MINUTE of MEETING of the AREA NURSING & MIDWIFERY COMMITTEE s2

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MINUTE of MEETING of the AREA NURSING & MIDWIFERY COMMITTEE 12 AUGUST 2008 – 11.00 am Board Room, John Dewar Building, Inverness

Present: Heidi May (In the Chair) Doreen Bell Helen Bryers Alan Caswell Lynn Chalmers Jonathan Gray Laura Greenshields Nigel Hobson Hilda Hope Alison Hudson Veronica Kennedy Marie Law Stephen Loch Una Lyon Gill MacNeill Margaret MacRae Paula McCormack Sarah McLeod Muriel McNab Ruth Miller Helen Morrison Joan Philip Pat Tyrrell Elizabeth Watson Mhairi Will Isobel Woods Eric Wiseman Sandie Young

Also Present Findlay Hickey, Lead Pharmacist, Mid Highland CHP

In Attendance: Brian Mitchell, Board Committee Administrator Fiona Mundell

1 WELCOME AND APOLOGIES

Apologies were received from Mary Burnside, Peter Cartwright, Lorraine Coe, Kathleen Clarke, Caroline Henderson, Malcolm Iredale, Trisha Kelly, Chrissie Lane, Jennifer Lobban, Jenny MacGregor, Alison MacLean, Liz McClurg, Iona McGauran, Mairi Milne,

Working with you to make Highland the healthy place to be

Patricia Morrison, Lesley Randall, Fiona Riddell, Fiona Sharples, Hazel Smith, Rachel Soplantila, Helen Tissington, Mary Vance, Angela Watt, and Catherine Zawalnyski.

2 PATIENT GROUP DIRECTIONS

Mr Hickey gave a presentation to the Committee in relation to Patient Group Directions (PGDs), advising that these had emerged as a result of the expansion of professional roles within the NHS and the need for development of safe and effective new patient focused services. PGDs were considered by the Area Drug and Therapeutic Committee Sub Group of the same name. PGD themselves provided a written instruction for the supply or administration of medicines to groups of patients, subject to specified exclusions, where patients could not be individually identified prior to presentation for treatment. PGDs were legal documents and would only be valid once authorised by the PGD Sub Group. PGDs would be used by a range of healthcare practitioners although would be restricted to those named in the specific document, a master copy of which was to be held by a responsible person within the location. Practitioners were required to have been trained on and understand the PGD as well as ensure that their continuous professional development was up to date. HDL(20001)7 stated that “supply or administration of medicines under PGD should be reserved for those limited situations where this offers an advantage for patient care (without compromising patient safety) and where it as consistent with appropriate professional relationships and accountability.” PGDs would be useful in relation to drugs in routine use by healthcare professionals, would increase patient convenience without compromising safety, and provide clearly defined criteria and conditions such as in the case of administration of vaccines by practice nurses. It was stated that all professionals involved in the development, review and operation of the PGD must act within the legal requirements as well as their own professional code of practice and conduct. In terms of development of a PGD there would be need to consider whether this was appropriate, if there was an existing PGD in place, and if not then the development group would be required to collaborate with the PGD Sub Group. The draft PGD would then be submitted to the Sub Group, be disseminated accordingly, and be valid for a period of two years after approval with a planned review after 12 months. Mr Hickey then went on to outline the responsibilities of both Line Managers and Healthcare professionals and added that if supplying or administering a medicine under a PGD then the individual concerned required to ensure they had up to date knowledge relating to the clinical situation covered by the PGD, the medicine and its use for the indications specified. There was also a need to ensure that any training required for the operation of the PGD had been taken, for satisfaction that the PGD is legally valid and has the appropriate authorisation, that when medicines are supplied or administered the agreed protocol must be followed and the information specified in the PGD recorded, and that the individual acted within the legal requirements of the PGD as well as their own code of professional practice and conduct.

During discussion, Mr Hickey advised that in relation to reviewing PGDs the responsibility lay with the relevant Sub Group and the professionals involved. It was confirmed that the Sub group would initiate this process. On the matter of drugs that were not to be covered by PGDs it was stated that this would be Controlled Drugs but also include antibiotics, and those involving relevant licensing conditions. Ms May raised the issue of compliance monitoring and the need for formal guidance to be issued and Mr Hickey undertook to refer this point to the PGD Sub Group.

