and reducing backlog maintenance by removing poor quality parts of the estate.  Service redesign around Dingwall, this has identified a need to look at how the estate supports services in this area, once the service redesign is complete.

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A summary delivery chart can be seen below:

This represents an investment of over £25m in the NHSH estate; this will have the following effect on the backlog maintenance figures for High Risk.

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The current investment plan will reduce the high and significant backlog maintenance figure down to 16%, a reduction of 20%. Although this remains above the 10% target, if more of the plans being developed come to pass the 10% figure should be achieved. It must be noted though that this also assumes that no significant additions are added, we have indicated that Raigmore backlog may be under estimated, also we have the social care infrastructure to add on to this so the total may increase.

However if the current level of investment is maintained the 10% backlog target should be met in 2019, within the 10 year timescale.

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Roles and Responsibilities

The CEL 35 (2010) also places the following mandatory requirements:

• All NHS Scotland bodies must have appropriate Board level and supporting governance, accountability and reporting arrangements in place to ensure the efficient and effective planning, operation, management and disposal of assets. • All NHS Scotland bodies must hold appropriate up to date information to ensure the effective planning, operation, management and disposal of the assets held and utilised in support of service delivery. • All NHS Scotland bodies must have a PAMS which is technically robust, achievable and affordable within the context of agreed financial plans (capital and revenue). Such strategies should demonstrate clear and explicit links to Scottish Government and Local Delivery Plan objectives, HEAT targets and clinical/service strategies, Local Authority Structure Plans and broader planned outcomes. • Where NHS Scotland bodies are responsible for the delivery of regional and/or national Services, the PAMS must reflect the links to the appropriate regional and/or national Service strategies, priorities and targets.

In addition to the above our Board must ensure an appropriate structure of suitably qualified staff to provide the comprehensive management of the estate, covering all statutory and mandatory requirements. The team requires the demonstration a suitable range of qualifications, being experienced and up to date, and capable of delivering the informed client role when commissioning support from external sources.

This role will be provided for NHS Highland by the estates team. The estates team will also have the responsibility for informing the survey work required annually to populate the electronic Asset Management System The intention is to manage Corporate Asset Management through the Board’s existing Asset Management Group arrangements. RICS best practice guidance on Asset Management recommends that the Board appoint an Asset Champion. This Champion will be charged with promoting and sustaining good practice in Asset Management within the Board. This suggestion is currently being considered.

The Boards Asset Management Group will set priorities in accordance with the Boards Clinical Strategy and within the resources available. The Board’s Asset Management Group chaired by the Finance Director will agree the PAMS and the resulting priorities in order to agree an annual capital investment plan. The PAMS and Capital Investment Plan will be submitted to the Board for approval along with the Local Delivery Plan in February each year.

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Performance Monitoring

Scottish Government guidance lists a set of PAMS key performance indicators which must be reported against. Key Performance Indicators are a key part of measurable objectives which are made up of a direction, a measure, a target and a timeframe. These KPIs must be Specific, Measurable, Agreed, Realistic and Timed. NHS Highland has Key Performance Indicators for measurement of performance of property. These KPIs will demonstrate going forward how improvements are being made in the following key estate areas:

• Reduce age profile • Improve physical condition • Reduce backlog maintenance • Improve space utilisation • Improve functional suitability • Improve environmental performance • Improve quality • Improve statutory compliance

These KPIs will be reported to the Board annually and the expectation is that there is an improvement in all areas of the estate over time.

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Indicative 10 Quality Key year Ambition Performance KPI Performance Performance 2010 2011 2012 Performance Measure No. Indicator Benchmark performance Performance target Score Percentage of Properties categorised as either A or B for Physical Condition Quality of facet of Patient Physical estate Centred environment 1 appraisals 90 26 33 37 Percentage of properties categorised as either A or B for Quality facet of the estate 2 appraisals. 90 71 33 40 Positive response to Patient Questionnaire on patient Patient Opinion rating of of Healthcare hospital Accommodation 3 environment 95 96 96 98 Patient needs are accommodated Percentage of in modern, well properties designed less than 50 facilities. 4 years old 70 83 86 87 PAMS Quality PAMS reflective Checklist of service needs Overall Score and patient (max score preferences 5 100) 95 Statutory Overall compliance percentage status of compliance property asset score from base 6 SCART 95 51 71 80 Backlog Cost per maintenance square metre expenditure for backlog Safe requirement 7 maintenance £100 353 346 300

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Level of risk Significant associated with and high risk outstanding backlog backlog maintenance maintenance as percentage requirement 8 of 10% 48 37 30 Percentage of properties categorised as either A or B for Functional Suitability facet of Functionally estate suitability 9 appraisal 90% 78 78 80 Percentage of properties categorised as ‘Fully Utilised’ for space utilisation facet of estate Effective Utilisation 10 appraisals. 90% 12 70 75 Building volume (cu.m) per 1000 population (from Cost (and 11 Book 2,240 2434 2431 2399 Property maintenance costs £ per Property 100 cu.m maintenance (from Cost efficient) costs 12 Book) £958 726 731 760 Rent and rates costs £ per 100 cu.m Rent and rates (from Cost costs 13 Book) £411 522 436 430 Energy costs £ per 100 cu.m (from Energy costs 14 Cost Book) £617 649 741 760 Giga Joules per 100 cu.m Energy per year consumption 15 (from eMART) 44 36.7 34.7 34

Figure 16

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NHS Highland is showing consistent improvement across all the KPI’s and this document highlights many areas where work is on-going to further improve performance.

