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NHS HIGHLAND ACCOUNTABILITY REVIEW 2009/2010

SELF ASSESSMENT

NHS HIGHLAND – ANNUAL REVIEW – MONDAY 22nd JUNE 2010 CONTENTS

AGENDA ITEM 2: 2008/09 Annual Review Action Points update

AGENDA ITEM 3: Improving the Quality of Care and Treatment for Patients 3.1 Performance against Treatment Targets 3.2 Quality Strategy 3.3 Governance Systems 3.4 Healthcare Associated Infection 3.5 Patient Experience 3.6 Single Outcome Agreement and Partnership Working 3.7 Access

AGENDA ITEM 4: Improving Health and Reducing Inequalities 4.1 Life Expectancy & Indicators on Health Inequality 4.2 Performance against Health Improvement Targets 4.3 Reducing Health Inequalities

AGENDA ITEM 5: Shifting the Balance of Care towards Primary and Community Care 5.1 Extending the Role of Community Nursing 5.2 Mental Health 5.3 Dentistry 5.4 Pharmacy 5.5 Other Examples of Shifting the Balance of care

AGENDA ITEM 6: Finance and Efficiency, including Workforce Planning & Service Change 6.1 Performance against Efficiency Targets 6.2 Financial & Workforce Planning 6.3 Efficiency Measures and Best value.

NHS HIGHLAND – ANNUAL REVIEW – MONDAY 22nd JUNE 2010 AGENDA ITEM 2: 2008/09 ANNUAL REVIEW ACTION POINTS

ACTION POINT 1: Maintain progress towards meeting 4% sickness absence target.

The position within NHS Highland has improved during 2009/10 – as at the end of March 2009 – the rolling annual sickness absence figure was 4.92%, and by the end of February 2010 this had fallen to 4.75%. One of the key factors in this improving position has been the development of a comprehensive Occupational Health Service across NHS Highland – called OHSxtra which is now funded as a mainstream service. The services on offer are cognitive behaviour therapy, physiotherapy, and occupational health services. In addition to the establishment of the above service, there has been an increase in the monitoring of long term sickness cases to ensure individual case management is appropriate to the specific circumstances. The reporting framework has been developed to allow individual operational units to receive detailed sickness absence reports on a monthly basis and additional support to line managers has been made available to ensure consistent application of our Promoting Attendance Policy, this will be regularly monitored to ensure continued compliance. To ensure that we maintain the improvements in our sickness absence rates we aim to continue our proactive and positive management of long term sickness to focus on abilities and return to work through into 2010/11.

ACTION POINT 2: Keep Health Directorate updated on the progress on the review of services in Skye and Lochalsh.

The Review of Health Services in Skye and Lochalsh has been underway for 12 to 18 months and, although aimed at all services, the hospital issues have dominated due to considerable public and staff angst about loss of beds carried out as an efficiency measure and then fear of further reduction or even closure of one of the hospitals. During a Public meeting in May of last year, a plea was made for much wider public engagement and therefore the Mid Highland Community Health Partnership commissioned Highland Community Care Forum and Skye and Lochalsh Council for Voluntary Organisations, to undertake focus groups and a questionnaire to elicit the views of people in the area that would assist in shaping the review and redesign of services. This work was completed in October and the report made available in December.

A public engagement exercise was conducted in the locality which ran from 21 st September until 23rd October. The Highland Community Care Forum (HCCF), with support from the Council for Voluntary Agencies (Skye and Lochalsh), facilitated the exercise. A number of focus groups were held and the survey was available in both paper and electronic format. The paper copies were distributed widely across the area, with press releases going into local and regional papers. There were 401 responses and the HCCF collated the results and completed a report with recommendations on behalf of the Locality. The results from the report helped to steer the direction of the independently facilitated workshop held on 12 th February. The aim of the public engagement was:  To involve a wide range of members of the public, partners and health staff  To establish views on use, importance and any improvements required to the existing provision  To identify the barriers people with long term conditions experience in being able to remain living at home and what has helped people remain in their own homes.

NHS HIGHLAND – ANNUAL REVIEW – MONDAY 22nd JUNE 2010 The findings of the engagement exercise showed that many people praised current services, but they also stressed the need to safeguard against future withdrawal of services or support. The aspect of the health services that most people considered to be most important to them was quality of care or treatment. The exercise identified location of treatment and speed of appointments as the two top issues that needed improvement. The three major changes identified were a need for more local services and facilities, particularly a local general hospital with modern medical facilities; better emergency/24 hour cover; and an NHS dentist. A workshop was held on 12th February in the Dunollie Hotel, Broadford. Pennie Taylor, Journalist and Broadcaster, facilitated the event and delegates heard feedback from the engagement exercise as well as information from the national and Highland perspectives. The event focused on identifying priorities for action that will deliver the outcomes described in the national policies.

A new group has now been set up to shape the future delivery of local health services in Skye and Lochalsh. The Skye and Lochalsh Health Services Reference Group was established at a meeting at the MacKinnon Country House Hotel at Kyleakin on Skye on Monday May 10th to consider the health needs of local people and use the combined expertise of members to plan for the future. This group has the important job of ensuring that the process of service redesign is robust and that the models of healthcare are appropriate to the health needs of the community it serves and within the available resources. The reference group, which is made up of Highland councillors, community councillors, statutory and voluntary partners, clinical staff, professional advisors and NHS Highland managers, is chaired by Sleat Community Council Chair, Roddy Murray, with Dr Nancy Burge, of Dunvegan Medical Practice, as vice chair. The next meeting is to be held on 21 st June when the group will consider the current financial situation for the Mid Highland Community Healthcare Partnership to give members a clearer picture of the resources available for services in the area. The reference group will also start work on an action plan for service change and improvement based on the priorities identified during the earlier work with patients, carers and other local people. The reference group will then meet quarterly to continue working up the action plan and to oversee its implementation.

ACTION POINT 3: Keep Health Directorates update on progress on orthodontic services

We continue to face challenges across all of our Dental services, due to reliance on visiting specialist services and recruitment difficulties. However we have made progress in a number of areas and are continuing our discussions with regional colleagues to secure a more integrated and robust solution for these services under the auspices of the North of Scotland Oral and Dental Subgroup.

Orthodontics NHS Highland has maintained the target of 12 weeks maximum wait for new outpatients. At the end of March 2010 there were 290 patients waiting for treatment. We are still working to reduce the “bulge” of patients which resulted from the use of short term locums to tackle the new outpatient waits at the end of 2007. Once this has been addressed we will see a marked improvement in the maximum wait for treatment as the additions to the list (less than 10 patients per month) in the last 12 months are significantly reduced. Although we have gone to advert twice, we have still to make a permanent appointment to the vacant 2nd consultant post, but we intend to extend the contract for the current locum until August 2010. The Aberdeen Consultants continue to provide a locum service to

NHS HIGHLAND – ANNUAL REVIEW – MONDAY 22nd JUNE 2010 Caithness to complete the treatment for existing patients, but no new patients are seen at these clinics.

Oral Maxillofacial Services Significant progress has been made in with the permanent appointment of one of the 2 consultant posts in February 2010. This appointment, together with the extensive use of external consultant services in March 2010, meant that we were able to see and treat the large backlog of patients that had accumulated during the long period of vacancies. With the exception of only a few patients we met the March 2010 maximum wait targets for new outpatient appointments and admission. We continue to develop the regional network approach to OMFS in the north of Scotland with the new appointment. We have been unsuccessful in our attempts to appoint the second consultant.

Restorative Dentistry We have continued to seek alternative solutions to increase our capacity for this service, which is currently provided as an ad hoc visiting service form NHS Grampian which is not adequate or sustainable to meet NHS Highland’s needs. This has been a particular challenge and although we have been able to supplement our capacity with a locum from south of the border, we have yet to find a sustainable solution. We have particular difficulties in meeting the waiting times target for the complex cases which require joint input from both a restorative dentistry and orthodontic consultant.

ACTION POINT 4: Keep Health Directorates informed of progress on the palliative care service at Campbeltown Hospital.

During 2008/9 Argyll & Bute CHP commenced discussions with MacMillan Cancer Relief on the building of a palliative care facility within Campbeltown Hospital. This came on the back of local funding raising over a number of years. Macmillan agreed to allocate additional funding to support the scheme if the design of the building complied with Macmillan requirements. The need to work within an existing building resulted in some design challenges which delayed progress by a few months, but plans were agreed towards the end of 2009 and the tendering process commenced. The purpose of this palliative care facility is to allow end of life care to be provided in the community hospital to a standard that would be found within a purpose build hospice. The facility comprises one single room with ensuite facilities, plus an adjoining room for family members linked by a sun room within an enclosed court yard. The total cost of this project will be £135,359. The works contract has been awarded to a local builder and work will commence on site in June 2010 with an estimated completion date of 30th September 2010. This project is a good example of the NHS working with the local community and the independent/voluntary sector to meet the needs of a community.

ACTION POINT 5: Continue to work towards a ‘whole journey’ maximum waiting time of 18 weeks from GP referral to receiving treatment.