The Committee:

 Noted the position in relation to Patient Group Directions.  Noted that Mr Hickey would refer the issue of governance and formal guidance to the PGD Sub Group for consideration.

Mr Hickey left the meeting at 11.25 am.

3 MINUTE OF MEETING OF 8 APRIL 2008

The Committee Approved the Minute of meeting held on 8 July 2008.

4 MATTERS ARISING

4.1 Appointment of Representative to Area Clinical Forum

Ms May advised that she had received 3 expressions of interest in undertaking the role of additional representative on the Area Clinical Forum, from this Committee. Ms May was to hold further discussion with the individuals before making a final nomination.

The Committee Noted the position.

4.2 Hand Hygiene Audits

Ms May expressed concern that NHS Highland may not meet the compliance requirements at the next audit and this was likely to be raised as part of the forthcoming Annual Review. It was stated that 2 wards at Lorne & Islands were still to be audited, that the eventual final compliance figure was to be 83-97%, and that it was possible NHS Highland would be the only Board to fail to meet the requirements. There was need for discussion with Lead Nurses as to next steps and audit processes, including notification of the position to CHP General Managers etc. Ms May also wished to record her thanks to those staff in areas where compliance rates had been met, recognising the great effort involved in this achievement.

The Committee:

 Noted the position.  Agreed that the matter be discussed at the Informal Leads meeting that afternoon.

4.3 AAHP Professional Leadership

Ms May advised that the roles of Professional Heads of Service for Speech and Language Therapy, Physiotherapy had been advertised. CHP AHP Leads had been appointed for North, Mid, and Argyll and Bute CHPs. The post of Associate Director was to be advertised shortly and this would be for a fixed 2 year term at Senior Management (B) level.

5 REVIEW OF NURSING IN THE COMMUNITY IMPLEMENTATION

Ms May spoke to the circulated Implementation Plan, which had been agreed by the NHS Board at their meeting held on 3 June 2008. The Committee was advised Ms Sharples was now on maternity leave and as such project management arrangements were being considered.

6 GIRFEC

Ms Watson spoke to the circulated local NHS Highland GIRFEC Update, dated August 2008, relating to recent Key Achievements and significant issues including agreement as to the Child Plan for Health. Information was to be available shortly on the Intranet site and this was to include the assessment triangle previously considered by the Committee.

Relevant training was underway, especially in RONC sites and a multi-agency structure had now been put in place. Ms Young added that there would be a strong quality assurance framework in place along with a necessary Transitional Protocol. Ms May requested that Ms Young consider and create a Strategy for Practice for RONC sites. On the point raised as to the role of Lead Professionals, it was stated that these would be named Professionals, be the most appropriate Health Professional involved, be dependent on the child’s age, and where there were issues relating to Child Protection/Education could be a Social Worker for instance.

The Committee

 Noted the position.  Noted that Ms Young would consider and prepare a Strategy for Practice relative to RONC sites.

7 KEEPING CHILDBIRTH NATURAL AND DYNAMIC

Sarah McLeod gave a presentation to the Committee in relation to the Keeping Childbirth Natural and Dynamic Programme (KCND), advising that this is a government led initiative and formed part of Better Health Better Care. It covered a multi-professional programme of work and the overarching aims covered ante, intra and post natal periods, providing a strategic and systematic approach throughout Scotland. In terms of delivery, each NHS Board had appointed a consultant grade midwife to lead and implement KCND and would work locally/regionally and nationally to a range of specific aims and objectives. There would also be development of national pathways, the drafts of which were to be issued for consultation shortly. It had been considered necessary to take this approach in light of the great variation in maternity care over the last 100 years and this plethora of change had led to confusion. In addition it was recognised that changes within the Health Service would lead to fewer obstetricians, that the new MMC and GMS contracts had associated implications, and reflecting that there had been an expansion in midwifery practice as well as introduction of Maternity Care Assistants. Overall there was a desire to provide women with an informed/evidence based choice. In terms of objectives, Midwives were to become the first point of contact for women, would carry out the initial risk assessment, and have caseload responsibility for healthy women who would be offered a normal birth pathway regardless of setting. There was to be discontinuation of Cardiotocograph (CTG) at admission and again there was to be provision of Nationally agreed pathways. To date NHS Boards had appointed Consultant Midwives, NHS QIS had prepared national referral criteria and care pathways, and NES had established a leadership programme with regional events for key stakeholders. In order to underpin KCND evaluation plan the Chief Scientists’ Office NMAHP Research Unit were to undertake a literature review. in NHS Highland there was a need to ensure engagement with all stakeholders, recognise the excellent work already undertaken, ensure that the Steering Group take a systematic approach, and ensure that the national lead was followed whilst being mindful of the uniqueness that existed in Highland. In summary KCND represented a unique opportunity for maternity care provision in Scotland, was woman focused, would involve the right care delivered by the right health professional, would provide a valuable contribution to the Public Health agenda, and was to be a long term Programme.