There are a couple of areas in this KPI worthy of further explanation. The national comparator on rates is a little misleading. NHS Highland is in partnership with other boards to challenge our rates costs and employ the services of a specialist to do this. The methodology of assessing rateable value for most of our properties is based on a national scheme for the NHS. This however also allows for age and functional suitability to be taken into account so rates bills will vary with the age and suitability of each boards estate.

For primary care estate there has been a move away from a national scheme to local schemes, meaning that regional variation will increase. NHS Highland is diligent in appealing valuations and has been very successful in the past at doing this, so while improvement towards the desired figure is and will remain on-going we cannot guarantee success as the scheme application is not in our control.

The energy cost figure reflects NHS Highland’s dependency on fossil fuel; we have no main facility on mains gas as it is not available throughout the Highlands. This is why NHSH is leading the way on the installation of Biomass as indicated in the main body of our report.

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IM&T

Minimum Data Set

All assets over £5k are held on the finance asset register as per the minimum data set with the exception of the service and maintenance information which is held directly by the Finance department.

All assets under £5k are held on an asset register by IM&T department this includes software assets.

NHSH has a 5 year Capital Plan for investment in the IT infrastructure. At present this is not being fully funded as NHSH focuses its limited capital resources on it’s estate backlog.

The plan is attached as Appendix D.

2010 2011 2012 IM&T Spend IM&T Spend as Percentage of total Up to date Asset Register hard ware and software Yes Yes Confirmation of all business cases by SGHD Ehealth Directorate Yes Yes

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Transport

NHS Highland utilise the following number of vehicles in the delivery of healthcare across NHS Highland.

Commercial Vans and Lorries 8 Pool cars including those held at departmental level Not reported Personal Lease Cars Not reported

All vehicles are managed through our transport department. No further information is available at present.

This area is to be a focus of development over the next twelve months and we will be including a full report on the entire transport fleet in the next update.

Costs £ Maintenance costs per vehicle Hire costs of cover vehicles Tyre cost per vehicle Insurance costs per vehicle Fuel costs per vehicle Operating costs per vehicle Cost per mile

Fleet use Days per annum Vehicle downtime Vehicle availability Vehicle utilisation

Compliance Number Accidents Vehicle Defects Mot passes (First time) MOT Failures (First Time) Voluntary Safety Checks carried out?

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Medical Equipment

NHS Highland owns a large amount of medical equipment in common with all other boards. This is managed directly by the Medical Physics Department.

All our medical equipment is kept on our own Oracle database and this system also records planned maintenance activity. The data sets kept are as follows:

Asset Data Reference number, model, type, serial number commissioning date, decommissioning date, hospital where used, area where used, owner department, equipment status, ownership status.

Purchase Information Selling Agent, address, contact details, link to website, order number, purchase price, PPQ date and estimated life.

Maintenance Details Maintenance type, warranty period, warranty expiry date, last serviced date, contractor name, software version, configuration version, location of service manuals, manual reference number, safety class, PPM list, Team responsible for maintenance, contract type contract and order number.

Client Contact Hospital name and full address, telephone number, location of equipment, name and contact details of responsible person including email address, speed dial etc.

Service Contact Manufacturer’s name, address, telephone number, contact names, mobile numbers, emails and website. Service agent’s name, address, telephone number, contact names, mobile numbers, emails and website.

Notes Freehand notes to record anything about the equipment.

Decommissioning Why decommissioned, how disposed of, what replaced it.

Service History Access to complete service history, including acceptance, maintenance, repairs, upgrades, calibrations, spare parts used, calibration and test equipment used, staff who carried out work, time taken for work, order numbers for spare parts, time out of service, etc..

Equipment type No. Clinical Dispensing Therapeutic Diagnostic Clinical equipment includes patient monitoring and dialysis machines; Dispensing includes infusion pumps and nebulisers; Therapeutic covers venous flow stimulators and CPAP machines and diagnostic examples are ultrasound machines and ECG recorders. The medical Equipment Data set is included as Appendix E

NHSH PAMS March 2012 Page 48 NHS Highland Property Asset Management Strategy (PAMS) Case Study – Broadford Health Centre

Challenge – Broadford Health Centre is on the Island of Skye and provides healthcare to a geographically remote area. The health centre provides a range of Primary Care services and is a key asset for the delivery of healthcare in the locality. The building was housed in a rented building which was no longer fit for purpose. NHS Highland had applied for and had accepted a bid to replace this with a purpose built building for £1.2m in 2008. For various reasons this was delayed until 2012, the challenge was to deliver the same building footprint for the original budget, while costs have risen over the intervening 5 years without compromising quality or performance and adopting the sustainability agenda by achieving a minimum B energy rating. This presented a considerable challenge, this meant getting construction costs down to £1900 per m2, considerably less than is being achieved using recent procurement figures. To add to this, Skye is a remote and rural location; materials, labour and equipment are not so readily available in these locations and usually carry a premium.

