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MINUTE of MEETING of the STAFF GOVERNANCE COMMITTEE 26 May 2009 – 10:00 Board Room, Assynt House, Inverness

Present Mrs Anne Clark, Non-Executive Director (Chair) Dr David Alston, Non-Executive Director Ms Pam Courcha, Non-Executive Director Mr Colin Punler, Non-Executive Director Mr Ray Stewart, Employee Director

Also Present Mr Ian Gibson, Non-Executive Director

In Attendance Mr Ian Brown, Staff Side Representative (AMICUS) Ms Diane Fraser, Staff Side Representative (RCN) Mrs Anne Gent, Director of Human Resources Ms Judith McKelvie, Learning and Development Manager (item 10) Mr Adam Palmer, UNISON/Highland Partnership Forum Miss Irene Robertson, Board Committee Administrator

1 WELCOME AND APOLOGIES

Apologies were noted from Mr Garry Coutts, Mrs Pamela Cremin, Dr Roger Gibbins, Mr Donald Shiach and Mr Philip Walker.

2 MINUTE OF MEETING HELD ON 17 FEBRUARY 2009

The minute of the meeting held on 17 February 2009 was approved subject to the inclusion of Mrs Pamela Cremin in the list of apologies and not in the list of attendees.

3 MATTERS ARISING

3.1 Volunteering Policy

Mrs Gent advised that following the Workshop held in January the Volunteering Policy was being further refined to reflect NHS Highland’s strategic approach to volunteering. There were a number of actions to be implemented. These included the further development of the Volunteering Policy and completion of a self assessment in line with the Investing in Volunteers Standard, by end of July 2009, from which an action plan would be developed to assist NHS Highland to attain the level at which it would be externally assessed. It was proposed to bring the finalised Policy document to the September meeting of the Highland Partnership Forum and thereafter to the Staff Governance Committee meeting on 17 November 2009.

Working with you to make Highland the healthy place to be The Committee Noted that further work was being done on the Volunteering Policy and that the document would be submitted to the Highland Partnership Forum and the Staff Governance Committee for consideration at their meetings in September and November 2009 respectively.

3.2 Staff Award Ceremonies

Three Staff Long Service Award Ceremonies had taken place across Highland to cover the last financial year. The Chair reported on the ceremony held in Argyll and Bute which she and Ray Stewart had attended, the North CHP had hosted a similar event. It was noted that the Endowment Funds Committee would be giving consideration to the possible extension of the Long Service Award scheme to include members of staff on the point of retiral, who had not previously received an Award.

The proposed date for the Annual Staff Award ceremony was 25 September 2009 at the Centre for Health Science in Inverness. The Chair advised that the categories may be reviewed to align them with the principles of Better Health Better Care, nominations would be sought through the usual route. Some thought was also being given to the process in terms of timescales for shortlisting, the format of the ceremonies, etc.

The Committee Noted the position.

3.2 Staff Governance Development Session, 10 June 2009

A draft agenda had been drawn up for this event. Topics would include an overview of the Staff Governance Committee’s performance, workforce implications of Changing for the Better, workforce priorities for the CHPs/Raigmore, partnership arrangements and engagement, workforce targets (KSF, sickness absence, etc) and the shape of the future workforce.

While the event was intended primarily for the Non-Executive members, the Committee agreed that all members and attendees should be invited to attend.

The Committee Agreed that an invitation should be issued to all members and attendees of the Staff Governance Committee to attend the Development Session planned for 10 June 2009.

4 ‘FORCE FOR IMPROVEMENT’ AND THE NHS HIGHLAND WORKFORCE STRATEGY

Mrs Gent reported on the discussion that had taken place at the last meeting of the Workforce Strategy Sub Group of the Highland Partnership Forum around the development and implementation of NHS Highland’s Workforce Strategy. The focus would remain on the strategic priorities identified in terms of benefits to patient care, to staff and to the organisation as a whole, at the same time ensuring that these were in alignment with the key workforce challenges identified in ‘Force for Improvement’. The Committee noted that the Sub Group would be submitting a report detailing progress against the actions to the Board at its meeting in August 2009.

The Committee:

 Noted the progress made and the further work planned.

2  Agreed to request an update on progress for consideration at its next meeting on 25 August 2009.

5 STAFF SURVEY

Mr Stewart updated the Committee on the position. The results of the Survey had been made available to the General Managers of the CHPs and Raigmore in order for them to undertake an analysis of the findings and identify any specific issues or areas of concern for action as necessary. The Committee agreed that it would now be appropriate for the results to be published on the Intranet to ensure feedback to staff. Mr Stewart indicated that he would be pleased to give a presentation to each of the operational units, with a view to exploring the outcome of the survey in more detail.