NHS Highland now has a comprehensive understanding of the nature and scale of the challenge to deliver and sustain reduced waiting times. Throughout 2009/10 there has been a major focus on developing the significant building blocks we feel will help us deliver the 18 weeks referral to treatment pathway. These building blocks are also facilitating significant improvements for service change across the whole system. The following are some key examples of the service re-design and improvements which are underway:

NHS HIGHLAND – ANNUAL REVIEW – MONDAY 22nd JUNE 2010  NHS Highland Booking Service was developed following the successful introduction of a similar model in the radiology service in Raigmore Hospital. In Radiology “Did Not Attend” and cancellation rates have been sustained at below 2% for a number of years now. The new booking service aims to ensure the standardised systems and process are developed and adhered to. This will support best use of planned clinical and administrative resources. Importantly, the new booking service also has more robust systems to address Patient Access Support needs. Services such as ENT, Endoscopy and Orthopaedics who are already using the booking service have reduced their DNA rates to less than 5%. Other benefits include assuring fairness by taking routine patients in turn, reducing cancellations, rescheduling of appointments leading to improved utilization of clinic time. Plans are well progressed to have migrated all outpatient appointments for the medical and surgical specialities by the end of June 2010.  Within the Acute Hospitals, re-design work is ongoing in Theatres, Bed utilization, improving Day Case rates, Pre-Operative Assessment, Out Patients, Medical Records and a review of administrative services. The work NHS Highland has undertaken as part of our Theatre Re-design has been recognised nationally.  The establishment of a new community Dermatology service resulted from a new approach to managing demand in Primary care. A change in the management and referral pathways for skin lesions led to the creation of a centralised receipt and vetting centre led by an experienced GP with a Special Interest and supported by Consultant Dermatologists. Despite still being in its infancy the service has already reduced the number of referrals into dermatology by 40% and waiting times by 50%, with 75% of patients now seen within 3 weeks, and all within 6 weeks. WE believe that this approach will provide a solid platform to progress further initiatives to supporting shifting the balance of care. There has been considerable interest in our approach and results from colleagues across Scotland.  One of the key commitments of NHS Highlands 18 week referral to treatment programme has been the involvement of patients and carers. Over 1000 patients and patient representatives have been involved through completing questionnaires, 1:1 conversations, focus and working group involvement and some are taking part in a Patient’s Diary project. This has proved invaluable in shaping the direction of our 18 week programme.  We have carried out an in-depth review of our data and information systems which will support the measurement and performance for the 18 weeks RTT target. We have recently been commended through the National 18 RTT Programme Team for the rigorous approach taken which will support sustainability.  Other pieces of work being under taken to support the achievement of the 18 weeks referral to treatment pathway include a major review of Consultant Job Plans to strengthen evaluation of our capacity, and the implementation of a comprehensive Patient Access Policy.

ACTION POINT 6: Continue to deliver robust arrangements for controlling Healthcare Associated Infection.

Clostridium Difficile Infection (CDI). NHS Highland has shown a steady reduction in the rates of CDI over the last 3 quarters of 2009, reducing from 34 cases in April-June 09, to 19 cases in October- December 09. The rate of CDI in patients aged 65 and over for the period October 09-December 09 is 0.37 per 1000 occupied bed days. This is one of the lowest rates in NHS Scotland (For the same quarter Borders 0.18, Forth valley 0.22, GG&C 0.36). We remain on track to achieve the

NHS HIGHLAND – ANNUAL REVIEW – MONDAY 22nd JUNE 2010 Scottish Government target of a 30% reduction in the rate of CDI among patients aged 65 and over by March 2011 NHS Highland has also reduced prescribing of ceftriaxone to less than 10 defined daily doses per 1000 occupied bed days in all acute hospitals, thereby reducing the risk of CDI associated with this high risk antibiotic. Data to the end of January 2010 shows a peak in antibiotic use in November coinciding with the increase in cases of suspected infection of H1N1 Influenza. Antibiotic use has fallen to pre November levels in December and January 2010. The data shows an increase in the use of preferred agents and a drop in the use of those agents associated with CDI. We have successfully introduced triggers for CDI rates for all acute and community hospitals, to facilitate early detection of a rise in cases and an integrated care pathway to facilitate improved care of patients with CDI has been successfully introduced. Enhanced surveillance is carried out on each incident of CDI in the Board. Surveillance has been expanded to include 30 day follow up from diagnosis for CDI.

Staphylococcus aureus bacteraemia (SAB) The SAB target has been identified consistently as very challenging for the Board due to a low base rate of infection to begin. The annual SAB target for NHS Highland was 54 cases for the year ending March 2010, against which NHS Highland registered 73 cases. The SAB rate for the period October - December 2009 is 0.31 SABs per 1000 acute occupied bed days. This rate is the second lowest in Scotland after the Western Isles. NHS Highland invited QIS to support us in the effort to reduce the number of cases. The Highland Action Group was formed in February 2010 under the chairmanship of Dr Andrew Hay, Infection Control Lead. The SAB Action Plan is closely monitored; the main focus is the insertion and care of central and peripheral venous catheters and the appropriate taking of Blood Cultures using aseptic techniques. A Root Cause Analysis is carried out on each incident of SAB across the Board. NHS Highland has achieved compliance in Hand Hygiene as demonstrated in the National Audits and in the rolling audits each ward/area is expected to complete on a monthly basis with an average compliance of 93% with opportunity and 86% with technique. Cleaning performance is monitored bi-monthly across NHS Highland. Compliance averages 92%. Development of surveillance triggers for SAB, to facilitate early detection of a rise in cases, has been successfully achieved. NHS Highland is fully engaged with QIS Infection, Improvement & Implementation Programme. Working closely with the Scottish Patient Safety Programme, a revised roll-out of peripheral and central venous care bundles has been implemented targeting areas identified through the use of pareto charts, to help reduce infection. Two central venous catheter infections have been identified in the ITU since surveillance began in January 2008 to date.

NHS HIGHLAND – ANNUAL REVIEW – MONDAY 22nd JUNE 2010 AGENDA ITEM 3: IMPROVING THE QUALITY OF CARE AND TREATMENT FOR PATIENTS

3.1 PERFORMANCE AGAINST TREATMENT TARGETS

Individual target performance is detailed in the supporting “At a Glance” report.

Main Achievements

Target T6: Reduce the admissions rates for Long Term Conditions by March 2011 In 2009/10, between March 2009 and December 2009, we have consistently been reducing the number of hospital bed days for patients with a Long Term Condition, from 9950 to 8855 per 100,000 of our population and are already ahead of our March 2011 target of 9130.

Target T12: Reduce emergency inpatient bed days for those aged 65 and over to 3,238 per 1000 population by March 2011 NHS Highland has a target of reducing the number of emergency bed days for patients aged 65+ per 1000 of the population to 3238 by the 31st March 2011 – by December 2009, we have already achieved 2985 bed days per 1000 population – well ahead of plan.

Target T2: NHS Quality Improvement Scotland clinical governance and risk management standards is covered in Section 3.3; Target T11: Reducing Hospital Acquired Infections is covered in Section 3.4; and Targets T3: Reducing the prescribing of anti-depressants, T4: Reducing the number of psychiatric readmissions and T9: Improvements in the early diagnosis and management of patients with dementia are covered in Section 5.

3.2 QUALITY STRATEGY

Over the past year NHS Highland has been developing its Strategic Framework which places quality at its forefront and which is built around a simple vision – Quality Care to Every Person Every Day. This is underpinned by three key aims Better Health - Improving the Health of the Population Better Care - Enhancing the Experience of Care Better Value - Controlling the per Capita Cost of Care

One of the key building blocks of the strategic framework is the NHS Highland Quality and Patient Safety Framework which was approved by the Board in April 2010. This Framework was influenced by a number of factors, including:  The National Quality Strategy  Scottish Patient Safety Programme  The outcome of review of our services against national reports which identify incidences of poor quality care or serious service failure - in particular, NHS Highland Response to Mid Staffordshire NHS Foundation Trust Report

The Quality & Patient Safety Framework is based on three key areas  Patient Safety, covering the Scottish Patient Safety Programme, Learning from Incidents and Risk Assessment  Patient Experience, covering Patient Feedback, Complaints and compliments and Patient Participation  Clinical Effectiveness, covering Clinical Outcomes, Clinical Audit and Evidence Based Practice

NHS HIGHLAND – ANNUAL REVIEW – MONDAY 22nd JUNE 2010 Each area is considered under the headings of ‘What does this mean for Patients and Staff?’ and ‘What does this mean for NHS Highland?’, with the latter outlining the Board’s commitment to empowering frontline staff to initiate and lead change that improves quality of care for patients. NHS Highland is also developing a Clinical Dashboard model, which is currently being progressed in Maternity Services.

An Implementation Group has been established with the remit of developing a robust plan to support implementation of the Framework and also to consider and act upon any additional requirements of the NHS Scotland Quality Strategy.

To date, a number of actions have taken place:  Survey issued to all NHS Highland staff – on 20th May, 108 responses – information noted to be useful and informative  Article included in April/May Team Update  Intranet site established  Presentation prepared which covers NHS Highland/NHS Scotland Quality Strategy/Framework and Mid-Staffordshire – has already been discussed at Area Nursing & Midwifery Advisory Committee, Area Partnership Forum, Area Clinical Forum with plans for delivery to other groups  Return outlining activities supporting the Quality Strategy sent to Scottish Government at end of April (attached)

3.3 GOVERNANCE SYSTEMS

Target T2: Improve the QIS Clinical Governance and risk management Standards score from 8 in October 2007 to 10 by March 2010 NHS Highland was awarded a score of 10 by QIS as a result of its assessment undertaken by March 2010, draft report released in May 2010.