Solution:

To deliver this type of building for the budget required an innovative procurement strategy in order to reduce costs. NHSH felt that we had considerable in house expertise in delivering health centre projects in remote and rural locations. Therefore we decided to reduce costs by completing the designer role internally, supplemented by some consultant input on fixed price packages. We also managed the tender and construction process internally providing the project manager role and Cost advisor.

NHSH PAMS March 2012 Page 49 NHS Highland Property Asset Management Strategy (PAMS) The building design also put users and patients at the centre of the design process with extensive involvement of user, patients and the public to ensure that the building delivered exactly the environment required.

The building was completed at the end of March 2012 and is currently being commissioned and occupied. The final bill for construction costs is £1870 per m2, design and management cost is 6.9% of the total bill, clearly demonstrating value for money and vindicating the procurement strategy. Other procurement methods have delivered cost in the region of £2200-£2500 per m2 for comparable buildings with fee percentages in excess of 15%. The building was finished on programme which is an excellent result given that the discovery of significant archaeological remains stopped work on the site for 4 weeks with a total on site construction time of 36 weeks. There were also sub-contractor liquidations which lengthened the timescale.

The design was well received by planners and building users alike. It fits beautifully into the stunning natural landscape of Skye, while achieving the functionality required from a modern health centre. It also achieves the quality of environment to support the delivery of first class healthcare services to the population of Broadford and surrounding area.

The design of the building also features the latest in sustainable construction utilising super insulated timber construction, latest ground source heating technology, airtight construction, heat recovery and high performance glazing which has resulted in the building achieving a B+ EPC Rating. The services have been designed to easily accommodate the inclusion of Solar Panels or wind turbines at a later date which would ensure an A rating.

What went well –

 Procurement strategy, fixed price basis for consultant support, reduces costs.  Keep design simple, quality does not require complex architecture.

 Fit building into natural landscape, good design does not require expensive consultants.  Adoption of NEC contract, simpler administration, shared risks and collaborative working.

 Involvement of users and the public ensures design is optimised for the users.

 Tight control of change management, once designs signed off ensure little or no changes approved.

 Tight control of quality on site from start, ensures final build is done right first time, minimises delays and disputes. What didn’t go so well –

 Archaeology remains found on site, delay could have been minimised.

 Main Contractor procurement schedule should have been more detailed earlier, caused minor delays.

 Sub-contractor liquidations, need good sub-contractor control from Main Contractor and ensure this is tightly managed.

NHSH PAMS March 2012 Page 50 NHS Highland Property Asset Management Strategy (PAMS)

Case Study – Enterprise Asset Management System

NHS Highland has introduced an Enterprise Asset Management System (EAMS) to control the maintenance of its estate. The difference between an EAMS and a normal standalone Computerised Maintenance System (CMS) is that in an EAMS everything is integrated into the system for example purchasing, maintenance, asset history, contract maintenance as shown in the diagram below.

EAMS allows detailed accurate reports to be produced that ensure the optimum arrangements are in place to help plan for future maintenance and replacement programmes by allowing the introduction of maintenance techniques like condition based monitoring and reliability centred maintenance. These are useful tools in optimising maintenance and can all be supported by the system.

NHSH PAMS March 2012 Page 51 NHS Highland Property Asset Management Strategy (PAMS)

In addition NHSH has introduced electronic work orders, so that work is scheduled electronically and no paper is used. Apart from the obvious time savings in not producing and filling in paper work orders, this speeds up the system information, moving to real time information.

In geography like Highland it is essential that travelling time is minimised. In order to achieve this electronic scheduling automatically picks the most efficient method of allocating the workforce to the list of tasks based on a set of rules and a GPS mapping system. Equally when a priority one request is added to the system it will reschedule to ensure minimised disruption.

This has enabled NHSH to achieve a turnaround in maintenance performance. In 2007 75% of the work done was unscheduled reactive maintenance. That figure is now down to 40%. Only around a quarter of planned maintenance was regularly done, this is now steadily improving towards 100% with areas of sustained performance of over 70%.

The EAMS system also allows schedule optimisation by means of forward resource levelling. This allows resources to be moved around to meet peaks and troughs in the workload and to ensure that the optimum arrangements are in place.

What went well –

 Selection of mature software products that require little customisation.

