Highland Nhs Board s3

Assynt House Beechwood Park Inverness IV2 3BW Tel: 01463 717123 Fax: 01463 235189 HIGHLAND NHS BOARD Textphone users can contact us via Typetalk: Tel 0800 959598 DRAFT V3 www.nhshighland.scot.nhs.uk/ MINUTE of MEETING of the BOARD Board Room, Beechwood Park, Inverness 2 June 2009 – 8 30 am

Present Mr Garry Coutts, Chair Dr David Alston Mrs Ann Bethune Mr Bill Brackenridge Mrs Anne Clark Ms Pam Courcha (until 12.00 noon) Mr Quentin Cox Cllr Margaret Davidson (from 8.40 am) Mr Ian Gibson Mrs Gillian McCreath Mr Okain McLennan Mr Colin Punler Cllr Elaine Robertson Mr Ray Stewart (until 12.20 pm) Dr Vivian Shelley Dr Roger Gibbins, Chief Executive, NHS Board Dr Eric Baijal, Director of Public Health and Health Policy (from 10.10 am) Dr Ian Bashford, Board Medical Director Mrs Anne Gent, Director of Human Resources Mr Malcolm S Iredale, Director of Finance Ms Heidi May, Board Nurse Director Ms Elaine Mead, Chief Operating Officer (from 10.10 am)

Also present Ms Josephine Bown, Head of Service Integration, Argyll & Bute CHP (Item 52 by VC) Ms Judith Catherwood, Associate AHP Director Ms Suzanne Dawson, Scottish Ambulance Service (until 12.15 pm) Mr Derek Leslie, General Manager, Argyll & Bute CHP (Item 52 by VC) Ms Gill Keel, Head of Public Engagement (item 52) Mr Chris Meecham, Board Secretary Dr Ken Oates, Pandemic Flu Co-ordinator (Item 51) Mr Kenny Oliver, Patient Access Manager (Item 62) Mrs Lorraine Power, Board Services Assistant Ms Lesley-Anne Smith, Head of Clinical Governance & Risk Management (item 60)

Apologies – An apology was received from Ms Moira Paton.

The Chair welcomed Ms Suzanne Dawson, Non-Executive, Scottish Ambulance Service who was shadowing Bill Brackenridge and Ms Judith Catherwood, Associate AHP Director who was shadowing Heidi May.

25 37 Minute of Meeting of 7 April 2009

The minute of 7 April 2009 was accepted as an accurate record.

The Board a Approved the Minute of Meeting held on 7 April 2009.

38 Matters Arising

Carbon Management Implementation Plan (CMIP) – It was noted that the Carbon Management Board was meeting on 26 June and a further report would be submitted to the August Board meting.

Emergency Transfer of Patients from Islands – Cllr Robertson asked for an update on progress and Bill Brackenridge advised that it was hoped this would be operational by the end of June.

The Board a Noted that a report on the Carbon Management Implementation Plan would be submitted to the August meeting of the Board. b Recommended that the Board be advised in writing when this project is operational.

REPORTS BY GOVERNANCE COMMITTEES

39 Argyll & Bute CHP Committee – Draft Minute of Meeting held on 8 May 2009

Mr Brackenridge, Chair of Argyll & Bute CHP updated on the meeting held on 8 May 2009. He highlighted the success of the CHP in achievement of a financial breakeven position as well as having achieved £3m of Cash Releasing Savings. Mrs Gent referred to Progress with Reviews on page 3 of the minute and advised that this in fact related to equal pay reviews rather than Agenda for Change reviews.

40 Mid Highland CHP Committee – Draft Minute of Meeting held on 24 April 2009

The Chair referred to recent media interest in hospitals on Skye relating to removal of beds and advised that these actions were the same as were happening in other localities in relation to unused beds. He confirmed that there was no discussion at present relating to the future of the two hospitals on Skye. Mrs Bethune, Chair of Mid Highland CHP, advised that the figure for completed PDPs in Mid Highland CHP as at 29 May was 91%. Mrs Gent advised that this coming Friday 5 June was the absolute deadline for final figures being submitted to the Scottish Government. The Chair highlighted the importance of ensuring final figures were submitted to the Scottish Government on 5 June 2009.

41 North Highland CHP Committee – Draft Minute of Meeting held on 14 April 2009

The Board congratulated North Highland CHP on having 99% of PDPs in place. It was noted that the Community Health Partnership had worked successfully with staff and the Highland Council and agreed closure of a number of unused beds.

It was noted that the North CHP has had a prescribing deficit for a number of years. Dr Alston advised that the North CHP Committee was well briefed on the challenge in managing the financial position and were monitoring the situation. It was agreed that a report on North

26 Highland CHP Financial Position be submitted to the next meeting of the Improvement Committee. Mr Stewart referred to item 6.3 on the Staff Survey and advised that he was willing to give a more detailed presentation to localities. There was some discussion on the Government publicity campaign in relation to infection control and it was noted that a number of publicity materials including posters would be rolled-out across NHS Highland. The Chair asked members to be aware of these when they were on NHS Highland sites and asked that they give feedback. He also suggested that this should be discussed at each of the CHP/Raigmore Committees.