Mrs Morrison queried the assessment and monitoring of workload/workforce implications for relevant staff and was advised that much was already underway. Mrs Bryers advised that the work fed into the Women’s Health Network and Ms McLeod that this would form part of the relevant progress reporting process. On the point raised by Ms Hope it was stated that it was hoped the Programme would have a positive impact on the rate of c- sections undertaken. The issue of GP involvement was raised and Ms McLeod stated that this aspect would be challenging given that this was not an Enhanced Service although it was clear that they would have an important role to play. In relation to the proposed QIS pathway it was advised that the first draft was expected in early course, and

that national pathways would take precedence.

The Committee:

 Noted the position.  Agreed that a Steering Group be established, with membership including GPs and Lead Nurses.  Agreed that an Action Plan be prepared.  Agreed that there be engagement with Lead Midwives.

8 REVENUE BUDGET 2008/09

Ms May advised as to the financial position for NHS Highland in 2008/09 and stated that there would be requirement in the coming year to identify a range of savings at operational level. Discussion identified several ways that Lead Nurses and Midwives may contribute:

 Reduction in bank and agency.  Standardisation of equipment such as catheters.  Capping mileage and encouraging videoconferencing.  Economic use of lights, power and heating.

The Committee Noted that Mr Iredale, Director of Finance was to address the next meeting, as he was unable to do so today.

9 LESSONS FROM RY CASE

Mr Hobson advised the Committee as to a complex clinical case that had learning implications for a range of staff. The main points that emerged were in relation to continuous assessment of high risk patients in terms of appropriate location for care and associated staff skill levels, usage of SEWS (Early Warning) Charts and associated roster/staff skill issues, the move from informal and uncoordinated care to utilisation of an hourly checklist, and the lack of a written formal Care Plan in this instance.

The Committee:

 Noted the issues raised.  Agreed the need for structured shared learning from clinical incidents.

Elizabeth Watson left the meeting at 12.55 pm.

10 NURSING ASSISTANTS LEADERSHIP

Muriel MacNab, Practice Development Coordinator for Support Staff spoke to the Committee in relation to the Nursing Assistants Leadership Programme and advised that this related to a range of support staff, including Nursing Auxiliaries. The aim was to consider how best to include these staff in day to day activity and empowering them to take an active role, including suggesting and implementing agreed changes. Discussion with the RCN had led to appropriate funding and this led to six individuals being identified as potential leaders. A number of experts had travelled from Edinburgh to discuss various topics with Nursing Assistants and the feedback received had been rated by the RCN representative as excellent and in line with from Registered Nurses. Individuals had then been requested to suggest potential, cost neutral, ideas for implementation within their own areas and these had included matters relating to Violence and Aggression, Infection Control, Health and Safety, and patient fluid balance observation. For those involved in the scheme, the RCN had granted specific Certificates in Nursing Assistant Leadership,

and Ms May was to present these at an appropriate event at the Centre for Health Sciences. Ms MacNab further advised that the relevant teaching materials were available should there be a wish to introduce this scheme elsewhere within NHS Highland, although RCN funding was no longer on offer.