NHS QIS Clinical Governance & Risk Management Standards The Peer Review visit to NHS Highland took place on 10/11 March 2010. The draft report has been received which made the following assessment:

Standard 1 Risk Management 3 Emergency & Continuity Planning 2 Clinical Effectiveness 3 Total 3

Standard 2 Access, Referral, Treatment and Discharge 3 Equality & Diversity 2 Communication 3 Total 3

Standard 3 Clinical Governance 4 Fitness to Practice 4 External Communications 3 Performance Management 4 Total 4

OVERALL 10

NHS HIGHLAND – ANNUAL REVIEW – MONDAY 22nd JUNE 2010 The conclusions of the Peer Review Team included:

“ NHS Highland has robustly implemented its arrangements for risk management and is monitoring how effective these are across the organisation. The review team was pleased to note the embedded nature of risk management at the operational level, the increased local governance arrangements since the last visit and the availability of training.”

“NHS Highland has robust arrangements in place for ensuring clinical effectiveness across the Board areas and these are subject to regular monitoring and evaluation. The review team considered the nursing and midwifery record keeping and care planning audit to be a good example of staff empowerment driving the agenda for clinical effectiveness from the bottom up. ……. The audit has been improved year on year …..”

“NHS Highland has continued to display a positive clinical governance and quality assurance culture that is well embedded throughout the organisation. It is evident that NHS Highland considered continuous review and improvement to be fundamental to the success of the organisation. It has been able to demonstrate that clinical governance is well embedded within the operational units and there is a rolling programme of planned and systematic evaluation.”

Scottish Patient Safety Programme NHS Highland has been actively implementing the Scottish Patient Safety Programme (SPSP) at four sites since the start of the programme – Raigmore Hospital, Caithness General Hospital, Belford Hospital and Lorn & Islands Hospital. A Senior Leadership Team meets on a monthly basis to support the front line teams at all four sites to deliver improvements in patient safety. We are currently at level 2.5 on the assessment scale - Improvement being noted in process and/or outcome measures for pilot populations in all 5 workstreams.

We have concentrated on refining the reporting structure and producing new templates, transforming data collection tools to be much more user - friendly We have also developed a new spread plan and have populated this according to pareto analysis- targeting high risk areas of infection to delivery of appropriate bundles.

The senior leaders in the organisation, including the Chief Executive who is taking a particular interest in Raigmore, take part in regular Walkrounds, visiting pilot sites and spread wards to support the delivery of SPSP in the four sites.

At this stage in the programme, some process measures are demonstrating sustained reliability. Examples include:  Implementation of Safety Briefings in ward setting  Reliable completion of Scottish Early Warning Score (SEWS) Chart  Appropriate actions taken in relation to SEWS score  Conducting Surgical Briefing and Surgical Pause  Reliable implementation of Peripheral vascular Catheter Bundle, Central Line Bundle and ventilator associated Pneumonia Bundle.

In addition some of our hospital based outcome measures, such as infection rates, are meeting the target we have set. Examples include:  826 days since last Staph. Aureus Bacteraemia (SAB) in General Wards, Belford Hospital  735 days since the last C Difficile case in ITU/HDU in Caithness General Hospital

NHS HIGHLAND – ANNUAL REVIEW – MONDAY 22nd JUNE 2010  637 days since the last C Difficile case in General wards, Lorn & Islands Hospital  A downward trend and statistically significant shift in the Adverse Event Rate at Raigmore Hospital

3.4 HEALTHCARE ASSOCIATED INFECTION

Target T11.1: Reduce all staphylococcus aureus bacteremia (including MRSA) to 54 by March 2010 Target T11.2: Reduce the bed day rate of C Diff infection in hospitals in the over 65’s by at least 30% by March 2011, to 0.77 infections per 1000 occupied bed days

Please see Action Point 6 from the Annual Review 2008/09 for performance against both of the above targets.

3.5 PATIENT EXPERIENCE

2009-10 has been associated with a significant agenda of change and quality improvement. This has been the focus of a wide range of actions aimed at promoting and supporting dialogue with and involvement of patients, carers and other members of the public. A few examples are presented in the annual self assessment on patient focus and public involvement including:  Work to improve efficiency in outpatient services, included the booking system and the reasons patients “did not attend” (DNA). A variety of methods and approaches were used to gather feedback and input from patients and patient groups, and this has been very influential in changing working systems and practices. Overall this joint work has contributed to a tangible reduction in DNA rates.  Developing and testing new working systems and tools to improving our approach to anticipatory care. This has also provided an excellent opportunity to explore with patients the aims of anticipatory care, and to sound out our approaches to adapting practice.  Exploring the role of our community hospitals, and their potential as a key part of locality healthcare systems. This has included considering jointly some complex issues which are feeding in to the development of a multi agency policy on the admission, transfer, and discharge of patients.  Work on day case procedures in a rural general hospital has been very helpful in developing our understanding of patients’ perceptions of the service. Exploring this jointly has helped to identify aspects of the service we had not considered a barrier, and as a result of introducing changes, there has been a tangible increase in the uptake of day case procedures.  Development work on patient pathways from referral to treatment. Feedback from patients’ real experiences has illustrated areas for improvement, including communication from clinical departments. As a result, a number of changes and new initiatives are being introduced.

3.6 SINGLE OUTCOME AGREEMENTS AND PARTNERSHIP WORKING

Main Achievements The achievements in this section reflect development of processes to support partnership working through the Single Outcome Agreements. Information on achievements in terms of

NHS HIGHLAND – ANNUAL REVIEW – MONDAY 22nd JUNE 2010 outcomes for the population of NHS Highland is reflected in the information presented throughout this document.  The Highland Community Planning Partnership has undertaken a review and strengthened its leadership and governance mechanisms, introducing an approach designed to support a greater degree of scrutiny and challenge of partnership progress towards achieving intended outcomes.  Review of identified 7 priority local outcomes within Highland SOA is nearing completion. Strategy and delivery mechanisms, outcomes measures and indicators for these are being strengthened.  Promoted use of logic modelling to strengthen integrity of links between outcomes, intermediate outcomes, service delivery outcomes and activity.  Local area community planning groups established in Argyll & Bute involving wide range of stakeholders and delivering good progress in development of local plans  I.T. system to support detailed performance recording and reporting across all Argyll & Bute CPP partners introduced

Main Challenges The following challenges relate to generic issues for developing partnership working through the Single Outcome Agreements. Specific challenges are described in the information presented throughout this document.  Developing robust approach to delivering outcomes and linking inputs and outputs to outcomes across complex partnership networks across vast geography  Maintaining a focus on upstream preventative and long-term work in the current financial climate  Maintaining a collaborative approach to tackling priority issues in current financial climate

3.7 ACCESS

3.7.1 PERFORMANCE AGAINST ACCESS TARGETS

Main Achievements Target A10.3 – No Patient will wait longer than 12 weeks from being placed on a waiting list to admission for an inpatient or day case treatment from 31 st March 2010 NHS Highland in line with other NHS Boards in Scotland met this target in March 2009 – a year ahead of plan. This target was to be further reduced to 9 weeks, by 31 March 2010. This was achieved with the exception of 16 patients who represent 0.7% of the total number of patients on the waiting list.

Target A10.2 – No Patient will wait longer than 12 weeks from referral to first outpatient appointment from 31 March 2010. NHS Highland in line with other NHS Boards in Scotland met this target for referrals from GP’s and Dentists in March 2009, a year ahead of plan. For 2009/10 the target was expanded to include referrals from all sources and as at the end of March 2010, this was achieved with the exception of 29 patients which represent 0.4% of the total number of patients on the waiting list.

LDP target – No patient will wait longer than 4 weeks for any of the 8 Key Diagnostic Tests from 31 March 2010. Throughout NHS Highland, as at the end of March 2010, there were no patients waiting over 4 weeks

NHS HIGHLAND – ANNUAL REVIEW – MONDAY 22nd JUNE 2010 Main Challenges  Sustaining local access for patients through the wide range of remote and rural outpatient clinics, particular during periods of bad weather.  With changes in junior and middle grade medical staffing rotas and an increasing reliance on Consultant staff to cover on call etc, there is a reduction in availability of direct clinical care.  Increasing demand for Bariatric services and shortage of NHS Scotland providers.  Current lack of Theatre capacity poses a risk for a number of surgical services.  Developing sustainable solutions for some of the dental services.  Maintaining service delivery for single-handed consultants and addressing some significant and unforeseen consultant staffing issues in some specialities.  Reliance on visiting specialist services.  Balancing local access with clinical time lost due to significant travel commitment.

3.7.2 CANCER

Target A9: At least 95% of patients with a suspicion of cancer should have a maximum wait from urgent referral to treatment of 62 days NHS Highland were the first Board to meet the 95% target in Quarter 2 2007, and NHS Highland has consistently met this target in each quarter since. This was achieved through a focus on the management of cancer waiting times targets, a self assessment approach was taken in relation to the use and application of the SGHD Confidence Assessment (key improvement criteria)  Management Grip essential  Systems and Processes  Engaging clinicians, raising awareness of clinical responsibilities  Breach Review  Scrutiny of robust and accurate information to guide decisions  Streamlined pathways and pathway flows In addition, when anticipated performance was at risk mid year, we again went back to this tool and used our assessment to pin-point the weak areas, improve ownership and direct improvements.

Main Achievements  A step change in approach to pathway redesign has seen both refinement of existing work and some radical changes.  Refresh of referral guidance for GPs.  Secured agreement from specialists to implement electronic referral protocols – work in early stages.  The extension of existing models of same-day tests in urology.  Successful move to one-stop Triple Assessment for all Breast patients (including Western Isles patients).  The introduction of same-day tests in Upper & Lower GI.  Well-embedded role of weekly Cancer Meeting providing close scrutiny.  Regular case-specific look-back-and-learn & sharing provides a strong platform for governance.  Development of a new and comprehensive Cancer Tracking and Reporting Tool.