Dr Shelley referred to clinical governance issues in Caithness, in particular clostridium difficile and maternity services. It was noted that there had been a discussion on maternity services at an in Committee meeting. It was suggested that reference could have been made to these issues at the Governance Committee meeting which was open to the public. The Chair agreed that it was important that facts were reported in public and asked that all CHPs/Raigmore ensure that their discussions reflected the work of the clinical governance and risk management groups locally.

In relation to governance Mr Gibson referred to the previous day’s Development Session, which had been held at the Centre for Health Sciences and the lack of visibility of hand hygiene guidance. Mr McLennan, Chair of the Control of Infection Committee confirmed that this had already been picked up by the Board Nurse Director and would be followed up.

42 Raigmore Hospital Committee – Draft Minute of Meeting held on 20 April 2009

Ms Courcha, Chair of Raigmore Hospital updated on the meeting held on 20 April. She confirmed there had been a discussion on the No Smoking Policy on Raigmore site and advised that a full report would be submitted to the August Board meeting. The figure for completed PDPs at Raigmore was 94% and Ms Courcha extended her thanks to the HR team for their support with this.

In terms of vacancy management it was noted that 23 posts would not be filled. These were posts, which had been vacant for some time, and the workload associated with these roles had been redistributed through various means, including service redesign.

43 South East Highland CHP Committee – Draft Minute of Meeting held on 26 March 2009

Mrs Bethune referred to item 8.4 relating to the Nairn Hospital Development and asked if the pharmacy referred to was a hospital or community pharmacy. Mrs McCreath, Chair of South East Highland CHP advised that she would look into this.

The Board congratulated South East Highland CHP where almost 100% of staff had PDPs in place. Mr Stewart asked about PDP figures for Corporate Services and Mrs Gent confirmed that the figures were current 97% for Corporate Services, 87% for Facilities and 98% for Pharmacy. The Chair asked that once the final figures had been submitted to the Scottish Government on Friday 5 June that Mrs Gent e-mail the final figures to Board members for information. PDPs were critical to the business of NHS Highland, and it was noted that a detailed action plan was being developed on reporting and monitoring mechanisms for PDPs over the coming year, which would be considered by the Staff Governance Committee.

The Board a Noted the minutes. b Recommended that there be an item on the next agenda of the Improvement Committee on North CHP Financial Position.

27 c Recommended that the Infection Control poster campaign be discussed at each of the operational committees. d Noted that a report on the implementation of the No Smoking Policy on Raigmore site would be submitted to the August Board meeting. e Noted that final figures for PDPs would be submitted to the Scottish Government on 5 June and Board members would be circulated final details following submission. f Noted that a detailed action plan for reporting and monitoring mechanisms for PDPs would be submitted to the Staff Governance Committee.

44 Improvement Committee Assurance Report of 11 May 2009 and Balanced Scorecard

The Board noted the Improvement Committee Assurance Report of 11 May 2009 and Balanced Scorecard. The Chief Executive referred to the end of year scorecard and highlighted some of the major achievements. Some targets had been missed but many challenging targets had been met. This was being refined into an “at a glance” format for use at the Annual Review.

It was noted that there had been significant progress on smoking cessation but committees need to be vigilant in order to meet the targets for 2010.

Dr Shelley referred to access targets in relation to endoscopy and asked how this risk was being managed. Dr Gibbins asked if there was an opportunity to reduce the number of return patients. Mr Cox advised that repeat endoscopy was part of treatment management and surveillance which required to be done. There was a specific item later on the agenda in relation to Patient Access Policies, which would allow an opportunity for fuller discussion.

45 Clinical Governance Committee Assurance Report and Draft Minute of Meeting of 13 May 2009

The Board noted the Clinical Governance Assurance Report and Draft Minute of Meeting of 13 May 2009. Dr Shelley, Chair of the Clinical Governance Committee referred to the minute and advised there had been considerable debate on Clinical Governance and Risk Management in the operational units. In relation to the minutes of the DHS Management Team it was noted that these would be monitored. It had also been recommended that a Clinical Governance Forum be established where clinical governance issues could be discussed in depth and good practice shared. Dr Gibbins confirmed that these proposals would be submitted to the Corporate Team for consideration to ensure that risks were covered and the appropriate systems in place. Cllr Robertson referred to page 11 of the Assurance Report and the follow-up to the Healthcare Commission’s report on Mid Staffordshire NHS Foundation Trust. Dr Shelley advised that a detailed report and action plan would be submitted to the next meeting of the Clinical Governance Committee.