During discussion, it was confirmed that the scheme had only been introduced in Raigmore to date and that an article was to be placed in a forthcoming edition of Team Update. In terms of evaluation Ms MacNab confirmed she would be undertaking this after 27 October 2008, on a qualitative basis, with a review after 12 months and stated that findings would be shared as appropriate. On the point raised by Mt Hobson it was confirmed that the scheme had been received positively among Charge Nurses. Ms May referred to the associated workforce development issues and requested that Mr Loch, Mr Hobson and Mrs Morrison also be involved in such consideration.

The Committee:

 Noted the position.  Noted that relevant teaching materials were available.  Agreed that Mr Loch, Mr Hobson and Mrs Morrison link to consideration of associated workforce development issues.

11 QIS REVIEW AND BEST PRACTICE STATEMENT FOR PEOPLE WITH LEARNING DIFFICULTIES.

Mr Gray gave a presentation to the Committee advising that there was to be a NHS QIS Review in the week commencing 12 January 2009, and would relate to Quality Indicators (QIs) 2 and 3. These Indicators would cover aspects concerning Promoting Inclusion and Wellbeing, and Meeting General Healthcare Needs as indicated. In terms of preparation for the Review visit, this was to be led by the Clinical Effectiveness Team and the first relevant meeting was to be held in August 2008. This was to include all parts of NHS Highland and plan was to be developed to complete the required self assessment documentation. During discussion it was confirmed that the Health Promotion department would be contacted regarding access to appropriate resource. A pre-audit process had begun in respect of which identifying risk assessment capabilities would be important and which would highlight areas of existing good practice. On the point raised by Ms May, it was stated that the highest areas of risk would exist in primary and hospital care settings although it may prove difficult to evidence such issues. In terms of awareness at CHP level this would be via Lead/Key Nurses.

In terms of the Best Practice Statement this would relate to ‘Promoting Access to healthcare for people with a learning disability – a guide for frontline NHS staff.’ The Core Principles would be attitude and identification of additional need, communication, structure and arrangements to facilitate access, and appropriate education and training. In terms of NHS Highland compliance there was an audit planned for September 2008 with focus on primary healthcare services, the Clinical Effectiveness team had developed an audit template for use in best practice statements, and consideration would be required as to the best route in which to feed results to operational areas. Ms May emphasised that the move to community care in recent years had helped to focus attention in this area and it was clear that staff would encounter a learning curve whilst increasing relevant experience.

12 SCREENING UPTAKE FOR WOMEN WITH LEARNING DIFFICULTIES

Mr Gray spoke to the circulated report giving data relating to the uptake of cervical screening amongst women with learning disabilities in NHS Highland and advising that

this stood at approximately 26%. The report included a number of recommendations moving forward including determination of uptake rates in Argyll and Bute CHP, assessment for inclusion in the call/recall process, educational package production, the contribution of Learning Disability Nurses, and training needs of support staff in social care services.

The Committee Noted the detail of the report.

13 24 HOUR ROTATIONAL NURSING POLICY

Ms Tyrrell advised that that the Highland Partnership Forum had discussed the proposed Policy and were generally supportive of a process that would allow those staff on permanent night duties to work day shifts in order to meet their KSF requirements etc. A further meeting with the Employment Director was to be held to discuss the matter, the outcome of which would be reported to the next meeting.

14 INCIDENT REPORTS

The Committee Agreed to Defer consideration of this Item to the next meeting.

15 SUB GROUP PROGRESS REPORTS

Clinical Governance

There had been circulated report informing as to the progress and outcomes of the NMAHP Clinical Governance Sub Group workplan, this being almost complete. It was stated that since the workplan was originally developed there had been a range of organisational changes whereby a number of key objectives have become the remit of other Committees and Groups. As a result it had been recommended that that the Clinical Governance Sub Group be amalgamated with the Policy Sub Group and chaired by the Associate Director of Nursing.

The Committee:

 Noted the progress and outcomes of the Sub Group workplan.  Agreed the proposal to merge the Clinical Governance and Policy Sub Groups.