The approach described above has pro-actively encompassed planning for the new 31-day target and taken account of patients on the National Screening Programmes in both the new 62-day target and the 31-day target.

NHS HIGHLAND – ANNUAL REVIEW – MONDAY 22nd JUNE 2010 Main Challenges  Endoscopy capacity raised concern over the 2009/10 period, particularly as we prepared to launch the national bowel screening programme. Using the SGHD Confidence Assessment template, prompt action to review Endoscopy across Highland provided an opportunity to ensure all available capacity was utilised and efficient processes in relation to booking scope appointments and minimising ‘Did Not Attend’ have been successful.  Similarly ongoing concerns about radiotherapy delays with a challenging backdrop of consultant and Radiotherapy Physics vacancies prompted a similar scrutiny and redesign of booking and Radiotherapy planning processes which is now well underway.

3.7.3 PROGRESS AGAINST FUTURE TARGETS

GP ACCESS

Target A8: Provide 48 hour access or advance booking to an appropriate member of the GP Practice Team by 2010/11 The results of the national 2009/10 GP Patient Experience Survey were released in late April 2010, and have been reviewed Community Health Partnerships at various levels throughout the organisation. Community Health Partnership Primary Care Managers are working with each Practice on a Practice specific plan, seeking to address the poorer performing areas (where these have been highlighted). The common issues where improvement could be made have been discussed with GP Subcommittee, and shared with all GP Practices.

Main Achievements  Overall, the survey demonstrates a very high level of patient satisfaction across all 102 GP Practices. Practice nurses score especially well.  Most remote, small Practices have achieved outstandingly high scores across all aspects of the questionnaire,

Main Challenges  There are some common, generic issues raised around a number of areas of communication, in particular concerns around confidentiality at reception desks and the level of understanding of what medications are being prescribed for were identified in the survey.  Urban Practices generally have found access highlighted as an issue by some respondents.  The complexity of access routes to primary care and improving the use of plain English in information provided by practices have also been highlighted by patients.

DRUG AND ALCOHOL TREATMENT

Target A11: By March 2013, 90% of clients will wait no longer than 3 weeks from referral received to appropriate drug treatment that supports their recovery. Waiting times appropriate to alcohol treatment will be defined and incorporated into a target covering both drugs and alcohol by April 2011 Drug Treatment Waiting Times data is being collected by all NHS Highland Tier 3 and Tier 4 substance misuse services. This includes day care and community services across the 4 Community Health Partnership (CHP) operational units. The data is used locally to produce quarterly reports for the CHP General Managers. The report provides information on waiting times, highlights areas of non compliance on data submission, and progress against the key performance measures (KPM) for Target A11. Latest reported progress is detailed in the table below

NHS HIGHLAND – ANNUAL REVIEW – MONDAY 22nd JUNE 2010 KPM 1 - Referral to Assessment: KPM 2 - Assessment to start of Percentage offered an appointment within treatment: Percentage offered an 4 weeks appointment with in 4 weeks Apr to Jul to Oct to Jan to Apr to Jul to Oct to Jan to Jun 09 Sep 09 Dec 09 Mar 10 Jun 09 Sep 09 Dec 09 Mar 10 North 18% 59% 57% 20% 100% 100% 67% 60% Mid 87% 88% 77% 84% 100% 100% 94% 96% South East 38% 61% 96% 91% 100% 100% 99% 100% Argyll & Bute 96%* 100% 97% ** 96%* 100% 93% ** NHS Highland 68%* 73% 92% ** 98%* 100% 97%* ** * Data based on ISD reports, may contain voluntary sector statistics ** Data is not available at this time

Main Achievements  An Alcohol Liaison service has been developed at the Lorne and Isles Hospital facilitating early identification, treatment and support and education for hospital staff.  Successful recruitment to additional nursing posts in Cowal and Kintyre to further develop alcohol treatment and rehabilitation services including home detox; Health Improvement Co-ordinators to support the health improvement agenda and enhance health input and assessment for youth action services.  Introduction of a Triage referral system at Osprey House, Inverness, from mid February 2010, to allow quicker access to drug and alcohol assessment to address the identified long waits in that area.  Training of volunteer counsellors within the Council on Alcohol services to enhance local service provision and ensure engagement in faster access to treatment for alcohol services to support the developing HEAT target.  An Inverness based pilot in the training of basic life support skills and administration of Naloxone commenced in July 2009. By May 2010, 200 people have been trained including users, family members and homeless/hostel accommodation staff. A training DVD has been produced and the project has been recognised nationally as best practice.

Main Challenges  Local service capacity issues including staff turnover.  The development of a new range of performance measures to support the developing Outcomes Based Performance Frameworks in line with the Delivery Reform guidance.  Recruitment in some areas due to the non-recurrent nature of funding.  Capacity to achieve consistent data collection within the Argyll & Bute area

CHILD & ADOLESCENT MENTAL HEALTH SERVICES

Target A12.1: By March 2013, no one will wait longer than 26 weeks from referral to treatment for specialist Child and Adolescent Mental Health Services (CAMHS)

Main Achievements  Systems in place across NHS Highland to record waiting times on a monthly basis.  Tier 3 services are in the process of migrating to the main hospital patient administration system which will provide robust patient management and data for monitoring purposes.

NHS HIGHLAND – ANNUAL REVIEW – MONDAY 22nd JUNE 2010  A referral and prioritisation process has been introduced to the Tier 3 service to ensure that resources are targeted to those in most need.  A group to oversee the development of CAMHS has been established, which also regularly reviews the waiting time information.

Main Challenges  Recruitment and retention is a major issue in this highly specialised area – with long term vacancies across NHS Highland.

18 WEEKS REFERRAL TO TREATMENT

Main Achievements Please see Action Point 5 from the Annual Review 2008/09.

Main Challenges While NHS Highland has made considerable progress across the majority of the work streams, delivery still poses a significant challenge:  In common with other Boards, significant work is still required to develop and implement 18 weeks RTT compliant monitoring systems. In most cases the systems developments required are out with the direct control of NHS Highland. We have additional complexity in that different systems are used within Northern Highland and Argyll & Bute.  Not having a current accurate position of where each specialty is towards delivering 18 weeks means that delays cannot yet be systematically identified. Therefore, an accurate assessment for each specialty against the 18 week standard can’t be carried out.  Even with improved theatre utilisation there will be a lack of Theatre capacity which poses a risk for a number of surgical services.  A potential risk to Argyll and Bute CHP is the reliance upon NHS Greater Glasgow and & Clyde to provide many of its secondary care services.  The delivery of 18RTT together with the financial position is proving to be a significant catalyst for change. It should be noted that there are inherent risks of moving from one system of working to another, especially early on when the benefits may not be immediately apparent.

3.7.4 PERFORMANCE AGAINST ACCESS STANDARDS

4 HOUR A&E WAITING TIME STANDARD

For 11 out of 12 months during 2009/10 NHS Highland maintained at least 98% of patients waiting under 4 hours from arrival to treatment in the 20 accident & emergency departments across our area. During February 2010, 97% of our patients waited less than 4 hours – this reduction in performance was primarily due to the impact on the availability of beds because of the noro-virus.

NHS HIGHLAND – ANNUAL REVIEW – MONDAY 22nd JUNE 2010 AGENDA ITEM 4: IMPROVING HEALTH AND REDUCING INEQUALITIES

4.1 LIFE EXPECTANCY & INDICATORS ON HEALTH INEQUALITY

Target H8: Achieve the agreed number (57) of inequalities targeted cardiovascular health checks during 2009/10 We have achieved more than three times (189) the required number of inequalities targeted cardiovascular health checks required to be delivered in the North West Sutherland area during 2009/10. Plans are now in place to achieve another 60 health checks during 2010/11.

4.2 PERFORMANCE AGAINST HEALTH IMPROVEMENT TARGETS

4.2.1 HEALTHY WEIGHT OF CHILDREN Target H3: Achieve the agreed completion rates for child healthy weight intervention programme by 2010/11 By the end of March 2010 we had achieved 221 child healthy weight interventions against a plan of 78 – these interventions are targeted at children aged between 5 and 15 years old and defined as overweight. NHS Highland aims to achieve 484 such interventions by March 2011.

Main Achievements  96.4% of Primary 1 and 94.5% of Primary 7 children have had BMI surveillance undertaken.  Total of 100 staff across NHS Highland now trained to deliver the family based healthy weight intervention (the X Programme).  Development of classroom based “mini-X” programme for delivery to whole-classes in school-time. Complements the full X-programme, and furthers Health and Wellbeing Outcomes of Curriculum for Excellence including links with the Active Schools programme.  Delivery of mini-X piloted, and rolling-out ahead of trajectory with 191 children from all areas across Highland having taken part in the school based programme.

Main Challenges  Recruitment to the full X-programme due to a number of factors including; non recognition of unhealthy weight by family; reluctance due to perceived stigma; logistics for the family to attend; small numbers in rural communities; issues with referral pathways for medical staff.  Staff capacity to deliver the full X-programme and dedicated local co-ordination. Work capacity to support Public Health Practitioner (PHP) posts and delivery of X-programme is an ongoing pressure as school nurses remain heavily committed to a range of school based and community activity.