46 Area Clinical Forum – Draft Minute of Meeting of 26 March 2009

Mr Cox, Chair of the Area Clinical Forum advised that the minute of the meeting of 26 March 2009 was now confirmed, and the Forum had met again last week. An Area Clinical Forum Conference had been held the previous week and 7 members from NHS Highland’s ACF had attended. It was noted that it was anticipated that Scottish Government would re-issue guidance on the role and remit of ACFs later in the year.

Dr Shelley asked about progress in enhancing capacity in respect of Infection Control Medical Leadership given the level of work involved and the area to cover. The Board Nurse

28 Director advised that this was being progressed and it was hoped that there would be a service redesign agreed in the near future.

Mr Gibson referred to the discussion on redesign proposals and the number of managers employed in the NHS. Mr Cox advised that the minutes reflected what had been said at the meeting, although sometimes this could be unbalanced. He indicated that he did not feel that the clinical community was underestimating the challenges ahead.

Mr Brackenridge referred to the National Study of CHPs, which had been referred to as a “National Review” in the minutes and asked that this be amended.

47 Endowment Funds Committee – Draft Minute of Meeting of 6 April 2009

Mr Gibson updated on the meeting held on 6 April 2009. Mrs Gent referred to the Valuing Service Awards and welcomed the proposal to consider retrospective awards for staff with over 40 years service and those on the point of retirement.

The Board Noted a Noted the Minutes. b Noted:  that the Improvement Committee met on 11 May 2009.  the Assurance Report and agreed actions resulting from the review of the specific topics detailed and the Balanced Scorecard.  the next meeting of the Improvement Committee will he held on 6 July 2009. c Noted:  that the Clinical Governance Committee met on 13 May 2009.  the Assurance Report and agreed actions resulting from the consideration of the specific items detailed.  the items for discussion at the next meeting to be held on 18 August 2009. d Noted that proposals in relation to clinical governance and risk management would be considered by the Corporate Team to ensure that appropriate systems were in place. e Recommended that the Area Clinical Forum minute be amended to read “National Study of CHPs”.

Council/Highland NHS Board Joint Committees

48 Highland Council Partnership – Joint Committee for Children and Young People – Minute of Meeting of 13 March 2009

Ms Courcha referred to a Corporate Parenting Seminar being held by Highland Council on 25 June and asked that Board members aim to attend. It was noted that this was the same day as the NHS Highland Audit Committee meeting to consider Annual Accounts and it was agreed to look at the timings of the events.

49 Highland Council Partnership – Joint Leadership and Performance Group – Minute of Meetings of 16 February and 21 April 2009

The Chair highlighted the ongoing work on the Joint Community Care Plan. Ms Courcha sought clarification on the telecare demonstrations to be held in secondary schools to promote awareness, which was mentioned on page 3 of the minute of 21 April. The Chair

29 advised that it was recognised that many teenagers had an awareness of technology, some were young carers and with the move towards telecare in the future it could be of benefit to promote awareness of this in secondary schools. The Board Medical Director wholeheartedly supported this initiative.

Ms Courcha also asked about the Report on the Stakeholder Event. The Chair updated on this, however Mr Gibson felt that the minute did not fully capture what had been discussed and advised that another meeting should be arranged. The Chair asked that Jan Baird, Director of Community Care take this forward and ensure that regular meetings were arranged over the next 18 months.

Dr Baijal referred page 4 of the meeting held on 16 February and the reference to insufficient home carers to meet requirements. He wished to highlight this for future consideration as due to future demographics this could be a significant issue in the longer term.

There was some discussion regarding both meetings of the Highland Council Partnership and the feeling that the minutes did not reflect the debate, often did not acknowledge that debate had occurred at the meeting and did not always detail timescales. It was agreed that the Highland Council should be advised of these comments and it was suggested that it would be beneficial to have a rolling action plan for each of these committees.

The Board a Noted the minutes. b Agreed that the comments on the Joint Committee minutes should be fed back to Highland Council.

50 Argyll & Bute Health and Care Strategic Partnership

Mr Brackenridge advised that the April meeting of the Argyll & Bute Health and Care Strategic Partnership had had to be cancelled as it would have been inquorate. In view of the continuing problems in this area revised dates and chairing arrangements had been agreed.

The Board a Noted the position.

51 Governance Committee Annual Reports Report by Chris Meecham, Board Secretary

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

 Audit Committee  Clinical Governance Committee  Staff Governance Committee  South East Highland CHP Committee  Health & Safety Committee  Remuneration Sub-Committee  Risk Management Committee  Spiritual Care Committee

30 It was agreed that in future all Committee Annual Reports should be submitted to the May meeting of the Audit Committee. The remaining reports would be scrutinised by the Audit Committee Chair.

The Board a Noted the views of the Audit Committee on the Annual Reports of the Governance Committees. b Agreed that in future all Committee Annual Reports should be submitted to the May meeting of the Audit Committee.