Workforce Planning

Mrs Morrison spoke to the circulated progress report in relation to the eight relevant workstreams, ongoing actions in relation to which were outlined. It was stated that the Sub Group had found it difficult to remain up to date and sufficiently responsive to the fast moving national timescales, particularly in relation to the implementation of the workload measurement tools. In response to concerns the Sub Group was to consider the current Terms of Reference and priorities, the outcome of which was to be reported to the next meeting along with a draft report for the NHS Board incorporating an update against the original Nursing and Midwifery Workforce Programme as required by the Scottish Government. Ms May emphasised the need for National issues to be used as drivers for activity to benefit NHS Highland.

The Committee:

 Noted the progress report.  Noted that proposals relating to Terms of Reference and Sub Group Priorities would be submitted to the next meeting.

 Noted that a draft NHS Board report incorporating an update against the original Workforce Programme would be submitted to the next meeting.

Education

There had been circulated report advising that the Sub Group had considered a range of matters including taking forward mandatory training in aspects of Health and Safety such as Moving and Handling, Violence and Aggression etc. Considerable work had been undertaken in determining the most appropriate preparation of Nursing Assistants ready for anticipated regulation requirements i.e. the NiCHE Programme or SVQ route to competency development. The Sub Group had also reviewed the work of the eKSF system. Current work included consideration of a strategy/framework to support staff through demanding academic work, particularly PHDs, the requirements for implementation of the Leading Better Care programme, and the hosting of an Educational Network Day as a means of supporting and informing colleagues who have a remit for education/staff training.

The Committee:

 Noted the progress report.  Noted that proposals for the Educational Network Day would be submitted to a future meeting.

Policy

There had been circulated report advising as to activity work which had been completed by the Policy Sub Group, including a review of the electronic Marsden Manual with consideration of the J Briggs initiative which had concluded that this would be complementary in nature hence the approval of a three year deal for the new electronic version of the Marsden Manual to be available across the organisation. In terms of the current and future work programme, the Policy for Nursing Assistant Scope of Practice was due to be submitted to the next meeting of the Committee. The first draft of the Policy for Patient Observation (Incl. Recording SEWS score) was being led by Mr Peter White and was expected in October 2008. The Resuscitation Policy was to be revised in light of new guidance and the first draft was expected in October 2008. Blood Glucose Monitoring (Near Patient Testing) was under discussion. As advised, and agreed, above this Sub Group was to be amalgamated with the Clinical Governance Sub Group.

The Committee:

 Noted the position.  Noted the draft Policy for Nursing Assistant Scope of Practice would be submitted to the next meeting.

Ms May requested that Informal Leads consider future requirements in relation to Committee Sub Groups, and that the outcome of such discussion be brought back to a future meeting for consideration.

The Committee so Noted.

16 PAPER FOR INFORMATION

There had been circulated for information report relating to “Just in Case”, a new initiative for end-stage palliative care patients which had been successfully piloted in Skye, Beauly, and Inverness. The initiative provides the necessary medication on site in the patient’s home, and ensures there are no delays in treatment and pain relief. It was planned to roll out the initiative across North, Mid and South East Highland CHPs in coming months and

discussion was being held with colleagues in Argyll and Bute where patients were supported by specialist care services from NHS Greater Glasgow and Clyde. Training was to be cascaded by involving key personnel as trainers for each locality, allowing time for locality cascade training and troubleshooting before the Christmas period. Further information and documentation was available from Mr Ron Ward.

17 AOCB

The Committee was advised that a number of responses were awaited in relation to letters issued regarding the Mentorship Database. This had resulted in there being a number of gaps in data and these required to be addressed. Ms May requested that Lead Nurses look into this point and provide appropriate information/responses in two weeks. Pat Tyrrell reminded the Committee that the Argyll and Bute register would remain separate, reflecting the link with the West of Scotland University.

The Committee:

 Noted the position.  Noted that Lead Nurses were to provide the required data within two weeks.

Mrs Bryers advised the Committee that the NHSH Research Survey looking into what research is currently/recently being undertaken was still ongoing and urged that staff be encouraged to complete this.

The Committee so Noted.

18 DATE OF NEXT MEETING

The next meeting of the Committee would be held on Tuesday 9 September 2008 in the Board Room, Assynt House, Inverness at 11.00am.

The meeting closed at 2.00 pm