 IBM Maximo and Click software, top quartile of Gartner Index (a recognised marker of excellence), good to use tried and tested systems.  Important to understand business requirements fully first, this takes time. Also important to visit installations using preferred solution.  Single Source Responsibility, system hosted by supplier, who is an IBM approved reseller.

 Multiple resellers, competitive market exists for supply, not fixed to one organisation.

 New maintenance schedule produced good exercise in checking what is done against what should be done.

 Move towards process based operations, good to create process manual. What did not go so well –

 Issues with mobile integration and phone security. Difficult to solve took a lot of time.

 Issues with mobile phone reception, still resolving some of these.  Mobile device selection, must be quality devices.

 Training issues, process of evolution better than revolution.

 Finance (Cedar) integration took a lot longer than planned, much more difficult than originally anticipated.

 Takes a lot longer than anticipated to effect change across so many departments.

NHSH PAMS March 2012 Page 52 NHS Highland Property Asset Management Strategy (PAMS)

Appendix A

SART Improvement Programme.

NHSH PAMS March 2012 Page 56

ID Task Name Duration Start Finish rte 2nd Quart 3rd Quart 4th Quarte 1st Quart ar Apr a Jun Jul u e Oct o e Jan e Mar 1 NHS Highland SCART Improvement Programme 230 days Mon 02/04/12 Fri 15/02/13 2 Legionella Compliance - Led by Senior Water Services Engineer. 80 days Mon 02/04/12 Fri 20/07/12 3 Complete Legionella Policy Revisal 50 days Mon 02/04/12 Fri 08/06/12 4 Institue NHS Highland Water Group. 30 days Mon 02/04/12 Fri 11/05/12 5 Authorise and Appoint as per Policy 20 days Mon 11/06/12 Fri 06/07/12 6 Complete review of all NHS Highland Legionella Risk Assesments. 60 days Mon 02/04/12 Fri 22/06/12 7 Complete review of all Log books 60 days Mon 02/04/12 Fri 22/06/12 8 Independent Authorising Engineer Audit. 20 days Mon 25/06/12 Fri 20/07/12 9 Electrical Compliance - Senior Electrical Engineer 71 days Mon 02/04/12 Mon 09/07/12 10 HV Electrical Safety 51 days Mon 02/04/12 Mon 11/06/12 11 Complete training of additional Engineers. 21 days Mon 02/04/12 Mon 30/04/12 12 Complete familiarisation with Raigmmore HV installation 20 days Tue 01/05/12 Mon 28/05/12 13 Appointment by AE 10 days Tue 29/05/12 Mon 11/06/12 14 LV Electical Safety 40 days Mon 02/04/12 Fri 25/05/12 15 Carry out refresher training for LV AP's 20 days Mon 02/04/12 Fri 27/04/12 16 Renew LV AP appointments 20 days Mon 30/04/12 Fri 25/05/12 17 Electrical Safety Policy and Rules. 71 days Mon 02/04/12 Mon 09/07/12 18 Revise HV and LV elctrical Safety Policy and rules. 10 days Mon 02/04/12 Fri 13/04/12 19 Review and refresh permits 15 days Mon 16/04/12 Fri 04/05/12 20 Electrical Rules Implementation plan. 25 days Mon 07/05/12 Fri 08/06/12 21 Independent Authorising Engineer Audit. 20 days Tue 12/06/12 Mon 09/07/12 22 Ventilation Compliance - Senior Mechanical Engieer 190 days Mon 02/04/12 Fri 21/12/12 23 Theatre Ventilation Compliance 190 days Mon 02/04/12 Fri 21/12/12 24 Complete all actions listed on Audit 60 days Mon 02/04/12 Fri 22/06/12 25 Compliance audit on Theatre Ventilation 10 days Mon 25/06/12 Fri 06/07/12 26 Disinfection proccedure for all wet components 30 days Mon 09/07/12 Fri 17/08/12 27 identification of all wet components 40 days Mon 09/07/12 Fri 31/08/12 28 Review of Maximo Maintenance schedule 30 days Mon 03/09/12 Fri 12/10/12 29 Completion of Maximo templates 20 days Mon 15/10/12 Fri 09/11/12 30 Update of Maximo 20 days Mon 12/11/12 Fri 07/12/12

Task Milestone External Tasks Project: SCART Implementation Progr Split Summary External Milestone Date: Mon 26/03/12 Progress Project Summary Deadline