4.2.2 ALCOHOL BRIEF INTERVENTIONS Target H4: achieve agreed number of screenings and appropriate alcohol brief interventions (ABIs) by 2010/11. As part of a plan to tackle Alcohol related issues, NHS Highland has an ambitious target of delivering 8964 alcohol brief interventions by the end of March 2011. These interventions take place in a variety of settings and aim to sign post people with alcohol related problems to appropriate services. By the end of March 2010 NHS Highland achieved 2104 interventions and was ahead of trajectory.

NHS HIGHLAND – ANNUAL REVIEW – MONDAY 22nd JUNE 2010 Main Achievements  Training delivered to 761 staff across primary care, A&E and acute care staff as at the end of March 2010 with further training for staff in the Maternity Services planned for April and May.  As at 31st March 2010, 4373 (2267 during year 08/09 and 2106 during 09/10) ABIs have been delivered equating to 49% of the target.

Main Challenges  Streamlining the recording and reporting procedures from the original LES. More practices (77 out of 102) have now signed up to the LES covering 80% of the practice population.  Developing an effective recording system to capture activity outwith GP practices.

4.2.3 SUICIDE PREVENTION TRAINING Target H5: Reduce suicide rate between 2002 and 2013 by 20%, supported by 50% of key frontline staff in mental health and substance misuse services, primary care and accident and emergency being educated and trained in using suicide assessment tools/suicide prevention training programme by 2010. We are aiming to have 50% of key frontline staff educated and trained in using suicide assessment tools/suicide prevention training programmes by the end of December 2010 – as at the end of March 2010, 34% of staff had been trained

Main Achievements  We have developed a system of monthly monitoring and reporting for staff training. This monitoring programme was rolled out in January; each CHP General Manager receives the monthly report.  The named mental health lead in each CHP is monitoring this HEAT target, and undertaking any necessary actions. With these actions in place, we remain confident that we will be able to achieve HEAT training target in 2010

Main Challenges  Capacity to release staff to attend courses.  Appropriateness of available courses for General Practitioners.

4.2.4 SMOKING CESSATION Target H6: through smoking cessation services support 8% of Board’s smoking population in successfully quitting (one month post quit) over period 2008/09 -2010/11. NHS Highland has achieved almost 5% of the smoking population having successfully quit (at 1 month post quit) up to February 2010 – more than half way to the target of 8% by March 2011. This represents 3,037 one month quits out of the target of 3,166 for this time period.

Main Achievements  For the period from January – December 2009, 1,735 of those who set a quit date remain quit at one month. This figure has increased year on year from 852 in 2007 and 1355 during 2008.  NHS Highland’s quit rate of 50% compares favourably with the Scottish figure of 36% (last published figures from ISD May 2009)  The reported figures relate to specialist smoking cessation services, however, we recognise smoking cessation activity is carried out in other settings and by other health professionals such as GPs and Pharmacists. Work is ongoing to encourage GP practices to share current smoking cessation activity, which meets criteria for inclusion in the minimum data set monitoring, with the smoking cessation service.

NHS HIGHLAND – ANNUAL REVIEW – MONDAY 22nd JUNE 2010  All pharmacies in NHS Highland offer a Smoking Cessation Service.

Main Challenges  GPs not signed up to referring patients to the service, the smoking cessation advisors continue to visit GPs to advise them of the merits of referral to the specialist smoking cessation service.  Persuading the practices whose Practice Nurses provide a smoking cessation service to complete and submit the information.

4.2.5 BREAST FEEDING AT 6 TO 8 WEEKS Target H7: increase proportion of newborn children exclusively breastfed at 6-8 weeks from 26.6% in 2006/07 to 33.3% in 2010/11 Working towards a target of 36% of newborns being exclusively breastfed by March 2011, our performance during the year has varied between 32.4% and 31.1%.

Main Achievements  Raigmore Hospital was re-accredited with its BFI award in September 2009, Caithness General was awarded full status in November 2009. The rest of NHS Highland (all four CHPs) has achieved stage 1 of BFI accreditation and has detailed action plans in place to achieve full accreditation by 2011.  An established network of 50 UNICEF breastfeeding trainers within NHS Highland, who work with the infant feeding advisors to train all staff who have contact with pregnant and breastfeeding women.  The UNICEF breastfeeding management training has been rolled out very successfully over the past year with over 400 staff being trained. This training now includes early Year Workers, GPs, School Nurses and Social Work.

Main Challenges  Data capture and timeous reporting – we require complete data recording and return, to ensure performance against target is accurate.  Initiation rates within NHS Highland are higher than the Scottish average, but unfortunately the women who chose to continue breastfeeding at discharge has decreased. Rates at discharge are about 49 %.

4.3 REDUCING HEALTH INEQUALITIES

Main Achievements  Policy, protocol and care pathway to support best practice with adult survivors of childhood sexual abuse developed and implemented.  With Highland Council and Northern Constabulary, developed policy to support appropriate responses to anti-social behaviour  Community Health Profiles have been developed for local areas to aid targeting of services at those in greatest need.

The following universal services are targeted at our geographically challenged and most deprived areas  Well North’ anticipatory care projects in North West Sutherland and Skye and Lochalsh, carried out 189 health checks against a target of 57.  Argyll & Bute have set up an annual programme to tackle remote and rural access through visits to the Islands. The 5 day visit to Coll and Tiree visit included a mental health workshop within a primary school, Safetalk training and a health quiz.

NHS HIGHLAND – ANNUAL REVIEW – MONDAY 22nd JUNE 2010  Implementation of Girfec (getting it right for every child) – within Argyll &Bute this includes tackling issues around transition from child and adolescent mental health services to adult services and support.  Progress within the Caithness Partnership Health Improvement Forum includes: establishment of a breastfeeding group within the Ormlie Community Association young mothers’ group; vegetable planting by a children’s group; Caithness College practical training for employability programme included clients with learning disability.  Condition Management Programme: NHS Highland, in partnership with Jobcentre Plus, supports people who are in receipt of Incapacity Benefit/Employment Support Allowance and who have health issues preventing them moving into work or training. Since 2004, the team in Argyll & Bute has seen 1414 customers. The Highland team (which covers Orkney) has seen 1121 customers since April 2007.  Breastfeeding peer support groups have been established in areas of high deprivation.  The Healthy Working Lives advisors actively promote the National employability initiative Fit for Work Service.  NHS Highland participates in the Jobcentre Plus Local Employment Partnership. This programme provides subsidies to companies who offer short term work (at least 26 weeks) to customers of Jobcentre Plus who have been claiming Jobseeker’s Allowance for six months or more

We are ensuring a coordinated approach to tackling health inequalities, informed by the Equally Well Implementation Plan (Scottish Government 2008) through the Early Years Framework by  Detailing how health inequalities are addressed through action to implement the Early Years Framework (Scottish Government 2008).  Detailing how redesign of maternity services through the GIRFEC Midwife post will ensure pregnant women with high levels of need access appropriate care to better manage risks.  The development of an infant feeding pathway with identified approaches to developing peer support in local communities where there is acknowledged disadvantage and access to peer support for women who may be disadvantaged in communities not defined as such.  Ensuring that GIRFEC approaches to assessment and intervention in the early years capture and address where disadvantage may result in poor health and other adverse outcomes  Detailing how integrated children’s service partners will further develop integrated community/school orientated approaches to intervening and addressing health and social need for the most vulnerable children and young people.  Considering the needs of children and young people where parental alcohol and drug misuse takes place.  Supporting the development and implementation of interventions that are evidenced based to offset disadvantage in the early years  Ensuring access to and uptake of benefits to support low income families

We tackle the inequalities faced by our hard to reach groups through specific service provision:  Clinical nurse specialist for Hepatitis C continues to attend prison twice monthly and liaises with Highland Sexual Health, prison health service and community services to provide continuity of testing, treatment, care and support.  Public Health Consultant raising awareness of Bowel Screening Programme to client groups which may not have permanent home addresses.

NHS HIGHLAND – ANNUAL REVIEW – MONDAY 22nd JUNE 2010  SE Highland CHP’s Health Improvement Nurse for Vulnerable People has developed a service linked to the Highland Council’s Housing Service for people presenting themselves as homeless and holds sessions with clients at Inverness Day Centre, Cale House, Nairn Courthouse and with members of Gypsy Traveller community.  Highland Homeless Trust (HHT) – Active Referral Scheme. HHT’s key partners in the scheme are NHS Highland, Highland Council and Inverness Aquadome. The scheme was established with the aim of providing a minimum of 25 supported individual interventions and 20 supported group interventions during the year 2009-2010. As at 31/3/2010 there have been 128 supported individual interventions and 64 supported group interventions and the scheme has 83 registered members with a wide range of activities (e.g. football, fishing, walking, gym). Qualitative success on this particularly vulnerable and isolated client group has also been measured e.g. clients with alcohol problems abstaining while training for football. The scheme reached the “active communities” final stages of the Physical Activity and Health Alliance’s national awards.  Highland Council and NHS Highland – Highland Care Programme Approach Co- ordinating service finalised protocols and flowcharts in December 2009, aimed originally at preventing homelessness among CPA clients, the flowcharts are useful for preventing homelessness among any vulnerable group. Widely distributed.  Inverness Homeless Day Centre (SE CHP): the day centre has 3 “customised employment support workers” working with the GP and CPN(A) in the health team to support patients on opiate detox or maintenance programmes to access training/education/work.  The nurse covering homeless clients in Dunoon, Bute, Kintyre & Mid Argyll dealt with over 250 referrals and healthcare assessments during 2009.