The Committee:

 Noted the current position.  Agreed that the results of the Staff Survey should be published on the Intranet.

6 STAFF GOVERNANCE SELF ASSESSMENT (SAAT) PROCESS

There was circulated for information the completed NHS Highland Self Assessment for 2008/09 together with some supporting information. Mr Stewart took the Committee through the various documents. A number of points were raised.

Appendix B Letter from Audit Scotland dated 24 April 2009 The Committee was reassured to note that Audit Scotland was satisfied that overall NHS Highland had a robust process in place for the production of its Staff Governance Action Plan.

Audit Scotland had noted that there were a number of actions which required clear timescales to be assigned to them. Some timescales had now been set, however it was acknowledged that not all actions lent themselves to having a target timescale as they were ongoing/evolving actions.

Mr Gibson commented that many of the measures were process orientated, whereas he felt that there should have been more focus on outcomes. This point would be raised with the Audit Committee.

Appendix E 2008/09 Mandatory Statistical Information It was suggested that the information contained in this report should be subject to more rigorous scrutiny by the Committee. It was remitted to Mrs Gent and Mr Stewart to review the current and last year’s reports with a view to identifying any key differences in performance and tie this in with the Workforce Report. Areas of improvement should also be highlighted.

Overall Mr Stewart felt that NHS Highland was performing reasonably well, however there was a lack of ownership in relation to partnership working and staff governance, in some areas. There was a need to hold the operational units accountable for progress with change. It was suggested that the Staff Governance Standards should be better integrated with the Workforce Strategy, however it had been agreed to continue with the existing framework during 2008/09, although a revised approach was now planned for 2009/10.

3 The Committee expressed its thanks to Mrs Cathie Walker, Personnel Manager for her work in pulling together the information for the report.

The Committee:

 Noted the Staff Governance Self Assessment and associated documents.

7 WORKFORCE INFORMATION REPORT (INCLUDING SICKNESS ABSENCE)

There was circulated copy of the Workforce Report March 2009 by Philip Walker, Head of Personnel. Mrs Gent highlighted the need to use the information that was now available to inform actions. It was suggested that a narrative could be produced to better support the information. A number of issues were raised.

Establishment Monitoring An increase in WTE staff had been noted. This was explained in part by short term contracts, the majority of which were related to short term Government funding for specific projects. There did not appear to be a substantial increase in the core substantive workforce. Mechanisms in place to monitor advertising and recruitment procedures were being further developed, and the opportunity would be taken where possible through organisational change policies to redeploy existing staff. Mrs Gent indicated that any new monies coming into the system would also be monitored to ensure the most effective use of resources. Posts coming through Agenda for Change for banding were being monitored, further work was to be done to firm up this process.

It was noted that the numbers of WTE staff employed during February and March appeared to be above the funded level and the reason for this would be further explored. It was felt that more clarity was also needed around the Planned WTE category. It was suggested that a breakdown of the information by CHP area would provide a clearer picture and enable any trends to be identified. Information on skill mix would also be helpful.

Concern was expressed about the impact of the European Working Time Directive. There was a need for the CHPs and Raigmore to monitor the position closely in their respective areas and to respond to any developments.

The Committee agreed that it should focus on a few key areas to explore in more detail. These areas to include:

 Establishment Monitoring  Timescales in relation to PIN Policy Investigations  Sickness Absence: It was reported that a reduction in absence rates had been achieved. Mrs Gent explained the slight variation between local figures and the SWISS rate. She would arrange for the average rate, based on the national and local figures, to be obtained. Data on the use of bank and agency staff to cover sickness absence would also be useful. It was suggested that a development session might be arranged on data collection and how the information can be used.

On the point raised in relation to Employee Conduct and Concerns, it was felt that it would be helpful to have an indication of how long suspensions were lasting and consideration given as to whether suspension was the appropriate response in each case. It was suggested that a report on the use and effectiveness of the mediation service would also be helpful in due course, although this might link in more appropriately to Dignity at Work. It was noted from a national benchmarking exercise that the level of employee concerns within NHS Highland was low in comparison with many other organisations across the UK.

4 The Committee:

 Noted the Workforce Report.  Agreed to provide more rigorous scrutiny of key areas as identified above and to seek further information on these issues to inform its discussions.

8 STAFF GOVERNANCE STANDARD

8.1 Treated Fairly and Consistently

There was circulated paper from Donald Shiach, Pay and Equality Manager and Caroline Tolan, Policy Development Manager setting out the current and planned work of the Workforce Equality and Diversity Sub Group of the Highland Partnership Forum. In particular work was ongoing to progress specific issues in relation to recruitment, employment, training and development, appraisal and equal pay. The paper also highlighted the publication of the draft Equalities Bill and the implications for the work of the Sub Group.