Page 1 ID Task Name Duration Start Finish rte 2nd Quart 3rd Quart 4th Quarte 1st Quart ar Apr a Jun Jul u e Oct o e Jan e Mar 31 Independent AE audit on Ventilation compliance. 10 days Mon 10/12/12 Fri 21/12/12 32 COSHH Compliance - Operations Manager 55 days Mon 02/04/12 Fri 15/06/12 33 Complete COSHH Sypol Update 25 days Mon 02/04/12 Fri 04/05/12 34 Complete Manuals for each operational area 10 days Mon 07/05/12 Fri 18/05/12 35 Programme of toolbox talks and refresher trainning 10 days Mon 21/05/12 Fri 01/06/12 36 COSHH audit 10 days Mon 04/06/12 Fri 15/06/12 37 Control of Contractors Policy Implementation - Senior Electrical Engineer 165 days Mon 02/04/12 Fri 16/11/12 38 Arrange consultation day for non-Estates Stakeholders 30 days Mon 02/04/12 Fri 11/05/12 39 Revise Policy and Rules after consultation 10 days Mon 14/05/12 Fri 25/05/12 40 Agree Implementation period for Gemsoft 15 days Mon 14/05/12 Fri 01/06/12 41 Gemsoft Implementation period 50 days Mon 04/06/12 Fri 10/08/12 42 Training Period 20 days Mon 13/08/12 Fri 07/09/12 43 Control of Contractors policy proving period 40 days Mon 10/09/12 Fri 02/11/12 44 Audit of Control of Contractors policy 10 days Mon 05/11/12 Fri 16/11/12 45 Lone working Improvements - Maintenance Manager 164 days Mon 02/04/12 Thu 15/11/12 46 Agree rules for Scheme 10 days Mon 02/04/12 Fri 13/04/12 47 Agree Implementation programme 20 days Mon 16/04/12 Fri 11/05/12 48 Write Procedure and gain approval 46 days Mon 14/05/12 Mon 16/07/12 49 Implement Lone Working scheme 48 days Tue 17/07/12 Thu 20/09/12 50 Lone working proving period 30 days Fri 21/09/12 Thu 01/11/12 51 Audit of Lone working system. 10 days Fri 02/11/12 Thu 15/11/12 52 Fire Compliance - Senior Building and Fire Engineer 230 days Mon 02/04/12 Fri 15/02/13 53 Implementation of New Fire Policy 50 days Mon 02/04/12 Fri 08/06/12 54 Complete appointments 30 days Mon 02/04/12 Fri 11/05/12 55 Publish list of appointments by operational unit on Intranet. 20 days Mon 14/05/12 Fri 08/06/12 56 Complete Fire Risk Assesment Review on 3i Fire manager 230 days Mon 02/04/12 Fri 15/02/13 57 Raigmore Sleeping Accomodation 110 days Mon 02/04/12 Fri 31/08/12 58 Raigmore Clinical / Public Areas 80 days Mon 03/09/12 Fri 21/12/12 59 Raigmore Office areas 40 days Mon 24/12/12 Fri 15/02/13 60 Community Sleeping Accomodation 110 days Mon 02/04/12 Fri 31/08/12

Task Milestone External Tasks Project: SCART Implementation Progr Split Summary External Milestone Date: Mon 26/03/12 Progress Project Summary Deadline

Page 2 ID Task Name Duration Start Finish rte 2nd Quart 3rd Quart 4th Quarte 1st Quart ar Apr a Jun Jul u e Oct o e Jan e Mar 61 Community Clinical / Public areas 80 days Mon 03/09/12 Fri 21/12/12 62 Community Office spaces 40 days Mon 24/12/12 Fri 15/02/13 63 Review of action plans 200 days Mon 02/04/12 Fri 04/01/13 64 Reiew of Raigmore arrangments 40 days Mon 02/04/12 Fri 25/05/12 65 Review of Raigmore Plans 40 days Mon 28/05/12 Fri 20/07/12 66 Publication of plans 5 days Mon 23/07/12 Fri 27/07/12 67 Review of Community action Plans 80 days Mon 02/04/12 Fri 20/07/12 68 Publication of Community action plans 5 days Mon 23/07/12 Fri 27/07/12 69 Audit Fire Safety Arrangments 10 days Mon 24/12/12 Fri 04/01/13

Task Milestone External Tasks Project: SCART Implementation Progr Split Summary External Milestone Date: Mon 26/03/12 Progress Project Summary Deadline

Page 3 NHS Highland Property Asset Management Strategy (PAMS)

Appendix B

NHSH PAMS March 2012 Page 57

2011 2014 2017 ID Task Name Duration Start Finish Qtr 1 Qtr 4 Qtr 3 Qtr 2 Qtr 1 Qtr 4 Qtr 3 Qtr 2 Qtr 1 Qtr 4 1 2 Property Resurvey Programme 1365 d... Mon 06/02... Sun 30/04/17 3 Raigmore Hospital 520 days Mon 02/04... Sun 30/03/14 4 M&E Services 175 days Mon 02/04/... Fri 30/11/12 5 Building fabric 212 days Mon 04/02/... Tue 26/11/13 6 Staff accomodation 54 days Wed 15/01/... Sun 30/03/14 7 Argyll and Bute 325 days Mon 04/06... Fri 30/08/13 8 Hospital sites 121 days Mon 04/06/... Mon 19/11/... 9 Primary care premises 171 days Sun 06/01/13 Fri 30/08/13 10 North and West Highland 501 days Wed 30/04... Wed 30/03... 11 Hospital premises 262 days Wed 30/04/... Thu 30/04/15 12 Primary care premises 240 days Thu 30/04/15 Wed 30/03/... 13 South and East Highland 260 days Sat 30/04/16 Sun 30/04/17 14 Hospital premises 240 days Sat 30/04/16 Thu 30/03/17 15 Primary care premises 262 days Sat 30/04/16 Sun 30/04/17 16 Social Care Estate 127 days Mon 06/02/... Tue 31/07/12