Main Challenges  Developing a monitoring framework to monitor changes in our inequalities at a local level.  Ensuring universal services are both accessible to all and also targeted to those in greatest need.

NHS HIGHLAND – ANNUAL REVIEW – MONDAY 22nd JUNE 2010 AGENDA ITEM 5: SHIFTING THE BALANCE OF CARE TOWARDS PRIMARY AND COMMUNITY CARE

The examples detailed in this section provide some detail of the progress being made by NHS Highland in the eight improvement areas identified as key to the delivery of the national and local outcomes and targets. These are to  Maximise flexible and responsive care at home and support for carers.  Integrate health and social care and support those in need and at risk.  Reduce avoidable unscheduled hospital attendances and admissions.  Improve scheduled care capacity and flow management.  Extend services by non medical practitioners outside acute hospitals.  Improve access to care for remote and rural populations.  Improve palliative and end of life care.  Improve joint use of resources.

5.1 EXTENDING THE ROLE OF COMMUNITY NURSING

Over the past 2 years a further 44 non medical prescribers have undergone training bring NHS Highland total to over 250. The staff who have undertaken the training come from a variety of backgrounds including nurses, physiotherapists, radiographers, podiatrists and optometrists. In recent years a more targeted approach has been taken to ensure those who are training as non medical prescribing will:  Benefit patient care and access to medicines  Make better use of professionals knowledge and skills  Make services more efficient

5.2 MENTAL HEALTH

5.2.1 DEMENTIA Target T9: Each NHS Board will achieve agreed improvements in the early diagnosis and management of patients with dementia by March 2011. The number of people recorded on practice registers increased by 6%, from 2069 in March 2009 to 2188 in March 2010, towards a target of 2659.

Main Achievements  Commencing full operation of a specialist memory clinic for people aged under 70 years based at Raigmore Hospital in Inverness. This clinic has markedly reduced delays in diagnosis in this age group.  Re-designing mental health services in Argyll and Bute to release money for investment in mental health community services for older adults.  Commencing a partnership with the University of Stirling’s Dementia Services Development Centre to make best practical use of existing academic knowledge in the care of people with dementia.  Identifying best practice in care for people with dementia care in rural areas as part of the work with the University of Stirling, and agreeing a memory clinic expansion in Highland as a result of this work.  Identifying reasons that some people, who are known to have dementia, are not recorded on practice registers, and developing a method of working with practices to reduce this.

NHS HIGHLAND – ANNUAL REVIEW – MONDAY 22nd JUNE 2010 Main Challenges  Lack of belief by some professionals and some members of the public, of the value of having a dementia diagnosed. We plan to work with Alzheimer’s Scotland to raise awareness when the first phase of the wider memory clinic network is launched. We will deliver professional training through the new link with the University of Stirling.  Limited availability of organised support immediately after diagnosis. We are re- designing two services to increase capacity for this, and will expand the model to other areas of Highland if it successful.  Making psychological services available in this age group. We are examining options for the wider delivery of therapies within existing resource.

5.2.2 ANTI-DEPRESSANT PRESCRIBING Target T3: Reduce the annual rate of increase of defined daily dose per capita of anti- depressants to zero by 2009/10, and put in place the required support framework to achieve a 10% reduction in future years Although NHS Highland has been behind trajectory during 2009/10, we remain below the Scottish average prescribing rate. Work on this target has focused on making alternative therapies more available.

Main Achievements  Redesigning services in the Argyll and Bute CHP to release resource for re-investment. The CHP will be able to appoint 1.7 new Clinical Psychology posts and 5 new CBT posts in 2010/11.

Main Challenges  Improving information availability to allow better planning and monitoring. Although information on Clinical Psychology waiting lists is fairly well developed. This does not include all individuals waiting for a named therapy, as some therapies are delivered by other practitioners.  Redesigning service delivery to increase therapy availability. Existing service arrangements cannot deliver the required volume of therapies, so a wider range of therapies and delivery methods will be required.

5.2.3 PSYCHIATRIC READMISSIONS Target T4: Reduce the number of readmissions (within one year for those that have had a psychiatric hospital admission of over 7 days by 10% by the end of December 2009) The NHS Highland target was to reduce to 289 readmissions. The latest available information reports that NHS Highland had 234 readmissions for the period ending September 2009. The readmission numbers have been consistently below the trajectory for the last two years, and it seems likely that the target will be achieved at the final measurement.

Main Achievements  Developing a system to provide information to Community Mental Health Teams on admissions and readmissions  Linking Mental Health SPARRA information to Care Programme Approach and Compulsory Treatment Order information in the Highland Council area to provide Community Mental Health Teams with better information on readmission risk

5.2.4 ARGYLL AND BUTE MENTAL HEALTH REDESIGN PROJECT The reduction of mental health beds in Argyll & Bute Hospital will release resource to deliver the planned community care model. This will facilitate

NHS HIGHLAND – ANNUAL REVIEW – MONDAY 22nd JUNE 2010  Dementia redesign- putting in place a creative partnership with Alzheimer Scotland and aligning to our Mental Health Network as part of the redesign to embed economy of scale and practical response to service need, improving continuity of care and sharing good practice. Alzheimer Scotland have commenced recruitment to support worker posts.  Introduce a new Primary Care Mental Health Worker role aligned to GP Practices working to a new model of early stage Mental Health assessment.  Cognitive Behavioural Therapy (CBT) Practitioner role to be developed and delivered in Localities improving local access to specialist services..

5.3 DENTISTRY

Target H2: 80% of all 3-5 year olds registered with NHS Dentist Access for all patient groups is increasing in Highland and this target was achieved in the quarter ending 30 September 2009 and has been sustained since then. This has been the result of expansion in both the salaried and independent contractor sectors and continued prioritisation of access for children and the roll of the Childsmile programme which promotes the benefits of registration from the earliest opportunity. (Figure 1)

Age September 2009 Groups 0-2

18-64

3-5

6-12

65+

65-74

75+

Adults

Children

Oral Health Improvement in 5 and 12 year olds One of the dental targets set by the Scottish Executive in 1999 was that at least 60% of P1 and P7 children should be free of obvious decay experience by the year 2010. The charts below show the proportion of P1 and P7 children in Northern Highland with no obvious decay experience since 2004 and 2001 respectively. The target for P1 children was achieved in 2008. P7 data for 2009 is not yet available.

NHS HIGHLAND – ANNUAL REVIEW – MONDAY 22nd JUNE 2010 Proportion of P1 children in Highland (excluding Argyll & Bute CHP e

c 2004/2006) with no obvious decay experience n e

i 100 r e

p 90 x e

80 y

a National target for P1 children by 2010

c 70 e d

60 s

u 50 o i v

b 40 o 30 o 56.0 60.3

n 52.5

h 20 t i

w 10

% 0 2004 2006 2008

Proportion of P7children in Highland (excluding Argyll & Bute CHP) with no obvious decay experience 100

y

a 90 c e

d 80 National target for P7 children by 2010 s 70 u e o c i n

v 60 e b i r o 50

e o p

n 40 x

e h t i 30 55.2 59.4

w 48.0 20 % 10 0 2001 2005 2007 (2001 data from Scottish Health Boards' Dental Epidemiological Programme)

Main Achievements  Continued roll-out of integrated Childsmile programme across NHS Highland.  Undergraduate training continues to expand at the Inverness Dental Centre with BDS outreach students attending for the second year and the second cohort of BSc Oral Health Science students from the University of the Highland and Islands Millennium Institute starting their course in September 2009.  Construction of Campbeltown Dental Access progressing such that undergraduate training for students from Glasgow University Dental School will commence in January 2011.  The siting of the Inverness Dental Centre on the Raigmore Hospital site is facilitating the development of integrated care pathways for medically compromised patients into dental services.  Participation of independent contractors in the Dental OOH service is increasing.

Main challenges  Recruitment and retention of clinical staff in rural areas.

NHS HIGHLAND – ANNUAL REVIEW – MONDAY 22nd JUNE 2010  Achieving consistency in decontamination compliance across the salaried and independent contractor sectors.  Accessing training to support the development of enhanced services in primary care (e.g. orthodontics).  Uncertainty regarding funding for national oral health improvement programmes.

5.4 PHARMACY

5.4.1 SMOKING CESSATION SERVICE The increased involvement of Community Pharmacists in delivering direct primary care services increases the availability of services for smokers wishing to quit. In the 12 months ending 31 January 2010, 821 people accessed this service. A total of 60 patients either did not consent to follow-up, had died or no quit date was returned on the form, giving a cohort in the period of 761. Out of this cohort 301 had quit at the 4-week follow-up (39.6%). An average of 262 nicotine replacement supplies per month was made for the same period.

5.4.2 EMERGENCY HORMONAL CONTRACEPTION (EHC) SERVICE This service provides increased availability at weekends when other providers may not be available and contributes to the reduced numbers of unwanted pregnancies. In the 12 months ending 31 January 2010, an average of 212 nicotine replacement supplies per month was made.

5.4.3 MINOR AILMENT SERVICE (MAS) This service provides increased access to primary care, with eligible patients having immediate access to community pharmacies for minor ailments rather than having to make an appointment to see a GP. By February 2010, 34,054 patients were registered in NHS Highland for the Minor Ailments Service, and 59,932 items were dispensed in the 12 months ending 28 February 10. The average cost per dispensed item was £2.30.