Discussion followed on the impact assessment (EQIA) process. Consideration was being given to embedding the process into all the sub groups of the Highland Partnership Forum (HPF), and using the full HPF as a final check, to ensure that the process was applied appropriately and consistently across the area, to ensure that all Policies and Procedures were impact assessed.

The Committee:

 Noted the report, and that the EQIA Process should be embedded into the work of all the Highland Policies and Procedures.

9 AGENDA FOR CHANGE

The Committee considered a report by Donald Shiach, Pay and Equality Manager which detailed progress with the various elements of Agenda for Change (AFC). It was noted that the assimilation of staff from Whitley to AFC was complete. Work was ongoing to progress payment of arrears, and requests for reviews. The Committee acknowledged the concerns expressed about the length of time being taken to complete the review exercise.

In addition to the above work streams, work had now begun on dealing with significantly changed posts and the mainstreaming of Agenda for Change.

Noting the position, the Committee wished to record its thanks to the Agenda for Change Team for their work in progressing this project.

The Committee:

 Noted the progress made to date with all aspects of Agenda for Change.  Expressed its appreciation of the work of the Agenda for Change Team in taking forward this project.

Judith McKelvie joined the meeting

5 10 KNOWLEDGE AND SKILLS FRAMEWORK

The Chair welcomed Judith McKelvie, Head of Learning and Development to the meeting. Mrs McKelvie spoke to her circulated report which set out progress made against the Knowledge and Skills Framework (KSF) Project Implementation Plan. There was disappointment and concern expressed about the level of progress made against the 2008/09 HEAT target overall, as this was perceived to be an achievable target. The figure currently stood at 80%. The Committee recognised the competing time pressures on managers and staff, and the operational and other factors that had hindered progress in completing PDPs in some areas. However, while some challenges remained there was confidence that the 95% national target would be achieved by the deadline of 31 May 2009. The Committee acknowledged the contribution of the KSF Team in providing guidance and support to managers and staff to equip them with the necessary skills to undertake the programme.

As well as achieving the current target, the Committee emphasised the importance of maintaining the position year on year and the need to embed the process within the organisation. In this connection Mrs McKelvie outlined the work being undertaken by the KSF Team to develop the e-KSF programme, noting that an e-KSF implementation plan was being developed which would assist in the achievement of the next HEAT target and further mainstream the process. The KSF Team would also be reflecting on lessons learned and build on these. In response to a query, Mrs McKelvie confirmed that a process was in place to ensure that exemptions were followed up and that all staff should have KSF outlines and PDPs in place in the next few months. These would be monitored through e-KSF in the future.

The Committee Noted the progress made against the Implementation Plan, the development of the e-KSF Programme and the actions being taken to embed the process across the organisation.

Mrs McKelvie left the meeting Mr Stewart left the meeting

11 WORKING TIMES REGULATIONS

Mrs Gent spoke to the circulated report by Lindsey Mitchell, Medical Workforce Redesign Manager which provided an update on the current position of achieving Working Time Regulation (WTR) compliance for junior doctors within NHS Highland.

From 1 August 2009 NHS Highland will have to comply fully with all provisions of WTR which will entail all junior doctors moving to a 48 hour working week. This is from a current position of 56 hours with New Deal compliance and will require all junior doctors’ rotas to be amended to ensure that the Board meets the regulations and its legal responsibilities.

The Committee noted the current compliance levels, as detailed in the report, the work done to date within Raigmore and the CHP areas towards achieving compliance, and actions being taken/options being explored to address capacity and recruitment issues and to fill any service gaps. A query was raised in connection with two further posts proposed within the Surgical Directorate at Raigmore in addition to the bid to WTR for four posts. Mrs Gent clarified that these additional posts would be funded from within existing resources in the Directorate.

The Committee expressed concern about the issues and risks identified in relation to achieving compliance with the 48 hour week and also ensuring that rotas were compliant. There was also considerable concern about maintaining service provision, and the

6 Committee would wish to be assured that appropriate public engagement had taken place around access to services.

Mr Palmer left the meeting

Mrs Gent advised that the Board had alerted the Scottish Government to its concerns around achieving compliance. She undertook to follow up the concerns raised in relation to patient access to services. It was also agreed that an update on the position would be circulated to the Committee, providing more detailed information in terms of the risks to be managed towards achieving compliance.

The Committee:

 Noted the report.  Remitted to Mrs Gent to follow up the issue of public engagement around access to services.  Agreed that a detailed position report would be prepared and circulated to the members.