Task Project Summary Inactive Milestone Manual Summary Rollup Deadline

Project: Appendix B Split External Tasks Inactive Summary Manual Summary Progress Date: Wed 16/05/12 Milestone External Milestone Manual Task Start-only Summary Inactive Task Duration-only Finish-only

Page 1 NHS Highland Property Asset Management Strategy (PAMS)

Appendix

NHSH PAMS March 2012 Page 58

APPENDIX 4 NHS Estates High Risk Backlog Maintenance Reduction Plan FY12-13 FY13-14 FY14-15 FY15-16 FY16-17 £000's £000's £000's £000's £000's Raigmore Fire Compliance / Ward Upgrade Tower Block 900 900 900 900 Maternity 900 Ward 11 250 Caithness General Fire Alarm Panel / Head replacement 26 Emergency Lighting replacement 17 Cowal Hospital Compartmentation upgrade 70 Emergency Light replacement 9 L1 Fire Alarm Upgrade 24 Wick T&C Hospital Fire Alarm system replacement 23 0 Ross Memorial Hospital Fire Compartmentation 45 Emergency Lighting replacement 9 Community Hospitals Highland Wide Emergency Lighting replacement 50 50 50 50 50 Fire Compartmentation 0 200 200 200 200 Fire Door Replacement 10 10 40 50 50 Fire Complaince Works Sub-total 1,119 1,191 1,150 1,173 1,400 Theatre Ventilation Upgrade Work Raigmore 20 Caithness 180 180 Belford 40 LIDGH 25 Theatre Vent Imp. sub-total 200 220 25 0 0 Legionella risk Reduction Raigmore Underground Water tanks 40 Raigmore Internal Water tanks 20 Raigmore Mortuary Water system Upgrade 10 Raigmore labs Water supply Upgrade 10 Belford legionella improvements 54 Cowal Main Water tank Replac. 40 20 Rothesay Hospital 40 Raigmore Staff accomodation 100 Community Hospital Legionella works, Highland wide 100 100 100 Raigmore Phase One 110 Legionella Risk Reduction sub-total 120 20 350 100 154 Roof Replacement Programme Belford Hospital 100 90 Caithness General 180 250 Raigmore Phase One 200 200 200 Mckinnon Memorial hospital 170 Roof Works Sub-total 280 340 200 370 200 Electrical Infrastructure CGH generator Switch Gear 23 Cowal Infrastructure Upgrade 20 79 90 Raigmore LV board Replacement 0 75 75 75 75 Comm. Hosp, electrical Upgrading Belford Rewire 95 95 Electrical Infrastructure Sub-total 115 272 165 75 75 Patient Critcal Services Cowl Hospital Bedhead Services / Nurse Call 74 Medical Gas refurbishment 45 Caithness General Hospital Medical Gas refurbishment 55 Patient Critcal Services sub-total 0 0 45 129 0 Building Heating Controls Riagmore BMS Replacement 50 50 50 50 50 Rothesay Hospital 44 Dunbar Hospital 15 St vincents 22 Mckinnon Memorial hospital 19 Cowal Hospital 0 48 Heating Controls Sub-Total 65 142 50 72 69 Lift Compliance works Raigmore Quad Lift control replacement 75 Raigmore maternity lift control replacement 55 Community Hospital lift controller replacements 50 50 50 Lift Compliance Sub-Total 130 0 50 50 50

Total 2,029 2,185 2,035 1,969 1,948 NHS Highland Property Asset Management Strategy (PAMS)