The Board adjourned at 9.55 am and resumed at 10.10 am.

At this juncture the Chair agreed to consider items 4.5 and 5.1 on the agenda relating to Swine Flu and Redesign of Mental Health Services in Argyll & Bute. Derek Leslie and Josephine Bown joined the meeting by video conference.

CORPORATE GOVERNANCE / ASSURANCE

52 Swine Flu (H1N1 Influenza) Report by Ken Oates, Pandemic Flu Co-ordinator on behalf of Eric Baijal, Director of Public Health and Health Policy

Dr Oates updated on the current situation, which had changed since the report had been written. There had been more cases globally, as well as in the UK and Scotland and more recently in Dunoon. Contingency plans were in place in each of the operational units and anti virals had been distributed throughout NHS Highland. Dr Oates advised of recent figures and ongoing work relating to contacts. The situation was rapidly evolving, although it was still at containment phase and managers were looking at bringing in additional staff if required. Argyll & Bute Council was commended on their work, which had helped with the containment work.

The Board expressed its appreciation of the amount of work being undertaken by staff, particularly in Public Health and in Argyll & Bute Community Health Partnership. The Chair advised that the Minister had also asked that her thanks be passed onto staff.

The Board a Noted the emerging situation regarding ‘Swine’ Flu.

STRATEGY AND POLICY

53 Redesign of Mental Health Services in Argyll & Bute Report by Derek Leslie, General Manager, Argyll & Bute CHP

This paper described the background to the Redesign and Modernisation of Mental Health process in Argyll & Bute CHP, provided an overview of the process undertaken, a summary of the progress to date and the recommendation of the CHP Committee of the preferred option for implementation. It was anticipated that implementation and delivery of the preferred option would commence in September 2009, with the expectation that transition would be complete by September 2012, with the service redesign outcome as follows:

31  Primary care services with skilled staff to support GPs in treating mild to moderate mental illness.  Provision of enhanced and integrated community services offering a broader range of interventions to treat more severe and enduring mental illness and complex needs in the community.  A crisis response capability to more effectively respond to people in acute crisis, including 24 hours assessment capability in localities, reduce/avoid more admissions to hospital, treat people at home, and offer support on discharge from hospital.  Assertive outreach to tackle difficult to engage users who might otherwise disengage from care.  The closure of the existing Argyll & Bute Hospital in Lochgilphead with a redesigned bed configuration provided in a purpose built, modern environment in Lochgilphead of :

. 20-26 acute/rehab beds . 6 intensive psychiatric care unit beds . 10 dementia assessment beds . 20 dementia continuing care beds (Mid Argyll Hospital Summer/Autumn 2009)

Ms Keel highlighted the impact of the early involvement of users and carers in the consultation process, the importance of face-to-face sessions and the support of the Scottish Health Council (SHC).

Argyll & Bute CHP was commended for the consultation process it had undertaken. The Board also thanked the 560 people who had attended consultation events and all the people who had contributed to the process. Mr Gibson highlighted the need to involve the voluntary sector in the implementation process and Mr Leslie confirmed that this would happen. Mrs Gent also referred to the work in supporting staff through organisational change and confirmed that HR would work closely with Argyll & Bute CHP in this regard. Dr Shelley referred to the Education Centre, which did not appear to be detailed in the recommendations. Mr Leslie confirmed that this was detailed in section 3.2 of the report and would require further refinement. The Chair suggested that a brief summary of this service could be circulated to the Board in due course.

The Board a Noted the results of the formal consultation process. b Noted that Argyll & Bute CHP Committee had considered the outcomes of the process at its meeting on 8 May 2009. c Agreed the CHP Committee’s recommendation to the Board that option 4 be the agreed option for implementation subject to the developments described in the paper. d Noted that the eventual outcome would lead to the provision of a modern mental health service broadly summarised at paragraph 4.5 and a recommendation that Argyll & Bute Hospital would close when the redesigned service was in place. e Agreed that a brief summary of the service model would be circulated to the Board in due course.

32 CORPORATE GOVERNANCE / ASSURANCE

54 NHS Highland Financial Position as at 31 March 2009 Report by Malcolm Iredale, Director of Finance

Mr Iredale updated on the provisional year end and breakeven position for 2008/09. The position was currently provisional, pending completion of the annual audit exercise, which was underway, and would be reported to the Board in due course. The summary position was highlighted in Table 1 and confirmed that the provisional position was in line with previous projections of achievement of financial targets, with a small surplus of £60,000 on a £590m budget. This was in line with previous reports, with the non recurring application of slippage, income and central reserves to off-set any overspends within Operational Units. There were some small movements within individual Operating Units, and these were detailed in Table 2.

The cost of energy continued to be the most significant single cost pressure in year, although this would not continue into future periods with a lessening of the pressure on world wide energy prices.