12 NHS HIGHLAND WORKFORCE PROJECTIONS

There was circulated report by Pamela Cremin, Workforce Planning and Development Manager which set out the approach taken by NHS Highland to develop workforce projections and the workforce headlines for each staff group. The overall approach to be taken to workforce planning in the current year was to support the Board’s efficiency/redesign plan. Ten High Impact Workforce Planning Actions had been developed to support this, which would form a robust Workforce Action Plan for 2009/10.

Mrs Gent spoke to the paper, identifying key workforce issues and explaining the work to be done in relation to redesign and recycling of resources, and the development of different roles and skills in order to make the best use of existing staff rather than increasing the establishment, to ensure that the workforce was both affordable and sustainable.

Having noted the issues raised in the report, the Committee agreed that workforce planning and the implications thereof would be one of the main topics for discussion at the Staff Governance Development Session to be held on 10 June 2009. The NHS Highland Workforce Plan would be submitted to the next meeting of the Staff Governance Committee in August.

The Committee:

 Noted the development of NHS Highland Workforce Headlines and workforce projections key messages.  Noted the 10 High Impact Workforce Planning Actions to be taken forward in 2009/10.  Agreed to include workforce issues on the agenda for the Staff Governance Development Session on 10 June 2009.  Noted that the NHS Highland Workforce Plan for 2009/10 would be submitted to the next meeting of the Committee.

13 NHS QIS CLINICAL GOVERNANCE AND RISK MANAGEMENT STANDARDS

7 Mrs Gent gave a brief update on the work being done towards attainment of the NHS QIS Clinical Governance and Risk Management Standards. She explained that within this process there were a number of areas which were relevant to staff governance, and accordingly a self assessment was now being undertaken, particularly around fitness to practise, to ensure that NHS Highland met the Standards.

14 STAFF GOVERNANCE ANNUAL REPORT 2008/09

There was circulated copy of the Committee’s Annual Report covering the period April 2008 – March 2009. The document gave details of the Committee’s activity during the year, and also contained progress reports from each of the operational units indicating how they were delivering on the staff governance agenda.

The Committee Agreed the Annual Report for 2008/09.

Mr Brown left the meeting

15 REVIEW OF RADIOLOGY WAITING LIST INITIATIVE PAYMENTS

There was circulated NHS Highland Internal Audit Progress Report relating to waiting list initiative work undertaken by the Radiology Department at Raigmore and the payment thereof. The report made a number of recommendations in terms of the systems and processes in place. The Committee considered the aspects of the report which were relevant to staff governance, and noted that the Audit Committee would be giving further consideration to the issues raised at its forthcoming meeting.

The Committee Noted the Report in relation to the staff governance implications.

16 FOR INFORMATION

16.1 Minute of Meeting of the Remuneration Sub Committee held on 17 February 2009

16.2 Minute of Meeting of the NHS Highland Partnership Forum held on 20 February 2009

16.3 Minute of Meeting of the NHS Highland Partnership Forum held on 13 March 2009

16.4 Minute of Meeting of the NHS Highland Partnership Forum held on 17 April 2009

The Committee:

 Noted the circulated Minutes.  Noted from the HPF minute of 13 March 2009 that applications were currently being invited for the Working Well Challenge Fund.  Noted from the HPF minute of 17 April 2009 that there had been no meetings of the Mid Highland CHP Partnership Forum since October 2008 and suggested that it may be necessary to review the position.

17 AOCB

17.1 Medical Locum Policy

Mrs Gent reported that the Clinical Governance Committee at a recent meeting had considered the Medical Locum Policy and where this should sit. The Clinical Governance Committee had suggested that the Staff Governance Committee would be the appropriate body to monitor implementation of the policy and its effectiveness, and apprising the Clinical Governance Committee of any clinical governance issues that arose. Mrs Gent advised the Committee that this issue had been formally remitted to the Medical Workforce and Planning Development Group for consideration. She would report on the outcome of their deliberations in due course.

The Committee Noted the position and would await feedback from Mrs Gent.

17.2 Preparedness for Pandemic Flu

There was discussion on pandemic flu activity and the impact on staff. Considerable work was ongoing at local level across the operational units and partner organisations to ensure the necessary arrangements were in place. It was noted that staff involved in/affected by pandemic flu activity were coping well in terms of capacity and flexible working, and were commended for their excellent response to the situation.

18 DATE OF NEXT MEETING

The next meeting will be held on Tuesday, 25 August 2009 at 10:00 in the Board Room, Assynt House, Inverness.

The meeting closed at 1:00 pm.