Appendix D

NHSH PAMS March 2012 Page 59

IM&T Assets

Infrastructure Equipment Cabling Communications Networks Servers systems Desktop Mobile Number of individual pieces of equipment or separate systems under each of these headings 174 145 1026 5025 1361 Age (by number of pieces of equip or % of system): Less than 2 years 5% 5% 20% 5% 5% 2 to 5 years 1% 90% 40% 90% 90% > 5 years 94% 5% 40% 5% 5% Condition (by number of pieces of equipment or % of system): Worn out or damaged beyond economic repair 0% 0% 0% 0% 0% Unreliable (based on service history) 0% 0% 5% 0% 0% Technically obsolete 0% 0% 40% 0% 0% Spare parts no longer available 0% 0% 0% 0% 0% Superceded by more cost effective or effective equip 0% 40% 40% 40% 40% Insufficient capacity to cope with loads/usage 0% 20% 0% 20% 20% Net Book Asset Value at 31/03/12 Replacement Cost at 31/03/12 Total maintenance & servicing expenditure for the year to 31/03/12: in-house staff £902K external contracts £25K Equipment/system availability - No days in year when available for use 365 365 365 365 365 Equipment/system downtime - No days in year when not available 0 0 0 0 0 Equipment/system utilisation - No days in year when in use 365 365 365 365 365 Expenditure for year ending 31/03/12 on new equipment/systems: Capital £11K Revenue £120K Leases £0 Has there been a survey of the infrastructure in the last 2 years? Yes/No No Is there a costed 5 year replacement programme in place? (Yes/No) Yes But not funded Confirmation that there is an up-to-date asset register (Yes/No) Yes Confirmation that there is an up-to-date IM&T Strategy (Yes/No) Yes What is your general assessment of the current level of risk associated with IM&T: High Significant Moderate Low General Safety X Disruption to services X Poor Fairly well Good Excellent What is your general assessment of how well the current provision of IM&T equipment and infrastructure supports service delivery? X What is your general assessment of the opportunities in relation to IM&T equipment and infrastructure for investing in: High Significant Moderate Low More efficient technology X Safer technology X

1) On a separate sheet, identify the main focus for investment in IM&T infrastructure and equipment over the next 5 years See separate sheet On a separate sheet, identify the key priorities for improvement in environmental performance of your IM&T equipment and 2) Not provided infrastructure over the next 5 years 3) On a seperate sheet describe your sustainability policy in regard to IM&T planning, procurement and selection of equipment Not provided

General Comments

confusion over what was meant by cabling networks & Communication systems we have taken cabling to mean pure cabling (CAT5 type networks) and communication systems to be switches, firewalls, hubs etc The investment plan for the next 5 years is provided however this is currently unfunded by NHSH NHS Highland Property Asset Management Strategy (PAMS)

Appendix E

NHSH PAMS March 2012 Page 60

Vehicle Assets

Cars Vans Lorries Buses/people carriers Other Number of vehicles Nil Two Eight Nil Age (by number of vehicles): Less than 2 years Nil Nil Nil Nil 2 to 5 years Nil One Nil Nil > 5 years Nil One Eight Nil Condition (by number of vehicles): Good - no significant wear or damage Nil Nil Nil Nil Acceptable - some signs of wear and minor damage Nil Two Eight Nil Poor - signs of significant wear and damage Nil Nil Nil Nil Fuel type by number of vehicles: Petrol Nil Nil Nil Nil Diesel Nil Two Eight Nil LPG Nil Nil Nil Nil Bio fuels Nil Nil Nil Nil Electric Nil Nil Nil Nil Net Book Asset Value at 31/03/12 Nil Nil Nil Nil Replacement Cost at 31/03/12 N/A N/A N/A N/A Total mileage per annum N/A 3,000 16,643 N/A Total insurance costs per annum N/A 884 3,536 N/A Total maintenance & servicing cost for year to 31/03/12: in-house staff N/A N/A N/A N/A External contracts/expenditure N/A 2,300 20,206 N/A Total Tyre Costs £ per annum N/A Nil 546 Nil Vehicle availability - No days in year when available for use N/A 365 365 Vehicle downtime - No days in year when not available N/A 256 256 N/A Vehicle utilisation - No days in year when in use N/A 260 260 Annual Spend on new vehicles for year to 31/03/12: Nil Nil Nil Nil Capital £ Nil Nil Nil Nil Revenue £ Nil Nil Nil Nil Leases £ Nil Nil Nil Nil Managerial Technician Craftsmen Operators/drivers Number of in-house fleet/vehicle staff: One Nil Nil Six Is there a 5 year replacement programme in place? (Yes/No) No Confirmation that there is an up-to-date asset register (Yes/No) Yes Vehicle asset acquisition/disposal linked to organisation's transportNo & travel policy (Yes/No) Confirmation that there is an up-to-date Fleet Management StrategyNo What is your assessment of the current level of risk associated with vehicles:High Significant Moderate Low General Safety N/A N/A Yes N/A Disruption to services N/A N/A Yes N/A What is your general assessment of the opportunities in relation to vehiclesHigh for investing Significant in: Moderate Low More efficient technology N/A N/A N/A Yes Safer technology N/A N/A N/A Yes Poor Fairly well Good Excellent What is your general assessment of how well the current provisionN/A of vehicles supports N/A service delivery? Yes N/A

On a separate sheet, identify the main focus for investment in 1) vehicles over the next 5 years, as identified in your Fleet On a separate sheet, identify the key priorities for improvement 2) in environmental performance of your vehicle fleet over the next NHS Highland Property Asset Management Strategy (PAMS)

Appendix F

NHSH PAMS March 2012 Page 61

Notes: Medical Equipment definition - equipment used for diagnosis or treatment (includes laboratory analyzers) Part 1 should be completed for individual pieces of equipment with a replacement value in excess of £150,000

Part 2 should be completed for all Medical Equipment (as per definition above)