5.5 OTHER EXAMPLES OF SHIFTING THE BALANCE OF CARE

Remote Monitoring of Patients with Long Term Conditions Patients with Chronic Obstructive Pulmonary Disease (COPD) on the Isle of Bute are benefiting from the installation of telehealth monitoring equipment which allows a patient’s condition to be monitored remotely from their own home. Patients with COPD use the monitor to take and record vital signs on a daily basis, as well as answering a series of questions on their general state of health. This information is then transmitted remotely to the primary care team who monitor the daily results and using the trended data, can anticipate any deterioration in the patient’s condition and proactively treat this before a crisis occurs. Evaluation of the telehealth monitoring systems in Bute is almost complete and indicates a reduction in interactions with the formal healthcare system for those patients who use the monitors. Qualitative evaluation from both the service users and the healthcare staff involved in the project has been very positive.

Anticipatory Care NHS Highland has developed an Anticipatory Care Patient Alert (ACPA) for patients at high risk of admission or readmission to hospital. Patients at high risk are identified by primary care teams using various case-finding methodologies. In discussion with the patient and their carers, an alert form is then developed which identifies proactive measures that can be put in place in the event of an anticipated decline in a person’s condition.

NHS HIGHLAND – ANNUAL REVIEW – MONDAY 22nd JUNE 2010 This information is shared with the Out of Hours Hub and the patient holds a copy of the information in their own home so that the information can be used to assist decision making in the event of a crisis. By the end of March 2010, 2,079 ACPAs had been developed for patients across NHS Highland. Evaluation of the impact of ACPAs on reducing preventable hospital admissions and lengths of stay is in the process of being concluded, however the initial results indicate a reduction in unscheduled admissions and occupied bed days for this cohort of patients. Further evaluation and analysis is required to ascertain whether this reduction in admissions/OBDs can be attributed to the development of ACPAs.

Self Management It has been recognised that provision of effective, co-ordinated supported self management can best be achieved when organisations work together to develop and provide access to self management support and education. To this effect, a partnership organisation with members from a variety of voluntary organisations, health and social care has been set up within the NHS Highland region to take forward self management opportunities. The partnership named ‘Let’s Get on With It Together’ is in the early stages of development. A 5 year vision and strategy document for the Partnership has been developed and signed off by the partner organisations and a formal workshop is planned for September 2010 to agree the operational details.

Community Rehabilitation – North CHP A variety of community rehabilitation outreach services are being developed from the Cambusavie Unit in Golspie. The initial pilot in East Sutherland has been extended to a wider geographical area with staff from the unit working with patients in their own homes to prevent admission to hospital or complete the rehabilitation process following discharge from hospital. Opportunities to develop aspects of the model elsewhere in the CHP are being sought with voluntary sector involvement in community based rehabilitation services agreed in North West Sutherland.

Community Dermatology Service The establishment of a new community Dermatology service resulted from a new approach to managing demand in Primary care. A change in the management and referral pathways for skin lesions led to the creation of a centralised receipt and vetting centre led by an experienced GP with a Special Interest and supported by Consultant Dermatologists. Despite still being in its infancy the service has already reduced the number of referrals into dermatology by 40% and waiting times by 50%, with 75% of patients now seen within 3 weeks, and all within 6 weeks. We believe that this approach will provide a solid platform to progress further initiatives to supporting shifting the balance of care. There has been considerable interest in our approach and results from colleagues across Scotland.

Optical Service – Argyll and Bute CHP Diabetic retinopathy screening has been transferred from a hospital visiting to high street Optometrists in Argyll and Bute, enhancing local access and improving take up of the screening programme.

Community Pharmacy A wide range of ‘Patient Group Directions’ enable GPs, Allied Health Professionals and nurses to provide more care to patients nearer to, or in their homes. A particularly successful example of this was during the H1N1 influenza pandemic. NHS Highland was the first Board to have to deal with an outbreak of the virus, which occurred in Dunoon. An emergency centre was rapidly established, which became a template for other areas of the country and Patient Group Directions were developed (in advance of national PGDs) to support the

NHS HIGHLAND – ANNUAL REVIEW – MONDAY 22nd JUNE 2010 centre and ensure swift and appropriate treatment of patients. Close pharmacy collaboration between hospital sites and CHPs ensured that antiviral medicines were distributed throughout NHS Highland and that a network of antiviral distribution points was ready should they be needed.

Living & Dying Well  Implementation of Highland wide ‘Just in case anticipatory prescribing project’ has allowed the provision of medication to patients in their own homes to ensure that when symptoms develop, immediate and pre-prescribed treatment is available. The provision of ‘Just in Case Boxes’ has prevented hospital admissions and allows patients the choice to remain at home if they choose to. The associated ‘Just in Case’ guideline and tools provides a safe framework for the use of palliative care medicines in the home as well as an audit trail.  Take up of the Palliative care DES has been 100% in the North and SE CHP, 85% in Mid CHP and 60% in A&B. This contractual arrangement ensures there is a systematic approach to palliative and end of life care in general practice settings. Yet all general practices have a palliative care register to monitor progress and assessment of ongoing care needs building on from the Gold Standards Framework project.  The Liverpool Care Pathway has been fully implemented across all care settings to improve care in the last few days of life. This has been audited and recommendations implemented.

Integrated Resource Framework The NHS Highland and Highland Council Partnership was one of the four successful applicants to achieve test site status within the National "Integrated Resource Framework Programme". The Partners are therefore actively mapping their resource use (in terms of cost and activity) to understand variation (in terms of allocative equity and efficiency). The aim is to understand how resource is used around specific populations (in this case the population over 65), to identify changes that we wish to make in these patterns; and to identify the methods and mechanisms that we will use to achieve this change. In the case of the Highland test site, of principal interest is the totality of resource available across the whole health and social care system for the older population and we plan to have an active, integrated approach in use by April 2011. Progress to date has enabled relatively comprehensive mapping of the NHS (albeit that there are refinements required to capture community activity in more detail) and first cuts of mapping by the two partner local authorities. The partnership has also put in place a number of closely aligned arrangements including complex case funding; voluntary organisation funding; joint community store and a "virtual ward" arrangement.

A “virtual ward” model is being piloted in Nairn and Invergordon, where financial contributions from both the Raigmore Hospital in Inverness, and the Highland Council has created a small funding pool which is being used to provide nursing auxiliaries to avoid admission and support patients at home, allowing early discharge when clinically appropriate. Following early success it is planned to roll this out more widely across the Highland Partnership area.

Redesign of Services for Older People in Cowal & Bute The implementation of the Cowal Older Peoples Joint Services Plan has resulted in the replacement of continuing Care beds in Cowal Community hospital with a community based model with anticipatory care focus supported by a joint health and social work Integrated Care Team. The traditional Consultant Gerontology model for the Victoria Annexe, Bute has been replaced with a GP and Nurse led model, with the consultant now providing outpatient and inpatient assessment for more complex cases.

NHS HIGHLAND – ANNUAL REVIEW – MONDAY 22nd JUNE 2010 AGENDA ITEM 6: FINANCE AND EFFICIENCY, INCLUDING WORKFORCE PLANNING & SERVICE CHANGE

6.1 PERFORMANCE AGAINST EFFICIENCY TARGETS

Target E4.1: NHS Boards to deliver agreed improved efficiencies to increase the use of day surgery by March 2011 NHS Highland has continued to increase its use of day surgery during 2009/10 – from 69.8% in March 2009 to 77.3% in March 2010 – a 7.5% increase throughout the year. Work continues towards our final target of 78.9% by March 2011. This is progressing well and actions are being taken to improve data recording of procedures carried out in outpatient settings, and enhance pre-operative assessment. There is currently no purpose-built day surgery facility within NHS Highland. Although planning is well under way for the construction of a dedicated Day Care Unit, it is unlikely that this will be available until 2012, but interim plans are being finalised for the use of a dedicated mobile day case theatre from mid 2010.

Target E4.3: NHS Boards to deliver agreed improved efficiencies to reduce the ratio of return to new outpatient attendances by March 2011 Throughout 2009/10 NHS Highland has remained ahead of trajectory with an average of 2.05 return appointments for every new appointment. Through our 18 week Referral to Treatment programme we have instigated, in a number of specialties, a review of return outpatients and identified a number of patients who don’t need to be seen by Consultants. This is freeing up outpatient appointments to increase capacity for new patients.

Target E4.4: NHS Boards to deliver agreed improved efficiencies to reduce the number of patients who fail to attend for their first outpatient appointment by March 2011. NHS Highland has always had one of the lowest “Did Not Attend” rates in Scotland. During 2009/10 we have maintained a small but steady reduction through the year – from 7.8% in March 2009 to 7.0% in March 2010 and we remain on course to achieve our target of 6.9%. One of the main reasons for this improvement has been the development of the NHS Highland Booking service, already detailed in Action Point 5 from the Annual Review 2008/09. To support this work NHS Highland has actively involved patients and patient representatives and has carried out an Equality and Diversity Impact Assessment.

Main Challenges  Mental Health Services have a particularly high number of “Did Not Attend” patients – joint work between the 18 Referral to Treatment Programme and the Mental Health Collaborative are seeking to identify appropriate actions for the patient group involved.  Ensuring continued adherence to NHS Highland’s Patient Access Policy  Ensuring that implementation of the Patient Access policy and the new booking procedures do not inadvertently disadvantage any particular patient groups.

Target E8: NHS Highland is required to reduce emissions over the period to 2011 NHS Highland was expected to reduce its energy consumption and carbon emissions by 4% by March 2010. As at the end of March 2010, we had reduced both of these by over 9.5% - more than double our target reduction.