The 2008/09 Savings Plan had been fully delivered, including the identification of recurring savings of some £9.4m in additional to non recurring savings £6.5m, which represented a significant achievement by Operational Units. The result of these savings meant that the Board had further reduced its reliance on non recurring resource, which at the end of 2008/09 was £8m, with further plans and initiatives in place to eliminate this entirely at the start of 2009/10, to ensure that NHS Highland has no ongoing reliance on non recurring resource.

The Board a Noted the provisional year end breakeven position for 2008/09. b Noted the full achievement of the Savings Plan in 2008/09. c Noted the 2009/10 financial position. d Noted the revised capital planning process currently under consideration.

55 Director of Public Health and Health Policy Annual Report 2008/09 Report by Eric Baijal, Director of Public Health and Health Policy

Dr Baijal presented his Annual Report to the Board in his role as Director of Public Health (DPH) for NHS Highland and Designated Medical Officer for the Highland Council and the Argyll & Bute Council. There had been a number of highlights in the past year. The Scottish Government had published a number of important policy documents, in particular the Health Inequalities Strategy “Equally Well”. We had seen the advent of the Single Outcome Agreement between local authorities and Scottish Government and the publication of the Equally Well Implementation Plan in December 2008. Dr Baijal highlighted the Board’s commitment to the public health agenda, the ongoing work on refreshing the health profile of the NHS Highland area and the Health Profile Indicators. It was noted from the comparative indicators relating to the wider determinants of health that North Highland CHP had areas of super sparsity, which were more disadvantaged and challenging.

Dr Baijal referred to partnership working in relation to drug and alcohol issues and the refreshed community planning arrangements with the Highland Council. He complimented those involved in this agenda and also thanked Dr Oates for the significant work in relation to the pandemic flu planning which meant that NHS Highland was very well prepared.

33 Regarding points for the future, social marketing was key and should be taken forward locally. There was also a focus on horizon scanning. There had been clearly evidenced progress over the past year including the development of a toolkit to give a careful and considered profile of health in the NHS Highland area. Another highlight was the action on smoking, where NHS Highland had seen a significant rise in the number of people engaging with our services and successfully quitting.

The Board welcomed the report and Dr Baijal agreed to bring out some of the action points to ensure they were embedded in the work of NHS Highland. It was agreed that consideration be given to a presentation on this report to each of the Community Health Partnerships and local authorities.

It was noted that this was the last NHS Highland Board meeting for Dr Baijal and the Board thanked him for his contribution to the Board and wished him well in his new post.

The Board a Noted the report and its implications. b Agreed that consideration be given to a presentation on this report to each of the Community Health Partnerships and local authorities.

Dr Baijal left the meeting at 11.00 am.

56 Breast Cancer Services Report by Ian Bashford, Board Medical Director

Following discussion at the last meeting of the Board it was noted that a report would be submitted to the June meeting for consideration. NHS Highland achieves the National 62 Day Target, which states that by 2005, “the maximum wait from urgent referral to treatment for all cancers will be two months.” This is significant progress but meeting the 31 day target continues to be a challenge both locally within NHS Highland and nationally.

Dr Bashford advised that the national recommendation was for one stop triple assessment, which involved examination, diagnostics and cytology / tissue sampling all in one area. In addition to this recommendation he suggested that consideration should be given, where appropriate to using appropriately trained staff in different areas, reviewing breast care pathways and reviewing capacity at Raigmore Breast Centre for the future.

Reference was made to the Chetty Report, which identified a number of issues affecting the delivery of the symptomatic breast service in NHS Highland. The implementation of this report had been monitored locally through the production of an Action Plan, which was most recently updated in March 2009. This provided further recommendations on the two outstanding urgent actions within the Chetty Report. These were:

I. The need for a review of the diagnostic service provided across all sites to ensure that women receive equitable quality of care. II. The development of a timed pathway for a pan Highland Breast Service involving teams in rural general hospitals.

Dr Bashford highlighted the lack of a breast surgeon on the Western Isles and in Elgin and the issue of the number of surgeons due to retire and advised that Mr Chetty had been commissioned to undertake additional work for NOSCAN to review the current configuration and quality of breast services throughout the North of Scotland, consider the profile of the entire clinical workforce and make recommendations on the development of a sustainable service fit for the future.

34 There followed a detailed discussion on the proposals. It was noted that there was a general surgeon based at the Belford Hospital who was an accredited breast surgeon and there was some discussion on the use of this resource. Issues were also noted in relation to radiologist availability and theatre capacity. It was agreed that there should be an additional recommendation “to maximise the use of all skills and capacity in a single managed service which draws together all clinicians in a multi-disciplinary team”.

The Board agreed that Raigmore Hospital would be the one-stop centre of the Highland Breast Service for “triple assessment” of patients from the Highland Council area. Patients in Argyll and Bute receive services from NHS Greater Glasgow and Clyde. Triple assessment requires mammography and specialist ultrasound, which can only be provided at one centre in NHS Highland.