Equipment Assets

Diagnostic Imaging Equipment Medical & Laboratory

General X-ray Fluoro Interventional CT MRI Other Nuclear Med. Digital mobile Mammo Radiotherapy Lab analyzers Surgical lasers Microscopes Others Part 1 Age (by number of pieces of equipment): Less than 2 years 3 1 1 0 1 0 0 0 1 2 to 7 years 0 0 1 1 0 6 1 0 0 > 7 years 20 4 0 0 1 24 1 0 1 Condition (by number of pieces of equipment): Worn out or damaged beyond economic repair 0 0 0 0 0 0 0 0 0 Unreliable (based on service history) 0 1 0 0 0 0 0 0 0 Clinically or technically obsolete 0 3 0 0 0 0 0 0 0 Spare parts no longer available 2 1 0 0 0 0 0 0 0 Superseded by more cost effective or clinically effective equip 0 0 0 0 0 0 0 0 0 Unable to be cleaned or decontaminated effectively 0 0 0 0 0 0 0 0 0 Has there been a survey of condition in the last year? (Yes/No) YYYYYYYNY Net Book Asset Value at 31/03/12 Replacement Cost at 31/03/12 2690000 1420000 1500000 4000000 2500000 3090000 1200000 0 350000 Total maintenance & servicing expenditure for the year to 31/03/12: in-house staff NNNNNNNNN external contracts YYYYYYYNY Equipment availability - No days in year when available for use 365 365 365 365 365 365 365 0 365 Equipment downtime - No days in year when not available 7 7 7 7 7 7 7 7 7 Equipment utilisation - No days in year when in use 247 247 247 247 247 247 247 247 247 Expenditure for year ending 31/03/12 on equipment acquisition: 0 300000 0 0 0 0 0 0 150000 Capital Y Y Revenue Leases

Part 2 Is there a costed 5 year replacement programme in place? (Yes/No) Yes Confirmation that there is an up-to-date asset register (Yes/No) Yes Confirmation that there is an up-to-date Medical Equipment Strategy (Yes/No) No Is there a quality assurance system in place for medical equipment management? (Yes/No) Yes Net Book Asset Value at 31/03/12 Replacement Cost at 31/03/12 £46,750,000 Total maintenance & servicing expenditure for the year to 31/03/12: £1,218,000 in-house staff £550,000 external contracts £668,000 Expenditure for year ending 31/03/12 on equipment acquisition: £820,000 Capital Yes Revenue Yes Leases No What is your general assessment of the current level of risk associated with medical equipment: High Significant Moderate Low General Safety Y Disruption to services Y Poor Fairly well Good Excellent What is your general assessment of how well the current provision of medical equipment supports service delivery? Y What is your general assessment of the opportunities in relation to medical equipment for investing in: High Significant Moderate Low More efficient technology Y Safer technology Y NHS Highland Property Asset Management Strategy (PAMS)

Appendix G

NHSH PAMS March 2012 Page 62

Property Assets

Number of Properties/Sites: 122 Floor Area (000's sq.m) 229883 Net Book Value (£m) Age Profile (%): Over 50 years old 14 30-50 years old 10 10-29 years old 69 Up to 10 years old 7 Tenure Types (%): Owned 90 Leased 1 PPP/PFI 9 Other 0 Condition Ranking - % of total in each category: A 6 B 27 C 56 D 11 Functional Ranking - % in each category: A 3 B 75 C 20 D 2 Quality Ranking - % in each category: A 6 B 27 C 63 D 4 Space Ranking - % in each category Empty 1 Underused 28 Fully used 70 Overcrowded 1 Backlog Cost (£m): Clinical areas Non Clinical Areas Low Risk Items £16,154,980£ 1,955,473 Moderate Risk Items £29,563,216£ 2,247,150 Significant Risk Items £15,789,655£ 461,827 High Risk Items £13,218,554£ 215,800 Total Backlog £74,726,405£ 4,880,250 Estimated capital receipts from property disposals over the next 5 years 2100000 % of the estate (by area) surveyed in last year 22% % of the estate (by area) surveyed in 5 years 100% Average SCART Score: 70 Energy Consumption (GJ) 1620 Heated Volume (100m3) Energy Performance (GJ/100m3)

CO2 Emissions (000's Tonnes) 39 Water Consumption (m3/m2) 28.29 Waste Volume (Tonnes): N/A Waste Recycled (Tonnes) N/A Managerial Technician Craftsman Operators Number of Estates & Facilities Staff 11 5 62 15

On a separate sheet, identify the main focus for investment in property over the next 5 years (as identified in your PAMS) and the contribution that this will make to improvements in National Asset Performance Framework KPIs i.e. Maintenance expenditure, improved functional suitability & space utilisation etc.

On a separate sheet, identify the key priorities for improvement in environmental performance over the next 5 years and the contribution that this will make to improvements in National Asset Performance Framework KPIs i.e. Energy usage, CO2 emissions etc. On a separate sheet, identify / list out any sources of external income from Estates and Facilities services