Main Achievements  Disposal of old Hospital Buildings i.e. Glencoe Hospital has contributed to the improvement in our energy consumption  Despite doubling the size of Nairn Hospital, the increase in energy consumption has been negligible due to the efficiencies of modern design and replacing the old heating system with a gas fuelled boiler.

NHS HIGHLAND – ANNUAL REVIEW – MONDAY 22nd JUNE 2010  Plans now in place to replace old inefficient boilers in 5 larger sites with new and more efficient biomass boilers.

Main Challenges  Improving the knowledge and skill base of staff to ensure that efficiencies are maximised  Maintaining momentum with staff through newsletters and poster campaigns  Shifting accountability for reduction on emissions from the Estates Departments to Operational units  Having achieved significant reductions during 2009/10, the ability to maintain a similar level of reduction is challenging

Target E9: NHS Highland is required to achieve universal utilisation of the Community Health Index number for radiology requests For the last 6 months, at least 98% of the 130,000 radiology requests received within NHS Highland during 2009/10 have included the community health index number, against a target of 97%.

Main Achievements  Extensive advice and support provided to clinical staff across the area and individual dialogue within different areas and shift patterns to solve specific and individual problems.  Wristband and label printers rolled out across Highland which improved general standards of clarity of information, accuracy, and patient safety.  Regular visits to key areas and process reviews in A&E and radiology across all CHPs.  Community Hospitals produced very good returns including several 100% returns for consecutive months. This reflected processes put in place such as internal audits, as well as a high level of interest, and work undertaken, by staff in these areas.

Main Challenges  Staffing issues e.g. A&E out of hours, combined with a high level of temporary residents at peak times e.g. holidays, Christmas, etc.  Geography, particularly where key areas of non-compliance were not close to the project base.

Target E10: 80% of staff within NHS Highland are required to have had a KSF/PDP review, completed and recorded on E-KSF by March 2011 By the end of March 2010, 4.59% of staff with a KSF Development Review had it recorded on E-KSF. 100% of staff have KSF outlines approved on E-KSF.

Main Achievements  Development of a range of short guidance documents, and revised and simplified paperwork to support staff in using e-KSF.  Two additional functions on e-KSF have been activated to further support managers and staff to use the system: “Complete on Paper “ and “Delegated Secretary Access rights”

Main Challenges  Competing priorities for operational managers.  IT infrastructure, access and skills. 6.2 FINANCIAL & WORKFORCE PLANNING

6.2.1 FINANCIAL PERFORMANCE & PLANNING.

NHS HIGHLAND – ANNUAL REVIEW – MONDAY 22nd JUNE 2010 Main Achievements  Delivery of all financial targets within the minimum revenue uplift to Scottish NHS Boards of 3.15%, and significant in year cost pressures - particularly prescribing, and fuel/energy and locum costs which have a disproportionate impact on geographically large, remote and rural Boards. Specific financial achievements were: . Revenue underspend against Agreed Revenue Target - £79,000 (0.01%) . Capital Breakeven against Agreed Capital Target . Cash Requirement Break even against Cash Requirement  Delivered total Savings of £15.5m of which £11.3m was recurring and £4.2 non- recurring.  Fully cleared underlying deficit at start of 2009/10

Main Challenges – 2009/10  Delivery of balanced financial position, and significant savings, with removal of underlying deficit alongside the ongoing delivery and development of safe, high quality patient services.  Delivery of savings plan of £15.6m of recurring savings.

Main Challenges - 2010/11 and beyond  The need to deliver recurring Savings Programme of £15m under the Board’s Efficiency and Re-design Programme based on savings required for 2010/11 - £10.8m and £4.2m savings carried forward from 2009/10.  Work underway on Efficiency and Re-design Programme but not yet complete. This is being undertaken under 11 Programmes of work which build on previous work plans and cover: . Corporate Services Re-design . Improve and develop use of Technology . Prescribing and drugs . Service Re-configuration – Bed Re-configuration . Consistency of Care and Clinical Variation . Scheduled Care . Unscheduled Care . Tertiary Services . Workforce - Nursing and Allied Health Professional . Workforce Efficiency and Effectiveness . Property, Estates, Facilities and Energy

Although good progress to date, building on previous work, it is becoming increasingly challenging as the more complex savings areas are progressed, coupled with the need to cover any emerging in year cost or activity pressures, including any potential variation in the level of Supplementary In year Allocations.  Continued efficiency improvements in the delivery of Support Services, including the appropriate development and application of National Shared services initiatives to ensure the maximum application of resource to front line services.  Delivery of the challenging Capital Programme. This is becoming more challenging due to the reduction in capital resources available, and the increasing need to devote additional resource to backlog maintenance and the refurbishment of the existing estate.  Future allocation reductions, with uncertainty of longer term future NHS allocations against growing public expenditure constraints, and the 2010 Comprehensive Spending Review which is unlikely to translate through to Scottish NHS Board allocations until the end of 2010.

NHS HIGHLAND – ANNUAL REVIEW – MONDAY 22nd JUNE 2010 6.2.2 INTEGRATION OF WORKFORCE WITH FINANCIAL AND DELIVERY PLANNING

Main Achievements  The integrated approach to the Scenario Workforce Plan in the Board’s Local Delivery Plan 2010/11.  NHS Highland Workforce Plan currently under development. Outline Workforce Plan indicating the main workforce challenges and key workforce plans submitted to Scottish Government Workforce Directorate on 30th April.  A revised strategic planning structure has been agreed which will establish an Integrated Planning Group aligning the clinical, service, workforce and financial planning functions in the Board. This is supported by a Workforce Planning and Development Sub Group, which is now up and running with finance, service planning and staff side representation.  NHS Highland workforce planning function follows ‘Six Steps’ workforce planning methodology and is supported by strategic engagement with NES, North of Scotland Planning Group, and the Remote and Rural Implementation Group, as well as engagement with a range of partners including staff side and local authorities.

Main Challenges Through the development of iterative workforce plans, NHS Highland has identified three key workforce challenges:

The vulnerability and sustainability of Rural General Hospitals is a key issue for the Board – evidenced by significant recruitment challenges in medical training grades and succession planning of trained medical posts. A number of initiatives need to be developed that make rural practice more attractive and plans are in place to take this forward in specific Rural General Hospital workforce plans, developed and delivered in partnership with Boards, North of Scotland Planning Group (NoSPG), The Remote and Rural Implementation Group (RRIG) and NHS Education for Scotland (NES). CEL 28 Reshaping Medical Workforce also identifies that moving to a trained doctor service in NHS Highland is neither sustainable nor affordable.

NHS Highland’s Local Delivery Plan outlines workforce savings of £8m, to be achieved in 2010/11. Through an integrated approach to financial, workforce and service planning and the development of NHS Highland Strategic Framework, there are in place a number of workforce plans that respond to the Redesign and Efficiency Programme of the Strategic Framework that will deliver the planned workforce savings (affordability). Whilst this integrated approach provides the opportunity to reshape, restructure and retrain the workforce to respond to drivers for change and align the workforce to deliver against the NHS Highland Strategic Framework components of 'Quality care to every patient every day' and the Triple Aim of Better Health, Better Care and Better Value, workforce plans and workforce development will have to be achieved against a very different financial background than there has been in the past; and maintain service continuity alongside those significant recruitment challenges as outlined above (availability).

Role redesign (adaptability) will be a significant requirement for the Board to support service design and delivery. There are a number of initiatives underway and the Board is working with NES, linking with Higher and Further Education Establishments, through the NES Strategic Engagement and portfolio of education solutions, to develop proactive workforce education solutions specific to the remote and rural needs of NHS Highland. In addition, workforce solutions are being sought through partnership working with local authorities in Highland and Argyll & Bute, for example, Generic Support Worker development. However,

NHS HIGHLAND – ANNUAL REVIEW – MONDAY 22nd JUNE 2010 there is a risk that timelines to develop new roles may not be aligned to the changes that services are undergoing and ability of workforce to respond.

6.3 EFFICIENCY MEASURES AND BEST VALUE

Main Achievements  Delivery of financial targets including over achievement of the 2% Efficient Government savings targets by £1.8m cumulative to date.  The Board applied the best value Information Management toolkit with the report from Audit Scotland confirming that the Board achieved ‘Better Practice’ assessment in 3 of the 5 categories.  The Boards Efficiency and Re-design Programme included maximisation of the use of the current bed stock across the area, including closure of an 8 bedded ward within Raigmore to transfer services to community hospital and community services provision within localities. Similar work is on-going across all areas in Highland and will continue under the 2010/11 Work Programme described.  Continued effective and efficient Performance Management arrangements to provide appropriate public information and assurance, together with discharging the Board’s Governance responsibilities. This is delivered through the Board’s Improvement Committee and its use of the Balanced Scorecard providing focus on areas requiring improvement in performance.  The successful implementation of the National Logistics Project to ensure maximum access to national, high quality procurement and supply services.  The Board has applied national data and progressed the Integrated Resource Framework to identify areas which offer potential efficiencies, savings and service re- design opportunities, and to target resource allocation in line with need.

Main Challenges  The delivery of Best Value in the provision of Health services in a large remote and rural area.  The need to embed Best Value as an integral part of the Board work with full participation of all staff so that the approach becomes a normal and a natural part of the delivery of all NHS Services.

NHS HIGHLAND – ANNUAL REVIEW – MONDAY 22nd JUNE 2010

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