The Board would explore further ways of maximising the capacity of the two breast surgeons in Raigmore, and another general surgeon at Belford Hospital who is a qualified breast surgeon. A single, managed breast service throughout NHS Highland will be established, delivered by the multi-disciplinary team.

Further work was required to clarify the range of treatments and surgical procedures, which could be carried out safely and appropriately in our Rural General Hospitals.

The Board a Noted the challenges in achieving the 31 day National Target for patients to be treated following referral. b Noted the measures put in place in 2009 in order to improve capacity within the service. c Agreed that the breast service for north NHS Highland patients should be a single managed service that maximises all skills and capacity as part of a managed multi- disciplinary team. d Agreed the recommendations, particularly those to establish a one-stop triple assessment service within the Highland Breast Centre at Raigmore for all North Highland patients and to maximise the use of all skills and capacity in the Rural General Hospitals, where appropriate. e Agreed the recommendation that once all local capacity has been fully utilised further work should be commissioned to review demand, capacity and activity of the NHS Highland Breast Service. f Agreed that there should be a further report on the implementation of the principles, to evidence that all potential skills and capacity are being fully used so that patients are seen as quickly and safely as possible g Noted the NOSCAN commissioned work.

57 Infection Control Update Report by Morag Greenshields, Infection Control Manager on behalf of Heidi May, Executive Lead for Infection Control

Ms May updated the Board on a range of infection control issues. The levels of Staph. aureus bacteraemias (SAB) were very low in NHS Highland and the report detailed the trend in SAB (both MRSA and MSSA), along with the baseline rate and the target (30% reduction in baseline rate). SAB numbers for both February and March were below the target rate.

35 The Scottish Government has provided funding to NHS Boards for the purchase of Steam Cleaners to facilitate improved cleaning standards in healthcare premises. NHS Highland will receive an allocation of 16 steam cleaners, which will be distributed at various locations in Highland. The Scottish Government has also provided additional funding to NHS Boards to support the recruitment of additional cleaners for NHS Scotland. The NHS Highland allocation is £270,604 (2009/10) and £324,725 (2010/11). The priority areas of need are currently being identified and may include cleaning hit squads. In the first three months of this year the Infection Control Team noted a heightened number of cases of Clostridium difficile infection (CDI) in Caithness General Hospital, concentrated on one ward. As part of the scheduled national “snapshot” programme for C difficile typing, two of four isolates from Caithness General Hospital, typed as the hyper-virulent strain 027. This prompted an immediate retrospective review of cases at Caithness General Hospital. Of the 9 cases of C difficile in February and March this year at Caithness General Hospital, 7 isolates were obtained for typing, five have returned as type O27. 3 patients who died during this period had C difficile noted as a contributory factor.

Heidi May outlined the actions, which were put into place to address this situation. These included patients with C difficile nursed in single rooms and discussions regarding antimicrobial prescribing with the medical clinicians. This had resulted in a significant reduction in the local prescribing of third generation cephalosporins.

During discussion it was noted that the public perceive CDI as associated with hospital cleanliness but the highest impact is through better antibiotic prescribing. It was confirmed that prescribing advisers were working with GPs on this. The Control of Infection Committee was to receive a proposal regarding norms for antibiotic prescribing.

Heidi May confirmed that the “triggers” for heightened alerts were being reviewed and that there is a programme of environmental audits for all hospitals.

The Board a Noted the contents of the Report.

58 Zero Tolerance to Non Hand Hygiene Compliance – NHS Highland Response Report by Una Lyon, Lead Nurse, Raigmore Hospital on behalf of Heidi May, Board Nurse Director

The Cabinet Secretary for Health and Wellbeing announced in January 2009 that a Zero Tolerance approach to non compliance with hand hygiene was to be adopted across the NHS Board areas. The CEL(2009)05 set out the requirements of Chief Executives and described the roles and responsibilities of various staff groups.

It was agreed that Zero Tolerance within NHS Highland required all staff to:

 adhere to the NHS Highland Hand Hygiene Policy and comply with the World Health Organisations ‘Your 5 Moments for Hand Hygiene and the six steps of Hand Washing’.

 achieve 100% in Hand Hygiene Compliance and Hand Hygiene technique with less than 90% being unacceptable

The Board discussed what would happen if someone did not comply. It was clarified that any such staff would receive further education and training and would be reassessed. If anyone ever wilfully refused to comply, this could potentially result in disciplinary action but each case would have to be reviewed on an individual basis. A question was raised in relation to compliance in the community, including GP practices, care homes etc. and it was suggested that the Control of Infection Committee should consider this in more detail.

36 Dr Shelley referred to the governance implications and in particular Patient and Public Involvement and highlighted that this should capture more than Highland Health Voice and Patient Council representatives.

The Board a Supported the implementation of a policy on Zero Tolerance to non hand hygiene compliance across NHS Highland. b Remitted to the Control of Infection Committee to consider compliance in the community in more detail.

59 Infection Control Annual Work Plan 2008/09 – End of Year Report Report by Morag Greenshields, Infection Control Manager on behalf of Heidi May, Executive Lead for Infection Control

In 2003 the Chief Medical Officer identified the prevention and control of Hospital Acquired Infection (HAI) as a high profile priority issue for NHS Scotland. This resulted in the development of the NHS Scotland Code of Practice for the Management of Hygiene and HAI. With effect from May 2004 all NHS Boards were instructed through SEHD / CMO (2004) 9 to implement the Code of Practice with immediate effect. Section 7 of the Code of Practice - Compliance Management, requires Boards to develop an annual infection control and monitoring programme. The 2008/09 Infection Control Work Plan was submitted to and approved by the Board on 5 August 2008. The report provided an update on the end of year position.

Ms May highlighted improved outcomes regarding reviewing single rooms and increased use of patient councils and areas for focus such as training and education.

The Board a Noted the Infection Control Work Plan 2008/09 End of Year Report.

60 Infection Control Annual Work Plan 2009/10 Report by Morag Greenshields, Infection Control Manager on behalf of Heidi May, Executive Lead for Infection Control

The purpose of this report was to provide a revised Annual Infection Control Work Plan for 2009/10. This was signed off by the NHS Highland Control of Infection Committee on 6 May 2009. A total of fifteen activity areas were identified for inclusion in the Infection Control Work Plan 2009/10. These include:-

1. The Local Delivery Plan – HEAT Targets 2. Corporate Objectives 3. Monitoring Healthcare Associated Infections (HAI) 4. Decontamination & Sterilization 5. Enhanced Environmental Cleaning 6. Immunisation 7. Policy Reviews 8. Pandemic Flu 9. Education 10. Audit 11. Advice & Support 12. Public Information and Involvement 13. Development of Infection Control Service for NHS Highland

37 14. Scottish Government Policy 15. Clinical Governance & Risk Management

Detailed information in respect of each activity was contained in Appendix 1.

The Board a Approved the Infection Control Work Plan 2009/10.

Mr Stewart left the meeting. The Board adjourned at 12.20 pm for lunch, and resumed at 12.50 pm.

61 Scottish Patient Safety Programme (SPSP) – Progress Report Report by Lesley-Anne Smith, Head of Clinical Governance and Risk Manager on behalf of Ian Bashford, Board Medical Director

In NHS Highland we believe that patients should be cared for in a safe environment that minimises risk. This means that we must continually and systematically review and improve our health care processes and working practices to prevent or reduce the risk of harm. NHS Highland has therefore set aims:

 To have a culture where patient safety comes first  To have no avoidable deaths or harm in our care

Dr Lesley-Anne Smith updated on progress on the Scottish Patient Safety Programme in terms of the current position and work of front line teams on various hospital sites. It was noted that there had been general improvement in Early Warning Scores (SEWS Charts). A considerable amount of work had been done in relation to accurate recording on the SEWS chart. This had resulted in the redesign of the chart in order to make the process of completion easier. The chart was now being rolled out to the rest of Highland. Regarding Medicines Management, a number of examples of improved patient care had been identified as a result of introducing a revised process and this was being fed back to staff to support the implementation. The success achieved in this area resulted in the Team being asked to present their work to the national Learning Set in May.

The Board a Noted the progress on the Scottish Patient Safety Programme within NHS Highland as a March 2009.

62 Chief Executive’s and Directors’ Report – Emerging Issues and Updates Report by Roger Gibbins, Chief Executive

This month’s report incorporated updates on:

 Annual Review Action Plan  Dental Leadership Group  eHealth Strategy Update  Governance Arrangements – Update following Review in June 2008  No Smoking Policy – Implementation in Operational Units  North of Scotland Planning Group  North of Scotland Planning Group Annual Report and Work Plan  Nursing, Midwifery and AHP Strategy  Obligate Networks

38  Patient Focus, Public Involvement – Year End Self-Assessment Report 2008/09  Remote and Rural Implementation Group – Update on Implementation in Highland  Emergency and Urgent Response to Remote and Rural Communities – Consultation Process  Rural Digital Economy Hub

Ms May referred to the update on the Nursing, Midwifery and AHP Strategy and advised that at present 95 out of 108 actions were green and 13 amber. It was noted that the Strategy would be reviewed in light of the current agenda and a revised strategy would be submitted to the Board in approximately 6 months time.

Dr Shelley referred to the Dental Leadership Group. The proposals relating to oral health and dentistry had been approved at the previous Board meeting, subject to these being within budget. Dr Bashford advised that work was ongoing and a meeting was planned for next week.

The Board a Noted the emerging issues and updates report.

STRATEGY AND POLICY

63 NHS Highland Updated Policies for Managing Access for Patients Report by Maimie Thompson, Programme Manager for 18 Weeks Referral to Treatment on behalf of Elaine Mead, Chief Operating Officer

The paper summarised the strategic context within which the Patient Access Policy sits. It covered the scope of the Policy including the supporting principles and the benefits once implemented. The policy meant that patients would only be called in for an appointment or added to a waiting list for treatment when they were medically ready, socially available and willing to attend. Appropriate utilisation would be made across all available capacity. A “reasonable offer” of appointment would be considered within the boundaries of NHS Highland. The Policy would cover the implications for patients if they decline a reasonable offer.

During discussion it was clarified that Argyll & Bute patients who normally go to NHS Greater Glasgow & Clyde for treatment would continue to do so. It was agreed that the question of “reasonableness” of offers of appointments in hospitals outwith the patient’s home area (e.g. a patient from Inverness being offered an appointment in Invergordon) would need to be considered in more detail, particularly in relation to vulnerable groups and their support needs.

The Board a Approved the scope and principles, which would underpin a detailed Patient Access Policy. b Noted the strategic context within which the updated Policy sat. c Noted its contribution to the delivery of reduced waiting times, other HEAT Targets and efficiency savings.

39 64 Policy Framework for Long Term Conditions / Anticipatory Care Report by Alexa Pilch, LTC Programme Manager on behalf of Ian Bashford, Medical Director and Elaine Mead, Chief Operating Officer

The Long Term Conditions Collaborative (LTCC) was launched in April 2008 to support the delivery of sustainable improvements in patient centred services for people with Long Term Conditions (LTCs). These improvements are crucial to the delivery of timely, safe, effective and efficient services for the people of NHS Highland who have one or more LTC.

Long Term Conditions currently account for approximately 80% of GP consultations and 60% of hospital bed days, and an ageing population will increase the prevalence of LTCs. Without significant redesign of the way we manage Long Term Conditions, services will become inappropriate, inefficient and unsustainable in the future.

The 3 main work streams of the Long Term Conditions Collaborative are:

 Anticipatory Care  Condition Management  Self Management

The paper summarised the strategic framework for delivering these three work streams across NHS Highland, with a particular focus on the approach for rolling out anticipatory care across the region.

The Board a Endorsed the framework for taking forward Anticipatory Care across NHS Highland. b Noted the context of the service improvement work to delivery Anticipatory Care within the framework of the Long Term Conditions Collaborative.

65 Community Nursing – Implementation of Key Standards for Practice Report by Pat Tyrrell, Lead Nurse, Argyll & Bute CHP on behalf of Heidi May, Board Nurse Director

The recommendations from the national Review of Nursing in the Community (RoNC) were currently being piloted in five sites in NHS Highland. It was the aim of the project that the new Community Nursing Model would support NHS Highland in achieving both the local and national policy agendas. Ms May advised that this work linked with Long Term Conditions and Anticipatory Care. It was noted that the new model of Community Health Nursing had received a mixed response from community nurses across Scotland and advocacy for the new Community Health Nurse role was not unanimous. Testing it in our pilot sites would allow us to evaluate its place in the delivery of healthcare in NHS Highland in the future.

The fifteen key standards and principles were as follows:

1. Each Community Nursing Team has a skills profile based on public health needs and community profiling tool 2. Each Community Nursing Team has identified key objectives and developed an annual plan to meet public health priorities within their community 3. Each Community Nursing Team has a system for prioritisation of care, using the intensive, additional and core classifications, in place for all patients, families and groups

40 4. Anticipatory Care Plans and Case Management for those with complex needs has been introduced within each Community Nursing Team 5. Each Community Nursing Team is actively promoting models of self care, utilising range of identified skills 6. There is a single point of access to the Community Nursing Team 7. Each Community Nursing Team has an established Team Leader 8. Each Community Nursing Team has a completed training plan based on individual Learning Development Plans 9. Each Community Nursing Team has Workload Management Systems in place which ensure effective communication and information sharing across the whole team 10. Each Community Nursing Team has introduced agreed assessment and care planning tools for all new referrals to the team 11. Referral Criteria are agreed for Community Nursing services and are available to other professionals, agencies and public 12. Each Community Nursing Team has a procedure for identifying Named Nurse 13. Care Aims has been implemented within each Community Nursing Team 14. Values Based Care (derived from 10 Essential Shared Capabilities) is delivered by each Community Nursing Team 15. Clinical Supervision Model is implemented by each Community Nursing Team

The Board supported the rationale for implementing the key standards for practice.

The Board a Supported and Agreed the proposed implementation plan for NHS Highland.

66 Date of Next Meeting

The next meeting of the Board will be held on Tuesday 11 August 2009 at 8.30 am in the Board Room, Assynt House, Inverness.

The meeting concluded at 2.00 pm.